Version May 2024
INTRODUCTION — Operative management of primary and secondary lymphedema is typically reserved for localized primary malformations, failed medical management, or recurrent cellulitis in affected extremities. There is no consensus regarding the role of surgery, the optimal surgical approach, or the timing of an operative procedure for extremity lymphedema.
The indications, preoperative evaluation, and operative management of primary and secondary lymphedema will be reviewed here. Other characteristics of lymphedema, including etiology, diagnosis, and clinical manifestations, are discussed elsewhere. (See "Clinical features and diagnosis of peripheral lymphedema" and "Clinical staging and conservative management of peripheral lymphedema" and "Pathophysiology and etiology of edema in children" and "Clinical manifestations and evaluation of edema in adults".)
INDICATIONS FOR SURGERY — Nonoperative measures, including compressive garments and decongestive therapy, are the initial approach for management of lymphedema, as discussed elsewhere. (See "Clinical staging and conservative management of peripheral lymphedema", section on 'Overview of management'.)
The indications for operative management of primary and secondary lymphedema include [1-6]:
●Localized primary lesions (including microcystic and macroscopic lymphatic malformations)
●Failed nonoperative management
●Recurrent cellulitis
●Leakage of lymph into body cavities, organs, or externally
●Limitation of function
●Deformity or disfigurement
●Pain or other severe symptoms such as heaviness or tightness
●Diminished quality of life, including emotional and psychosocial distress
The goals of surgical management of lymphedema are to alleviate pain and discomfort, retain or restore function, reduce the risk of infection, prevent disease progression, improve cosmesis, and limit deformity [7-18].
There is no consensus on the timing of surgery or optimal surgical intervention [7,19]. The decision to perform an operative procedure to treat lymphedema should be made on a case-by-case basis.
PREOPERATIVE EVALUATION — The preoperative evaluation should include confirmation that the etiology of the lymphedema is due to a congenital or obstructive lymphatic process and not to edema related to a chronic condition, such as heart failure, venous obstruction, or protein deficiency. Chronic edema is managed medically by treating the underlying disease. (See "Clinical features and diagnosis of peripheral lymphedema", section on 'Diagnosis'.)
The following preoperative assessments are performed:
●Assess the degree of lymphedema – The circumference, or preferably the volume, of the affected extremity is compared with the unaffected limb to document the degree of lymphedema. Measurements are taken at fixed intervals at specific anatomic sites (eg, ankle, mid-calf, knee, mid-thigh for lower extremity measurements), although there may be significant interexaminer variability with this approach [20]. Multiple measurements along the extremity can also be used to calculate limb volumes using the truncated cone formula [21]. Volumetric measurement using water displacement is the most accurate assessment tool but is cumbersome to perform and provides variable results when compression garments are used or there are changes in patient activity, and hence is rarely used [22]. Perometry (optoelectronic), a technique that utilizes infrared light, can estimate cross-sectional measurements at multiple intervals and convert this information into limb volume metrics [23]. The degree of lymphedema at other sites is performed by measuring the affected area. In our practice, we measure limb circumference at two points: above and below a major joint in addition to perometry. For example, in assessing upper extremity lymphedema, the circumference is measured 10 cm above and 5 cm below the olecranon on both the affected and unaffected limb.
●Lymphedema stage – The staging system of the International Society of Lymphology (ISL) is the most commonly used system for staging of lymphedema (table 1) [24]. (See "Clinical staging and conservative management of peripheral lymphedema".)
●Venous duplex ultrasound or MR imaging/MR angiogram – For patients who will undergo a physiologic procedure, ultrasound or an magnetic resonance (MR) imaging/MR angiogram is performed to rule out venous thrombosis, venous insufficiency, and/or valvular incompetence [25,26].
OPERATIVE MANAGEMENT — Operative management of lymphedema is categorized into two general approaches: physiologic techniques and reductive techniques. In some cases, physiologic procedures, such as lymph node transplantation or lymphovenous bypass, can be combined with reductive procedures such as liposuction to maximize results.
