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Page 8 of 12 Jabbour et al. Plast Aesthet Res 2021;8:43 https://dx.doi.org/10.20517/2347-9264.2021.59

the transferred lymph nodes begin to function. Others who have employed the combined approach have
also demonstrated similar benefits with this strategy for the treatment of lymphedema [49,50] .

Lymphatic vessel transfer
Another technique that was previously described as a transfer of a soft tissue flap that included lymphatic
vessels is beginning to witness a resurgence of this approach. The lymphatic interpositional flap transfer
functions based on transferring and orienting a soft tissue flap that allows for the existing lymphatic
channels in the affected limb to inosculate with the lymphatic vessel transfer allowing the fluid drainage and
absorption from the extremity. Early reports of this approach were performed as a means of preventing
lymphedema by restoring lymphatic flow from the injured leg [51,52] . However, the concept has now grown as
a therapeutic strategy to treat patients with lymphedema, and we await reports of early outcomes to evaluate
its true efficacy.

DISCUSSION
The field of lymphedema surgery has undergone tremendous advancements in a remarkably short period of
time since its resurrection in the modern age of super microsurgery with the introduction of ICG imaging,
specially designed instruments, and advanced microscopes with superior magnification and optics. With the
growing number of surgeons interested in lymphedema surgery, it is becoming a critical component of
microsurgery fellowship programs to provide broad and in-depth exposure to the techniques that will allow
the future of the field to continue to grow and evolve. After providing budding microsurgeons with the
techniques and premises in lymphedema, innovative ideas expanding on or perhaps even challenging the
established concepts are sure to arise. Since the earliest reports of lymphedema surgery at our institution,
[53]
the foundation was established to innovate new approaches to treat lymphedema . The description of the
laparoscopic omental harvest defined the basis for one of the most popular vascularized lymph node donor
[40]
sites currently employed at many institutions . The expansion of the BRILIANT approach stems from the
work of pioneers in the field [54,55] . While many lymphedema surgeons have their preferred donor site, there
is no single optimal donor site, and the decision for selecting one versus another is based on patient risk
profiles and availability of donor sites and surgeon experience and preference. We offer patients the entire
spectrum of VLNT donor sites and present a transparent description of the advantages and potential
complications and risks associated with each site so the patient can make the best decision .
[16]

As techniques, technology, and experience continue to grow and evolve, the limits of lymphedema surgery
have not yet been defined. Novel approaches to treat more extensive lymphedema continue to emerge, and
more and more patients have now been considered candidates for lymphedema surgery compared to
previously [25,56] . Despite these advancements, some patients are still relegated to debulking procedures which
are still a critical component in the algorithm to surgical treatment of lymphedema [57,58] . Given that
lymphedema has both a fluid component as well as a fat component, often debulking operations are
necessary to achieve the most optimal result. In the hands of some skilled surgeons, long-term efficacy and
improvement with lymphedema have been achieved with debulking procedures alone [59-61] . Therefore, the
authors tend to supplement the physiologic procedures with a debulking operation, typically 6-12 months
following the LVB and VLNT.

While many of these strategies are designed to improve patient symptoms and quality of life suffering from
lymphedema, there is no cure for lymphedema, in our opinion. While volumetric measurements may
normalize and the need for complete decongestive therapy eliminated, the drainage of the limb is not fully
restored, and any injury or infection can lead to recurrence. However, there are novel concepts that are
striving to achieve a cure. One future treatment strategy aims to use the concept of a free flap as a vector for