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Page 4 of 10 Nardulli. Plast Aesthet Res 2020;7:15 I http://dx.doi.org/10.20517/2347-9264.2019.56

and upper limb to drain excess fluid accumulating in the arm by creating bypasses of lymph flow, or are
[21]
based on the concept of inducing lymphangiogenesis . Such techniques can be utilized in the early
stages of BCRL, when a residual and functional lymphatic system can still be identified. “Pitting” edema is
often present because excess limb volume is mainly caused by the accumulation of interstitial fluid. When
edema progresses, the affected limb is characterized by increased tissue fibrosis, hypertrophy of adipose
tissue, and irreversible damage and obliteration of the lymphatic vessels, thereby becoming “non-pitting”.
In such cases, physiological or reconstructive techniques are widely considered futile because the upper
limb lymphatics are fibrotic and damaged. Moreover, the excess in limb volume is also attributed to fibrosis
and fat hypertrophy instead. In these advanced, “non-pitting” stages, ablative or debulking procedures can
reduce the excess volume of skin and/or subcutaneous tissue. In turn, this facilitates hygiene and improves
limb functionality [2,19-21] .

Ablative or debulking surgical techniques
Ablative techniques aim to remove excess limb bulk to reduce lymphedema-associated morbidity. The
[22]
Charles procedure was one of the earliest ablative techniques described. It involves the excision of excess
skin and subcutaneous tissue up to the deep fascia, followed by skin grafting. However, this technique leads
to extensive scarring, poor cosmetic results and the disruption of residual lymphatic vessels in the treated
area. Therefore, it may even result in exacerbation of lymphedema. For these reasons, the Charles procedure
is currently reserved for very advanced cases of lymphedema that are not susceptible to improvement
through other measures [2,21] .

Excess fat and fibrotic tissue in the lymphadematous upper limb can now be removed through suction-assisted
[23]
lipectomy. The technique was first applied to lymphedema treatment by O’Brien et al. . Brorson et al. [24,25] then
popularized a technique consisting of large volume lipoaspiration in a limb affected by lymphedema [24-26] .
These procedures are typically indicated in advanced, “non-pitting” chronic edema that is non-responsive
[26]
to conservative measures as explained above. Recently, Hoffner et al. reported the 5-year results after
liposuction and postoperative controlled compression therapy (CCT) in a series of 105 patients suffering
from “non-pitting” or minimal “pitting” BCRL. The study protocol consists of the reduction of excess
arm volume through liposuction or power-assisted liposuction, from the wrist to the shoulder, while the
hand is spared. Volume reduction was performed according to previously assessed, contralateral limb
volume measurements. In more recent cases, the authors used a tourniquet in addition to tumescence
with adrenaline and lidocaine to reduce blood loss during surgery. A sterilized custom-made compression
garment is also put on the arm in the operating theatre, as soon as surgery progresses, to reduce both
blood loss and postoperative edema. With this approach, the authors obtained complete reduction of
excess volume within 3-6 months and sometimes earlier. As expected, a key point of this approach is CCT,
based on the constant use of made-to-measure compressive garments after surgery and indefinitely thence
on. Despite the favorable long-term results achieved, CCT remains the main limitation of the treatment
and requires absolute patient compliance. On the other hand, such liposuction-based techniques allow
[26]
arm volume reduction and skin retraction without the need for skin excision or recurrence , thereby
[25]
improving patients’ quality of life . A reduced incidence of infections after liposuction has also been
[25]
reported and is linked to the improvement of skin blood flow after the reduction of excess arm volume .
Moreover, if liposuction does not restore the lymphatic pathways in the affected limb, further impairment
of lymphatic transport capacity after liposuction has not been proven [24-26] .

Reconstructive or physiological surgical techniques
Vascularized lymph node transfer
In vascularized lymph node transfer (VLNT), the lymph nodes (LNs) are harvested as a vascularized free
flap with a vascular pedicle. The flap contains donor LNs embedded within the surrounding fat, with or
without a skin paddle [2,27] . The rationale for VLNT is based on the concept that axillary LNs, if surgically