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Page 2 of 11 Friedman et al. Plast Aesthet Res 2022;9:58 https://dx.doi.org/10.20517/2347-9264.2022.77

patients who underwent prior debulking had a slight increase in limb volume without a change in hours of
compression, and demonstrated improvements in quality-of-life scores in nearly all subdomains. Overall, 17% of
patients discontinued compression therapy entirely. Improvement in extremity edema was present in 83% of
postoperative MRIs.

Conclusion: VLNT had varying effects on limb measurements while reliably improving quality-of-life and allowing
for the potential of discontinuing compression. Utilizing a staged approach wherein debulking is performed upfront
may be particularly beneficial for patients with fat-dominant disease.

Keywords: Lymphedema, vascularized lymph node transplant, lymphatic surgery

INTRODUCTION
Upper extremity lymphedema is a debilitating and progressive disease with a substantial impact on patient
[1-4]
quality of life . Conservative therapies such as decongestive physiotherapy and compression garments are
aimed at the palliation of symptoms and prevention of disease progression, but in certain cases, surgical
interventions are deemed necessary. An evolving body of evidence demonstrates the beneficial effects of
vascularized lymph node transplant (VLNT) on patient quality of life, occurrence of infection, and limb
[5-8]
volumes in patients with extremity lymphedema . Given its efficacy, VLNT has become a mainstay of
treatment for lymphedema and expanding recognition has even led to the creation of a medical policy for
[9]
insurance coverage for lymphatic surgery, including VLNT . As VLNT has become increasingly adopted by
lymphatic centers, programs have developed a staged approach in which VLNT and debulking lipectomy
are performed sequentially in efforts to optimize patient outcomes [10-15] . However, because VLNT and
debulking greatly differ in their underlying mechanisms and postoperative requirements for compression
therapy, the timing and relation of these procedures require careful consideration. To date, a unified
consensus has yet to be established on time intervals or the sequence of staged VLNT in relation to
debulking lipectomy .
[16]

Multiple studies have described a staged approach to treat upper extremity lymphedema. Schaverien et al.
suggested performing suction-assisted liposuction after physiologic operations to remove excess fatty tissue
[12]
that VLNT was unable to address . In a similar manner, Nicoli et al. performed laser-assisted liposuction
one to three months after VLNT . Similarly, Agko et al. performed liposuction six to eight months after
[11]
VLNT . Cheng et al. proposed using liposuction after VLNT for patients with lipodystrophy in the
[13]
proximal limb to decrease the burden of excess fluid on the lymph node flap . Conversely, Cook et al.
[10]
performed VLNT ten weeks after debulking lipectomy . Similarly, Granzow et al. reported first performing
[15]
debulking followed by VLNT six to twelve months later to improve functional lymphatic drainage, reduce
ongoing fluid accumulation, and decrease the need for compression therapy . Interestingly, these
[14]
procedures have also been used simultaneously to treat upper extremity lymphedema .
[17]
At our multi-disciplinary lymphatic center, we have implemented a VLNT program and standardized
treatment approach based on patient classification as fat- or fluid-dominant lymphedema phenotype [18-20] . At
our center, a debulking lipectomy is consistently performed upfront for patients with a fat-dominant
phenotype, followed by a staged VLNT one to two years postoperatively. Patients with a fluid-dominant
phenotype are offered VLNT without undergoing a prior debulking procedure. In the current study, we aim
to describe our institutional experience with VLNT for the treatment of upper extremity lymphedema and
report our postoperative outcomes, including limb volume measurements in the setting of hours of
compression therapy per week, radiographic changes, and quality of life. In addition, we describe our
management protocol when a combination of VLNT and debulking lipectomy is required for patients with