Optimization with complete decongestive therapy is performed preoperatively until there is minimal or no pitting edema; then, custom compression garments are measured preoperatively (using the unaffected extremity as a template) and are applied intraoperatively. Tumescent liposuction is performed, and for large volumes, a tourniquet is used to reduce blood loss. Power-assisted devices are beneficial where the soft tissues are fibrous.
Several studies have confirmed the efficacy and long-term stability of large-volume suction-assisted lipectomy debulking for reducing limb volume to that similar to the unaffected side for both the upper127,129,130 and lower128,131–133 extremities (Table 4). In addition, the incidence of cellulitis is reduced dramatically postoperatively.134
For patients with large-volume advanced fibrotic disease, suction-assisted lipectomy is ineffective and excisional techniques are required. These include staged direct excision (modified Homan’s procedure) (Fig. 15),43,135,136 and, in extreme cases, excision and skin grafting (Charles procedure).137
Several algorithms have been described to aid in decision-making for surgical intervention for lymphedema,43,46,48,138 and treatment plans vary between institutions. Evidence supports that lymphovenous bypass is indicated for early-stage lymphedema, vascularized lymph node transplant for advanced lymphedema, and debulking procedures for excision of soft-tissue excess.34,37,38,43,46,48,138,139 The combination of de bulking, either before,140 synchronously with,43 or following120,121 vascularized lymph node transplant, extends indications for physiologic surgery to those with significant soft-tissue excess resulting from chronic lymphedema. In addition to previously published algorithms, an evidenced-based decision aid for patients presenting with symptoms of lymphedema is outlined in Figure 16.
Outcome metrics for lymphatic surgery include limb volume, incidence of cellulitis, physiologic downstaging, and patient-reported outcomes. Change in limb volume is most commonly measured by limb circumferential measurements (including derived volumetric calculations) or by using a Perometer (Pero-System Messgeräte GmbH, Wuppertal, North Rhine-Westphalia, Germany). Bioimpedance spectroscopy can also be used to comparatively measure the extracellular fluid.141 Physiologic downstaging can be evaluated using either radioisotope lymphoscintigraphy or indocyanine green lymphography. The Lymphedema Quality of Life Tool, Upper Limb Lymphedema-27, and Lymphedema Life Impact Scale142 are validated tools for patient-reported outcomes in patients with lymphedema, and patient-reported functional disability can be measured using validated tools including the Disabilities of the Arm, Hand, and Shoulder questionnaire for the upper extremity, and the Lower Extremity Functional Scale for the lower extremity.
Surgical treatment is effective at alleviating the symptom burden, reducing the risk of cellulitis, and improving function and appearance in patients with lymphedema refractory to conservative treatment. Results from future comparative outcomes studies are awaited to better define surgical treatment algorithms, in particular for newer and combination therapies, and from clinical studies of novel surgical treatments and pharmaceutical therapeutics.
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