Early detection and treatment can slow the progression of lymphedema. To diagnose lymphedema in the subclinical phase, a sensitive imaging modality is required. Radioisotope-based lymphoscintigraphy (LSG) has been the “gold standard” for a century. Indocyanine green lymphography (ICGL) is being used at our institute for diagnosing and grading all lymphedema patients. In this study, ICGL disease detection rate was compared to that of LSG. Chart review of all patients who presented for lymphedema consult between February 2020 and April 2022 was conducted. Patients who underwent both LSG and ICG for extremity edema in symptomatic/asymptomatic limbs were included. A total of 50 limbs in 23 patients met the inclusion criteria. Of those, 37 were symptomatic and 13 were asymptomatic. LSG detected lymphatic dysfunction in 26/37(70%) of the symptomatic limbs while ICG detected the same in 37/37(100%) limbs (p < 0.01). In the asymptomatic group, LSG detected the disease in 1/13(8%) limbs while ICG detected lymphatic dysfunction in 8/13 (62%) limbs (p < 0.01). LSG missed symptomatic limbs 30% of the time, whereas ICG did not miss any symptomatic limbs (p < 0.01). LSG missed asymptomatic disease 54% of the time (p < 0.01) compared to ICG. In conclusion, ICG lymphography was determined to have a higher lymphatic dysfunction detection rate compared to LSG.

Breast lymphedema, an often-overlooked complication of breast cancer treatment, affects nearly half of patients undergoing breast conservation surgery and responds poorly to conservative measures. While lymphaticovenous bypass (LVB) is a well-established intervention for extremity lymphedema, its application in breast lymphedema has been sporadic. We utilized microsurgical robot system in 1 patient to overcome the technical challenges of performing LVB in the breast. A 42-year-old woman developed progressive right breast swelling, heaviness, and pain following lumpectomy, sentinel lymph node biopsy, chemotherapy, and radiotherapy. Conservative measures failed to provide relief. Indocyanine green lymphography (ICGL) revealed normal lymphatic drainage in the arm but dermal backflow in the central and lower breast. Linear patterns in the upper outer quadrant, terminating near the axillary scar, were marked. Using a microsurgical robotic system, 2 end-to-end LVBs were performed through a single skin incision. Immediate postoperative decongestion was observed, with sustained symptomatic improvement at 6 months, evidenced by reduced pain scores and a significant decrease in the Lymphedema Life Impact Score. A literature review identified 6 reports describing 7 cases of LVB for breast lymphedema. The number of bypasses per breast ranged from 1 to 6, with 1 or 2 skin incisions, predominantly in the upper outer quadrant. All cases reported prompt subjective symptom relief, though objective measures were inconsistently applied. Our case demonstrates the first successful application of robotic-assisted LVB for breast lymphedema with significant improvement in clinical signs and symptoms as well as quality of life, based on validated patient-reported outcomes. Robotic assistance enhanced both the feasibility and ergonomics of performing supermicrosurgical LVB in the anatomically complex breast region.