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

Despite minimal changes in limb volume and L-Dex scores among both groups at twelve months post-
VLNT, MRI studies obtained at this same time point demonstrated noticeable improvement in edema in
83% (n = 10) and confirmed lymph node flap viability in 92% (n = 11) of patients that underwent
postoperative imaging. The radiologic findings in the current study highlight the utility of MRI as an
additional modality for measuring subclinical changes in interstitial fluid and additionally underscore the
importance of applying a holistic, multi-disciplinary approach for monitoring patients after VLNT. Notably,
individual transferred lymph nodes were only visualized on MRI in two patients from the entire cohort,
although flap viability was confirmed by MRI in 92%. As the presence and quantity of lymph nodes within
the flap were confirmed on intraoperative ultrasound at the time of VLNT, we suspect that our MRIs at the
twelve-month time point lack the sensitivity to detect these nodes postoperatively.

A reduction in the median episodes of cellulitis per year was observed in both the fat- and fluid-dominant
groups. Only one patient in the fat-dominant cohort had a postoperative case of cellulitis within the twelve
months following VLNT, whereas three patients in the fluid-dominant cohort had episodes of cellulitis
following VLNT. It is possible that the significantly better outcome that was observed in the fat-dominant
patients could be related to the debulking that they previously underwent. This difference may underscore
the importance of debulking patients with fat-dominant disease prior to performing VLNT, as debulking
targets the removal of fibroadipose tissue, a component that has been established to drive inflammation and
clinical progression [37-39] . Mitigation of underlying inflammatory processes is likely related to a decrease in
postoperative cellulitis occurrences in patients who underwent prior debulking procedures.

This study is not without limitations. While the vast majority of VLNT procedures utilized a flow-through
technique for flap anastomosis, in three patients, this technique was not performed. While we believe the
[23]
flow-through technique is advantageous for enhancing flap hemodynamics , it remains uncertain how
other techniques used may affect outcomes. Additionally, as data collection was dependent on patient
surveillance visits, certain measures were missing from follow-up. Half the study period occurred as we
were initiating our center and the second half occurred during the start of the COVID-19 pandemic, during
which lymphatic operations and follow-up visits were frequently canceled or rescheduled. This hindered
our ability to obtain a complete dataset. Lastly, the sample size was underpowered and data were analyzed
descriptively.

Overall, VLNT had varying effects on limb measurements while reliably improving patient quality of life
scores. Importantly, VLNT potentially allows patients to reduce or discontinue compression therapy
entirely, and in our overall cohort, three patients were able to achieve this goal at twelve months
postoperatively. Furthermore, postoperative radiologic improvement in extremity edema and confirmed
flap viability were evident among the vast majority of the cohort. Utilizing a staged approach in which
debulking is performed prior to VLNT may be particularly useful in alleviating disease in patients with a fat-
dominant phenotype, as both fat and fluid components are targeted. This increases the possibility that a
patient in this cohort may reduce or discontinue compression therapy, a result that would not have been
achieved from debulking alone. This study provides further evidence for VLNT as an effective treatment for
lymphedema and underscores the need for consensus on sequence and timing when staging physiologic and
debulking procedures for the treatment of lymphedema.

DECLARATIONS
Authors’ contributions
Made substantial contributions to completion or design of the work: Friedman R, Morgenstern M, Bustos
VP, Singhal D, Fleishman A, Tsai LL, Critchlow JF