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Page 8 of 18 Laustsen-Kiel et al. Plast Aesthet Res 2024;11:17 https://dx.doi.org/10.20517/2347-9264.2024.32

However, the study did not specify the arm symptoms present in the different groups, precluding an
opportunity to report the incidence of BCRL.

Two studies reported a relatively high incidence of BCRL for patients treated with breast reconstruction
compared to other studies [70,142] . However, the study with the highest BCRL incidence after breast
reconstruction only included five patients with breast reconstruction and concluded there was no significant
[70]
difference in the effect of surgery type on BCRL . The other study included 72 patients but did not
describe how or when they measured lymphedema - only that the diagnosis was based on physical
[142]
[142]
examination . Unfortunately, this lack of description of measurement methods or diagnostic criteria was
observed for some of the studies [131,138] . Diagnostic methods used in other studies were
circumference [126,136,143] , bioimpedance spectroscopy (BIS) [70,134,141] , and perometry [129,140] . Several studies also
included patient symptoms in evaluating whether lymphedema was present [128,132,135] .

A study from 2017 investigated the effect of IBR on lymphedema and further elaborated on the difference
between implant-based and autologous IBRs . Here, the researchers found a statistically lower rate of
[144]
BCRL for immediate DIEP and LD flaps compared to patients receiving implant-based breast
reconstruction despite a higher rate of ALND in the LD flap group. Women in the autologous group had a
higher BMI, had more radiotherapy preoperatively, and were older, which all are demographic factors
associated with an increased risk of BCRL. When correlating to ALND, the researchers found that
autologous breast reconstruction significantly reduced BCRL for patients who had ALND and received
chemotherapy. Only one study reported the effect of oncoplastic surgery, where no arm lymphedema was
[141]
found .
EVOLVING TREATMENT APPROACHES FOR LYMPHEDEMA
Early detection and management of lymphedema, clinical as well as subclinical, at an early stage, is
imperative in preventing its advancement to a chronic stage. However, this narrative review has unveiled
the disparity among criteria used to diagnose lymphedema, leading to delayed detection and subsequent
treatment initiation. Clinicians lack superior treatment options considering patient preferences, resources,
and clinical settings. The following subsections address the currently available treatment modalities and
emerging treatment strategies.

Decongestive techniques
Treatment of subclinical lymphedema with compression garments, as seen in Figure 2, was shown to be
[145]
effective . Compression garments are often combined with manual lymphatic drainage (MLD),
therapeutic exercise, moisturizing skincare, and patient education; This combination of five modalities is
referred to as complex decongestive physical therapy . Several randomized trials and systematic reviews
[146]
with meta-analyses found that manual lymphatic drainage, a compression pump, or exercise do not lead to
volume reduction [147-150] . Conversely, several systematic reviews with meta-analyses present significant
volumetric changes due to MLD [151,152] , complex physical/decongestive therapy (CDT) , compression
[153]
pump , and laser therapy . In addition, a systematic Cochrane review found MLD to be safe and
[155]
[154]
[156]
beneficial to compression bandaging for volume reduction in patients with mild-to-moderate BCRL .
Rafn et al. presented a statistically significant effect in volume reduction across all interventions (MLD,
compression pump, exercise, kinesio taping, laser, and acupuncture) compared to any control. Notably,
most of the systematic reviews had chosen volumetric changes as their primary outcome and not the most
frequently reported arm symptom associated with BCRL, namely pain. However, no systematic reviews and
[159]
meta-analyses found an effect of either MLD [153,157] , laser therapy [152,155,157,158] , CDT , kinesio taping , or
[153]