Vascularized Lymph Node Transplantation Research Articles

74. Four Year Prospective Outcomes Following Vascularized Lymph Node Transplant (VLNT)

74. Four Year Prospective Outcomes Following Vascularized Lymph Node Transplant (VLNT)

Vascularized omental tissue transfer for the treatment of lymphedema: a review

Lymphedema is a debilitating disorder caused by impaired drainage of the lymphatic system. In the Western world, lymphedema most often arises secondary to the treatment of malignancy. Patients with lymphedema experience progressive swelling, pain, numbness, and tingling, and decreased quality of life. Those with persistent symptoms may be subject to chronic cellulitis. The advent of microsurgery has enabled clinicians to transplant donor lymph nodes and their blood supply from a healthy site to the affected area in a procedure known as vascularized lymph node transplant (VLNT). One donor region is the omentum. Vascularized omental lymph node transfer (VOLT) has been shown to decrease limb volume, circumference, and subjective symptoms of lymphedema. The immunologic properties of the omentum make it a particularly useful lymph node donor site for patients with lymphedema-related cellulitis. The omentum may be harvested laparoscopically, with robotic assistance, or through a small laparotomy incision. In this review, we describe the relevant anatomy and history of VOLT as well as operative techniques. The risks, benefits, and relevant outcome studies will be reviewed. Recent applications of robotic surgery to VOLT will be addressed.

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.

1819. The Impact of Vascularized Lymph Node Transplant in Reducing the Rate of Cellulitis in Patients with Breast Cancer–Related Lymphedema

Abstract Background Lymphedema following breast cancer surgery is a chronic and disabling complication that may lead to recurrent cellulitis. Innovative advances in treatment of breast cancer–related lymphedema have evolved beyond conservative management to include vascularized lymph node transplant (VLNT). Herein, we analyzed the impact of VLNT in reducing the rate of upper extremity cellulitis in breast cancer survivors. Methods The charts of all patients who had breast cancer and mastectomy, whose course was complicated by upper extremity lymphedema, and who ultimately underwent VLNT at our comprehensive cancer center from 2017 to 2021 were reviewed. Patients who had at least one episode of cellulitis within the year prior to VLNT and were followed for 24 months were included. Thereafter, we reviewed patients’ demographics, cancer management, breast reconstructive procedures, VLNT surgeries, and infectious complications. Results We included 66 patients in our study. Their median age was 57 years (IQR, 23-76 years) (Table 1). The majority were White (88%), with a mean (± SD) body mass index of 29.4 ± 6.7 kg/m2. Most patients had invasive ductal carcinoma (82%) and received chemotherapy (94%), including taxane-based regimens (85%), which increases the risk for lymphedema. Also, most patients received radiation therapy (86%), including to the axillary nodal basin (92%). Furthermore, most underwent unilateral mastectomy (74%) with axillary lymph node dissection (95%) followed by autologous or implant-based reconstruction (both 42%) (Table 2). VLNT was performed at a median of 92 months (IQR, 32-156 months) after mastectomy and were mainly harvested from the inguinal and gastroepiploic regions (both 32%). After VLNT, 58 (88%) patients remained infection-free throughout the 24-month follow-up period. The only factor associated with recurrent cellulitis was the need for a second lymph node transfer or lymphovenous bypass surgery, likely owing to a significant lack of lymphedema reduction (p=0.006). Conclusion The novel approach of VLNT in the management of breast cancer–related lymphedema is associated with significantly decreased recurrent cellulitis rates and should be considered as part of the infectious diseases treatment armamentarium. Disclosures All Authors: No reported disclosures

Pre- and Post-Microsurgical Rehabilitation Interventions and Outcomes on Breast Cancer-Related Lymphedema: a Systematic Review.

