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Raman et al. Plast Aesthet Res 2023;10:6 https://dx.doi.org/10.20517/2347-9264.2022.62 Page 11 of 16

Figure 3. Forest plot depicting the average improvement in overall LYMQOL scores for each of these studies. Studies that did not report
the standard deviations of the scores were excluded from this plot.

DISCUSSION
Lymphedema is a chronic, progressive condition that can significantly diminish the quality of life of
patients . Though conservative therapy is currently still the gold standard for management, evidence for
[24]
physiologic procedures such as VLNT is increasing [25,26] . Given their recent development, this systematic
review found that jejunal mesenteric, appendicular, and ileocecal donor sites have been relatively
understudied and warrant more consideration in future research. Overall, standardization in protocols and
outcome measures is lacking.

Clinical outcomes
There is limited data available to guide donor site selection in VLNT, leaving surgeon preference,
considerations for patient preference, and prior surgery or anatomic concerns to determine current
practice. Furthermore, the available studies implemented a variety of methodologies and study designs,
which restricted direct comparisons between investigations and made it difficult to draw definitive
conclusions regarding the optimal VLNT donor site [Supplementary Table 2].

Overall, some outcomes were reported in the literature more uniformly than others. For instance, the
majority of investigations reported limb measurements as an outcome to characterize the efficacy of the
procedure. From these studies, the vast majority reported reductions in limb size [Supplementary Table 3].
It cannot be understated, however, that contrasting methodologies could significantly affect the
generalizability of these results. Limbs were measured in circumference [27-29] or volume [30,31] , though variances
were also present beyond these two categories, including circumference rate reduction [32-34] , upper/lower
[38]
extremity lymphedema index [35-37] , and volume ratios [Supplementary Table 2]. The specific method used
to obtain circumference and volume measurements differed between investigations as well