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Guiotto et al. Plast Aesthet Res 2023;10:26 https://dx.doi.org/10.20517/2347-9264.2023.15 Page 9 of 14

While ablative surgeries aim to remove tissue excess and close the residual defect, microsurgery has the
purpose to re-establish lymphatic drainage, bypassing the blockage (lymphatic venous anastomosis (LVA),
multiple lymphatic-venous anastomosis (MLVA), or stimulating lymphaticogenesis [vascularised lymph
[20]
nodes transfer (VLNT)] .

These microsurgical techniques became more popular in the last decade with promising outcomes,
particularly for treating lower limb lymphoedema. However, no defined decision management has been
established yet for GL [21-24] .

In our experience, surgical indication for GL generally includes an insufficient volume reduction and the
ineffectiveness of conservative methods, recurrent episodes of lymphangitis/erysipelas, no responsive pain,
heaviness or discomfort to CDT, and finally urinary and sexual dysfunction [18,20] .

The quantification of GL is predominately based on preoperative lymphoscintigraphy, especially for
assessing the transport index (TI) according to Kleinhans , while for the GL staging, we usually adopt the
[25]
ISL classification.

According to the ISL, lymphoedema stage is determined not only by the volume (partially influenced by the
patient’s BMI), but also by the quality/changes of the skin/soft tissue, the level of fibrosis, the functional
lymph transport of the district (genital area, lower limbs, etc.).

Overall, in this study, although genital lymphoedema can be associated with an overweight patient
condition, the treatment choice depends on the global lymphoedema stage.

Lymphoscintigraphy consents to the visualisation of the lymphatic flux in both deep and superficial
lymphatic vessels, and the obstruction level, and also permits measurements of the transport index (TI) . A
[25]
score lower than 10 means a normal TI, and a score equal to or higher than 10 signifies a pathological TI.
Scores are made bilaterally, even in the cases of unilateral swelling . Unfortunately, the postoperative
[26]
lymphoscintigraphic comparison has not been homogenously implemented between all three centers.

Independently of the surgical approach, all our patients were followed by trained physiotherapists for
regular bandages and complete multimodal physical functional therapy. Compared to preoperative
conditions, patients manifested a significant reduction in scrotal painful oedema, infections, and
lymphorrhea. All patients continue to apply conservative treatments such as compressive garments, but
overall reduce the frequency of physiotherapy sessions.

Debulking surgery
Surgical debulking is followed by skin grafting/flap coverage depending on defect size and location [27,28] .
Most patients treated with this approach were the most severe cases of GL (stage IIb-III) with
lymphoscintigraphic images compatible with scrotal dermal backflow and slow or absent superficial/deep
lymphatic flow.

Despite the obvious immediate improvement after surgical resection of oedematous tissue, generally
patients presented a higher recurrence rate compared to derivative surgery or a combination of reductive
and microsurgical treatment [7,29] . This is related to the GL aetiology, which is not solved with a debulking
procedure, as it is merely a palliative procedure. The persistent lymphatic obstruction, or destruction
[30]
proximally, is generally the reason for the lymphoedema recurrency or its complications .