Breast cancer-related lymphedema (BCRL) is a debilitating progressive disease resulting in various impairments and dysfunctions. Complete decongestive therapy embodies conservative rehabilitation treatments for BCRL. Surgical procedures performed by plastic and reconstructive microsurgeons are available when conservative treatment fails. The purpose of this systematic review was to investigate which rehabilitation interventions contribute to the highest level of pre- and post-microsurgical outcomes. Studies published between 2002 and 2022 were grouped for analysis. This review was registered with PROSPERO (CRD42022341650) and followed the PRISMA guidelines. Levels of evidence were based upon study design and quality. The initial literature search yielded 296 results, of which, 13 studies met all inclusion criteria. Lymphovenous bypass anastomoses (LVB/A) and vascularized lymph node transplant (VLNT) emerged as dominant surgical procedures. Peri-operative outcome measures varied greatly and were used inconsistently. There is a dearth of high quality literature leading to a gap in knowledge as to how BCRL microsurgical and conservative interventions complement each other. Peri-operative guidelines are needed to bridge the knowledge and care gap between lymphedema surgeons and therapists. A core set of outcome measures for BCRL is vital to unify terminological differences in the multidisciplinary care of BCRL. Complete decongestive therapy embodies conservative rehabilitation treatments for breast cancer-related lymphedema (BCRL). Surgical procedures performed by microsurgeons are available when conservative treatment fails. This systematic review investigated which rehabilitation interventions contribute to the highest level of pre- and post-microsurgical outcomes. Thirteen studies met all inclusion criteria and revealed that there is a dearth of high quality literature leading to a gap in knowledge as to how BCRL microsurgical and conservative interventions complement each other. Furthermore, peri-operative outcome measures were inconsistent. Peri-operative guidelines are needed to bridge the knowledge and care gap between lymphedema surgeons and therapists.

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.

D30. Immediate Lymphatic Reconstruction (ILR) with Vascularized Lymph Node Transplant (VLNT)

PURPOSE: Patients undergoing exanteration of axillary/groin lymph nodes and radiation are at risk not only for lymphedema but painful contracture and limited range of motion (ROM). Traditional immediate-lymphatic-reconstruction (ILR) addresses the lymphatic defect but not the soft tissue one. The purpose of this study was to evaluate the safety and efficacy of ILR with a vascularized-omentum-lymphatic-transplant (VOLT) to reduce the risk of both contracture and lymphedema development in patients with extensive disease. METHODS: Patients with an overwhelming risk of developing severe lymphedema and contracture were offered VOLT at the time of axillary/groin dissection at a tertiary-cancer-center between 2016 to 2021. Demographic data, volume-measurements, Quality-of-Life scores, and cellulitis episodes were recorded. RESULTS: A total of eight patients underwent ILR with VOLT at the time of axillary (n=4)/groin (n=4) dissection. No complications were observed (0%). The mean follow-up time was 30.7±12 months. Three patients (37.5%) developed lymphedema. One patient (12.5%) experienced one episode of cellulitis. Limited ROM during abduction was reported by 3 patients (37.5%). The mean Lymphedema-Life-Impact-Scale (LLIS) scores after surgery reflected minimal Quality-of-Life impairment globally (7.6±14.4%), physically (2.6±4.6%), psychologically (1.2±2.8%) and functionally (1.3±2.3%). CONCLUSION: This is the first study to report ILR with VOLT. VOLT is a safe and reliable option for immediate-reconstruction of the highest-risk patient group who are almost certain to develop not only lymphedema but severe contracture and functional disability. While larger studies are required to better determine indications and outcomes, it is preferable to replace soft-tissue prior to radiation to mitigate pain and contracture.

43. A Decade of Vascularized Lymph Node Transplant (VLNT) for the Treatment of Lymphedema: A Meta-analysis of Prospective Clinical Trials

43. A Decade of Vascularized Lymph Node Transplant (VLNT) for the Treatment of Lymphedema: A Meta-analysis of Prospective Clinical Trials

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.

Diagnosis and Treatment of Post-Prostatectomy Lymphedema: What’s New?

