Surgical Treatment Of Lymphedema Research Articles

The Full Continuum of Robotic Breast Surgery: Robotic-assisted Mastectomy, Robotic DIEP Flap, and Robotic Supermicrosurgery

Summary: In recent years, robotic surgery has rapidly expanded to improve surgical outcomes in a variety of surgical subspecialties. Although plastic surgery has taken longer to integrate robotic surgery into practice, the advantages of robotic-assisted surgery, including improved visualization and resolution, minimally invasive approaches, and the ability to surpass human precision and scale, have driven its more recent adoption into plastic surgery. Currently, procedures performed with robotic assistance that are considered part of the continuum of surgical treatment of breast cancer include robotic-assisted nipple-sparing mastectomy, reconstruction with the robotic latissimus dorsi flap or the deep inferior epigastric artery perforator flap, and robotic microsurgery for the flap anastomosis and/or the surgical treatment of lymphedema. The authors provide an overview of robotic surgery and how it has been integrated into the field of plastic surgery, as well as a review of the most common procedures within the field where robotic assistance can be incorporated: nipple-sparing mastectomy, robotic latissimus flap, robotic deep inferior epigastric artery perforator flap breast reconstruction, and microvascular anastomoses.

Optimizing Outcomes in Lymphedema Reconstruction.

After studying this article, the participant should be able to: 1. Describe current surgical techniques for treating primary and secondary lymphedema. 2. Optimize the surgical care of patients with lymphedema. Over the past decade, significant advances have been made in the surgical treatment of lymphedema. The most notable changes have been the reintroduction and evolution of physiologic techniques, including lymphovenous bypass-sometimes referred to as lymphovenous anastomosis in the literature-and vascularized lymph node transplant. These surgical modalities are now often used as first-line surgical options or may be combined with nonphysiologic approaches, including direct excision and suction-assisted lipectomy. Surgeons continue to debate the most appropriate sequence and combination of surgical treatment, particularly for patients at both extremes of the severity spectrum. Furthermore, debate remains around the need to apply different treatment approaches for patients with upper versus lower extremity involvement and primary versus secondary cause. In this article, we provide a summary of the surgical techniques currently used for both primary and secondary lymphedema and provide our recommendations for optimizing the surgical care of patients with lymphedema.

Combination of lymphovenous anastomosis and lymph node transfer for breast cancer-related lymphedema

With the remarkable advancement of microsurgery, surgical treatment for lymphedema has been increasing, and its good results are well established. However, surgical treatment for advanced-stage lymphedema is still a challenging task. We reviewed several methods of combining lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) in breast cancer-related lymphedema (BCRL) patients. Representative VLNT flap options for BCRL patients include the omental flap, superficial circumflex iliac perforator (SCIP) flap, and deep inferior epigastric artery (DIEA) flap combined with inguinal lymph nodes performed simultaneously with breast reconstruction. The surgical outcome, technical details, and donor site morbidities of each surgical option were reviewed. While all three options show significant surgical benefits, each has its clear advantages and disadvantages. The decision on the surgical method may vary according to the needs of each patient and the clinical situation.

Cross-Sectional Analysis of Insurance Coverage for Lymphedema Treatments in the United States

Lymphedema is a debilitating condition that affects approximately 1 in 1000 individuals in the United States. Complete decongestive therapy is currently the standard of care, and innovative surgical techniques have demonstrated potential to further improve outcomes. Despite the growing armamentarium of treatment options, a large proportion of patients with lymphedema continue to struggle because of limited access to care. To define the current state of insurance coverage for lymphedema treatments in the United States. A cross-sectional analysis of insurance reimbursement for lymphedema treatments in 2022 was designed. The top 3 insurance companies per state based on market share and enrollment data maintained by the Kaiser Family Foundation were included. Established medical policies were gathered from insurance company websites and phone interviews, and descriptive statistics were performed. Treatments of interest included nonprogrammable pneumatic compression, programmable pneumatic compression, surgical debulking, and physiologic procedures. Primary outcomes included level of coverage and criteria for coverage. This study included 67 health insurance companies representing 88.7% of the US market share. Most insurance companies offered coverage for nonprogrammable (n = 55, 82.1%) and programmable (n = 53, 79.1%) pneumatic compression. However, few insurance companies offered coverage for debulking (n = 13, 19.4%) or physiologic (n = 5, 7.5%) procedures. Geographically, the lowest rates of coverage were seen in the West, Southwest, and Southeast. This study suggests that in the United States, less than 12% of individuals with health insurance, and even fewer patients without health insurance, have access to pneumatic compression and surgical treatments for lymphedema. The stark inadequacy of insurance coverage must be addressed through research and lobbying efforts to mitigate health disparities and promote health equity among patients with lymphedema.

