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Park et al. Plast Aesthet Res 2023;10:40 https://dx.doi.org/10.20517/2347-9264.2022.98 Page 7 of 10

Interestingly, limb volume change showed V-shaped improvements where the volume reduction effect
diminished during postoperative six months through 12 months and then improved dramatically at 24
months follow-up. This can be explained by the initial benefit of LVA immediately postoperatively due to
the diversion of the excess lymphatic fluid through the bypass. The effects of VLNT were evident at 24
months of follow-up after sufficient lymphangiogenesis.

It is important to note that both limb volume reduction and LLIS scores were best at 2~3-year follow-ups,
even more so than at 3-month postoperative follow-ups, where the benefit of LVA would be in effect. This
study provides evidence that combined LVA and VLNT may provide better outcomes than each operation
on its own.

DISCUSSION
While the exact mechanism behind the synergistic effects of LVA and VLNT has not been elucidated,
several possible explanations exist. First, the initial volume reduction induced by LVA can improve patient
compliance. In a study by Yang et al., liposuction allows chronic patients to apply compression garments
[35]
more easily, improving patients' compliance with complete decongestive therapy .
Secondly, LVA's physiological changes can improve the effectiveness of VLNT. Histological evidence shows
decreased hyperkeratosis, local inflammation, and dermal fibrosis . As Rustad and Chang pointed out,
[36]
LVA can reduce local tissue inflammation and promote better lymphangiogenesis from the VLNT .
[37]
Di Taranto et al. previously compared VLNT alone with LVA and VLNT in patients with secondary lower
limb lymphedemas . In all the patients, suction-assisted lipectomy (SAL) was also performed two weeks
[15]
after the initial lymphedema operation. Both groups showed a significant reduction in limb volume and skin
tonicity. Although not statistically significant due to the small sample size (P-value of 0.08), the addition of
LVA showed greater volume reduction above the knee.

In their preliminary report of 12 patients who underwent simultaneous supraclavicular VLNT and LVA for
lower limb lymphedemas, Chung et al. showed a significant reduction in both mean limb circumferences
and lower extremity lymphedema index . These findings can also be applied to BCRL patients.
[38]

Most BCRL patients have undergone axillary lymph node dissection, which causes fibrosis of the axilla.
Postmastectomy radiotherapy (PMRT) can further aggravate this fibrosis. In addition to worsening
[39]
lymphedema by constricting the drainage , fibrosis can cause neurologic symptoms such as tingling
sensations and neuropathic pain for the patients. While its definitive effect is still debated, releasing the scar
tissue and providing new fresh tissue (VLNT) can provide physiological benefits [11,17,40] .

Furthermore, LVA and VLNT have different mechanisms for improving lymphedema. LVA forms a shunt
between a functioning lymphatic vessel and a vein, allowing drainage of lymphatic fluid into the venous
[41]
system . On the other hand, VLNT's mechanism is thought to be multifactorial. VLNT acts as a "pump"
for lymphatic fluid from the limb to drain through the VLNT after lymphangiogenesis occurs into the
surrounding tissue . Because of the difference in the underlying mechanism, LVA's effect is evident almost
[42]
immediately after the operation, while VLNT shows a delayed effect after successful lymphangiogenesis into
the surrounding tissue. By combining these two techniques, synergistic benefits can be gained while
overcoming one of the drawbacks of VLNT, the absence of immediate effect, which can deter patient
compliance.