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Page 8 of 10 Nardulli. Plast Aesthet Res 2020;7:15 I http://dx.doi.org/10.20517/2347-9264.2019.56

managed with CDT first. Early stage BCRL with pitting edema can benefit from reconstructive procedures.
If functional lymphatic channels are available still, LVA can be considered. In patients with a scarred axilla,
they may benefit from VLNT instead. Some authors combine VLNT and LVA with satisfactory results
reported [2,21] . VLNT from the groin can also be performed simultaneously with deep inferior epigastric
perforator (DIEP)-flap breast reconstruction [49,50] to address BCRL concurrently [2,49] .

Finally, laser-liposuction in combination with VLNT has been described for treating II stage (ISL staging)
[51]
[51]
BCRL . Nicoli et al. described the use of laser liposuction in combination with VLNT to treat ten patients
with stage II (ISL staging) BCRL who had failed a 6-month-period of conservative treatment. The two-
stage procedure involved VLNT from the supraclavicular or groin area to the wrist, and liposuction at 1 to 3
months later. Laser-assisted liposuction was carried out after tumescent solution infiltration, exsanguination
and tourniquet positioning, using a high-power diode pulsed laser with 1470-nm wavelength. The laser
light, conveyed through the microcannula, achieved both lipolysis and skin retraction in the affected arm. A
traditional liposuction cannula was then used to aspirate the liquefied fat. Post-operatively, patients had to
wear compressive garments at all times for the first 2 to 4 weeks and thereafter, only at night. Improvements
in limb circumferences, skin tonicity and lymphoscintigraphic features in the treated arm have been reported
by the authors. Histological changes including the reorganization of adipose cells and collagen in the
reticular dermis have also been demonstrated in biopsies done post-procedure.

CONCLUSION
BCRL is a disabling sequela of breast cancer and associated treatments. A conservative approach (i.e., CDT)
is the first line treatment for newly diagnosed BCRL. This treatment is insufficient in some cases, however,
and these patients can benefit from surgical intervention depending on clinical and imaging assessment. To
date, there remains no gold standard in the surgical treatment of BCRL. However, it is generally agreed that
early stage BCRL can benefit from reconstructive procedures. Advanced stages with no or minimal pitting
edema can be improved through liposuction. Each patient should therefore be assessed thoroughly before
surgery and have a tailored treatment plan to maximize benefits. Newer strategies such as fat grafting and
ADSC injection have shown promising preliminary results but must be investigated further. BCRL remains
a highly challenging surgical problem.

DECLARATIONS
Authors’ contributions
The author contributed solely to the article.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
There are no conflicts of interest.

Ethical approval and consent to participate
Not applicable.

Consent for publication
A written informed consent for using photos for scientific purposes was obtained by each patient.