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Minasian et al. Plast Aesthet Res 2022;9:18 https://dx.doi.org/10.20517/2347-9264.2021.128 Page 5 of 9

[30]
[28]
which is less costly, more expeditious, and can provide real-time information . In 2015 Ito et al.
described for the first time the use of ICG lymphography specifically in the diagnosis of PTL.
While lymphoscintigraphy can image deep lymphatics and nodes beyond the depth of ICG (1 to 2 cm), it
has lower sensitivity for superficial lymphatics, which may be focally injured in PTL. The lymphatic vessels
are visualized in real time to characterize patency, pattern, and function. A linear pattern is typically
observed in limbs with preserved lymphatic function as it represents intact, linear lymphatic collectors.
Lymphatic dysfunction is indicated by dermal backflow patterns, including reticular, splash, stardust, and
diffuse patterns [31,32] . Although lymphoscintigraphy has traditionally been considered the gold standard for
the general diagnosis of lymphedema, ICG lymphography has been the primary diagnostic modality in all
PTL studies since its advent, and may represent a new standard.

Early conservative treatment and prevention
Early conservative treatment and prevention of lymphedema must be emphasized before discussing surgical
treatments. Acute lymphatic dysfunction is a normal physiologic reaction after trauma, to a certain extent;
continued lymphatic dysfunction leads to progressive pathology. It is therefore imperative to support
lymphatic return and lymphangiogenesis in this early phase to encourage a return to homeostasis as quickly
and completely as possible.

Initiation of conservative treatment measures early is highly encouraged in patients with orthopedic
traumas utilizing methods such as compression therapy and complete decongestive therapy (CDT) (also
[7]
known as complex physical therapy, or decongestive lymphatic therapy) . CDT consists of a 4-6 week
intensive phase aimed at volume reduction, including wrapping with low-stretch bandages, lymphatic
massage (manual lymphatic drainage), and limb exercises. If symptoms persist, a maintenance phase is
initiated with a fitted compression garment that is worn according to the patient’s needs . These methods
[33]
have shown positive results in significantly reducing lymphedema and limb volumes in orthopedic trauma
patients [7,33] .

Although the long-term effects of prophylactic CDT on lymphedema have not been studied, a 2017 study
used CDT in acute pilon fracture management to improve orthopedic outcomes . Pilon fractures are
[20]
typically high-energy injuries which may require a temporary external fixator until the injured soft tissue
envelope is ready for definitive fixation. Initiating CDT at the time of presentation decreased the median
time to internal fixation by 9 days compared to a group which did not receive CDT, and there was no
difference in wound complications. Similarly, another 2017 study in patients with burn injuries found that
initiating myofascial-manual lymphatic massages early in their treatment algorithm led to increased wound
microcirculation, with decreased rates of hypertrophic scarring and intralesional steroid injections over
time .
[34]

Surgical treatments of PTL fall into two categories: debulking and physiologic.

Debulking procedures
Debulking procedures include excision and liposuction. They are non-specific to the mechanism of injury
and deal with the late consequences of lymphedema. Excisional procedures involve extrafascial
dermolipectomy, typically with local flap closure. Liposuction is less invasive, utilizing cannulas to
effectively remove excess fat without skin resection. Debulking procedures carry a high morbidity and
require lifelong compression . In the modern era of lymphedema surgery, these procedures are rare,
[35]
typically reserved for refractory or end-stage disease states with a focus on salvage to improve