●Physiologic treatments consist of either lymph node transplantation wherein healthy lymph nodes are harvested from a donor area and microsurgically transplanted to the lymphedematous limb (arterial and venous circulation are reattached) or lymphovenous bypass in which a lymphatic vessel is drained into the venous circulation distal to the area of lymphatic obstruction. Physiologic procedures are used for patients with early-stage lymphedema prior to the deposition of excess fat and extensive tissue fibrosis (ie, International Society of Lymphology [ISL] stage I or II) (table 1). (See 'Physiologic techniques' below.)
●Reductive techniques for lymphedema aim to remove the deposited fibrofatty tissue. These procedures are performed using either liposuction with small cannulas inserted into the subcutaneous space or, less commonly, by radical resection of the excess tissues. Reductive techniques are best used in patients who have failed conservative measures or for patients who present with more advanced lymphedema after fat deposition and tissue fibrosis has occurred (ie, ISL stage II or III (table 1)). (See 'Reductive techniques' below.)
Physiologic techniques — Physiologic techniques create new channels to increase the capacity of the lymphatic system to transport lymph fluid [27]. The fluids trapped in lymphedematous tissues are drained into other lymphatic basins or into the venous circulation. In general, surgical intervention is feasible as long as tissue changes in the affected limb (eg, fibrosis, fat hypertrophy) are not severe. Patients with more advanced lymphedema have been treated with physiologic techniques; however, the results are variable, and only limited numbers of patients have been analyzed [18,19,28-30].
The surgical approaches to accomplish this goal include lymphatic bypass procedures, flap transposition procedures, and vascularized lymph node transfers. The lymphatic bypass procedures are more commonly used of the physiologic techniques. These procedures require a high level of technical skill, and performance of these procedures should be reserved for those surgeons who have expertise in microvascular surgery.
Because secondary lymphedema results in functional impairment and poor cosmesis, attempts have been made to prevent lymphedema by using physiologic procedures at the time of a lymphadenectomy [25,27,31-36]. A prospective trial included 46 patients with breast cancer undergoing an axillary lymphadenectomy with or without a lymphaticovenous anastomosis (lymphatic vessels anastomosed to branches of the axillary vein) performed at the same operative setting. Patients treated with a lymphaticovenous anastomosis (lymphatic vessels anastomosed to branches of the axillary vein) had a lower risk of lymphedema compared with patients without the procedure at 18 months of follow-up (4 versus 30 percent) [34]. The definition of lymphedema was 100 mL volume displacement in this trial, whereas others used 200 mL as the definition of lymphedema. This discrepancy in the definition of lymphedema should be standardized for ease in evaluating various treatment and preventive approaches. Improvements in patient symptoms and volumetric changes are also supported by meta-analyses [30,37].
Lymphatic bypass procedures — Lymphatic bypass procedures are used in the following settings:
●Failure of nonoperative management (see "Clinical staging and conservative management of peripheral lymphedema", section on 'Overview of management')
●Recurrent cellulitis or lymphangitis
●Dissatisfaction with compression garments or impaired quality of life
Relative contraindications to lymphatic bypass procedures include:
●Extensive tissue fibrosis
●Late-stage lymphedema changes
●Venous hypertension
●Recurrent cancer in the ipsilateral extremity or metastatic disease
●Patient noncompliance with compression therapy or postoperative care plans
●Body mass index >35
●Active smoking
Primary or secondary forms of lymphedema can be treated with this approach, although the efficacy of these procedures in primary lymphedema has been debated [4,7,38,39].
The basic principle is that lymphatic vessels distal to the lymphatic obstruction are anastomosed to a nearby vein such that lymphatic fluid is shunted to the venous system and bypasses the area of lymphatic obstruction. As an example, when the lymphatics are transected at the level of the axilla, a bypass is created by connecting the distal lymphatic vessels in the upper arm to a nearby venule.
