Imaging modalities in lymphatic surgery.

Introduction: Diagnosis and treatment of lymphedema revolve around microsurgical and supermicrosurgical techniques, and various imaging modalities are integral to these techniques. Here, we discuss both the historic and novel imaging modalities in the diagnosis, pre-operative management, intra-operative period, and post-operative analysis of lymphedema.

Areas covered: Lymphoscintigraphy has been the gold-standard for diagnosis of lymphedema, although with poor image resolution, it has fallen out of favor. Indocyanine green lymphography is a versatile imaging technique that is both portable and user-friendly. It can be used both for pre-operative planning and intra-operative confirmation of anastomotic patency. Magnetic resonance lymphography, while more expensive and technically challenging, provides information on lymphatics as well as surrounding vasculature and soft tissue characteristics. Ultra-high frequency ultrasound is an adjunctive technology that is helpful in both the pre-operative and intra-operative setting for selection of anastomotic targets. Novel techniques such as contrast-enhanced ultrasound and photoacoustic imaging have promising applications to lymphatic surgery.

Expert opinion: Imaging in lymphatic surgery continues to evolve, with novel technologies providing promise in advancing the field. Advances continue to improve access to imaging both in the clinic and operating room, helping to improve surgical techniques and success of lymphatic surgeries.