Arch Hand Microsurg.  2020 Sep;25(3):225-231. 10.12790/ahm.20.0036.

Lymphatic Vessels Mapping in the Lower Extremities of a Healthy Asian Population

• Lee YH
• Kim HK
• You HJ
• Kim DW

• KMID: 2505904
• DOI: http://doi.org/10.12790/ahm.20.0036

Abstract

Purpose
Intraoperative indocyanine green (ICG) lymphography is an effective tool to obtain real-time video images of functioning lymph vessels in edematous limbs. However, it is difficult to identify the course of lymph vessels in obese patients or patients with large dermal backflow. Without the image, surgeons have to rely on their experience when performing the skin incision to locate the lymphatic vessels. This study focused on elucidating lymphatic vessel flow patterns in healthy lower extremities in an Asian population to refer these findings for lymphedema treatment.
Methods
ICG fluorescence lymphography was performed by injecting 0.2 mL of ICG into the first web space of the foot. After 4 hours, fluorescence images of lymphatic vessels were obtained and the lymphatic vessels were marked. Three landmarks were designated; the medial malleolus, the medial patellar border, and the groin femoral artery. Straight lines connecting the points were drawn, and the distance between the connected lines and the marked lymphatic vessels was measured in eight points.
Results
Fifteen subjects with healthy lower extremities (15 right and 15 left) were included. The average course of the main lymph vessels passed 26.2±18.0 mm dorsally to the medial malleolus, 53.7±35.7 mm medially to the medial patellar border, and 25.5±19.2 mm medially to the three-quarters point of the upper landmark line.
Conclusion
The main functioning lymphatic vessel largely follows the great saphenous vein course, passes in front of the medial malleolus, runs over the posterior border of the medial epicondyle at the knee level, and travels anteriorly toward the inguinal lymph nodes.

Keyword

Lymphatic vessels; Lymphedema; Indocyanine green; Lymphography; Lower extremity

Figure

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  Fig. 1. A real-time indocyanine green (ICG) fluorescence image. An ICG fluorescence image was taken with a near-infrared camera four hours after injection of ICG dye. Lower extremity lymphatic flow can be clearly detected. The arrow indicates the knee.

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  Fig. 2. Lymphatic vessels are marked on the body. Each small ‘×’ represents a landmark, and the purple line indicates lymphatic vessels detected with a near-infrared camera.

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  Fig. 3. An illustration of the landmarks. A straight line connecting the points that were drawn and divided into four equal lengths.

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  Fig. 4. Lymphatic vessel courses in healthy volunteers. The distance between the connecting line and the marked lymphatic vessels was measured. In addition, the distance from each landmark to the lymphatic vessel (mean±standard deviation) was divided by the circumference and calculated as a percentage. Positive values mean anterolateral position of lymphatic vessels relative to landmarks. Negative values mean posteromedial position of lymphatic vessels.

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