D37. Commercial Insurance Rates and Coding for Lymphedema Procedures: The Current State of Confusion and Need for Consensus

PURPOSE: Surgical treatment of lymphedema has outpaced coding paradigms. In the setting of ambiguity regarding coding for physiologic procedures [(lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT)], we hypothesized that there would be variation in commercial reimbursement based on coding pattern. METHODS: We performed a cross-sectional analysis of 2021 nationwide hospital pricing data for 21 Current Procedural Terminology (CPT) codes encompassing debulking (direct excision, liposuction), physiologic (LVB, VLNT), and ancillary (lymphangiography) procedures. Within-hospital ratios (WHRs) and across-hospital ratios (AHRs) for adjusted commercial rates per CPT code quantified price variation. Mixed effects linear regression modeled associations of commercial rate with public payer (Medicare and Medicaid), self-pay, and chargemaster rates. RESULTS: 270,254 commercial rates, including 95,774 rates for physiologic procedures, were extracted from 2,863 hospitals. Lymphangiography codes varied most in commercial price (WHR 1.76 - 3.89, AHR 8.12 - 44.38). For physiologic codes, WHRs ranged from 1.01 (VLNT; free omental flap) to 3.03 (LVB; unlisted lymphatic procedure), and AHRs ranged from 5.23 (LVB; lymphatic channel incision) to 10.36 (LVB; unlisted lymphatic procedure). Median adjusted commercial rates for debulking procedures ($3,635.84) were higher than for physiologic procedures ($2,560,40; p<0.001). Commercial rate positively correlated with Medicare rate for all physiologic codes combined, though regression coefficients varied by code. CONCLUSION: Commercial payer-negotiated rates for physiologic procedures were highly variable both within and across hospitals, reflective of variation in CPT codes. Physiologic procedures may be undervalued relative to debulking procedures. Consistent coding nomenclature should be developed for physiologic and ancillary procedures.

Commercial Insurance Rates and Coding for Lymphedema Procedures: The Current State of Confusion and Need for Consensus.

Surgical treatment of lymphedema has outpaced coding paradigms. In the setting of ambiguity regarding coding for physiologic procedures [lymphovenous bypass (LVB) and vascularized lymph node transplant (VLNT)], we hypothesized that there would be variation in commercial reimbursement based on coding pattern. The authors performed a cross-sectional analysis of 2021 nationwide hospital pricing data for 21 CPT codes encompassing excisional (direct excision, liposuction), physiologic (LVB, VLNT), and ancillary (lymphangiography) procedures. Within-hospital ratios (WHRs) and across-hospital ratios (AHRs) for adjusted commercial rates per CPT code quantified price variation. Mixed effects linear regression modeled associations of commercial rate with public payer (Medicare and Medicaid), self-pay, and chargemaster rates. A total of 270,254 commercial rates, including 95,774 rates for physiologic procedures, were extracted from 2863 hospitals. Lymphangiography codes varied most in commercial price (WHR, 1.76 to 3.89; AHR, 8.12 to 44.38). For physiologic codes, WHRs ranged from 1.01 (VLNT; free omental flap) to 3.03 (LVB; unlisted lymphatic procedure), and AHRs ranged from 5.23 (LVB; lymphatic channel incision) to 10.36 (LVB; unlisted lymphatic procedure). Median adjusted commercial rates for excisional procedures ($3635.84) were higher than for physiologic procedures ($2560.40; P < 0.001). Commercial rate positively correlated with Medicare rate for all physiologic codes combined, although regression coefficients varied by code. Commercial payer-negotiated rates for physiologic procedures were highly variable both within and across hospitals, reflective of variation in CPT codes. Physiologic procedures may be undervalued relative to excisional procedures. Consistent coding nomenclature should be developed for physiologic and ancillary procedures.

Practical Strategies in Reconstruction of Soft-Tissue Sarcoma.

