Clinical UM Guideline

This document addresses select surgical procedures for the prevention or treatment of lymphedema in the upper and lower extremities. Lymphedema is the abnormal accumulation of fluid in the body tissues that results from the disruption of lymphatic drainage. Lymphedema can result in pain, recurrent infections, and functional impairment. The surgical procedures in this document are used to treat lymphedema by increasing the function of the lymphatic system. This document does not address lipectomy or liposuction.

Note: Not Medically Necessary services (as opposed to Investigational and Not Medically Necessary) may be subject to the Women’s Health and Cancer Rights Act of 1998 (WHCRA). Note also that some states have enacted legislation similar to WHCRA and some have expanded upon WHCRA.

Note: For more information on related topics, please see the following:

• ANC.00009 Cosmetic and Reconstructive Services of the Trunk, Groin, and Extremities
• CG-DME-06 Compression Devices for Lymphedema
• CG-DME-57 Lower Extremity Pressure Gradient Compression Stockings
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Medically Necessary:

Microsurgical procedures for the treatment of lymphedema (including mastectomy related lymphedema) are considered medically necessary when all of the following criteria (A, B, C and D) are met:

1. The individual has a diagnosis of lymphedema based on clinical findings and appropriate diagnostic testing; and
2. The individual has one or more of the following (1, 2 or 3):
   1. Physical function impairment (e.g., difficulty ambulating, performing activities of daily living); or
   2. History of chronic or recurrent skin conditions (e.g. cellulitis, ulcerations); or
   3. Significant pain or weakness in the affected extremity;
      and
3. Lymphedema persists or worsens despite at least 3 months of optimal conservative management; and
4. One of the following procedures are used:
   1. Lymphovenous anastomoses; or
   2. Lymphatic reconstruction techniques (for example, lymphatic-lymphatic bypass); or
   3. Vascularized lymph node transfer.

Not Medically Necessary:

Microsurgery for the treatment of lymphedema is considered not medically necessary when the criteria above are not met.

Microsurgery for the prevention of lymphedema, or immediate lymphatic reconstruction, is considered not medically necessary.

The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

When services may be Medically Necessary when criteria are met for treatment:
For the following procedure and diagnosis codes, or when the code describes a procedure indicated in the Clinical Indications section as medically necessary.

When services are Not Medically Necessary:
For the procedure codes listed above when criteria are not met for treatment of lymphedema or for situations designated in the Clinical Indications section as not medically necessary, for example prevention of lymphedema.

Summary

Lymphedema is a condition where fluid builds up in the body due to a damaged lymphatic system, causing swelling, pain, and other symptoms. It can be present at birth (primary) or occur later due to damage from cancer treatment, infections, or injuries (secondary). The accumulated fluid may lead to chronic inflammation and the scarring or hardening of body tissues. While lymphedema can affect any part of the body, it is most common in the upper or lower extremities. Symptoms include swelling, pain, a heavy feeling in the affected area, skin tightening, limited mobility, skin thickening, itching, and a burning sensation.

Lymphedema can be classified as primary or secondary. Primary lymphedema is caused by the abnormal fetal development of the lymphatic system and is considered a rare disorder. Secondary lymphedema is caused by damage to the lymphatic system from infection, injury, obesity, cancer, cancer treatment, inflammatory conditions, or surgery. Secondary lymphedema affects approximately 1 in every 1000 individuals in the United States. The most common cause of secondary lymphedema is malignancy or the treatment of malignancy, such as lymph node excision, radiation treatment, or medical therapy. Breast cancer is the most common cancer associated with secondary lymphedema, with one in five breast cancer survivors developing lymphedema (Sleigh, 2023). Approximately 15-40% of breast cancer survivors will develop lymphedema following axillary lymph node dissection (ALND) (Brown, 2023). Lymphedema, particularly breast cancer related lymphedema (BCRL) which is the most studied, can occur at any time following treatment. The incidence of BCRL appears to peak between 12 and 30 months posttreatment (McLaughlin, 2020).

While the condition cannot be cured, it can be managed. For most people, care starts with a treatment called complete decongestive therapy, which includes special massage, bandaging, exercise, and skin care. When this approach is not enough, some people may benefit from surgery that helps improve how the lymphatic system drains fluid. Surgical options include different techniques that connect or transfer lymphatic vessels or lymph nodes to improve drainage, reducing swelling, improving quality of life, and lowering the risk of infection. Not all techniques work for everyone, and results may vary depending on the stage of lymphedema and other individual factors. Immediate lymphatic reconstruction (ILR) is a newer preventive surgery that may reduce lymphedema risk during cancer surgery; however, clinical evidence does not yet establish it as a reliable and consistently effective prophylactic procedure which improves health outcomes.

Discussion

Diagnosis and staging

Lymphedema diagnosis relies on comprehensive clinical evaluation supported by objective measurements such as limb circumference, bioimpedance spectroscopy, and imaging when indicated. While characteristic signs like pitting edema and a positive Stemmer’s sign are commonly used, no single test is definitive and serial measurements and trend monitoring are often used for accurate assessment. Imaging modalities, particularly lymphoscintigraphy, serve as critical diagnostic tools. Lymphoscintigraphy is considered the gold standard for confirming lymphedema, involving intradermal injection of a radiolabeled tracer followed by gamma camera imaging to assess lymphatic flow and node uptake. Diagnostic findings include delayed tracer transit, dermal backflow, asymmetric lymph node uptake, or formation of collateral lymphatic channels. The test demonstrates high accuracy, with 96% sensitivity and 100% specificity, distinguishing lymphedema from other causes of extremity swelling (Hassanein, 2017). Despite established diagnostic methods, referrals to lymphedema clinics remain inconsistent, many individuals with early signs are not referred promptly, while others without true lymphedema are sent for evaluation. Approximately 25-29% of individuals referred for clinical assessment and treatment ultimately do not have lymphedema (Goss, 2019; Hassanein, 2017; Sudduth, 2020).

Lymphedema may be misdiagnosed as, or develop comorbidly with, lipedema, a painful, chronic, incurable disease that almost exclusively affects women after puberty and is characterized by abnormal bilateral enlargement of subcutaneous adipose tissue of the legs or arms but with normal hands and feet.

Severity of lymphedema is commonly determined using a staging system, such as the International Society of Lymphology (ISL) scale or the Campisi scale (see definitions). The ISL scale is now the more commonly used severity scale. The degree of lymphedema is assessed using several different measurement techniques, including comparing the circumference of the affected extremity to the unaffected side, volumetric measurement using water displacement, and infrared perometry.

Conservative treatment

Early and regular surveillance, paired with timely intervention, significantly reduces both the incidence and severity of lymphedema in individuals treated for breast cancer. Lymphedema results from irreversible lymphatic system damage; thus, curative treatment is not currently available. The clinical objective is volume reduction to control edema and alleviate symptoms. Advanced modalities such as lymphatic imaging can identify subclinical lymphedema months before clinical swelling occurs. Prophylactic or early-stage treatment during this subclinical period has been associated with a low rate of progression to overt disease (Kilgore, 2018; Paramanandam, 2022; Whitworth, 2024).

Complete decongestive therapy (CDT) is the current standard of care for lymphedema management (Donahue, 2023). CDT involves two phases (McLaughlin, 2020):

• Reduction Phase: CDT is initiated and includes manual lymphatic drainage (MLD), multi-layer compression bandaging, therapeutic exercise, meticulous skin care, and patient education.
• Maintenance Phase: Individuals transition to self-management strategies such as compression garment use, self-MLD, ongoing exercise, and skin care. Compression therapy, whether used independently or in combination with CDT, remains critical for limb volume control.

The 2023 International Society of Lymphedema (ISL) defines the levels of lymphedema as the following:

The concepts of "primary" and "secondary" prevention (including risk reduction) are receiving increased attention with an emerging new concept of "tertiary" prevention: "primary" prevention to avoid lymphedema before its onset; "secondary" prevention for lymphedema treatment at early stage; and "tertiary" prevention for lymphedema treatment at late stage.

Surgical treatment

When conservative treatment fails and disease progresses, individuals may be a candidate for microsurgery.Microsurgical interventions are not considered a cure for lymphedema, but these treatments attempt to address the underlying pathology causing impaired lymphatic drainage by restoring damaged lymphatic drainage. These techniques include reductive surgery to debulk diseased tissue or physiologic procedures, which are used to decrease fluid volume by restoring lymphatic system function. The decision to perform a physiologic or a reductive procedure depends upon disease stage. Bown and colleagues (2023) note:

While physiologic procedures are used for patients with early-stage lymphedema prior to the deposition of excess fat and extensive tissue fibrosis, reductive techniques are best used in patients who have failed conservative measures or for patients who present with more advanced lymphedema after fat deposition and tissue fibrosis has occurred.

Studies have been published comparing earlier surgical intervention. Jonis and colleagues (2024) reported on the 6-month interim findings from a multicenter, prospective randomized, controlled trial (RCT) comparing lymphaticovenous anastomosis (LVA) to CDT in 92 individuals with early-stage, (stage 1 or 2a on the ISL scale) unilateral BRCL. All participants had viable lymphatic vessels and were randomized to receive either LVA surgery or continued CDT following at least 3 months of initial conservative treatment. The primary outcome was health-related quality of life (HrQoL), measured by the Lymph-ICF questionnaire, while secondary outcomes included limb volume (via water displacement), limb circumference (UEL index), and compression garment use. After 6 months, LVA led to significant improvements in the physical and mental function domains of the Lymph-ICF, though total HrQoL scores did not differ significantly between groups. Volume and circumference did not significantly change in either group. However, 42% of the LVA group completely or partially discontinued compression garment use, compared to 0% in the CDT group. However, additional publications are needed to consider surgery a first-line treatment.

The following is a general listing of the microsurgical techniques used to treat lymphedema.

Lympho-venous anastomosis procedures

• Lymphovenous bypass: Lymphovenous bypass is the connection, using a microsurgical anastomosis technique, of a vein graft between distal lymphatic vessels and proximal vessels that are past an area of obstruction.
• Lymphaticolymphatic bypass (also called lymphatic-lymphatic bypass): Lymphaticolymphatic bypass is the direct connection of lymphatic vessels in a lymphedematous limb to lymphatic vessels in a healthy donor area of the body using a microsurgical anastomosis technique.
• Lymphaticovenular anastomosis (LVA): LVA is the connecting of lymphatic vessels in a lymphedematous limb to nearby veins using a microsurgical anastomosis technique. Lymphatic fluid is cleared by the one-way movement of excess lymph into the venous system.

Lymphatic transfer procedures

• Vascularized lymph node transfer (VLNT): VLNT is the transplantation of lymph nodes (including the surrounding tissue, fat, and blood supply) from a donor site to the lymphedematous limb using a microsurgical anastomosis technique between the blood vessels of the lymph node flap and the recipient site. It is unclear how VLNT improves lymphedema, although it is thought it may work by releasing scar tissue that is blocking lymphatic fluid, by bridging lymphatic pathways through lymphangiogenesis or by acting as a lymphatic pump. A potential complication of VLNT is the development of lymphedema at the donor site. To reduce this risk, researchers are investigating the use of the omentum, a fatty curtain of tissue that is thought to act as a giant lymph node, as a donor site.

Hahn and colleagues (2025a) note the following regarding appropriate techniques based upon the level of disease:

LVA relies on the presence of patent lymphatic channels and is therefore typically limited to patients with earlier stages of lymphedema. Because VLNT does not necessitate that patients have complete lymphatic vessel function, the procedure is often reserved for patients with more advanced stages of lymphedema progression.

The goal of lymphatic microsurgery is to augment the rate of return of the lymph to the vascular circulation. In determining the health outcomes of individuals treated with surgery for lymphedema, objective outcomes include limb volume/circumference reduction, reduction in rate of infection, and adverse events. Subjective outcomes include quality of life and symptom improvement. Several systematic reviews have compared multiple lymphedema surgical treatments.

Lymphatic Bypass Procedures

Microvascular bypass surgery using varying techniques has been described to reduce lymphedema severity (Campisi, 2004; Chang, 2013; Koshima, 2000; Phillips, 2019; Poumellec, 2017; Yamamoto, 2003; Yamamoto, 2014).

Two systematic reviews further examined LVA outcomes. Scaglioni (2017) reviewed 18 studies (n=939) on LVA for upper and lower extremity lymphedema and found consistent reductions in limb circumference and symptom relief in 50-100% of participants, along with fewer episodes of cellulitis. However, methodological variability and short follow-up durations precluded meta-analysis or firm conclusions. Similarly, Cornelissen et al. (2018) reviewed 15 studies (n=268) focusing on breast cancer-related lymphedema and found that 13 studies showed volume or circumference reduction and 12 reported symptom improvement. While results varied, LVA showed efficacy, particularly in early-stage disease.

Vascularized Lymph Node Transfer

A number of prospective, retrospective studies and systematic reviews have evaluated VLNT for the treatment of lymphedema, generally reporting positive clinical outcomes (Brown, 2022; Ciudad, 2017; Gratzon, 2017; Koide, 2019a; Koide, 2019b; Maldonado, 2017; Nguyen, 2017; Ozturk, 2016; Scaglioni, 2018). Dionyssiou and colleagues (2016) conducted a RCT in individuals with BCRL, demonstrating significantly greater limb volume reduction (57% vs. 18%) and fewer infections in the VLNT group compared to physiotherapy alone, with no major complications reported.

Meta-analysis of LVA and VLNT

In 2023, Meuli and colleagues published a systematic review and meta-analysis on the effectiveness of LVA and VLNT treating lymphedema. The meta-analysis was comprised of studies (n=29) which reported the % change in excess circumference and focused on VLNT (n=20), LVA (n=8) or a combination of these techniques (n=1). A total of 12 studies reported on changes in excess volume. For the 1002 participants, the overall pooled decrease in excess circumference was -35.6% (95% confidence interval [CI]; -30.9 to -40.3%) and a 32.7 % (95% CI: -19.8% to -45.6%) decrease in excess volume postoperatively. While the majority of the studies were nonrandomized, 2 of the studies were randomized controlled studies. The authors concluded that there is a growing body of evidence showing that lymphedema microsurgery can be effective in reducing the severity of secondary extremity lymphedema.