Methods — There are several methods used to perform a bypass procedure. There is no consensus for the specific type of lymphatic bypass procedure to be performed; these decisions are made based on surgeon preference and experience. To help identify the lymphatic vessels, prior to making an incision, isosulfan blue dye or other dyes such as fluorescein or indocyanine green are injected into the subdermal tissues distal to the operative site [27].
Lymphaticovenous anastomosis — This is a super-microsurgical technique used to anastomose distal subdermal lymphatic vessels and adjacent venules less than 0.8 mm in diameter [27,38,40]. Distal subdermal lymphatics are less affected by lymphedema and are more readily available for a bypass procedure than deeper lymphatic channels. The pressure in the subdermal venules is lower than found in the deeper, larger veins. Hence, there is less venous backflow in the subdermal vessels, and, at least in theory, this should result in a permanent improvement of lymphedema.
Vascularized lymph node transplant — Lymph node transplantation is a procedure that includes the transplantation of healthy lymph nodes en bloc from one nodal basin to the site of obstruction [41-43]. The recipient site can be the site of the prior lymph node excision or a nonanatomic site. Some authors have suggested that a "lymphatic pump" is created when lymph nodes are transferred nonanatomically; however, the mechanisms regulating lymphatic repair in this setting remain unknown [15,42]. The nodes are transplanted using microsurgical techniques with arterial and venous anastomosis at the recipient site; there is usually no lymphatic anastomosis with this approach. A limiting factor of this approach is that lymphedema can develop in the donor extremity. This possibility has led to the use of mesenteric lymph nodes (eg, omentum [44], intestinal mesentery lymph nodes) as an alternative since harvesting lymph nodes from these areas does not result in lymphedema. These issues have to be balanced, however, with potential complications from intra-abdominal procedures (eg, hernia, small bowel obstruction, pancreatic injury). Prospective studies from tertiary cancer centers have shown that these procedures are effective in most carefully selected procedures [28,29].This concept is also supported by systematic reviews that support a beneficial role (ie, decreased limb volume and improved quality of life) for this procedure in the majority of patients [28,30,37,45,46].
Outcomes — Most of the outcome data for physiologic techniques are from retrospective reviews of mostly lymphatic bypass procedures [47]. Prospective studies have also been reported [28,48].
Lymphatic bypass procedures result in highly variable responses, ranging from a complete response to none. The variability of results among the different studies is likely due to a number of factors including differences in assessing volume or circumference, length of follow-up, variable use of postoperative compression garments and/or physical therapy, and the use of nonstandardized or nonvalidated questionnaires for subjective analysis. There has been no standardization of assessing volume of lymphedematous limb, and numerous techniques are reported to approximate volume changes following an operative procedure. Few studies report the use of complimentary techniques (eg, volume measurements and bioimpedance or lymphoscintigraphy) to corroborate measurements. However, these limitations have been addressed in later studies [48]. Other caveats include mixed series of patients, either based upon etiology (eg, primary congenital conditions, or secondary lymphedema following nodal resections, trauma, or filariasis); location of lymphedema (eg, upper or lower extremity); and/or variable criteria for patient selection, selection of procedures, timing of intervention, and identification of suitable lymphatic vessels for bypass surgery.