After studying this article, the participant should be able to: 1. Discuss the natural history and pathophysiology of sarcoma. 2. Summarize the most up-to-date multidisciplinary management of soft-tissue sarcoma. 3. Provide a synopsis of reconstructive modalities based on anatomical location. 4. Highlight some novel strategies for treatment of lymphedema and phantom limb pain that are common sequelae following treatment and resection of soft-tissue sarcomas. The management of soft-tissue sarcoma presents unique challenges to the reconstructive surgeon. The optimal management mandates a multidisciplinary approach; however, reconstruction must take into account the extent of the resection and exposed vital structures, but often occurs in the setting of adjuvant treatments including chemotherapy and radiation therapy. Reconstruction is based on the extent of the defect and the location of the primary tumor. As such, an evidence-based, algorithmic approach following the reconstructive ladder is warranted to minimize the risks of complications and maximize success, which varies from head and neck to torso to breast to extremity sarcomas. Aside from reconstruction of the defect, advances in the surgical treatment of lymphedema and neuropathic pain resulting from treatment and extirpation of soft-tissue sarcoma are critical to maintain function and patients' quality of life.

A critical analysis of American insurance coverage for imaging and surgical treatment of lymphedema

BackgroundOver 35 million Americans have lymphedema. Nonetheless, lymphedema is underdiagnosed and undertreated worldwide. We investigated whether the rates of coverage for imaging and surgical procedures may contribute to the limited care provided for lymphedema. MethodsWe performed a cross-sectional evaluation of 58 insurers, chosen based on state enrollment and market share. A web-based search or phone call determined whether a publicly available policy on lymphedema-specific imaging, physiological procedures, and excisional procedures was available. Coverage status and corresponding criteria were extracted. ResultsOf the two-thirds of insurers who included a policy on imaging, 4% (n = 2) provided coverage and 4% (n = 2) specified coverage only on a case-by-case basis. Forty-eight percent (n = 28) of insurers had a statement of coverage on lymphovenous bypass or vascularized lymph node transfer, in which reimbursement was almost universally denied (96%, n = 26; 93%, n = 26). Liposuction and debulking procedures were included in 25 (43%) and 13 (22%) policies, in which seven (28%) and four (31%) insurers would provide coverage, with over 75% having criteria. Coverage of liposuction was significantly more than for lymphovenous bypass (P < .04). ConclusionsNearly one-half of American insurers do not have a publicly available policy on most imaging, physiological, or excisional procedures, leaving coverage status ambiguous. Reimbursement was uncommon for imaging and physiological procedures, whereas the majority of insurers who did offer coverage for excisional procedures also had multiple criteria to be met. These elements may together be a limiting factor in receiving appropriate care for lymphedema.

Advances in surgical treatment of lymphedema.

An estimated 250 million people worldwide suffer from lymphedema. In the past, the firstline option for treatment was nonsurgical management, either in the form of compression garments or wrapping, or comprehensive decongestive therapy, with debulking surgery reserved for the more advanced cases. However, with improvements in microsurgical techniques and imaging modalities, surgical intervention is increasingly being utilized. This review highlights recent advancements in the surgical treatment of lymphedema, specifically focusing on improvements in imaging, surgical techniques, and prevention of lymphedema.

The relationship between lymphedema severity and awareness of lymphedema surgery.

BackgroundDuring the early stages of lymphedema, active physiologic surgical treatment can be applied. However, lymphedema patients often have limited knowledge and misconceptions regarding lymphedema and surgical treatment. We analyzed the correlations between lymphedema severity and surgical technique according to patients’ awareness of surgical treatment for secondary upper extremity lymphedema (UEL).MethodsPatients with UEL diagnosed between December 2017 and December 2019 were retrospectively evaluated. At the time of their presentation to our hospital for the treatment of lymphedema, they were administered a questionnaire about lymphedema and lymphedema surgery. Based on the results, patients were classified as being aware or unaware of surgical treatment. Lymphedema severity was classified according to the arm dermal backflow (ADB) stage and the MD Anderson Cancer Center (MDACC) stage based on indocyanine green lymphography conducted at presentation. Surgical techniques were compared between the two groups.ResultsPatients who were aware of surgical treatment had significantly lower initial ADB and MDACC stages (P<0.05) and more frequently underwent physiologic procedures than excisional procedures (P=0.003).ConclusionsIf patients are actively educated regarding surgical treatment of lymphedema, physiologic procedures may be performed during the early stages of UEL.

