Modern approaches to lymphatic surgery: a narrative review.

Background and Objective: Lymphedema is a chronic, progressive disease secondary to damage to the lymphatic system that results in interstitial fluid accumulation, fat deposition and inflammation. Lymphatic surgery includes a spectrum of procedures aimed to treat these sequelae of lymphedema as well as decrease the risk of lymphedema if performed as prophylactic surgery. We reviewed the literature regarding current surgical treatment options for lymphedema, imaging approaches, and directions the field may head towards both in treatment access and techniques. Methods: We systematically reviewed PubMed, Embase, and Cochrane Library databases to identify approaches to surgical management of lymphedema, including physiologic and reductive methods, as well as challenges that lymphedema patients face for adequate access and insurance coverage to surgical treatment options. Key Content and Findings: Lymphatic surgery can be broadly categorized as physiologic or reductive. Physiologic lymphatic surgery functions to decrease the fluid burden associated with lymphedema and includes lymphovenous bypass as well as vascularized lymph node transplant procedures. Reductive lymphatic surgery reduces the fibroadipose component of lymphedema and include suction lipectomy and excisional procedures. Advances in imaging technology as well as supermicrosurgical techniques have allowed for reproducible, positive clinical outcomes after lymphatic procedures. Access to care and coverage of procedures are persistent challenges in the field, though increasing adoption and research have led to important strides forward to providing patients with this care. Conclusions: Lymphatic surgery can improve symptoms and quality of life for lymphedema patients. A clear understanding of the predominant pathology in a patient (i.e., fluid dominant vs. fat dominant) can help guide counseling and surgical management options for patients. Despite the established benefits for patients, equitable access and insurance coverage for lymphedema surgery are still required.