In spite of these limitations, most authors report improvements in limb volumes (30 to 50 percent decreased), although a few individual patients experienced marked reductions, particularly for the upper extremity [18,26,27,38-40,49,50]. In a study in which lymphovenous bypass was performed in 89 upper extremities and 11 lower extremities, the mean volume differential reductions were significantly better for stage I or II lymphedema compared with stage III or IV lymphedema (61 versus 17 percent at six months) [49]. In a prospective study of 100 consecutive patients undergoing lymphovenous bypass, 96 percent of patients with upper extremity lymphedema had symptomatic improvement (lighter, softer, less painful arms), and 74 percent had quantitative reduction in excess volume [49]. Progression of lymphedema postoperatively is uncommon [18,38,39]. Long-term studies (follow-up >3 years) have shown improvements with bypass procedures are maintained even when the use of a compression garment is discontinued [26,38,40]. A systematic review identified 24 studies evaluating the outcomes of lymphovenous microsurgery [51]. The majority of patients (91.2 percent) reported a subjective improvement. At follow-up, 65 percent of patients discontinued compression garments. Outcomes stratified by type of procedure and anatomic location are given below:
●Excess percent circumference reduction
•All – 48.8 percent (95% CI 42.8-54.8) (11 studies; 131 patients)
•Upper extremity – 46.0 percent (95% CI 39.0-53.0) (7 studies; 90 patients)
•Lower extremity – 57.4 percent (95% CI 44.5-70.3) (4 studies; 34 patients)
•Lymphovenous shunt – 48.9 percent (95% CI 40.7-57.2) (7 studies; 80 patients)
•Lymph node transfer – 48.5 percent (95% CI 35.3-61.6) (4 studies; 51 patients)
●Absolute circumference reduction
•All – 3.31 centimeters (95% CI 2.58-4.04) (11 studies; 138 patients)
•Upper extremity – 2.73 centimeters (95% CI 1.63-3.83) (6 studies; 79 patients)
•Lower extremity – 3.52 centimeters (95% CI 2.28-4.75) (5 studies; 52 patients)
A large retrospective review not included in the above systematic review included approximately 1800 patients undergoing a microsurgical lymphatic-venous bypass procedure [26]. Subjective improvement was reported in 87 percent, objective improvement in 83 percent, and the mean volume reduction was 67 percent. The incidence of cellulitis was decreased by 87 percent following lymphatic bypass procedures. Several other case reports and small series suggest that lymphatic bypass procedures may also be effective in reducing primary and secondary genital lymphedema [26,38,39,52,53]. Prospective studies are required to evaluate the efficacy of lymphatic bypass procedures in this setting.
Three large prospective studies have reported outcomes following vascularized lymph node transfer (VLNT) alone or in combination with lymphovenous bypass (LVB) [28,29,48]. A study of 134 patients who underwent VLNT or VLNT and simultaneous LVB for primary and secondary lymphedema reported significant reductions in limb volume and L-Dex score [28]. The authors reported that 97.1 percent of patients had decreased L-Dex scores, 90.2 percent had decreased limb volume, and 96.2 percent had an improved quality-of-life score using a validated lymphedema questionnaire. When analyzed one and two years postop, this study reported a reduction of 34.7 and 45.7 percent in limb volume, respectively. Similar improvements were noted for L-Dex measurements and quality-of-life outcomes. Another study with 89 patients reported an 85 percent reduction in the rates of recurrent infections in patients treated with vascularized lymph node transplantation [29].
A study of 274 patients who underwent VLNT with or without LVB or LVB alone reported similar outcomes [48]. In this study, nearly 90 percent of patients with upper extremity lymphedema and 60 percent of patients with lower extremity lymphedema had decreased limb volume after surgery. At one and two years after surgery, upper limb volume decreased by 25.7 and 47.4 percent, respectively. Approximately 86 percent of patients with upper extremity lymphedema also had improvements in quality-of-life outcomes as measured by a validated questionnaire. Outcomes for lower extremity lymphedema were also excellent, though less impressive than those noted in patients with upper extremity lymphedema.
The rate of complications following lymphatic bypass procedures is low [7,27,32,38]. Most complications are minor, such as delayed wound healing and lymphatic fistula, and typically improve spontaneously. Postoperative cellulitis is uncommon, most likely due to long-term postoperative antibiotic therapy [32,38]. In the systematic review, surgical site infection occurred in 4.7 percent, lymph leak in 7.7 percent, reexploration was needed for flap congestion in 2.7 percent, and other procedures were performed in 22.6 percent [51].