Abstract PS9-35: Volumetric assessment of lymphedema with 3D sensor

Abstract Volumetric assessment of lymphedema with 3D sensor: A new practical method Secondary lymphedema of the upper extremities is an important quality-of-life issue for around 40% of patients who were treated for breast cancer and required axillary nodal dissection and radiotherapy. Volume measurement is an important aspect of diagnosis, follow up, and evaluation after conservative or surgical treatment for lymphedema. Until now, there have been complex techniques to assess volume of affected limbs: bioimpedance, liquid-displacement volumetry, CT, MRI. There is a need for a practical method of volumen assessment in lymphedema patients. The objective of the present study is to confirm whether or not 3D scanning for volumetric assessment is useful and correlates with direct perimeter measurement and indirect volume calculation. Methods: A 3D sensor (Structure Sensor, Occipital Inc) mounted on an Ipad (Apple, Inc.) was used to make a 3D model file of the affected limb, that was later analyzed by 3DsizeME software (TechMed 3D, Inc.) in a desktop computer. 3D model analysis allows to measure perimeters and volumes. Fifteen patients were measured, lymphedema and normal limbs (30 extremities) by this technique and were also measured with tape, as traditional method; results were compared to assess correlation. Results: There were not statistical difference between the two techniques (p 0.05). Table attached. Discussion: volumetric assessment by 3D sensor allows consistent and reproducible measurements. It is practical as we only need the space of an ipad, it can be performed in the clinic visit, by any doctor, nurse or physical therapist. It is not expensive, as the software charges US$10 by each analysis. It do not expose the patient to any harmful radiation, as is obtained by and infrared camera. Allows electronic records of all measurements. Average time to capture 3D model is 5 minutes. We think this new method is a valuable tool for any lymphedema clinic as volume measurement is important for disease evaluation and now, more important, with a growing field of surgical treatment for this disease. Citation Format: Alejandro Maciel-Miranda, Miriam I Otero-Hernández, Darinka Martínez-Silva, Jesus F Escrivá-Machado. Volumetric assessment of lymphedema with 3D sensor [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS9-35.

Surgical Treatment Options of Breast Cancer-Related Lymphedema

Lymphedema after cancer treatment is a progressive, debilitating condition that is becoming increasingly common as mortality rates decline. The purpose of this review is to summarize the evolution of treatment of lymphedema focusing on surgical management and outcomes. With the development of supermicrosurgical techniques and advanced imaging technology, surgical treatment of lymphedema has evolved past reductive measures and sought to address the underlying pathophysiology. Particularly in breast cancer-related lymphedema, our group follows a novel algorithm to address both the autologous breast reconstruction with physiologic treatment of the affected extremity. Patients and physicians alike should be educated about the risk factors for developing lymphedema after cancer treatment, prompt and proper diagnosis, as well as conservative and surgical treatment options. While the optimal treatment algorithm remains to be elucidated, a multi-modality treatment approach has demonstrated promising outcomes in symptom improvement, volume reduction, and quality of life.

Surgical Approaches to the Prevention and Management of Breast Cancer–Related Lymphedema

Upper extremity lymphedema is a much-feared complication of breast cancer treatment leading to significant impairments in patients’ quality of life. The mainstay of treatment for this debilitating chronic disease has been non-surgical modalities, namely complete decongestive therapies. Surgical treatment of lymphedema has emerged as an option for patients who have exhausted these conservative measures and consists of both physiologic procedures (vascularized lymph node transplant and lymphovenous bypass) which aim to reduce the burden of lymphatic fluid and reductive procedures to remove excess soft tissue. Opinions vary among surgeons regarding the appropriate surgical indications in patients with different stages of lymphedema for each type of surgery, as well as the optimal donor site for lymph node transplant, and recent studies are beginning to address these questions. Additionally, there is growing data regarding the benefits of preventative lymphatic surgery at the time of axillary lymph node dissection, as well as the cost effectiveness of this approach. Surgical approaches for the prevention and treatment of breast cancer–related lymphedema are gaining popularity as a means of improving patients’ quality of life. There is an expanding body of literature demonstrating the effectiveness of these surgical procedures in terms of reduction in arm circumference, decreased cellulitis incidence, and overall quality of life, as well as emerging evidence of their cost effectiveness.

