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Another question to consider is the future roles of old debulking surgeries, such as the Charles procedure, in
more advanced BCRL patients. As mentioned previously, performing SAL in conjunction with other
methods, such as LVA and VLNT, can improve patient compliance by reducing the volume immediately
[16]
after the operation . Reducing the volume can ease the elastic stocking application process and motivate
patients to comply with CDT. While radical procedures have been considered the last resort for severe
cases, they may also be performed in combination with LVA and VLNT either simultaneously or in stages
as technology and techniques advance.

As emphasized in this study, patients may have different clinical situations when considering LVA
combined with VLNTs for patients in advanced BCRL. Patients may or may not want breast reconstruction,
and each patient's degree of axillary fibrosis and contracture can differ. In addition, the availability of
laparoscopic or robotic surgery for omental flap harvest in the institution performing the surgery may vary.
Considering these various clinical situations, the optimal surgical method should consider the patient's
lymphedema pattern, severity, and clinical needs.

CONCLUSION
A further randomized clinical trial is needed to compare the benefits and disadvantages of combined
procedures. However, if combined procedures can be performed without increasing overall operation time
and complication rates, current evidence does not seem to direct the surgeons away from these combined
procedures.

DECLARATIONS
Authors' contributions
Made substantial contributions to the conception and design of the study and performed data analysis and
interpretation: Park Jh, Myung Y

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.

Ethical approval and consent to participate
Not applicable. Informed consent was obtained from the patients involved in this manuscript.

Consent for publication
Written informed consent for the publication of the images has been obtained.

Copyright
© The Author(s) 2023.

REFERENCES
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lymphedema in the upper extremities. J Reconstr Microsurg 2000;16:437-42. DOI PubMed
2. Yamamoto T, Koshima I. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity