Surgical management of lymphedema: prophylactic and therapeutic operations.

Purpose of Review: Lymphedema is chronic limb swelling from lymphatic dysfunction and is currently incurable. Breast-cancer related lymphedema (BCRL) affects up to 5 million Americans and occurs in one-third of breast cancer survivors following axillary lymph node dissection. Compression remains the mainstay of therapy. Surgical management of BCRL includes excisional procedures to remove excess tissue and physiologic procedures to attempt improve fluid retention in the limb. The purpose of this review is to highlight surgical management strategies for preventing and treating breast cancer-related lymphedema. Recent findings: Immediate lymphatic reconstruction (ILR) is a microsurgical technique that anastomoses disrupted axillary lymphatic vessels to nearby veins at the time of axillary lymph node dissection (ALND) and has been reported to reduce lymphedema rates from 30% to 4-12%. Summary: Postsurgical lymphedema remains incurable. Surgical management of lymphedema includes excisional procedures and physiologic procedures using microsurgical technique. Immediate lymphatic reconstruction has emerged as a prophylactic strategy to prevent lymphedema in breast cancer patients.

Surgical treatment algorithm for breast cancer lymphedema-a systematic review.

Background: Various surgical treatments are increasingly adopted and gaining popularity for lymphedema treatment. However, challenges persist in selecting appropriate treatment modalities targeted for individual patients and achieving consensus on choice of treatment as well as outcomes. The systematic review aimed to create a treatment algorithm incorporating the latest scientific knowledge, to provide healthcare professionals and patients with a tool for informed decision-making, when selecting between treatments or combining them in a relevant manner. This systematic review evaluated and synthesized the evidence on the effectiveness of three surgical treatments for breast cancer-related lymphedema (BCRL): lymphovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), and liposuction. Methods: We conducted a systematic search of electronic databases on 18 June 2023, including Medline, Embase, Cochrane Library, Google Scholar, and ClinicalTrials.org. Eligible studies were randomized controlled trials, non-randomized comparative studies, and observational studies that assessed the outcomes of LVA, VLNT, or liposuction in managing BCRL. The primary results of interest were changes in arm volume, lymphatic flow, and quality of life. Two independent reviewers performed the study selection and data extraction. Following this, we systematically reviewed and conducted a risk of bias assessment. Results were qualitatively presented, and a treatment algorithm was developed based on the available data. Results: We identified 16,593 papers, after removal of duplicates. Following assessment of studies, 73 articles met the inclusion criteria, including 2,373 patients. We were not able to conduct a meta-analysis due to considerable heterogeneity in the methodologies and outcome measures across the studies. Liposuction appears effective for patients presenting with non-pitting lymphedema. LVA indicates variable success rate, with some evidence indicating a reduction in limb volume and symptomatic relief amongst early stages of lymphedema. VLNT showed promising results for limb volume reduction and symptom improvement in patients presenting with mild and moderate lymphedema. Conclusions: Liposuction, LVA, and VLNT seem to be effective treatments for BCRL, when targeted for the appropriate patient. Well-conducted high evidence clinical studies in the field are still lacking to uncover the efficacy of surgical treatment for BCRL.

Lymphaticovenous Anastomosis and Vascularized Lymph Node Transfer for the Treatment of Lymphedema-A Canadian Case Series.

Introduction: Lymphedema is a chronic and debilitating condition. This study aims to assess the efficacy and safety of lymphaticovenous anastomosis (LVA) and vascularized lymph node transfers (VLNT) for the treatment of patients suffering from lymphedema, mainly by comparing pre- and postoperative daily compression use, limb volumes, and occurrence of cellulitis. Methods: We performed a retrospective analysis of patients who were treated by a single surgeon for lymphedema with LVA and/or VLNT between March 2018 and February 2020. Eighteen limbs met the inclusion criteria. The severity of lymphatic dysfunction was assessed by indocyanine green lymphangiography. Patients with patent vessels were offered LVA, whereas those without were offered VLNT. Pre- and postoperative circumferential limb measurements, use of compression garments, and postoperative complications were compared. Results: Nine limbs underwent LVA, 8 underwent VLNT, and one both. The minimum follow-up was 12 months. Postoperatively, all but 3 patients (83%) were able to cease daily compression. When considering excess limb volumes, the average reduction was 58%. This reduction was achieved despite compression weaning. Forty-four percent of patients (8) reported episodes of recurrent cellulitis preoperatively, while postoperatively, only 3 of those patients (17%) experienced cellulitis, which was statistically significant (P = .018). No surgical complications occurred. Conclusions: Patients with lymphedema can benefit from LVA and VLNT surgery. An important effect of surgery is decreased dependence on daily compression garments to maintain a stable and reasonable limb volume. The reduction of limb circumference after 1 year was similar to LVA and VLNT. Episodes of cellulitis were significantly lower after the intervention.