A 2025 systematic review and meta-analysis (Hahn) synthesized data from 52 studies examining outcomes of microsurgical treatment for upper and lower extremity lymphedema (UEL and LEL) using LVA, VLNT or a combination of both. Across 1920 participants, the pooled mean clinical improvement, measured by reduction in limb circumference or volume, was 36.5% for UEL and 34.2% for LEL. Subgroup analyses revealed greater improvement with VLNT than LVA in both extremities: UEL improved by 41.7% with VLNT versus 29.4% with LVA, while LEL improved by 39.5% with VLNT versus 31.9% with LVA. One study evaluating the combined approach (VLNT + LVA) in UEL reported a 32.8% improvement. A subgroup analysis showed that clinical improvement increased in the more advanced ILS stages. Most studies were rated at low or moderate risk of bias, with only 1 deemed serious. The authors concluded that while both procedures are effective, VLNT may offer superior outcomes, particularly in advanced cases.

Society Statement

Chang and colleagues (2021) reported on the risks and benefits of the surgical treatment of lymphedema in a systematic review and meta-analysis developed at a consensus conference, sponsored by the American Association of Plastic Surgeons (ASPS). The conference members developed the following consensus and recommendations:

There is evidence to support that lymphaticovenous anastomosis can be effective in reducing severity of lymphedema (grade 1C*). A plurality of studies demonstrates that patients with earlier stage disease have better outcomes. There is no evidence that lymphovenous bypass can cure lymphedema.

There is evidence to support that vascularized lymph node transfer can be effective in reducing the severity of lymphedema (grade 1B*). There is no evidence that vascularized lymph node transfer can cure lymphedema.

Currently, there is no consensus on which procedure (lymphovenous bypass versus vascularized lymph node transfer) is more effective (grade 2C*).

* See Definitions

Immediate Lymphatic Reconstruction (ILR)

The use of surgical techniques to prevent lymphedema, also known as Lymphatic Microsurgical Preventive Healing Approach (LYMPHA), has been proposed as a more proactive approach when damage to the lymphatic system is anticipated. ALND is a leading cause of lymphedema (Levy, 2023). Prior to dissection, axillary reverse mapping is done to map upper extremity lymphatic drainage using blue dye. The goal is to avoid removing the blue stained lymphatics or nodes as much as possible. Avoidance is combined with immediate surgical reconstruction. Surgically severed lymphatic channels are connected to nearby veins using microsurgical techniques during lymph node dissection.

A 2025 systematic review and meta-analysis by Silva and associates reported on the safety and efficacy of ILR using lymphovenous anastomosis in breast cancer. This meta-analysis included 18 studies (2 RCTs and 16 nonrandomized cohorts) with a total of 47,645 individuals, of whom 1401 underwent ILR during ALND for breast cancer. Pooled results showed a significant reduction in BCRL incidence with ILR compared to control (9.6% [98/1026] vs. 41.6% [584/1405] respectively). This corresponds to a risk ratio (RR) of 0.35 (95% CI; 0.27-0.47; p<0.001) and a number needed to treat of 3.4. The authors concluded that ILR may be an effective and safe preventive strategy for BCRL, although further work regarding who may benefit from this approach is needed as well as additional evaluation regarding long-term oncologic outcomes. Limitations included short and asymmetric follow-up between groups, heterogeneity in diagnostic criteria for BCRL, variability in control group selection, and uneven distribution of key clinical factors (for example, radiation, chemotherapy exposure). While study quality was generally acceptable, methodological flaws and incomplete recurrence data reduce certainty of findings.

Jakub and associates (2024) published the clinical outcomes of a prospective, two-site, pragmatic trial that explored lymphedema rates in breast cancer individuals undergoing (ALND) with or without (ILR). Out of 230 participants, 99 underwent ALND alone and 131 received ALND with ILR. Approximately 37% of the ILR procedures received a microsurgical LVA and the remainder of the procedures were performed by a breast surgical oncologist using a non-microsurgical technique. Placement into each group was based on surgeon or participant preference. The primary measure was defined as a limb volume change of 10% or greater postoperatively. Results showed no significant difference in lymphedema rates between the groups, except when measured through ICD-10 codes, which were deemed unreliable. Self-reported freedom from lymphedema at 6, 12, 24 and 36 months was not statistically different between the groups (81.7%, 69.8%, 64.4%, and 60.2%, respectively). Quality of life assessments also showed no significant disparity.

Coriddi and colleagues (2023) reported on preliminary results of an unblinded RCT assessing the impact of ILR on reducing lymphedema rates in women undergoing ALND for breast cancer. The study involved 144 participants, divided equally between ILR group and a standard of care control group. Measures were taken at baseline, 12, 18, and 24 months. The reported data included 99 (68%), 70 (47%), and 40 (28%) participants with 12, 18, and 24 month follow-up, respectively. The primary outcome was the incidence of BRCL, defined as a relative volume change of ≥ 10% in the affected limb. The results showed a significant reduction in BRCL incidence in the ILR group compared to the control group, with a cumulative 24-month incidence of 9.5% for ILR compared to 32% for the control. This suggests ILR potentially improves clinical outcomes by reducing lymphedema incidence and its associated symptoms. However, with the high degree of loss to following in this study, these findings are not reliable.

