From the initial search, 34 studies were identified. After screening and applying the exclusion criteria, 19 studies were selected for inclusion in the review (Fig. 1). Of the 19 abstracted articles, 13 were systematic reviews (SR) [19,20,21,22,23,24,25,26,27,28,29,30,31], 3 were randomized clinical trials (RCT) [32,33,34], 2 were both SRs and meta-analyses (MA) [35, 36], and 1 was a review of the literature [37]. The most common procedures represented were LVA (N = 12) and VLNT (N = 10). Liposuction [N = 4] and excisional techniques [N = 3] were also discussed. Further details regarding the procedures, indications, and outcomes of surgical techniques are outlined in Table 3.

PRISMA Flowsheet for article extraction

Lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) were the focus of most studies and yielded favorable results in terms of volume reduction, quality of life, and infection control [19,20,21,22,23, 25,26,27,28,29,30,31,32, 34,35,36,37]. One multicenter RCT compared LVA to CDT for breast cancer-related lymphedema (BCRL) and found no significant volume reduction in either group after 6 months [32]. SRs that examined outcomes after LVA for various indications overwhelmingly found volume reduction after surgery with losses ranging from 13.7—73.9% [19,20,21,22, 25, 27,28,29]; however, two BCRL reviews found studies with insignificant postoperative volume reductions [29, 31]. VLNT was evaluated in one RCT and performed superiorly to conservative therapy in terms of BCRL volume reduction [34]. One MA of VLNT for BCRL found an average reduction in limb volume of 40.31% [35]. SRs similarly reported that VLNT reduces both volume and circumference with low complication rates [22, 25, 26, 28,29,30].

Although the methodology of QOL assessments varied, most reports agreed that both LVA and VLNT improve QOL ratings for 25—100% of patients [19,20,21,22,23, 25,26,27,28,29,30,31, 35, 36]. Only one study revealed a 6% decrease in QOL for patients after LVA according to an ad hoc survey [23], while another showed no QOL improvement for patients undergoing LVA for BCRL [30]. Fallahian et al.’s review noted no difference in QOL improvements for patients receiving LVA versus VLNT [25], while the Grunherz group found higher postoperative QOL scores after VLNT than LVA [29]. In a single RCT, LVA produced QOL scores superior to those of control CDT subjects [32]. Both physiological procedures were shown to partially or completely reduce episodes of cellulitis [19, 21, 23, 25,26,27,28, 31, 32, 34, 36]. Two reviews found greater cellulitis reductions in those who had undergone VLNT vs LVA [25, 28].

Of 5 studies that evaluated reductive procedures such as liposuction and radical excision (Charles procedure), 3 found reductions in volume and/or circumference [22, 24, 37]. One SR that looked strictly at liposuction for lower extremity lymphedema (LEL) found > 50% volume reduction in all patients that persisted up to 5 years in some studies [24]. The same analysis reported that liposuction reduced higher volumes for secondary versus primary lymphedema.

Reductive procedures, in two reports, were found to improve QOL scores [22, 37]. However, liposuction and other excisional procedures may also lead to poor cosmetic outcomes and higher complication rates [28]. Infection rates also varied; Forte (2019) found reduced infection rates after liposuction for LEL [24], whereas Park reported that excisional procedures increase the risk of infection [37].