MICROSURGICAL LYMPHATIC VASCULAR GRAFTING AND SECONDARY LIPOSUCTION: RESULTS OF COMBINATION TREATMENT IN SECONDARY LYMPHEDEMA

Surgical treatment of lymphedema with liposuction typically requires subsequent compression therapy. Here we describe an approach where secondary arm lymphedemas are initially treated by autologous lymphatic grafting to bypass the axilla and restore lymphatic flow. In the presence of excess adipose tissue, liposuction is then performed in a second procedure. To assess outcomes, the authors evaluated 28 consecutive adult patients who had undergone secondary liposuction following lymphatic grafting. Arm volumes were measured prior to lymphatic grafting and after the secondary liposuction. The necessity for additional treatment by compression garment and manual lymphatic drainage was assessed prior to lymphatic grafting and after the secondary liposuction following the direct postoperative regimen. The mean arm volumes were reduced significantly (p<0.001) from a mean of 3417± 171 (SEM) cm3 prior to lymphatic grafting to 3020±125 cm3 after reconstruction of the lymphatic vascular system and finally to 2516±104 cm3 after the secondary liposuction (SLS). All 28 adult patients underwent continuous compression and manual lymph-drainage (MLD) prior to the reconstructive surgery. All 28 patients were evaluated regarding necessity of any additional therapy more than 6 months after SLS with a median follow up period of 37 months (range, 7-160 months). 18 of 28 patients did not require any supportive therapy beyond 6 months after SLS to maintain the results. Three patients continued to utilize manual lymphatic drainage, 4 used a combination of MLD and compression therapy and 3 used elastic compression therapy (one patient only while at work). These results indicate that microsurgical restoration of lymphatic outflow followed by SLS eliminates the need for additional treatment in more than two thirds of patients.

Surgical management of lymphedema: a review of current literature

Lymphedema may be characterized by a progressive clinical course and limitations in improvement despite multi-modality treatment. In westernized countries, it most commonly presents as an undesirable complication of cancer treatment, particularly breast cancer. In the past several decades, surgical treatments for lymphedema have advanced, alongside developments in microsurgery. Lymphovenous anastomosis (LVA) and lymph node transplantation are physiological therapies that may reduce lymphedema through addressing its route cause. Ablative techniques such as liposuction and subcutaneous excision aid in resolving the accumulation of proteinaceous adipose and fibrotic tissue seen in advanced lymphedema. The goal of this review is to examine the outcomes and limitations of current surgical techniques used in lymphedema management.

Lymph node transfer combined with deep inferior epigastric perforators and transverse rectus abdominis myocutaneous procedures: a systematic review.

The surgical treatment of lymphedema can be conducted alone or in combination with microsurgical autologous breast reconstruction. We performed a systematic review of the literature at PubMed database regarding autologous breast reconstruction for deep inferior epigastric perforators (DIEP) or muscle-sparing transverse rectus abdominis myocutaneous (ms-TRAM) and vascularized lymph node transfer (VLNT) in patients with lymphedema following breast cancer surgery. We hypothesized that autologous breast reconstruction combined with VLNT has positive outcomes. Eligibility criteria included investigations reporting data studies evaluating female patients with lymphedema in an upper extremity after breast cancer who underwent autologous breast reconstruction combined with VLNT. The search resulted in 93 potential papers, but only 6 studies fulfilled the study eligibility criteria. The total number of patients was 103. Most of the studies evaluated the outcomes in patients treated with DIEP or ms-TRAM combined with VLNT. The studies described groin lymph node transfer as treatment for lymphedema. In most of the studies, all patients reported a reduction of arm circumference, volume, and symptoms of the upper extremity with lymphedema comparing the preoperative to the postoperative period. Overall, patients experienced successful breast reconstruction. All authors reported reduction of the circumferential size of the affected upper limb, as well as a decrease in cellulitis, in addition to favorable breast reconstruction results.

Controversies in Surgical Management of Lymphedema.

Summary:Surgical treatment of lymphedema has expanded in recent years. Lymphovenous bypass and vascularized lymph node transfer are both modern techniques to address the physiologic dysfunction associated with secondary lymphedema. While efficacy of both techniques has been demonstrated in numerous studies, there are several questions that remain. Here, the authors discuss the most pertinent controversies in our practice as well as the current state of surgical management of lymphedema.

Systematic Review of Patient-Reported Outcomes following Surgical Treatment of Lymphedema.

