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Page 2 of 13 Venkatramani et al. Plast Aesthet Res 2020;7:19 I http://dx.doi.org/10.20517/2347-9264.2019.70

to various causes such as filariasis or more commonly due to the various cancer treatment modalities. The
resultant accumulation of lymphatic fluid causes persistent swelling of the limb, fat hypertrophy, tissue
[2]
fibrosis, ulceration, infection and sepsis. Lymphoedema progresses through four stages . Stage 0 indicates
a clinically normal limb, but with abnormal lymph transport. Stage 1 shows early pitting oedema which
improves with limb elevation. In stage 2, there is limb oedema that does not improve with limb elevation.
Stage 3 represents pitting limb oedema with skin changes such as acanthosis, further deposition of fat and
fibrosis and warty overgrowths. Currently, there is no cure for lymphoedema, and the optimal treatment is
yet to be determined. The treatment for lymphoedema starts with conservative management followed by
surgery if necessary. The various surgical modalities for lymphoedema are detailed in this review.

Lymphoedema management should ideally start with non-surgical modalities such as compression therapy,
lymphoedema-specific manual lymphatic drainage and use of external sequential pneumatic compression
[3]
devices . This would not only reduce the amount of lymphoedema but would also facilitate surgical
procedures by making the skin more pliable and soft. Lee recommends using non-surgical modalities
[4]
for 2 years before attempting any surgical procedure . The patient should be encouraged and counselled
regarding the importance of conservative measures which can be difficult to achieve. Compliance is a
[5]
problem as it can be costly, time-consuming and uncomfortable .
Patients with early-stage lymphoedema benefit from physiological procedures such as lymphovenous
anastomosis (LVA), where the lymphatics are connected to the veins or by vascularised lymph node
transfers (VLNTs), in which lymph nodes from one part of the body are transferred to the affected area to
drain excess lymphatic fluid. Liposuction is done for those patients whose swelling is mainly due to excess
fat. For patients with end-stage disease and large fibrotic limbs, conservative therapy can be ineffective, and
excisional surgery alone or in combination with other physiological procedures such as VLNT and LVA, is
performed.

LVA
LVA is a microsurgical approach used to augment the return of lymph to the blood circulation in which
lymphatic vessels smaller than 0.8 mm are connected to the subdermal venules using fine microsurgical
[6]
sutures, instruments and high resolution magnification microscopes . LVA is used to treat early stage
[7]
lymphoedema. Chang et al. found that LVA was more effective when used for early stage lymphoedema
(Stages 1 & 2) when compared to late stage lymphoedema (Stages 3 & 4) according to the M.D. Anderson
Classification based on indocyanine green (ICG) lymphangiography. They postulated that this observation
was because LVA needs intact functional lymphatic channels and minimal irreversible tissue fibrosis for it
to be effective. In later stages, LVA could be combined with VLNT.

The patient is advised to wear compression stockings without exception during the day for at least 6 months
to reduce oedema before LVA is attempted. The stockings are to be replaced with a new pair if they get
loose. The patients are also told that they would have to continue wearing the compression stockings
even after surgery to get the best results. Although LVA can be done without ICG lymphangiography, this
imaging technique helps to assess the severity of lymphoedema and determine whether LVA would be
[8]
effective, and it also aids in localising the position of the lymphatic channels in the limb . The position of
the lymphatic channels is marked using a pen on the skin. ICG lymphography can detect the position of
the lymphatic channels only up to a depth of 10 mm from the skin surface. LVA can be done under regional
or general anaesthesia under tourniquet control, or it can be done with a local anaesthetic containing
adrenaline to limit bleeding from the dermal edges. A 3-cm incision is made where the lymphatic ducts
are located by ICG lymphography. Although there is no consensus on the number of anastomoses needed
to obtain a significant reduction in lymphoedema, it is believed that increasing the number of LVA can
[9]
improve lymphoedema better . If ICG lymphography is not available, 5 to 10 incisions can be made