Reductive techniques — Reductive techniques (also called ablative techniques) remove fibrofatty tissue that has been generated from sustained lymphatic fluid stasis. The reductive procedures are designed to reduce bulk due to lymphedema and are palliative, not curative, for patients with secondary lymphedema (figure 1), but can be curative in patients with localized primary lymphatic malformations. This category of procedures includes direct excision and liposuction. The goals of these techniques are the same as the physiologic techniques: alleviate pain, restore function, reduce swelling, and limit deformity. There are no randomized trials to determine the optimal procedure to treat lymphedema.
Direct excision — A variety of direct excision procedures have been described for the treatment of extremity and genital lymphedema [14,25,34,54-60]. Lymphedematous tissues are excised en bloc, including the skin and soft tissues. The resulting defects are covered either with tissue flaps (Homans, Sistrunk, Thompson procedures) or with skin grafts (Charles procedure).
Radical excision of skin and subcutaneous tissues is generally reserved for patients with very severe disease who have failed all other measures. These procedures are particularly useful in areas where liposuction is not possible (eg, scrotal lymphedema). These procedures are much more invasive than liposuction and may result in substantial morbidity. Nevertheless, severe symptoms in some patients justify this approach [61].
Liposuction — Liposuction is highly effective in the upper extremity. While liposuction has also been reported in a more limited number of patients, the technique also appears to be effective for treatment of lower extremity lymphedema [62-68]. This procedure is relatively simple to perform and has low rates of complications, such as minor infections and paresthesias. Patients treated in this manner may have substantial (>90 percent) long-term decrease in limb volume and improved quality of life if compression garments are worn at all times [69,70]. However, liposuction does not cure the underlying disorder, and noncompliance with the use of compression garments results in reaccumulation of fibrofatty tissues, usually within three to six months.
Lymphedema of the upper arm following breast cancer surgery is associated with a 73 percent increase in adipose tissue by volumetrics; hence, liposuction is an alternative procedure for treating upper extremity lymphedema [62,71]. Liposuction should be used in conjunction with compression garments [63,72-75] and physiologic techniques [76] to treat lymphedema of the upper extremities.
The indications for liposuction for the treatment of upper extremity lymphedema include [73,77]:
●Nonpitting edema that has failed nonoperative management for greater than three months
●Localized fat deposits
●Symptomatic complaints including heaviness, shoulder and/or neck strain or pain
●Functional impairments
●Recurrent infections
The contraindications for liposuction for the treatment of upper-extremity lymphedema include:
●Lymphangiosarcoma of the affected arm
●Open wounds in the lymphedematous arm
●Active smoking
Outcomes for reductive techniques — Most of the outcome data for reductive techniques are from retrospective reviews and small case series and case reports. Liposuction can also be combined with physiologic techniques [78,79].
Direct excision outcomes — Procedures that involve direct excision of lymphedematous tissues are invasive and may result in pain, wound healing complications, infections, lymphatic fistulas, and a suboptimal cosmetic result [14]. Severe wound healing complications may, in some cases, even worsen lymphedema necessitating amputation [80]. The range and rate of complications is not well reported.
The effectiveness of operative management of lymphedema by reductive techniques varies with location and extensiveness of the involved tissues.
Primary lymphedema of extremities and genitalia – Postoperative complications following surgical excision and reconstruction of the extremities include infection, necrosis of the skin graft, poor cosmesis and poor functional results, and foot edema [14]. Complications following surgical excision of lymphedematous tissue and reconstruction of the genitalia include hemorrhage, urethral injury, infection, painful erection, sexual dysfunction, decreased sensation, and scar in suture line [81,82].
The largest single-institution observational study of excision and reconstructive procedures to reduce the bulk of lymphedematous extremity and genital tissue illustrates the effectiveness of this procedure [10]. Quality of life was assessed using the SF-36 questionnaire.