Introduction : Le lymphœdème est une affection chronique et débilitante. La présente étude vise à évaluer l'efficacité et l'innocuité de l'anastomose lymphaticoveineuse (ALV) et des transferts des ganglions lymphatiques vascularisés (TGLV) pour le traitement des patients ayant un lymphœdème, surtout en comparant l'utilisation quotidienne des vêtements compressifs, le volume des membres et l'occurrence de cellulites avant et après l'opération. Méthodologie : Les chercheurs ont procédé à une analyse rétrospective des patients chez qui le même chirurgien a procédé à une ALV ou à un TGLV à cause d'un lymphœdème entre mars 2018 et février 2020. Dix-huit membres ont respecté les critères d'inclusion. Les chercheurs ont évalué la gravité du dysfonctionnement lymphatique par lymphangiographie au vert d'indocyanine. Les patients ayant des vaisseaux perméables se sont fait offrir une ALV, et les autres, un TGLV. Les chercheurs ont comparé les mesures du périmètre des membres et l'utilisation de vêtements compressifs avant et après l'opération, de même que les complications postopératoires. Résultats : Une ALV a été effectuée sur neuf membres, des TGLV, sur huit membres, et les deux interventions, sur un membre. La période de suivi minimale était de 12 mois. Après l'opération, tous les patients, sauf trois (83%), ont pu cesser la compression quotidienne. En moyenne, le volume excessif des membres a diminué de 58%. Les chercheurs ont obtenu cette réduction malgré le sevrage de la compression. Au total, 44% des patients (huit) ont signalé des récurrences de la cellulite avant l'opération, mais après l'opération, seulement trois d'entre eux (17%) en ont souffert, ce qui est statistiquement significatif. Aucune complication chirurgicale n'a été signalée. Conclusions : Les patients ayant un lymphœdème peuvent profiter d'une ALV ou d'un TGLV. Parmi ses effets importants, l'opération réduit la dépendance au port quotidien de vêtements compressifs afin que les membres conservent un volume stable et raisonnable. La réduction du paramètre des membres au bout d'un an était semblable après l'ALV et les TGLV. Les épisodes de cellulite étaient considérablement moins fréquents après l'intervention.

Arm lymphedema after vascularized lymph node harvest following Covid-19 vaccination.

There is evidence that COVID-19 vaccines may affect the lymphatic system. We report a case of a 40-year-old female who had undergone lymph node transfer for treating primary lymphedema of the legs. Six months later, the patient developed lymphedema of the right arm closely related to mRNA vaccination against COVID-19.

Surgical Treatment of Lymphedema in the Upper Extremity.

The advent of supermicrosurgery has led to an increasing interest in the surgical management of lymphedema through the reconstruction of the lymphatic network, that is, the physiologic approach. Broadly, this can be divided into 2 main techniques: lymphaticovenous anastomosis and lymph node transfer. In the United Kingdom, the British Lymphology Society does not provide any recommendations on surgical management. Moreover, surgical treatment of lymphedema is not widely practiced within the National Health Service due to low-certainty evidence. Herein, we discuss our experience in physiologic reconstruction for lymphedema.

Predesigned chimeric deep inferior epigastric perforator and inguinal lymph node flap for combined breast and lymphedema reconstruction: A comprehensive algorithmic approach.

The combined use of a deep inferior epigastric perforator (DIEP) flap coupled with vascularized inguinal lymph nodes (VILNs) for simultaneous breast and lymphedema reconstruction has already been well established, and promising results have been reported. However, a standardized approach for the planning and shaping of this combined flap is still lacking. We aimed to propose a comprehensive algorithmic approach for delayed unilateral breast and lymphedema reconstruction using a predesigned abdominal flap associated with inguinal lymph node transfer. We present in detail the preoperative measurements and surgical technique of the chimeric flap, which combines a predesigned DIEP template and a preselected inguinal lymph node flap, based on the preoperative computed tomography angiography and SPEC-CT findings, respectively; four different flap types are described according to the location of the pedicles of the two flap components. Our results of a series of 34 consecutive female patients with unilateral mastectomy and arm lymphedema, who underwent this combined predesigned reconstructive procedure, are retrospectively analyzed and reported. We recorded a high survival rate of the chimeric flaps in our series, with only one case of partial ischemic loss of a DIEP skin island. In the majority of our patients, the pedicles of the combined flaps were located in opposite positions. After a mean 35-month follow-up, we recorded a 47% mean volume difference reduction of the lymphedematous compared to the unaffected arm; no donor-site lymphedema was documented. Self-evaluation questionnaires showed high patient satisfaction rates regarding breast reconstruction. This algorithmic approach provides standardized guidance for accurate design and transfer of the DIEP-VILN chimeric flap while achieving highly satisfactory outcomes for both breast and lymphedema reconstruction.

Safety and efficacy of intracranial vascularized submental lymph node transfer for treating hydrocephalus.

Hydrocephalus is routinely treated with ventriculoperitoneal shunt drainage of cerebrospinal fluid (CSF), a procedure plagued by high morbidity and frequent revisions. Vascularized submental lymph node (VSLN) transplants act as lymphatic pumps to drain interstitial fluid (ISF) from lymphedematous extremities. As the field of neuro-lymphatics comes to fruition, we hypothesize the efficacy of VSLN in the drainage of intracranial CSF-ISF. We report novel placement of VSLN in the temporal subdural space in two patients diagnosed with symptomatic communicating hydrocephalus. At a minimum follow-up of 1 month postoperatively, both experienced radiological and clinical improvements.

Prophylactic lymphedema surgery in lower limb soft tissue sarcomas: A clinical paradigm in a promising field.

INTRODUCTION: Oncological treatments, such as radiotherapy and surgery, are high-risk factors for the development of secondary lymphedema in the upper and lower limbs, as well as the genitalia. Prophylactic lymphedema surgery (PLS) has previously demonstrated promising results in reducing secondary lymphedema in breast cancer and urogenital cancer patients. We conducted a study to adapt this principle for patients with lower-extremity sarcomas. MATERIAL AND METHODS: Inclusion criteria included patients with tumors on the medial aspect of the thigh and leg and tumor size larger than 5 cm. Group A (19 patients) comprised a prospective cohort (2020-2023) in which a PLS protocol was executed. Lymphaticovenous anastomosis (LVA) was performed when lymphatic channels were interrupted due to tumor resection, intraoperatively verified by indocyanine green. Lymph node transfer was employed exclusively in cases involving preoperative radiotherapy and inguinal lymph node resection. Measurements were collected both preoperatively and at 1, 3, 6, and 12 months postoperatively. Group B (26 patients) constituted a retrospective cohort (2017-2020) without PLS reconstruction, where the prevalence of lymphedema was determined. RESULTS: In total, we enrolled 45 patients with soft tissue sarcomas located on the inner aspect of the thigh and leg (26 in the control group vs. 19 in the prophylactic group). In the control group, lymphedema was observed in 10 out of 27 patients (37.04%). In the prophylactic group, two patients exhibited signs of lower-extremity lymphedema (2/19, 10.52%) with a median follow-up of 14.15 months (6 months-33months), demonstrating statistically significant differences between the two groups (p = 0.02931). CONCLUSIONS: PLS for lower limb soft tissue sarcomas shows promising results, although it is premature to reach solid conclusions. Multicentre studies, standardization of criteria, larger sample sizes and longer-term follow-up are imperative for further validation.

Journey to an Improved Quality of Life: Filarial Lymphoedema and Physiotherapy Rehabilitation.

Filarial lymphoedema is a tropical parasitic worm illness caused mostly by Wuchereria bancrofti. This disease impacts millions of individuals in endemic areas, causing significant impairment and financial discomfort. Elephantiasis is a chronic lymphatic drainage failure causing swelling in the legs and genitalia. It is a chronic condition characterized by the buildup of lymphatic water, causing pain and reduced limb activity. Genetic abnormalities, trauma, surgery, infection, or cancer cause the disease. Treatment options include antiparasitic drugs, surgical interventions, and nonsurgical interventions like compression therapy. Lymphatic system transplantation, liposuction, and vascularized lymph node transfer are surgical procedures that restore lymphatic circulation and reduce swelling, potentially lifesaving for individuals with lymphedema who have not responded well to conservative treatment. The present case report concerns a 30-year-old male with a history of chronic lower leg elephantiasis for 17 years. Duplex color Doppler revealed a large, well-defined collection in the right foot with a heterogeneous group with few solid cystic components suggestive of a solid cystic mass lesion. MRI showed diffuse subcutaneous edema in the dorsum, medial, and lateral aspect of the foot with the medial, lateral, and posterior aspect of the leg appearing hyperintense on T2/proton density spectral attenuated inversion recovery (PDSPAIR), and hypointense on T1. Dilated lymphatic channels were seen coursing through in the cutaneous plane. The patient underwent a comprehensive surgical procedure that included excision of fibrotic tissue and subcutaneous adipose tissue, followed by lymph node transfer. Following the surgeon's clearance, a targeted early physiotherapy intervention could normalize functional potencies and help in recovery. Post-treatment changes such as reduction in lymphoedema, strength, and mobility, which are essential for patients with the activity of daily living, were observed.

Giant Penoscrotal Lymphedema-What to Do? Presentation of a Curative Treatment Algorithm.

BACKGROUND: While rare, penoscrotal lymphedema (PL) is accompanied with devastating effects on the quality of life of patients. Moreover, especially for patients with excessive (giant) PL, no standardized curative treatment has been defined. This article therefore retrospectively evaluates the authors' surgical treatment approach for giant PL, which includes resection alone or in combination with a free vascularized lymph node transfer (VLNT). METHODS: A total of ten patients met the inclusion criteria. One patient dropped out of the study before therapy commenced. Eight of the nine remaining patients presented with end-stage (giant) PL. One patient presented with manifest pitting edema. All patients were treated with penoscrotal resection and reconstruction. Additionally, five patients received VLNT into the groin or scrotum. RESULTS: The extent of the lymphedema was specified with a treatment-oriented classification system. The median follow-up was 49.0 months. No patient showed a recurrence. Patients who received VLNT into the scrotum displayed a significantly improved lymphatic transport of the scrotum. CONCLUSIONS: Advanced PL should be treated in a standardized surgical fashion as suggested by our proposed algorithm. VLNT from the lateral thoracic region into the scrotum must be considered. If treated correctly, surgical intervention of end-stage PL leads to good results with a low recurrence rate.

[Advances in treatment of lymphedema with supraclavicular vascularized lymph node transfer].

Objective: To review the research progress of supraclavicular vascularized lymph node transfer (VLNT). Methods: The research literature related to supraclavicular VLNT at home and abroad in recent years was extensively reviewed, and the anatomy of supraclavicular lymph nodes, clinical applications, and complications of supraclavicular VLNT were summarized. Results: The supraclavicular lymph nodes are anatomically constant, located in the posterior cervical triangle zone, and the blood supply comes mainly from the transverse cervical artery. There are individual differences in the number of supraclavicular lymph nodes, and preoperative ultrasonography is helpful to clarify the number of lymph nodes. Clinical studies have shown that supraclavicular VLNT can relieve limb swelling, reduce the incidence of infection, and improve quality of life in patients with lymphedema. And the effectiveness of supraclavicular VLNT can be improved by combined with lymphovenous anastomosis, resection procedures, and liposuction. Conclusion: There are a large number of supraclavicular lymph nodes, with abundant blood supply. It has been proven to be effective for any period of lymphedema, and the combined treatment is more effective. The more clinical studies are needed to clarify the effectiveness of supraclavicular VLNT alone or in combination, as well as the surgical approach and timing of the combined treatment.

Current Concepts in the Management of Primary Lymphedema.

Primary lymphedema is a heterogeneous group of conditions encompassing all lymphatic anomalies that result in lymphatic swelling. Primary lymphedema can be difficult to diagnose, and diagnosis is often delayed. As opposed to secondary lymphedema, primary lymphedema has an unpredictable disease course, often progressing more slowly. Primary lymphedema can be associated with various genetic syndromes or can be idiopathic. Diagnosis is often clinical, although imaging can be a helpful adjunct. The literature on treating primary lymphedema is limited, and treatment algorithms are largely based on practice patterns for secondary lymphedema. The mainstay of treatment focuses on complete decongestive therapy, including manual lymphatic drainage and compression therapy. For those who fail conservative treatment, surgical treatment can be an option. Microsurgical techniques have shown promise in primary lymphedema, with both lymphovenous bypass and vascularized lymph node transfers demonstrating improved clinical outcomes in a few studies.

Preservation of supraclavicular nerve while harvesting supraclavicular lymph node flap.

Lymph node transfer has recently become one of the popular techniques for surgical treatment of lymphedema. We aimed to evaluate postoperative donor site numbness and other complications in patients who underwent supraclavicular lymph node flap transfer to treat lymphedema with preservation of the supraclavicular nerve. From 2004 to 2020, 44 cases of supraclavicular lymph node flap were reviewed retrospectively. In the donor area, sensorial evaluation was clinically done with the postoperative controls. Among them 26 had no numbness at all, 13 had short-term numbness, two had numbness for > 1 year and three had numbness for > 2 years. We suggest that careful preservation of the supraclavicular nerve branches can avoid the major complication of numbness around the clavicle.

Retroauricular lymph node flap: An anatomic and surgical feasibility study.

BACKGROUND: The study investigated the anatomy of the retroauricular lymph node (LN) flap and evaluate its surgical feasibility as a new donor site for a free LN flap in lymphedema surgery. METHODS: Twelve adult cadavers were examined. The course and perfusion of the anterior auricular artery (AAA) and the location and sizes of the retroauricular LNs were studied. RESULTS: The AAA was available in 87% and absent in 13% specimens. The AAA's origin had a mean vertical distance of 12.2 ± 6.9 mm and a mean horizontal distance of 19.1 ± 4.2 mm from the superior attachment of the ear. The mean diameter of the AAA was 0.8 ± 0.2 mm. The mean number of LN per region was 7.7 ± 2.3, with an average LN size of 4.1 ± 1.9 × 3.2 ± 1.7 mm. The LN were categorized into anterior (G1) and posterior (G2) groups, with a total of 59 and 10 LN, respectively. In a cluster analysis, three LN clusters could be detected across the anterior group (G1). CONCLUSIONS: The retroauricular LN flap is a delicate but feasible flap with reliable anatomy, containing a mean of 7.7 LNs.

[Research progress of combined surgical treatment of lymphedema based on vascularized lymph node transfer].

Objective: To summarize the research progress of combined surgical treatment of lymphedema based on vascularized lymph node transfer (VLNT), and to provide systematic information for combined surgical treatment of lymphedema. Methods: Literature on VLNT in recent years was extensively reviewed, and the history, treatment mechanism, and clinical application of VLNT were summarized, with emphasis on the research progress of VLNT combined with other surgical methods. Results: VLNT is a physiological operation to restore lymphatic drainage. Multiple lymph node donor sites have been developed clinically, and two hypotheses have been proposed to explain its mechanism for the treatment of lymphedema. But it has some inadequacies such as slow effect and limb volume reduction rate less than 60%. To address these inadequacies, VLNT combined with other surgical methods for lymphedema has become a trend. VLNT can be used in combination with lymphovenous anastomosis (LVA), liposuction, debulking operation, breast reconstruction, and tissue engineered material, which have been shown to reduce the volume of affected limbs, reduce the incidence of cellulitis, and improve patients' quality of life. Conclusion: Current evidence shows that VLNT is safe and feasible in combination with LVA, liposuction, debulking operation, breast reconstruction, and tissue engineered material. However, many issues need to be solved, including the sequence of two surgeries, the interval between two surgeries, and the effectiveness compared with surgery alone. Rigorous standardized clinical studies need to be designed to confirm the efficacy of VLNT alone or in combination, and to further discuss the subsistent issues in the use of combination therapy.

Advances in treatment of lymphedema with supraclavicular vascularized lymph node transfer / 中国修复重建外科杂志

OBJECTIVE@#To review the research progress of supraclavicular vascularized lymph node transfer (VLNT).@*METHODS@#The research literature related to supraclavicular VLNT at home and abroad in recent years was extensively reviewed, and the anatomy of supraclavicular lymph nodes, clinical applications, and complications of supraclavicular VLNT were summarized.@*RESULTS@#The supraclavicular lymph nodes are anatomically constant, located in the posterior cervical triangle zone, and the blood supply comes mainly from the transverse cervical artery. There are individual differences in the number of supraclavicular lymph nodes, and preoperative ultrasonography is helpful to clarify the number of lymph nodes. Clinical studies have shown that supraclavicular VLNT can relieve limb swelling, reduce the incidence of infection, and improve quality of life in patients with lymphedema. And the effectiveness of supraclavicular VLNT can be improved by combined with lymphovenous anastomosis, resection procedures, and liposuction.@*CONCLUSION@#There are a large number of supraclavicular lymph nodes, with abundant blood supply. It has been proven to be effective for any period of lymphedema, and the combined treatment is more effective. The more clinical studies are needed to clarify the effectiveness of supraclavicular VLNT alone or in combination, as well as the surgical approach and timing of the combined treatment.

