Key topic: Patient selection and evidence-based algorithmic approach to surgical management of lymphedema

Patients presenting with limb swelling undergo comprehensive evaluation to diagnose and stage their lymphedema, exclude other causes, and identify contributing comorbidities. Surgical treatment of lymphedema has demonstrated superior outcomes compared with optimized conservative therapy alone. To be eligible for consideration for surgical intervention, however, patients must have completed a course of complete decongestive therapy (CDT) and be compliant with optimized conservative therapy. The available data supports that lymphovenous bypass (LVB) is most effective as a treatment for early-stage lymphedema, and vascularized lymph node transplantation (VLNT) is indicated for the treatment of advanced lymphedema. Suction-assisted lipectomy (SAL) with controlled compression therapy (CCT) is effective in advanced lymphedema where the volume excess is predominantly fibroadipose; direct excision is indicated for the most severe cases characterized by fibrotic lymphedema. An evidence-based algorithmic approach to the nonsurgical and surgical management of lymphedema enables outcomes of surgery to be optimized, and standardized approaches enable group analysis of results for comparison between different treatments.