Plastic surgery in lymphedema treatment: a microsurgery perspective

Resumen

Lymphedema, which affects more than 250 million people worldwide, represents a significant clinical and socioeconomic burden, especially for cancer survivors. While conservative management remains essential, microsurgery, as a discipline within reconstructive plastic surgery, has emerged, redefining the therapeutic paradigm. Current scientific evidence demonstrates the superior efficacy of these techniques. Lymphovenous anastomoses (LVAs), performed with the aid of indocyanine green mapping, achieve a 35-50% volume reduction in the extremities and significantly decrease cellulitis episodes. Meanwhile, vascularized lymph node transfer (VLNT) substantially improves quality of life and reduces edema volume in secondary lymphedema, including that associated with breast cancer. Hybrid approaches, combining LVA and VLNT, are becoming established as standard practice in referral centers, synergizing the immediate reduction of edema with long-term lymphatic regeneration. Beyond treatment, prophylactic VLNT during oncological surgeries, such as mastectomy, stands out as a promising strategy for the active prevention of lymphedema. However, the author identifies critical challenges that limit its impact: restricted accessibility to a limited number of tertiary centers, the need for standardized protocols based on multimodal staging, and the urgent demand for specialized microsurgical training and public funding. In conclusion, it is considered necessary to integrate lymphatic microsurgery into healthcare systems not as a last resort, but as an early and essential intervention that modifies the natural course of this condition, thus democratizing high-quality care.