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Page 2 of 10 Onishi et al. Plast Aesthet Res 2024;11:5 https://dx.doi.org/10.20517/2347-9264.2023.102
Keywords: Lymphedema, complex decongestive therapy, CDT, lymphaticovenular anastomosis, LVA, early
intervention, early surgical indication
INTRODUCTION
Lymphedema is a progressive degenerative disease that can develop in severe cases with massive swelling,
elephantiasis, and repeated infection. Conservative and surgical treatments can be offered to patients with
lymphedema, with conservative treatment usually preceding surgery. CDT, a conservative treatment,
comprises compression therapy, manual lymph drainage, remedial exercises, and skin care. Delay in the
initiation of therapeutic intervention may cause resistance to treatment, which is one of the worst problems
associated with lymphedema.

Over the past decade, LVA has evolved as a surgical treatment for lymphedema. LVA is indicated as an
[1]
adjunct to CDT or when CDT fails to eliminate edema . In general, LVA is best suited for the treatment of
early-stage lymphedema. Campisi et al. reported that lymphatic reconstruction in the early stages of disease,
when tissue changes are minimal, can offer excellent outcomes with complete restoration of lymphatic
[2]
flow . However, the dilemma of LVA becoming less effective arises when long-term CDT is not sufficient
for improvement due to the progression of tissue fibrosis . Therefore, LVA should be performed prior to
[3,4]
[5]
disease progression .
However, the proper timing for LVA after CDT initiation remains unclear. Since the deterioration of
lymphatic function due to tissue fibrosis would not cease even with CDT unless the edema disappeared
completely, we hypothesized that earlier surgical indications should be considered and that early LVA
would improve treatment outcomes.

This study aimed to test this hypothesis by evaluating whether the time from the start of CDT to LVA
affects treatment outcomes, including conservative and surgical treatments.

METHODS
We retrospectively studied 50 consecutive patients with upper extremity lymphedema of the arm with
clinical stage II (International Society of Lymphology ) who underwent LVA between September 2015 and
[1]
November 2022. All of them presented with secondary lymphedema after breast cancer treatment.

The patients were divided into two groups based on the duration of CDT before LVA: patients with
CDT < 6 months (early group) and those with CDT > 6 months (non-early group). We compared the PEV
between the two groups using the propensity score weighting method to adjust for confounding factors.

CDT
Patients were fitted with elastic sleeves of compression classes 1-3, depending on their condition, under the
supervision of lymphedema therapists. Some patients ceased compression therapy or continued light
compression of less than compression class 1 because of intolerance or adverse effects. In this case, the
compression class was classified as Class 0 for analysis. All patients received complex decongestive therapy
(CDT) postoperatively during their hospital stay, which included:

- Compression therapy: Patients were fitted with individualized elastic compression garments before
discharge.