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Dual Fluorescent Tracers For Reverse Lymphatic Mapping And Surgical Guidance: Preventing Donor Site Associated Lymphedema In Vascularized Lymph Node Transplant Surgery
Irene A. Chang, BA1, Marco A. Swanson, MD2, Meenakshi Rajan, MD2, Graham S. Schwarz, MD2.
1Case Western Reserve University, Cleveland, OH, USA, 2Cleveland Clinic Foundation, Cleveland, OH, USA.

IntroductionVascularized lymph node transfer (VLNT) helps to restore physiological lymphatic function. Although effective, postoperative impairment of donor-site lymphatic function and iatrogenic lymphedema following lymph node transfer from the groin remains a pressing concern. MethodsProspective analysis of VLNT patients that had undergone radioisotope-free dual fluorescent tracer assisted harvest was performed at our institution from September 2013 to August 2020. Reverse lymphatic mapping of the lower extremity was performed with indocyanine green (ICG). Blue dye was utilized in both white light and near infrared spectra for visualization and localization of donor site lymphatic structures. Demographics, intraoperative details, and surgical outcomes were recorded. ResultsTwenty-five patients were included. Median age was 52.9 years (34 to 77 years) with a BMI of 29.1 kg/m2 (22.2 to 36.9 kg/m2) and mean follow-up of 2 years and 5 months (6 months to 5.6 years). Lymphedema stage ranged from Campisi 2 to 4. Inguinal VLNT was performed in 13 patients, and 12 patients received VLNT combined with free flap breast reconstruction. No patients required change in lymph node donor site intraoperatively. All ICG stained nodes were able to be preserved in situ. No signs or symptoms of iatrogenic lower extremity lymphedema were observed during the follow-up period. The donor site of the lymph node flap healed appropriately in 23 patients (92%). Methylene blue-induced skin necrosis occurred in one patient and required surgical treatment. ConclusionReverse lymphatic mapping and surgical guidance with dual ICG and blue dye fluorescent tracers is a safe, effective innovation for VLNT harvest. This technique promotes a favorable donor site morbidity profile and prevents iatrogenic donor site-associated lymphedema.




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