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Raman et al. Plast Aesthet Res 2023;10:6 https://dx.doi.org/10.20517/2347-9264.2022.62 Page 5 of 16

Table 1. Article characteristics
Characteristic Number of articles, n (%)
Retrospective 42 (63.6)
Prospective 24 (36.4)
Levels of evidence
I 0 (0)
II 24 (36.4)
III 41 (62.1)
IV 1 (1.5)
V 0 (0)
Staging scale
ISL 30 (45.5)
Cheng 8 (12.1)
Taiwan 1 (1.5)
MD anderson scale 2 (3.0)
Campisi 1 (1.5)
ICGN 1 (1.5)
Unspecified 2 (3.0)
None 22 (33.3)

ISL: International society of lymphology; ICGN: indocyanine green. † Unspecified donor site in the neck region.

lymphedema than lower extremity lymphedema. On average, patients followed up for 24.1 ± 16.4 months
after surgery [Table 2].

Clinical outcomes
Overall, 47 out of 66 (71.2%) studies reported differences in limb circumference or volume postoperatively
[Table 1 and Supplementary Table 2]. The vast majority (95.7%) of these investigations reported improved
limb circumference/volume following VLNT, while two studies found no significant improvement. These 2
studies involved groin, supraclavicular, and lateral thoracic donor sites [Supplementary Table 3]. The
remaining donor sites reported improvements in limb size differences within all studies evaluating this
outcome [Supplementary Table 3].

Fourteen (21.2%) studies reported reduction or discontinuation of conservative therapy following the
VLNT. In all studies assessing this outcome, a reduction or discontinuation of conservative therapy was
observed postoperatively [Supplementary Table 3].

Twenty-four (36.4%) studies reported preoperative and postoperative episodes of cellulitis. The overall
reduction of infection was 76.6% ± 1.4 % postoperatively [Table 3].

Intra-abdominal flaps had a more significant reduction in postoperative infectious episodes than extra-
abdominal flaps, 88.2% ± 2.8 % vs. 79.9% ± 2.2%, respectively (P = 0.009). There was no significant difference
in infection rate reduction for patients who underwent VLNT for treatment of upper limb lymphedema and
lower limb lymphedema, 86.8% ± 1.6% vs. 73.3% ± 2.5 %, respectively (P = 0.81). Additionally, differences in
infection rate reduction between the different donor sites were not significant (P = 0.12) [Figure 2]. While
there was a 100% infection reduction rate for ileocecal and jejunal mesenteric flaps, there were only two
investigations involving ileocecal VLNT and one involving jejunal mesenteric VLNT. Otherwise, the
greatest infection rate reduction was found in omental VLNT (87.9% ± 2.9 %), while the smallest decrease in