In 2022, Ciudad and colleagues published a systematic review and meta-analysis evaluating the evidence on ILR in preventing cancer-related lymphedema. The meta-analysis included 24 studies involving 1547 individuals. The pooled results showed that ILR using prophylactic LVA after lymphadenectomy reduced the incidence of cancer-related lymphedema, 5.15% for upper extremity after ALND and 6.66% for lower extremity after ilioinguinal or related dissections, with significant relative risk (RR) reductions compared to no preventive intervention (18.7% and 30.3% absolute reductions, respectively). The authors caution that the evidence is limited by substantial heterogeneity in cancer types, surgical techniques, diagnostic methods, and follow-up durations. Also, the studies were comprised of low-quality observational designs with a high risk of bias and only two RCTs.

Current evidence evaluating ILR for the prevention of lymphedema remains insufficient to establish medical necessity. While recent meta-analyses and systematic reviews suggest that ILR may reduce short-term lymphedema incidence compared with standard care, the available data are largely derived from small, nonrandomized, and heterogeneous studies with limited follow-up duration. Aschen (2025) reported a pooled BCRL incidence of 13.3% with ILR vs. 26.1% without (RR, 0.51). Li (2025) reported a similar reduction in pooled risk (RR, 0.41) but noted that benefit was no longer statistically significant beyond three years. A meta-analysis by Hinson (2025) included lymphedema across a range of cancer types, reported a pooled RR of 0.31. Across these analyses, variations in surgical technique, participant selection, and methods of lymphedema assessment, and potential duplication of cohorts across included studies, limit interpretability.

In 2019, a Cochrane review was published evaluating the evidence for surgical interventions for the prevention and treatment of lymphedema after breast cancer therapy (Markkula, 2019). Only two RCTs were identified that met study criteria. The review concluded:

There is low‐certainty evidence that lymphaticovenular anastomosis is effective in preventing the development of lymphoedema after breast cancer treatment based on the findings from two studies. One study providing very low‐certainty evidence found that vascularised lymph node transfer is an efficacious option in the treatment of established stage 2 lymphoedema related to breast cancer. Important secondary outcomes in this review were rarely reported in the included studies. More high‐quality RCTs are required to further elucidate the effectiveness of surgical interventions in the prevention and treatment of lymphoedema after breast cancer treatment.

ASPS clinical conference paper (Chang, 2021) notes the following consensus statement regarding prophylactic lymphovenous bypass:

A few studies show that prophylactic lymphovenous bypass in patients undergoing extremity lymphadenectomy may reduce the incidence of lymphedema (grade 1B*). More studies with longer follow-up are required to confirm this benefit.

* See Definitions

The 2023 ISL guidelines report that in several studies, there was a reduced incidence of post-operative lymphedema in individuals who had undergone prophylactic lymph surgery, but that long-term studies are lacking.

Retrospective studies, as well as prospective and single-institution investigations, have been published; however, ILR has not been established as a standard treatment (Cook, 2021; Hassan, 2025; Granoff, 2023; Otsuki, 2024). The existing body of literature is constrained by methodological limitations, including small sample sizes, short follow-up intervals, and variability in study design. Some studies have compared individuals undergoing ALND with ILR to those who did not undergo ILR, but these comparisons are subject to potential confounding, as the non-ILR group may have included individuals with more advanced disease or who required more extensive surgical procedures (Coriddi, 2023). At present, the evidence base is not sufficiently developed to support recognition of ILR as a standard of care. Larger RCTs (NCT03428581, NCT03941756, NCT04241341) with extended follow-up are ongoing and may further inform the clinical utility of ILR. Until the data demonstrates consistent and robust outcomes, ILR is outside accepted standards of medical practice (Agarwal, 2020; Coriddi, 2021; Johnson, 2021; Levy, 2023).

American College of Chest Physicians Task Force Grading of Recommendations and Quality of Evidence in Clinical Guidelines*:

* Guyatt G, Gutterman D, Baumann MH, et al. Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians Task Force. Chest. 2006; 129(1):174-181.

Anastomosis: The surgical connection between two structures.

Campisi Staging System for Lymphedema:

• Stage 1A: “Latent” lymphedema, without clinical evidence of edema, but with impaired lymph transport capacity (provable by lymphoscintigraphy) and with initial immuno-histochemical alterations of lymph nodes, lymph vessels and extracellular matrix.
• Stage 1B: “Initial” lymphedema, totally or partially decreasing by rest and draining position, with worsening impairment of lymph transport capacity and of immuno-histochemical alterations of lymph collectors, nodes and extracellular matrix.
• Stage IIA: “Increasing” lymphedema, with vanishing lymph transport capacity, relapsing lymphangitic attacks, fibroindurative skin changes, and developing disability.
• Stage IIB: “Column shaped” limb fibrolymphedema, with lymphostatic skin changes, suppressed lymph transport capacity and worsening disability.
• Stage IIIA: Properly called "elephantiasis", with scleroindurative pachydermitis, papillomatous lymphostatic verrucosis, no lymph transport capacity and life-threatening disability.
• Stage IIIB: “Extreme elephantiasis” with total disability (Campisi, 2010b).