Lymphoedema surgery in Australia: a narrative review.

Background and Objective: Lymphoedema is a chronic condition that affects millions of people worldwide. It is often caused by the damage or removal of lymph nodes during cancer treatment. One of the most effective management options for lymphoedema is surgery, which can reduce swelling and potentially improve lymphatic drainage. Throughout history, Australia has been at the forefront of research and development in this field. In this review, we aim to examine the contributions of Australian research to lymphoedema surgery. Methods: We conducted a search in the PubMed and Embase databases to identify Australian research relating to lymphoedema surgery from inception to the present day. Studies that met the inclusion criteria were reviewed and analysed, and the results were presented. Key Content and Findings: After reviewing the literature, it was apparent that the field of lymphoedema surgery owes much to the contributions of Australian research. Early work from famous Australian surgeons such as Bernard O'Brien and Geoffrey Ian Taylor laid the bedrock for modern surgical techniques. Furthermore, more recently, Australia has seen a resurgence of clinical research contributing to the international evidence for lymphoedema surgery. Conclusions: Australia has made significant contributions to the field of lymphoedema surgery, particularly in the development of modern microsurgical techniques such as lymphovenous anastomosis or vascularised lymph node transfer. These contributions have led to improved patient outcomes and quality of life. Going forward, Australia will hopefully continue to be a leader in research and innovation in this field.

Approach to Lymphedema Management.

Millions of people worldwide suffer from lymphedema. In developed nations, lymphedema most commonly stems secondarily from oncologic treatment, but may also result from trauma. More recently, lymphedema has been identified in patients after gender-affirmation phalloplasty reconstruction. Regardless of the etiology, the underlying pathophysiology involves blockage of lymphatic flow, resulting in lymph stasis, thus triggering a cascade of inflammation culminating in fibrosis and adipose deposition. Recent technical advances led to the refinement of physiologic and reductive surgeries-including lymphovenous anastomosis and free functional lymphatic transfer, which collectively encompass a variety of flap procedures including lymph node transfer, lymph channel transfer, and lymphatic system transfer. This article provides a summary of our approach in the assessment and management of the lymphedema patient, including detailed intraoperative photography and imaging, in addition to advanced technical considerations in physiologic reconstruction.

Current Concepts in Surgical Management of Lymphedema.

The decision on whom to offer surgical interventions for lymphedema requires collaboration and input from all involved specialists and should address patients' expectations, invasiveness of procedures, and disease severity. There is no consensus on what constitutes success or failure of complex decongestive therapy and when to pursue surgical intervention. Surgery has the potential to fundamentally affect the pathophysiology of the disease state and can be a powerful tool when used correctly. The dogma of which surgery to offer for a given clinical situation has been undergoing revision and is an area of ongoing research.

Vascularized lymph node transplantation successfully reverses lymphedema and maintains immunity in a rat lymphedema model.

Vascularized lymph node transplantation (VLNT) has shown inspiring results for the treatment of lymphedema. Nevertheless, it remains unclear how VLNT restores lymphatic drainage and whether or not immunity recovers after surgery. Hindlimb lymphedema model was created using rats with extensive groin and popliteal lymph node removable following with radiotherapy, and the lymphedema was confirmed using indocyanine green (ICG) lymphangiography and micro-computer tomography for volume measurement. VLNT was performed 1 month later. Volume measurement, ICG lymphangiography, histology, and immune reaction were done 1 month after surgery. VLNT successfully reduced the volume of the lymphedema hindlimb, restored lymphatic drainage function with proven lymphatic channel, and reduced lymphedema-related inflammation and fibrosis. It promotes lymphangiogenesis shown from ICG lymphangiography, histology, and enhanced lymphangiogenesis gene expression. Dendritic cell trafficking via the regenerated lymphatic channels was successfully restored, and maintained systemic immune response was proved using dinitrofluorobenzene sensitization and challenge. VLNT effectively reduces lymphedema and promotes lymphatic regeneration in the capillary lymphatic but not the collecting lymphatic vessels. Along with the re-established lymphatic system was the restoration of immune function locally and systemically. This correlated to clinical experience regarding the reduction of swelling and infection episodes after VLNT in lymphedema patients.