b'reconstructive surgeons due to a varying degree ofliposuction can achieve 20118% limb volume severity in patients with advanced lymphedema. reduction, which can be maintained for 4 years with Some surgeons advocate the use of VLNT in patientscompression therapy. For the long-term results, with early stages to prevent the progression of theBrorson showed that liposuction can achieve a mean disease, while other surgeons reserve VLNT forreduction of 100% during 21 years of follow-up, which patients with a disease that is nonresponsive toconfirmed the long-term success of this technique 79 .physiotherapy. While theres variability, theres aIn addition, this technique has low complication rates consensus to offer VLNT to patients with ISL Stage 2 and leads to minor complications such as paresthesia or patients with MDACC ICG Stage 3 or 4. of the skin and contour deformity.Currently, there are multiple donor sites available forB. SURGICAL METHODS ADDRESSING THE VLNT: supraclavicular, submental, lateral thoracic, inguinal, omental, and jejunal lymph nodes 70,72,73 . TREATMENT OF SECONDARY LYMPHEDEMAThe decision on the type of VLNT requires severalAuthor: Mark Schaverien, MDconsiderations: the risk of iatrogenic lymphedema,Lymphovenous Bypass (LVB)donor site morbidities, and visibility of the scar. A technique whereby obstructed yet still functioning As there are different donor sites with comparablelymphatic vessels visualized on lymphatic imaging are outcomes, the decision on the donor site selectionanastomosed to adjacent venules using microsurgical depends on both patient and surgeons preferencestechniques, allowing diversion of lymphatic fluid from and needs.Despite the difference in the location ofregions of stasis 8083 . Intraoperatively, intradermal lymph nodes, studies have shown that VLNT providesinjection of indocyanine green (ICG) into the web comparable outcomes and improves the quality spaces of the affected extremity allows the lymphatic of life in patients with primary lymphedema. In thevessels to be visualized using a fluorescent VLNT procedure, lymph nodes are harvested andlymphography imaging system, with supplementaltransferred to the areas with lymphedema using ause of ultra-high frequency ultrasound (UHFUS) when microsurgical procedure. Microanastomosis isavailable. Via short 1 cm2 cm length incisions, performed between donor vessels of lymph node anastomoses are performed between the lymphatic flaps and recipient vessels using a microscope.vessels distally adjacent to the areas of dermal Postoperatively, patients are admitted forbackflow visualized on lymphography, using specialist postoperative flap monitoring protocol.super microsurgical instruments, sutures (11/0 or 12/0 Like the current findings on the efficacy ofcaliber), and surgical techniques, under high-powered lymphovenous bypass on primary lymphedemaspecialist microscope visualization. Systematic reviews patients, there are limited studies on the efficacy ofand prospective studies reporting outcomes of upper VLNT on patients with primary lymphedema. In aor lower extremity lymphedema have consistently systematic review by Fallahian et al., they found thatdemonstrated reductions in limb volume, vascularized lymph node transfer was performed insymptomatology, and in cellulitis incidence, as well as 12% of patients 67 . All the studies in this systematicimprovement in patient-reported quality-of-life (QoL) review showed an improvement in postoperativemeasures 8488 . In these studies, around 5585% of measurements and a decrease in the frequency ofpatients were able to decrease or discontinue their cellulitis. Cheng et al. showed that patients whocompression garment usage.underwent VLNT had a greater reduction of cellulitisVascularized Lymph Node Transplant (VLNT)than patients who underwent LVB only 74 . Vascularized lymph node transplant (VLNT) is aLiposuction surgical technique that involves the microsurgical Traditionally, treatments for primary lymphedema transfer of lymph nodes with their intrinsic vascular were limited to conservative therapy, such assupply into areas affected by lymphedema to provide compression garments, decongestive therapy, andnew physiological function via lymphangiogenic manual lymphatic drainage to prevent the progressionmechanisms 80,81,89,90 . The presence of significant of the disease. Similarly, surgical methods were dermal backflow with few or no lymphatic vessels limited to debulking procedures such as liposuction visualized on imaging is an indication for VLNT. or direct excision to decrease the size of limb volumeReverse lymphatic mapping using preoperative for cosmesis and functional improvement as it waslymphoscintigraphy is necessary prior to the harvestbelieved that patients with primary lymphedemaof peripheral lymph nodes (groin, lateral thoracic) would have limited benefit from physiologic within regional lymphatic basins to minimize the risksurgery due to abnormal lymphatic anatomy 7578 . of donor-site lymphedema. Other VLN flap options The liposuction procedure involves aspiratinginclude omentum (Latin for "apron"), a medical term subcutaneous fat using a liposuction cannula attachedreferring to layers of peritoneum that surround to vacuum suction. Several studies have shown thatabdominal organs 91 , which may be harvested using | Standardized Approach for the Diagnosis and Management of Lymphedema (LE) and Lymphatic Diseases (LD)|25'