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Nardulli. Plast Aesthet Res 2020;7:15 I http://dx.doi.org/10.20517/2347-9264.2019.56 Page 3 of 10

A B

Figure 1. A: A patient who developed left upper limb lymphedema during neoadjuvant therapy with Paclitaxel for breast cancer; B: After
undergoing left nipple sparing mastectomy, sentinel lymph node biopsy and immediate breast reconstruction with a prepectoral implant,
the lymphedema improved spontaneously, especially at the level of the forearm

Table 1. Staging system for lymphedema

Stage 0 (or Ia) which refers to a latent or sub-clinical condition where swelling is not yet evident despite impaired lymph transport, subtle
changes in tissue fluid/composition, and changes in subjective symptoms. It may exist months or years before overt edema
occurs (Stages I-III)
Stage I represents an early accumulation of fluid relatively high in protein content (e.g., in comparison with “venous” edema) which
subsides with limb elevation. Pitting may occur. An increase in various proliferating cells may also be seen
Stage II signifies that limb elevation alone rarely reduces tissue swelling and pitting is manifest. Late in Stage II, the limb may not pit as
excess subcutaneous fat and fibrosis supervenes
Stage III encompasses lymphostatic elephantiasis where pitting can be absent and trophic skin changes such as acanthosis, alterations
in skin character and thickness, further deposition of fat and fibrosis, and warty overgrowths have developed
[17]
This table summarizes the lymphedema staging system according to ISL , from the 2016 Consensus Document of the ISL [17]
(adapted). These Stages only refer to the physical condition of the extremities. ISL: International Society of Lymphology

The first-line treatment for BCRL is a set of nonsurgical and conservative measures known as Complex
Decongestive Therapy (CDT). CDT includes lymphatic manual drainage, bandaging, skin care, exercise,
patient education and is coupled with the use of compression garments. The aim of CDT is to reduce
limb volume first, followed by maintenance of the results achieved. Normally, patients suffering from
lymphedema require lifelong adherence to such therapeutic measures [1,19,20] . Consequently, non-compliance
to conservative therapy is frequent. Nevertheless, in recent years, interest in lymphedema surgery has
increased all over the world and there have been many advances in both surgical techniques and imaging
modalities. Therefore, surgery can be offered as a complementary or alternative therapeutic strategy for
lymphedema, when conservative measures are inadequate [2,21] .

Below, we present an overview of the main surgical techniques currently adopted for the treatment of
BCRL.

SURGICAL TREATMENT FOR BCRL
Surgical techniques for BCRL can be classified as physiological or reconstructive, and ablative or debulking
procedures [2,20] . Physiological or reconstructive techniques aim to restore lymphatic pathways in the axilla