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Page 4 of 9 Onishi et al. Plast Aesthet Res 2021;8:50 https://dx.doi.org/10.20517/2347-9264.2021.75

categorical data. To assess the significance of volume reduction after treatment, LEL indices between 1
month preoperatively and 1 year postoperatively were compared using the paired Wilcoxon rank sum test
for both matched groups. Likewise, edema reduction was defined as the difference in LEL indices between 1
month before and 1 year after LVA surgery and was compared between the two groups using the Wilcoxon
rank sum test. All tests were two-tailed, and statistical significance was defined as P < 0.05. All analyses were
[16]
performed using EZR , a graphical user interface software for R (version 3.6.3; R Foundation for Statistical
Computing, Vienna, Austria).

RESULTS
The baseline characteristics and demographics of patients who underwent LVA surgery with and without
perioperative reduction therapy are summarized in Table 1. The current study included 116 patients with
lower extremity lymphedema. Six patients (5%) presented with primary lymphedema and 110 patients
(95%) developed lymphedema secondary to cancer therapy. Among these, 65 patients (56%) were treated
with LVA surgery without perioperative reduction therapy, whereas 51 patients (44%) were treated with
LVA followed by perioperative reduction therapy.

Overall, there was a significant difference between the two unmatched groups at the distribution in clinical
stage (P = 0.03). That is, all the patient in PORT group were classified as stage II, whereas control group
included 6 (9.2%) and 1 (1.5%) patients of stage I and III, respectively. Other covariates, including age, BMI,
sex, etiology, institute of treatment, LEL index at the first visit, previous radiotherapy/LVA, and duration of
preoperative conservative therapy, showed a slight difference between the two groups, although this was not
statistically significant.

After propensity score matching, patients in each group were evenly matched for age, BMI, sex, etiology,
clinical stage, institute of treatment, LEL index at the first visit, previous radiotherapy/LVA, and duration of
preoperative conservative therapy. PORT group demonstrated significantly lower LEL indices at 1 year
postoperatively than at 1 month preoperatively (P < 0.001), whereas the control group did not (P = 0.14).
Patients who underwent PORT had a significantly higher reduction in LEL index than those in the control
group (14.7 vs. 6.7; P = 0.03) [Table 2]. We did not experience any unfavorable complications in our cohort
related to PORT, including hemorrhage, wound infection, and wound dehiscence.

Case presentation
A 63-year-old female patient had bilateral lower extremity lymphedema secondary to cervical cancer and
had undergone over 5 years of compression therapy using elastic stockings [Figure 1A]. Preoperative
lymphoscintigraphy showed extensive dermal backflow in the right lower leg, right thigh, and left thigh
[Figure 2A]. The patient underwent LVA surgery followed by PORT of the right lower extremity during her
7-day hospital stay. After she was discharged from the hospital, compression therapy with elastic stockings
was continued. A remarkable improvement in the LEL index, by up to 20.9, was noticeable 1 year
postoperatively [Figure 1B]. Lymphoscintigraphy at 6 months after treatment demonstrated a significant
reduction in dermal backflow in the right lower extremity [Figure 2B].

DISCUSSION
This study demonstrated that the treatment efficacy of LVA surgery followed by PORT was significantly
higher than that of LVA with no combined therapy in the early postoperative period.