For patients with primary lymphedema of the extremities:
●In the retrospective component of this study, 78 patients had undergone 174 procedures, and 63 percent (49 patients) noted a decrease in limb size. Of these 49 patients, 71 percent would have opted again for the surgery while only 17 percent (5 of 29 with no improvement) would opt for an attempt at a surgical reduction again. Overall, quality of life improved for 23 patients and physical activity improved for 26.
●The prospective component included 10 patients; nine reported a decrease in limb size. Seven of the 10 patients would opt for the reconstructive procedure again. Quality of life improved in seven patients and physical activity improved for four.
For patients with primary lymphedema of the genitalia:
●In the retrospective review of 13 patients (12 male and 1 female) undergoing 32 excision and reconstructive procedures, the overall results were mixed. Quality of life was improved in eight patients, sexual function improved in five, physical activity improved in seven, and 11 stated they would still opt for the surgical attempt to reduce lymphedema. All patients did have a reduction in the size of the genitalia.
●The prospective review included eight patients, all with reduction in size of the genitalia. Quality of life was improved for seven patients, physical activity was improved for six, sexual function was improved for four, and all eight patients would opt again for surgical excision and reconstruction.
The perception that the operative procedure was worthwhile for reduction of lymphedematous tissue of the extremities and/or genitalia was significantly higher in the patients evaluated prospectively compared with patients evaluated retrospectively (83 versus 56 percent). The difference in perception may be secondary to poor recall or a deteriorating quality of life with time. Quality of life was significantly improved for patients undergoing genitalia reduction compared with those undergoing surgery for lymphedematous extremities (71 versus 34 percent).
●Long-term results of extremity lymphedema – A retrospective review of 38 patients with lower extremity lymphedema (primary or secondary) treated by skin and subcutaneous excision found long-lasting decrease in lymphedema and improved function and contour in 30 patients [57]. The average length of follow-up was 14 years (range 3 to 17 years). Five patients had progression of lymphedema following the procedure, and the sixth patient had progression of lymphedema associated with weight gain.
●Localized lesions – The recurrence rate after macroscopically resecting a localized lesion ranges from 15 to 40 percent [83]. Recurrence is hypothesized to result from a regrowth and re-expansion of microscopic, unresected lymphatic channels. Cutaneous vesicles may occur within the surgical scar and can be managed with additional surgical resections and/or sclerotherapy.
Liposuction outcomes — In general, circumferential liposuction for lymphedema is safe with few reported postoperative complications. When complications do occur, they tend to be minor and include occasional paresthesias and minor wound healing issues. The use of tourniquets and tumescent technique significantly decreases blood loss, and patients rarely require transfusions. Liposuction alone provides only temporary and palliative relief of symptoms for mild cases of lymphedema [66].
●Cadaver and imaging studies – Cadaver and imaging studies have demonstrated that liposuction does not disrupt lymphatic vessels (if performed parallel to the limb) and that treatment of lymphedema with liposuction does not decrease the already impaired lymphatic transport capacity of the limb [63,73,74,84-86].
●Upper extremity – The following prospective studies illustrate the results of liposuction for patients with upper arm lymphedema following an axillary dissection for breast cancer:
•A review of 37 patients with unilateral nonpitting stage II lymphedema treated with conservative management for two to four days followed by circumferential suction-assisted liposuction and continued use of compression therapy found the mean reduction in upper arm volumes was 118 percent 12 months after the procedure [75].
•A prospective case matched study (n = 28) found that patients treated with liposuction with continued use of controlled compression therapy had significantly decreased lymphedema compared with patients undergoing controlled compression therapy alone after one year (mean difference = 1000 mL) [72].