Lymphedema is a chronic progressive disorder that significantly compromises patients' quality of life. In Western countries, it often results from cancer treatment, as in the case of post-radical prostatectomy lymphedema, where it can affect up to 20% of patients, with a significant disease burden. Traditionally, diagnosis, assessment of severity, and management of disease have relied on clinical assessment. In this landscape, physical and conservative treatments, including bandages and lymphatic drainage have shown limited results. Recent advances in imaging technology are revolutionizing the approach to this disorder: magnetic resonance imaging has shown satisfactory results in differential diagnosis, quantitative classification of severity, and most appropriate treatment planning. Further innovations in microsurgical techniques, based on the use of indocyanine green to map lymphatic vessels during surgery, have improved the efficacy of secondary LE treatment and led to the development of new surgical approaches. Physiologic surgical interventions, including lymphovenous anastomosis (LVA) and vascularized lymph node transplant (VLNT), are going to face widespread diffusion. A combined approach to microsurgical treatment provides the best results: LVA is effective in promoting lymphatic drainage, bridging VLNT delayed lymphangiogenic and immunological effects in the lymphatic impairment site. Simultaneous VLNT and LVA are safe and effective for patients with both early and advanced stages of post-prostatectomy LE. A new perspective is now represented by the combination of microsurgical treatments with the positioning of nano fibrillar collagen scaffolds (BioBridgeTM) to favor restoring the lymphatic function, allowing for improved and sustained volume reduction. In this narrative review, we proposed an overview of new strategies for diagnosing and treating post-prostatectomy lymphedema to get the most appropriate and successful patient treatment with an overview of the main artificial intelligence applications in the prevention, diagnosis, and management of lymphedema.

Spotlight in Plastic Surgery: April 2023.

Spotlight in Plastic Surgery: April 2023.

Real-time Navigation for Vascularized Lymph-node Transplantation Using Projection Mapping with Indocyanine Green Fluorescence.

The medical imaging projection system (MIPS) is a real-time surgical navigation device using indocyanine green (ICG) emission signals and active projection mapping. The difference between the object and the projected image is within 1 mm, and the time lag is within 0.1 seconds. We herein report the application of the MIPS to vascularized lymph-node transplantation (VLNT) surgery for lower extremity lymphedema to detect inguinal lymph nodes and perform color-coded navigation surgery for lymph-node resection. A left superficial inguinal lymph node was planned to be used as a donor for VLNT to the right lower leg in a 73-year-old woman with lower extremity lymphedema. Under general anesthesia, multiple intradermal injections of 0.1 ml of ICG were administered around the left inguinal donor site. The MIPS showed a clear linear projection image from a lateral injected point connecting to a lateral superficial inguinal lymph node. The left superficial circumflex iliac artery and vein were dissected for vascularized VLNT. Intraoperative real-time MIPS navigation continuously guided the transection plane colored by ICG fluorescence signals without shifting the visual focus from the surgical field. This is the first report of the intraoperative use of ICG projection mapping for VLNT donor-site surgery. The MIPS was able to visualize functional lymph nodes to facilitate minimally invasive donor-site surgery.

Indications for selective lymphadenectomy and systematic axillary, inguinal and iliac lymph node dissection

Lymphadenectomy is asurgical procedure in which lymph nodes are surgically resected. It is usually carried out for oncological surgical treatment of various malignant diseases. These include carcinomas of the breast, penis, vulva and anus as well as malignant melanomas and the broad field of sarcomas. Adistinction is made between the removal of regional lymph nodes, the sentinel lymph node and the radical removal of lymph nodes in abody region. Cervical, axillary, inguinal and iliac lymph nodes are clinically relevant. The strategy of sentinel lymph node dissection, in which the first lymph node in the drainage system is resected and histopathologically examined for malignant tissue, has brought decisive advantages for the patients, as radical lymphadenectomy with its severe morbidities is utilized in fewer cases. This can improve the patient's quality of life by sparing the lymphatic drainage pathways and reducing lymphedema, inflammation and wound healing disorders. In addition, alymphadenectomy may be indicated as part of palliative interventions. Another form of lymph node removal is the vascularized lymph node transplantation, which is used for reconstructive purposes in lymphedema. Therefore lymph node grafts are transferred to the site where lymph nodes were previously removed. This review presents the current status of lymphadenectomy in accordance with the German guidelines, anatomical knowledge and specific indications for axillary, inguinal and iliac lymphadenectomy. In addition, an overview of vascularized lymph node transfer is given.

Single-Photon Emission Computed Tomographic Reverse Lymphatic Mapping for Groin Vascularized Lymph Node Transplant Planning.