Cellulitis: An infection that spreads to deep tissues of the skin and muscle, which may cause warmth, tenderness, fever, chills, swollen lymph nodes, and blisters.

International Society of Lymphology Staging System:

• Stage 0 - refers to a latent or subclinical condition where swelling is not yet evident despite impaired lymph transport, subtle alterations 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 types of proliferating cells may also be seen.
• Stage II - signifies that limb elevation alone rarely reduces the tissue swelling and pitting is manifest. Later in Stage II, the limb may not pit as excess subcutaneous fat and fibrosis develop. Edema is irreversible.
• 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 (ISL, 2016).

Interstitial compartment (also called tissue space): The space surrounding tissue cells.

Lipedema: A chronic disease affecting almost exclusively women after puberty, characterized by painful abnormal enlargement of subcutaneous adipose tissue of the arms and legs.

Lymphatic fluid: A clear fluid that contains white blood cells (lymphocytes) and plasma.

Lymph nodes: Small, bean-shaped structures, found in the axilla, pelvis, neck, abdomen, and groin, which filter lymphatic fluid and store white blood cells.

Lymphatic system: A network of lymph vessels, tissues, and organs that carry lymphatic fluid throughout the body and return it to the bloodstream.

Microsurgery: Surgery performed with miniaturized instruments under magnification.

Omentum: A curtain of fatty tissue that connects the stomach to other abdominal organs and plays a role in immunity.

Stemmer's sign: a physical examination technique that helps in the diagnosis of lymphedema, a condition marked by the accumulation of lymphatic fluid in tissues, leading to swelling. The test is named after the physician who first described it and is considered a reliable indicator of lymphedema's presence.

Peer Reviewed Publications:

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26. Fish ML, Grover R, Schwarz GS. Quality-of-life outcomes in surgical vs nonsurgical treatment of breast cancer-related lymphedema: a systematic review. JAMA Surg. 2020; 155(6):513-519.
27. Forte AJ, Boczar D, Huayllani MT, et al. Targeted therapies in surgical treatment of lymphedema: a systematic review. Cureus. 2019; 11(8):e5397.
28. Forte AJ, Huayllani MT, Boczar D, et al. Lipoaspiration and lymph node transfer for treatment of breast cancer-related lymphedema: a systematic review. Cureus. 2019; 11(11):e6096.
29. Forte AJ, Khan N, Huayllani MT, et al. Lymphaticovenous anastomosis for lower extremity lymphedema: a systematic review. Indian J Plast Surg. 2020; 53(1):17-24.
30. Goss JA, Greene AK. Sensitivity and specificity of the stemmer sign for lymphedema: a clinical lymphoscintigraphic study. Plast Reconstr Surg Glob Open. 2019; 7(6):e2295.
31. Granoff MD, Fleishman A, Shillue K, et al. A 4-year institutional experience of immediate lymphatic reconstruction. Plast Reconstr Surg. 2023; 152(5):773e-778e.
32. Gratzon A, Schultz J, Secrest K, et al. Clinical and psychosocial outcomes of vascularized lymph node transfer for the treatment of upper extremity lymphedema after breast cancer therapy. Ann Surg Oncol. 2017; 24(6):1475-1481.
33. Grünherz L, Hulla H, Uyulmaz S, et al. Patient-reported outcomes following lymph reconstructive surgery in lower limb lymphedema: a systematic review of literature. J Vasc Surg Venous Lymphat Disord. 2021; 9(3):811-819.e2.
34. Hahn BA, Kleeven A, Richir MC, et al. Objectifying clinical outcomes after lymphaticovenous anastomosis and vascularized lymph node transfer in the treatment of extremity lymphedema: a systematic review and meta-analysis. Microsurgery. 2025a; 45(3):e70050.
35. Hahn BA, Kleeven A, Richir MC, et al. The Qaly study: Quality of life and lower extremity lymphedema in 174 patients after inguinal lymphadenectomy. Surg Oncol. 2025b; 62:102257
36. Hassan AM, Hajj JP, Lewis JP, et al. Long-term outcomes of lymphedema after immediate lymphatic reconstruction following axillary lymph node dissection. Ann Surg Oncol. 2025; 32(8):5817-5826.
37. Hassanein AH, Maclellan RA, Grant FD, Greene AK. Diagnostic accuracy of lymphoscintigraphy for lymphedema and analysis of false-negative tests. Plast Reconstr Surg Glob Open. 2017; 5(7):e1396.
38. Hinson C, Sink M, Henn D, et al. Preventing secondary lymphedema: a systematic review and meta-analysis on the efficacy of immediate lymphovenous anastomosis. J Surg Oncol. 2025; 132(4):717-726.
39. Jakub JW, Boughey JC, Hieken TJ, et al. Lymphedema rates following axillary lymph node dissection with and without immediate lymphatic reconstruction: a prospective trial. Ann Surg Oncol. 2024; 31(11):7349-7359.
40. Johnson AR, Fleishman A, Granoff MD, et al. Evaluating the impact of immediate lymphatic reconstruction for the surgical prevention of lymphedema. Plast Reconstr Surg. 2021; 147(3):373e-381e.
41. Jonis YMJ, Wolfs JAGN, Hummelink S, et al. The 6 month interim analysis of a randomized controlled trial assessing the quality of life in patients with breast cancer related lymphedema undergoing lymphaticovenous anastomosis vs. conservative therapy. Sci Rep. 2024; 14(1):2238.
42. Kenworthy EO, Nelson JA, Verma R, et al. Double vascularized omentum lymphatic transplant (VOLT) for the treatment of lymphedema. J Surg Oncol. 2018; 117(7):1413-1419.
43. Kilgore LJ, Korentager SS, Hangge AN, et al. Reducing breast cancer-related lymphedema (BCRL) through prospective surveillance monitoring using bioimpedance spectroscopy (BIS) and patient directed self-interventions. Ann Surg Oncol. 2018; 25(10):2948-2952.
44. Koide S, Lin CY, Cheng MH. Delayed primary retention suture for inset of vascularized submental lymph node flap for lower extremity lymphedema. J Surg Oncol. 2020; 121(1):138-143.
45. Koide S, Lin CY, Chen C, Cheng MH. Long-term outcome of lower extremity lymphedema treated with vascularized lymph node flap transfer with or without venous complications. J Surg Oncol. 2020; 121(1):129-137.
46. Kraft CT, Eiferman D, Jordan S, Skoracki RJ. Complications after vascularized jejunal mesenteric lymph node transfer: a 3-year experience. Microsurgery. 2019; 39(6):497-501.
47. Levy AS, Murphy AI, Ishtihar S, et al. Lymphatic microsurgical preventive healing approach for the primary prevention of lymphedema: a 4-year follow-up. Plast Reconstr Surg. 2023; 151(2):413-420.
48. Li MX, Zhang J, Howard MA, Teven CM. Efficacy of immediate lymphatic reconstruction in prevention of breast cancer-related lymphedema: a systematic review and meta-analysis. Microsurgery. 2025; 45(6):e70109.
49. Mardonado AA, Chen R, Chang DW. The use of supraclavicular free flap with vascularized lymph node transfer for treatment of lymphedema: a prospective study of 100 consecutive cases. J Surg Oncol. 2017; 115(1):68-71.
50. Maruccia M, Elia R, Ciudad P, et al. Postmastectomy upper limb lymphedema: combined vascularized lymph node transfer and scar release with fat graft expedites surgical and patients’ related outcomes. A retrospective comparative study. J Plast Reconstr Aesthet Surg. 2019; 72(6):892-901.
51. McLaughlin SA, Brunelle CL, Taghian A. Breast cancer-related lymphedema: risk factors, screening, management, and the impact of locoregional treatment. J Clin Oncol. 2020;38(20):2341-2350.
52. Meuli JN, Guiotto M, Elmers J, et al. Outcomes after microsurgical treatment of lymphedema: a systematic review and meta-analysis. Int J Surg. 2023; 109(5):1360-1372.
53. Mousavi SR, Akbari ME, Zarrintan S. Vascularized gastroepiploic lymph node transfer significantly improves breast cancer-related lymphedema. J Surg Oncol. 2020; 121(1):163-167.
54. Nguyen AT, Suami H, Hanasono MM, et al. Long-term outcomes of the minimally invasive free vascularized omental lymphatic flap for the treatment of lymphedema. J Surg Oncol. 2017; 115(1):84-89.
55. Otsuki Y, Nuri T, Ueda K. Immediate lymphatic reconstruction for breast cancer-related lymphedema: current status and challenges. Gland Surg. 2024; 13(3):455-457.
56. Ozmen T, Lazaro M, Zhou Y, et al. Evaluation of simplified lymphatic microsurgical preventing healing approach (S-LYMPHA) for the prevention of breast cancer-related clinical lymphedema after axillary lymph node dissection. Ann Surg. 2019; 270(6):1156-1160.
57. Ozturk CN, Ozturk C, Glasgow M, et al. Free vascularized lymph node transfer for treatment of lymphedema: a systematic evidence based review. J Plast Reconstr Aesthet Surg. 2016; 69(9):1234-1247.
58. Paramanandam VS, Dylke E, Clark GM, et al. Prophylactic use of compression sleeves reduces the incidence of arm swelling in women at high risk of breast cancer-related lymphedema: a randomized controlled trial. J Clin Oncol. 2022; 40(18):2004-2012.
59. Phillips GSA, Gore S, Ramsden A, Furniss D. Lymphaticovenular anastomosis improves quality of life and limb volume in patients with secondary lymphedema after breast cancer treatment. Breast J. 2019; 25(5):859-864.
60. Poumellec MA, Foissac R, Cegarra-Escolano M, et al. Surgical treatment of secondary lymphedema of the upper limb by stepped microsurgical lymphaticovenous anastomoses. Breast Cancer Res Treat. 2017; 162(2):219-224.
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Government Agency, Medical Society, and Other Authoritative Publications:

1. American Society of Breast Surgeons Clinical Consensus Statement. Axillary management for patients with in-situ and invasive breast cancer: a concise overview. Approved on March 14, 2022. Available at: https://www.breastsurgeons.org/docs/statements/asbrs-ccs-management-of-the-axilla.pdf. Accessed on October 12, 2025.
2. Brackstone M, Baldassarre FG, Perera FE, et al. Management of the axilla in early-stage breast cancer: Ontario Health (Cancer Care Ontario) and ASCO guideline. J Clin Oncol. 2021; 39(27):3056-3082.
3. Chang DW, Dayan J, Greene AK, et al. Surgical treatment of lymphedema: a systematic review and meta-analysis of controlled trials. Results of a consensus conference. Plast Reconstr Surg. 2021; 147(4):975-993.
4. Executive Committee of the International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2023 consensus document of the international society of lymphology. Lymphology. 2023; 56(4):133-151.
5. International Society of Lymphology (ISL). The diagnosis and treatment of peripheral lymphedema: 2016 consensus document of the International Society of Lymphology. Lymphology. 2016; 49:170-184.
6. Markkula SP, Leung N, Allen VB, Furniss D. Surgical interventions for the prevention or treatment of lymphoedema after breast cancer treatment. Cochrane Database Syst Rev. 2019; 2:CD011433.
7. Mayo Clinic. Preventing Lymphedema in Axillary Lymph Node Dissection. NLM: NCT03428581. Last updated August 27, 2025. Available at: https://clinicaltrials.gov/study/NCT03428581?term=NCT03428581&rank=1. Accessed on October 13, 2025.
8. M.D. Anderson Cancer Center. Lymphovenous bypass procedure before underarm lymph node surgery in preventing lymphedema in patients with inflammatory or locally advanced non-inflammatory breast cancer. NLM Identifier: NCT03941756. Last updated on May 31, 2025. Available at: https://clinicaltrials.gov/study/NCT03941756. Accessed on October 13, 2025.
9. Memorial Sloan Kettering Cancer Center. A study comparing quality of life in patients with lymphedema who undergo surgical treatment versus non-surgical management. NLM Identifier: NCT03248310. Last updated on September 22, 2025. Available at: https://clinicaltrials.gov/study/NCT03248310?term=NCT03248310&rank=1. Accessed on October 13, 2025.
10. Memorial Sloan Kettering Cancer Center. Does Immediate Lymphatic Reconstruction Decrease the Risk of Lymphedema After Axillary Lymph Node Dissection. NLM: NCT04241341. Last updated on November 7, 2024. Available at: https://clinicaltrials.gov/study/NCT04241341?term=NCT04241341&rank=1. Accessed on October 13, 2025.
11. National Comprehensive Cancer Network^® (NCCN) Practice Guidelines in Oncology^™. ©2025 National Comprehensive Cancer Network, Inc. For additional information, visit the NCCN website: http://www.nccn.org. Accessed on October 13, 2025.
    • Breast Cancer. V4.2025. April 17, 2025.
    • Survivorship. V2.2025. May 23, 2025.
12. National Institute of Health. National Cancer Institute (NCI) PDQ^®. Lymphedema. December 14, 2024. Available at: https://www.cancer.gov/about-cancer/treatment/side-effects/lymphedema/lymphedema-hp-pdq#_75. Accessed on October 13, 2025.
13. Universitaire Ziekenhuizen KU Leuven. Added value of reconstructive lymphatic surgery to usual care in lymphoedema (SurLym). NLM Identifier: NCT05064176. Last updated on July 3, 2024. Available at: https://clinicaltrials.gov/study/NCT05064176?term=NCT05064176&rank=1. Accessed on October 13, 2025.

1. American Cancer Society. Lymphedema. Last Revised May 20, 2025. Available at: https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/swelling/lymphedema.html. Accessed on October 13, 2025.
2. Lipedema Foundation. What is Lipedema? Available at: https://www.lipedema.org/. Accessed on October 13, 2025.
3. National Cancer Institute. Lymphedema. Last updated March 6, 2024. Available at: https://www.cancer.gov/about-cancer/treatment/side-effects/lymphedema. Accessed on October 13, 2025.
4. National Lymphedema Network (NLN). Empowering the Patient Community. Available at https://lymphnet.org/page/patientinfo. Accessed on October 13, 2025.
5. Society of Vascular Surgeons. Lymphedema. Available at: https://vascular.org/your-vascular-health/vascular-conditions/lymphedema. Accessed on October 13, 2025.

Lymphaticolymphatic Bypass
Lymphaticovenular Anastomosis
Lymphedema
Lymphovenous Bypass
Omental Flap Transfer
Vascularized Lymph Node Transfer

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.