•Liposuction combined with physiologic techniques (myocutaneous flap transfer and lymph fascia grafting) in 11 patients with severe lymphedema of the upper extremity resulted in an approximate 10 percent decrease in lymphedema after three years [76]. The mean number of episodes of cellulitis decreased after the surgical procedure compared with preoperative episodes (0.7 versus 6.5 episodes per year).
●Lower extremity – Evidence for efficacy of liposuction for lower extremity lymphedema is less convincing and comprised primarily of case reports and small series [52,59,60,63-66,80]. The initial reports showed only minor improvements with lower extremity liposuction [66,80]. Small series and case studies have found improved cosmetic and functional results with advanced liposuction devices [8,60,65,72,87].
POSTOPERATIVE MANAGEMENT — Patients are admitted for one to five days after surgery for postoperative pain management and wound care [18,26,27]. The limbs are elevated for 24 hours for more limited procedures and up to one week for more extensive procedures [26,27,63].
Compression garments are worn postoperatively to prevent the recurrence of lymphedema following physiologic and reductive procedures [63]. The garment fit is reassessed every four to six months to ensure that adequate compression is maintained. There is no consensus on the start time, length of time to continue wearing garments, or even the type of garment [7,26,27,40]. Typically, however, compression garments are started one week after surgery and used for 6 to 12 months. Most patients continue to wear garments indefinitely, although in some cases these may be discontinued with close follow-up [26]. The use of postoperative compression garments is critical for maintenance of volume reductions in the upper extremity after liposuction. Fluid reaccumulation occurred rapidly without postoperative compression therapy [72]. Compression garments are adjusted as necessary to maintain a tight fit. Data assessing the effectiveness of upper extremity liposuction are based upon small series of patients [72-74].
Antibiotics are typically used for one week postoperatively; however, prolonged use of prophylactic antibiotics may extend from four weeks to one year [7,18,26]. The skin is managed with water-based, gentle moisturizing creams to prevent skin drying or cracking.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lymphedema".)
SUMMARY AND RECOMMENDATIONS
●Lymphedema surgery – Management of primary and secondary lymphedema is typically nonsurgical. However, advances in surgical techniques have shown significant promise for many patients with this disease. The decision to perform an operative procedure to treat lymphedema should be made on a case-by-case basis. (See 'Introduction' above.)
●Indications for surgery – Operative management of lymphedema using physiologic procedures is effective for most patients with stage I, II, and even in some cases stage III lymphedema (table 1). The majority of carefully selected patients who undergo physiologic reconstruction experience decreased limb volume and improved quality of life. Outcomes in the upper extremity tend to be better than those of the lower extremity. Patients with late-stage disease may benefit from reductive procedures or a combination of reductive and physiologic procedures. (See 'Indications for surgery' above.)
●Preoperative evaluation – The preoperative evaluation should include confirmation of etiology of the lymphedema (eg, congenital process or obstructive process versus chronic condition such as heart disease), limb measurements or volumetric assessment to determine degree of lymphedema, and in select cases, venous duplex ultrasound or MR imaging/MR angiogram to assess for valvular competency and/or thrombosis. (See 'Preoperative evaluation' above.)
●Physiologic techniques – The physiologic procedures create new channels to increase the capacity of the lymphatic system to transport lymph fluid. The basic principle is that the lymphatic vessels distal to the lymphatic obstruction are anastomosed to healthy lymphatic vessels or veins proximal to the obstruction. (See 'Physiologic techniques' above.)
●Reductive techniques – Reductive techniques (also called ablative techniques) remove fibrofatty tissue that has been generated from sustained lymphatic fluid stasis. (See 'Reductive techniques' above.)
●Operative management – Physiologic procedures are used for patients with lymphedema prior to development of extensive tissue fibrosis (eg, International Society of Lymphology [ISL] stage I, II, or early stage III) (table 1). We use reductive techniques when patients present with more advanced lymphedema after fat deposition and tissue fibrosis has occurred (eg, late-stage ISL II or ISL III). (See 'Operative management' above.)
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