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Page 8 of 11 Friedman et al. Plast Aesthet Res 2022;9:58 https://dx.doi.org/10.20517/2347-9264.2022.77

notable change in compression. We have previously reported that fat-dominant patients undergo significant
[19]
improvements in limb volume following debulking ; therefore, we suspect that a ceiling effect may have
occurred, indicating that a prior debulking is particularly beneficial for optimizing limb volume in patients
with fat-dominant disease. While debulking is targeted at the removal of the fibroadipose tissue, it does not
correct the underlying pathophysiologic mechanism of disease, and therefore, patients continue to require
lifelong use of compression garments to manage interstitial fluid accumulation [20,28,29] . With longer-term
follow-up, we anticipate progressively reducing hours in compression while maintaining optimum limb
volume in those debulking patients who underwent staged VLNT. Therefore, we propose the sequence of
debulking at least one year prior to VLNT for patients with a fat-dominant phenotype to mitigate disease
progression and optimize arm volumes prior to VLNT, as VLNT does not typically result in a total
reduction of relative limb volume [8,30,31] . Moreover, we remain concerned that performing debulking after
VLNT may put the transplanted lymph node flap at risk and potentially damage newly formed lymphatic
networks [32-34] .

Adequate compression therapy has a profound impact on limb volume; thus, it is important to present and
interpret changes in limb volume in the context of compression use. In the current study, a reduction in the
number of hours spent in compression per week was observed in fluid-dominant patients following VLNT,
alongside a reduction in limb volume. The overall hours spent in compression for those with fat-dominant
disease was unchanged at one year postoperatively, alongside a minimal increase in limb volume. Three
patients in the entire cohort did not require any compression therapy after one year. It is particularly
important to report changes in limb volume measurements alongside the time patients spend wearing
compression garments. Most prior studies that present patient outcomes following VLNT report
compression use as a binary variable (either patients are or are not using compression therapy) or as the
percentage of patients able to discontinue compression entirely. Quantifying the extent to which patients
use compression garments is valuable, as garments can be burdensome in terms of convenience, time
expenditure, cost, and comfort. Additionally, patients presenting to our lymphatic surgery clinic often
indicate a decrease in disease management as a treatment goal; therefore, delineating the amount of time
[18]
spent in compression can help determine whether this goal is being met . Additionally, objective measures
of limb volume such as RVC and L-Dex can change dramatically over short intervals, so it is useful to
interpret these changes in the context of compression garment use. Finally, we note that postoperative
changes in limb volume are relatively small in our study. We believe this is closely linked to the fact that our
lymphatic surgery program works in tandem with physical therapists in our clinic. Therefore, our patients
are already optimized from a limb volume perspective before going to the operating room for VLNT. In this
context, hours in compression is an even more important outcome measure.

Improvements in all LYMQOL subdomains were observed in patients with fluid-dominant disease.
Similarly, improvements in LYMQOL scores across all subdomains were seen in the fat-dominant group,
except for the appearance subdomain, which remained unchanged. The appearance subdomain scores
remained relatively constant in patients with fat-dominant disease, possibly because individuals in this
cohort likely experienced a dramatic change in their limb volumes following debulking, leading to a major
improvement in their perceived appearance that would have occurred prior to VLNT. Overall, the findings
from the current study are in concordance with other studies that have reported positive effects of VLNT on
patient quality of life [10,35,36] . However, in the current study, the beneficial effects may be less directly related
to changes in limb volumes and may be more heavily influenced by the reduction in time spent wearing
compression garments. Therefore, assessing patient-centered outcomes such as LYMQOL is imperative in
gauging whether treatment goals are being met and assessing the efficacy of VLNT procedures.