LETTERS TO THE EDITOR
Plastic surgery in lymphedema treatment: a microsurgery perspective
Cirugía Plástica en el tratamiento del linfedema: una mirada desde la microcirugía
Christian José Arencibia Pagés 1*, https://orcid.org/0009-0008-1790-6331
1 Camagüey University of Medical Sciencies. Camagüey College of Medical Sciencies. Camagüey, Cuba.
*Corresponding author: arencibiapages@gmail.com
Received: 15/07/2025
Aceppted: 15/12/2025
How to cite this article: Arencibia-Pagés CJ. Plastic surgery in lymphedema treatment: a microsurgery perspective. MedEst. [Internet]. 2025 [cited access date]; 5:e377. Available in: https://revmedest.sld.cu/index.php/medest/article/view/377
Dear Director:
Lymphedema, affecting over 250 million people worldwide, represents a significant clinical and socioeconomic burden, particularly for cancer survivors. (1) While conservative therapies (e.g., compression and manual drainage) remain the cornerstone of lymphedema management, microsurgery, as a subspecialty of reconstructive plastic surgery, has recently opened doors to redefine the treatment paradigm. However, critical challenges persist regarding accessibility and standardization.
The data are compelling, lymphatic microsurgery has demonstrated superior efficacy in recent studies. Lymphovenous anastomoses (LVA), facilitated by indocyanine green (ICG) mapping, achieve 35-50 % volumetric reduction in treated limbs, with a 17-44 % decrease in cellulitis episodes. (2,3)
Current international literature confirms that vascularized lymph node transfer (VLNT) significantly improves quality of life and reduces limb volume in patients with secondary lymphedema. This procedure leads to substantial improvements in both physical functioning and psychological well-being, regardless of donor site. (4) Orthotopic VLNT has demonstrated efficacy in treating breast cancer-related lymphedema. (5)
These outcomes, once considered unattainable, are now reproducible with demonstrated efficacy and safety in the scientific literature. However, optimal patient selection remains crucial: while LVA requires functional lymphatic vessels, VLNT shows superior efficacy in established fibrosis.
Hybrid approaches are emerging as the standard in tertiary referral centers. The LVA + VLNT combination synergizes benefits, delivering both immediate edema reduction and sustained lymphatic regeneration. (2) Despite these advances, only a limited number of global centers offer lymphatic microsurgery, highlighting unacceptable disparities in comprehensive cancer care.
Active prevention represents the immediate future. Studies demonstrate that prophylactic VLNT during mastectomy reduces lymphedema incidence. (6) However, widespread implementation requires three fundamental pillars: standardized protocols based on multimodal staging (ICG + lymphoscintigraphy), specialized microsurgical training for plastic surgeons, and public funding to democratize techniques currently concentrated in elite centers.
In the author's opinion, there remains a need to integrate lymphatic microsurgery into healthcare systems as an essential component of cancer survivorship. Current evidence supports its role not as a last resort, but as an early intervention that alters the natural history of this condition.
BIBLIOGRAPHIC REFERENCES
1. Maita K, Garcia JP, Torres RA, Avila FR, Kaplan JL, Lu X, et al. Imaging biomarkers for diagnosis and treatment response in patients with lymphedema. Biomark Med [Internet]. 2022 [cited 06/07/2025];16(4):303–16. Available from: http://dx.doi.org/10.2217/bmm-2021-0487
2. Bonapace-Potvin M, Lorange E, Tremblay-Champagne M-P. Lymphaticovenous anastomosis and vascularized lymph node transfer for the treatment of lymphedema-A Canadian case series. Plast Surg (Oakv) [Internet]. 2024 [cited 06/07/2025];32(2):305–13. Available from: http://dx.doi.org/10.1177/22925503221120572
3. Lin C-H, Yamamoto T. Identification of lymph vessels using an indocyanine green camera-integrated operative microscope for lymphovenous anastomosis in the treatment of secondary lymphedema. J Vasc Surg Venous Lymphat Disord [Internet]. 2023 [cited 06/07/2025];11(1):161–6. Available from: http://dx.doi.org/10.1016/j.jvsv.2022.06.012
4. Grünherz L, Barbon C, von Reibnitz D, Gousopoulos E, Uyulmaz S, Giovanoli P, et al. Analysis of different outcome parameters and quality of life after different techniques of free vascularized lymph node transfer. J Vasc Surg Venous Lymphat Disord [Internet]. 2024 [cited 06/07/2025];12(6):101934. Available from: http://dx.doi.org/10.1016/j.jvsv.2024.101934
5. Lo Torto F, Kaciulyte J, Di Meglio F, Marcasciano M, Greco M, Ribuffo D. Orthotopic vascularized lymph node transfer in breast cancer-related lymphedema treatment: Functional and life quality outcomes. Microsurgery [Internet]. 2024 [cited 06/07/2025];44(2):e31147. Available from: http://dx.doi.org/10.1002/micr.31147
6. Ciudad P, Escandón JM, Manrique OJ, Gutierrez-Arana J, Mayer HF. Lymphedema prevention and immediate breast reconstruction with simultaneous gastroepiploic vascularized lymph node transfer and deep inferior epigastric perforator flap: A case report. Microsurgery [Internet]. 2022 [cited 06/07/2025];42(6):617–21. Available from: http://dx.doi.org/10.1002/micr.30939
STATEMENT OF AUTHORSHIP
CJAP: Conceptualization, formal analysis, investigation, methodology, visualization, writing – original draft, writing - review and editing.
CONFLICT OF INTERESTS
The author declares that there is no conflict of interests.
SOURCES OF FUNDING
The author did not receive funding for the development of this article.