Introduction: Analysis of quality of life (QOL) outcomes is an important aspect of lymphedema treatment since this disease can substantially impact QOL in affected individuals. There are a growing number of studies reporting patient-reported outcomes (PROMs) for patients with lymphedema. The purpose of this study was to conduct a systematic review of outcomes and utilization of PROMs following surgical treatment of lymphedema. Methods: A literature search of four databases was performed up to and including March, 2019. Studies included reported on QOL outcomes after physiologic procedures, defined as either lymphovenous bypass (LVB) or vascularized lymph node transplant (VLNT), to treat upper and/or lower extremity primary or secondary lymphedema. Results: In total, 850 studies were screened—of which, 32 studies were included in this review. Lymphovenous bypass was the surgical intervention in 16 studies, VLNT in 11 studies, and both in 5 studies. Of the 32 total studies, 16 used validated survey tools. The most commonly used PROM was the lymph quality of life measure for limb lymphedema (LYMQOL) (12 studies). In the remaining four studies, the upper limb lymphedema 27 scale (ULL27), the short form 36 questionnaire (SF-36), the lymphedema functioning, disability and health questionnaire (Lymph-ICF), and lymphedema life impact scale (LLIS) were each used once. QOL improvement following surgical treatment was noted in all studies. Conclusions: Physiologic surgical treatment of lymphedema results in improved QOL outcomes in most patients. The use of validated PROM tools is increasing but there is no current consensus on use. Future research to evaluate the psychometric properties of PROMs in lymphedema is needed to guide the development and use of lymphedema-specific tools.

The Charles Procedure as Part of the Modern Armamentarium Against Lymphedema.

Over the past 2 decades, the surgical treatment of lymphedema has advanced considerably with lymphovenous bypass and vascularized lymph node transfer. Despite these advances, some patients can only be treated with a radical debulking procedure, commonly known as Charles procedure. However, the Charles procedure is not a commonly performed procedure and can have significant risks such as fluid shifts, blood loss and wound infections. In this article, we present our experience with Charles procedure and share pearls to perform this procedure expediently while avoiding potential pitfalls. Patients with severe lymphedema who were treated by the senior author with Charles procedure were evaluated. The medical record was queried for their pertinent medical history, including cause of lymphedema, prior treatments for the condition, medical comorbidities and preoperative and postoperative course. The surgical technique and lessons learned from each case are described. Three patients were identified within the study period who underwent treatment with the Charles procedure. All patients had secondary lower extremity lymphedema. All patients had single-stage direct excision and skin grafting. One patient required postoperative ICU stay due to significant fluid shifts and blood loss, another suffered from a wound infection. All 3 patients ultimately recovered to exceed their preoperative activity levels with satisfactory outcomes. The Charles procedure continues to have clinical utility in modern lymphedema treatment. Despite potential risks, it can be done successfully with proper planning and careful attention to technical details; it can be life changing for patients suffering from most extreme lymphedema.

Surgical Treatment of Lymphedema.

Lymphedema affects up to 250 million people worldwide. The understanding of the pathophysiology of the condition, however, is incomplete and a cure remains elusive. A growing body of evidence supports the effectiveness of modern surgical techniques in ameliorating the long-term disability and functional impairment inflicted by lymphedema on the lives of those affected. These procedures can be broadly categorized as physiologic, including lymphovenous bypass and using a vascularized lymph node transplant; or de bulking, by suction-assisted lipectomy or direct excisional procedures. The lymphovenous bypass procedure involves identification of obstructed lymphatic vessels and targeted bypass of these into neighboring venules. The vascularized lymph node transplant procedure involves microvascular anastomosis of functional lymph nodes into an extremity, either to an anatomical (orthotopic) or nonanatomical (heterotopic) location, to restore physiologic lymphatic function. In patients undergoing postmastectomy breast reconstruction, this may be performed by transferring a deep inferior epigastric artery perforator flap with a chimeric groin lymph node flap. For patients that have undergone breast-conserving surgery, in those for whom a free abdominal flap is contraindicated, or for those with lymphedema affecting the lower extremity, many other vascularized lymph node transplant options are available; these include flaps harvested from within the axillary, inguinal, or cervical lymph node basins, or from within the abdominal cavity. Chronic lymphedema is characterized by fibroadipose soft-tissue deposition that can only be removed by lipectomy, either minimally invasively using liposuction, or by direct excision. This article reviews the techniques and outcomes of surgical procedures used to treat lymphedema.