Superficial inguinal (groin) vascularized lymph node transplantation is the most common option for the treatment of lymphedema, particularly in combination with free abdominal flap breast reconstruction. This study examines the utility of single-photon emission computed tomographic (SPECT/CT) lymphoscintigraphy for lower extremity reverse lymphatic mapping in presurgical planning for groin vascularized lymph node transplantation and appraises the physiologic lymphatic drainage to the superficial inguinal lymph nodes. All patients who underwent bilateral lower extremity SPECT/CT reverse lymphatic mapping over a 5-year period were included. Retrospective case note analysis was performed to collect demographic, surgical, and outcomes data. The study included 84 patients; 56 of these subsequently underwent groin vascularized lymph node transplantation (58 flaps). Fifty-four of these flaps were combined with free abdominal flaps for breast reconstruction (55 flaps). Using SPECT/CT reverse lymphatic mapping investigation of 168 inguinal regions, drainage to at least one superficial inguinal region was visualized in 38.1 percent of patients; in 13.1 percent, drainage was visualized to both superficial inguinal regions. Using this information for presurgical planning, groin vascularized lymph node flap harvest was performed from the contralateral side in 57 of 58 cases (98.3 percent) using intraoperative gamma probe guidance, and no patient developed donor lower extremity lymphedema during follow-up (mean ± SD, 34.5 ± 15.4 months). The authors' use of presurgical SPECT/CT reverse lymphatic mapping together with limited flap dissection and intraoperative gamma probe guidance resulted in no clinical cases of iatrogenic donor lower extremity lymphedema. The high incidence of drainage from the lower extremity to the superficial inguinal region mandates the use of reverse lymphatic mapping when performing groin vascularized lymph node transplantation. Therapeutic, IV.

A Prospective Study on the Safety and Efficacy of Vascularized Lymph Node Transplant.

While vascularized lymph node transplant (VLNT) has gained popularity, there are a lack of prospective long-term studies and standardized outcomes. The purpose of this study was to evaluate the safety and efficacy of VLNT using all available outcome measures. This was a prospective study on all consecutive patients who underwent VLNT. Outcomes were assessed with 2 patient-reported outcome metrics, limb volume, bioimpedance, need for compression, and incidence of cellulitis. There were 89 patients with the following donor sites: omentum (73%), axilla (13%), supraclavicular (7%), groin (3.5%). The mean follow-up was 23.7±12 months. There was a significant improvement at 2 years postoperatively across all outcome measures: 28.4% improvement in the Lymphedema Life Impact Scale, 20% average reduction in limb volume, 27.5% improvement in bioimpedance score, 93% reduction in cellulitis, and 34% of patients no longer required compression. Complications were transient and low without any donor site lymphedema. VLNT is a safe and effective treatment for lymphedema with significant benefits fully manifesting at 2 years postoperatively. Omentum does not have any donor site lymphedema risk making it an attractive first choice.

QS33. Long-term Prospective Safety and Efficacy of Vascularized Lymph Node Transplant (VLNT)

QS33. Long-term Prospective Safety and Efficacy of Vascularized Lymph Node Transplant (VLNT)

QS5. Dual Fluorescent Tracers for Reverse Lymphatic Mapping and Surgical Guidance: Preventing Donor Site Associated Lymphedema in Vascularized Lymph Node Transplant Surgery

Purpose: Vascularized lymph node transfer (VLNT) helps to restore physiological lymphatic function. Although effective, postoperative impairment of donor-site lymphatic function and iatrogenic lymphedema following lymph node transfer from the groin remains a pressing concern. Methods: Prospective analysis of VLNT patients that had undergone radioisotope-free dual fluorescent tracer assisted harvest was performed at our institution from September 2013 to August 2020. Reverse lymphatic mapping of the lower extremity was performed with indocyanine green (ICG). Blue dye was utilized in both white light and near infrared spectra for visualization and localization of donor site lymphatic structures. Demographics, intraoperative details, and surgical outcomes were recorded. Results: Twenty-five patients were included. Median age was 52.9 years (34 to 77 years) with a BMI of 29.1 kg/m2 (22.2 to 36.9 kg/m2) and mean follow-up of 2 years and 5 months (6 months to 5.6 years). Lymphedema stage ranged from Campisi 2 to 4. Inguinal VLNT was performed in 13 patients, and 12 patients received VLNT combined with free flap breast reconstruction. No patients required change in lymph node donor site intraoperatively. All ICG stained nodes were able to be preserved in situ. No signs or symptoms of iatrogenic lower extremity lymphedema were observed during the follow-up period. The donor site of the lymph node flap healed appropriately in 23 patients (92%). Methylene blue-induced skin necrosis occurred in one patient and required surgical treatment. Conclusion: Reverse lymphatic mapping and surgical guidance with dual ICG and blue dye fluorescent tracers is a safe, effective innovation for VLNT harvest. This technique promotes a favorable donor site morbidity profile and prevents iatrogenic donor site-associated lymphedema.

