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Page 2 of 9 Liang et al. Plast Aesthet Res 2019;6:23 I http://dx.doi.org/10.20517/2347-9264.2019.33

untreated, could give rise to disabling physical and psychosocial complications in the long run. Currently,
the attention on lymphedema is far from enough resulting in delayed initial evaluation and treatment and
poor prognosis. There is no existing cure for lymphedema and current therapies mainly focus on limiting
progression and preventing severe complications. Early intervention is proved to be the root of improved
prognosis thus highlighting the significance of early detection. Various new and effective diagnostic
methods emerge over the years but there are still no standard guidelines for lymphedema diagnosis, let
alone early detection. The aim of this review is to provide an objective appraisal of current diagnostic
methods, focusing on their respective advantages and weaknesses, and hopefully shed some lights on
developing a practical diagnosis modality beneficial to early detection and clinical decision making of
lymphedema.

HISTORY AND MANIFESTATIONS
For suspected lymphedema patients, history and manifestations are invaluable and indispensable. The
onset of swelling could be diagnostic for lymphedema. Extremity swelling present for less than 3 months or
forms soon after lymphatic injury is not consistent with lymphedema. It’s very common to see pediatrics-
[2]
onset in primary lymphedema, boys’ present in infancy and girls’ during adolescence . For secondary
[2]
lymphedema, travels to parasite-endemic area (filariasis), obesity (BMI > 50) , radical cancer treatment for
breast, gynaecological, head and neck cancer (nodes dissection, chemotherapy and radiotherapy), nodes
biopsy can be crucial risk factors, while family history is more frequently seen in primary lymphedema.
Docetaxel-based chemotherapy has been shown to increase the incidence of breast cancer treatment related
[3]
lymphedema .
Complaints of extremity heaviness and fatigue could be the main manifestation of early stage lymphedema.
As it progresses, visible limb swelling and enlargement of circumference take place. Different tools are
utilized to assess extremity volume/circumference. Tape measurement is applying a flexible and non-stretch
tape to assess the girth of edematous limb at certain points following different protocols. Absolute values
are usually converted into volumes using respective mathematical formulae visualizing the limb as a series
[4]
of truncated cones, cylinders and trapezoidal solids . Absolute excess volume (affected limb-unaffected
limb), excess volume in percent [(affected limb-unaffected limb)/unaffected limb × 100], relative value in
percent (affected limb/unaffected limb × 100) and affected leg volume divided by BMI are useful indices in
unilateral lymphedema diagnosis. Girth assessment is the most fundamental and commonly used method
for its feasibility and economical advantages but is limited by its high inter- and intra-observer variability
and poor reproducibility. In water plethysmography, the amount of water displaced after immersing the
limb of interest into a water tank equals the extremity volume. It’s considered as the criterion standard
for lymphedema diagnosis but also deemed impractical in clinical setting for its cumbersome set-up,
patient-unfriendly measurement protocol and extra contraindications concerning water. Extremity volume
difference > 10%, volume change > 200 mL or circumference change > 2 cm at one certain point are deemed
[5]
diagnostic, though there are still no standardized cut-off points among health practioners .
A square frame emitting infrared lights is used in perometry. As the frame moves along the limb,
information of the interrupted lights is converted into coordinates to reconstruct a 3D model and
[6]
automatically calculate the volume . Similarly, three-dimensional imaging systems such as the VECTRA
XT surface photo imaging system (Canfield Imaging Systems, Fairfield, NJ) are developed to capture 360°
digital image data of the edematous extremity. Absolute values or image color change by photographs
contrast presents volume changes before and after treatment, thus making VECTRA valuable in both
[7]
diagnosis and monitoring . VECTRA, as a relatively new technique provides high resolution images and
[7,8]
might be applied to the whole body, facial and pubic region included . However, both three-dimensional
photography and perometry are costly and not obtainable in every clinic.