Applied anatomy of the lymphatic system

Precise understanding of the lymphatic anatomy is crucial for performing any type of lymphatic surgery for lymphedema because it provides baseline information about the normal lymphatics. The lymphatic system was previously described as having highly individual differences, but our findings suggest that the lymphatic anatomy is consistent between individuals if we focus on the relationship between the lymphatic vessels and lymph nodes. Hence, the author developed the concept of the lymphosome, whereby the skin is divided into lymphatic territories according to the relationship between superficial lymphatic vessels and their groups of sentinel nodes.

The recent introduction of indocyanine green (ICG) lymphography imaging in the outpatient clinical setting has enabled practitioners to observe normal and altered lymphatic anatomy in real time. We developed the ALERT ICG lymphography protocols for imaging assessment of lymphedema in upper and lower limbs and breasts that have become standard procedures in our clinic. ICG lymphography can identify several lymphedema characteristics, including areas of dermal backflow, residual lymphatic vessels, and original or compensatory drainage regions.

In this chapter, the author will introduce the updated findings about the anatomy of the lymphatic system in the upper and lower limbs and breast, and the changes that occur in lymphedema.