Outcomes and Technical Modifications of Vascularized Lymph Node Transplantation From the Lateral Thoracic Region for Treatment of Lymphedema

Surgical treatment of both primary and secondary lymphedema using vascularized lymph node transplantation (VLNT) resulted in significant progressive reduction in limb volume (upper and lower), decreased episodes of cellulitis, and improvements in life impact scores.

Physical and Functional Outcomes of Simultaneous Vascularized Lymph Node Transplant and Lymphovenous Bypass in the Treatment of Lymphedema.

The authors analyze the outcomes of simultaneous vascularized lymph node transplant and lymphovenous bypass for treatment of primary and secondary lymphedema. To the best of their knowledge, this is the largest study to date with long-term outcome data of this novel approach. Three hundred twenty-eight patients who underwent physiologic surgical treatment over a 5.5-year period were evaluated using a prospective database and chart review. Preoperative characteristics, operative details, and postoperative outcomes (volume difference change, Lymphedema Life Impact Scale score) were assessed. Statistical analysis including multivariate regression was performed. Two hundred twenty patients (67.1 percent) underwent simultaneous vascularized lymph node transplant and lymphovenous bypass. Mean body mass index was 26.9 ± 4.7 kg/m 2 . Ninety-two patients (41.8 percent) had lymphedema of the lower extremity, 121 (55.0 percent) had upper extremity involvement, and seven had lymphedema of upper and lower extremities (3.2 percent). Average duration of lymphedema was 95.4 ± 103.6 months. Thirty patients (13.6 percent) had primary lymphedema and 190 patients (86.4 percent) had secondary lymphedema. The majority improved and experienced volume reduction of an average 21.4 percent at 1 year ( p < 0.0001), 36.2 percent at 2 years ( p < 0.0001), 25.5 percent at 3 years ( p = 0.1), and 19.6 percent at 4 years. Median Lymphedema Life Impact Scale scores were 7.0 points lower ( p < 0.0001) at 3 months and improved progressively over time to 27.5 points lower at 3 years postoperatively ( p < 0.005). Simultaneous vascularized lymph node transplant and lymphovenous bypass is an appropriate and effective approach for both early and advanced stages of primary and secondary lymphedema, with significant objective and subjective improvements. Volume reduction in the affected limb was observed at all time points postoperatively, with significant improvement in Lymphedema Life Impact Scale scores. Therapeutic, III.

2. LONG-TERM PROSPECTIVE SAFETY AND EFFICACY OF VASCULARIZED LYMPH NODE TRANSPLANT (VLNT)

PURPOSE: Despite the increasing popularity of vascularized lymph node transplant (VLNT), there is lack of prospective long-term outcomes data and standardized outcome metrics, specifically following Vascularized Omentum Lymphatic Transplant (VOLT). The purpose of this IRB-approved prospective study was to evaluate the long-term outcomes of VLNT using a comprehensive set of outcome measures. METHODS: All patients underwent VLNT at our institution between November 2014 and July 2020. Demographic data, volume measurements, bio-impedance scores, Quality of Life scores and cellulitis episodes were recorded. RESULTS: A total of 89 patients with a mean follow-up time of 23.7±12 months were included. Donor sites consisted of the omentum (73%), axilla (13%), supraclavicular (7%), groin (3.5%), and others. 20% decrease (p=0.0239) in volume differential, and 27.5% decrease (p=0.0398) in L-DEX scores were recorded 2 years after VLNT. A significant improvement in Lymphedema Life Impact Scale (LLIS) scores manifested as 28.4% decrease (p=0.0398) was recorded 2 years after treatment. In addition, VLNT dramatically decreased the total number of cellulitis episodes by 93% (p=0.0008) 1 year after treatment as well as the average number of episodes per year (84.5% decrease, p=0.0002). No cases of donor site lymphedema were recorded (0%). CONCLUSION: This prospective study demonstrated satisfactory reduction in limb volume, bioimpedance, and improved quality of life. This is the largest long-term prospective study of VOLTs in comparison to most studies evaluating peripheral VLNT. VOLT is a reliable alternative to peripheral VLNT with no risk of donor site lymphedema and particularly significant impact in reducing the incidence of cellulitis.