{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,28]],"date-time":"2026-03-28T19:36:01Z","timestamp":1774726561716,"version":"3.50.1"},"reference-count":42,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2024,8,30]],"date-time":"2024-08-30T00:00:00Z","timestamp":1724976000000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Primary lymphedema is a chronic condition caused by a developmental abnormality of the lymphatic system, leading to its malfunction. Various surgical options, including physiologic and excisional procedures, have been proposed. The aim of this study was to present a comprehensive algorithm for the treatment of primary lower extremity lymphedema: the Primary LYmphedema Multidisciplinary Approach (P-LYMA). Methods: Nineteen patients were treated following the P-LYMA protocol. Patients underwent pre- and postoperative complex decongestive therapy (CDT). A variety of physiologic and excisional procedures were performed, either independently or in combination. The primary outcome was to assess the circumferential reduction rate (CRR). The Lymphedema Quality of Life Score (LeQOLiS), reduction in the number of cellulitis episodes, and complications were recorded. Results: The mean CRR was 73 \u00b1 20% at twelve months postoperatively. The frequency of cellulitis episodes per year decreased from a mean of 1.9 \u00b1 0.8 preoperatively to 0.4 \u00b1 0.6 during follow-up. Two patients experienced minor complications. The mean hospitalization time was 5 days. Patients\u2019 quality of life, as measured by the LeQOLiS, significantly improved from 70.4 \u00b1 12 preoperatively to 24 \u00b1 14 at twelve months postoperatively. Conclusions: The P-LYMA algorithm maximizes surgical outcomes and improves the quality of life in patients with primary lymphedema. CDT is essential for optimizing results.<\/jats:p>","DOI":"10.3390\/jcm13175161","type":"journal-article","created":{"date-parts":[[2024,8,30]],"date-time":"2024-08-30T09:39:32Z","timestamp":1725010772000},"page":"5161","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":8,"title":["Primary LYmphedema Multidisciplinary Approach in Patients Affected by Primary Lower Extremity Lymphedema"],"prefix":"10.3390","volume":"13","author":[{"given":"Pedro","family":"Ciudad","sequence":"first","affiliation":[{"name":"Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima 15082, Peru"},{"name":"Academic Department of Surgery, Faculty of Medicine, Federico Villarreal National University, Lima 15084, Peru"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6418-2873","authenticated-orcid":false,"given":"Alberto","family":"Bolletta","sequence":"additional","affiliation":[{"name":"Plastic Surgery Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56125 Pisa, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-5450-0498","authenticated-orcid":false,"given":"Juste","family":"Kaciulyte","sequence":"additional","affiliation":[{"name":"Unit of Plastic and Reconstructive Surgery, Department of Surgery \u201cP.Valdoni\u201d, Sapienza University of Rome, Policlinico Umberto I, 00185 Rome, Italy"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Oscar J.","family":"Manrique","sequence":"additional","affiliation":[{"name":"Department of Plastic, Reconstructive and Burn Surgery, Arzobispo Loayza National Hospital, Lima 15082, Peru"},{"name":"Division of Plastic and Reconstructive Surgery, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY 14642, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8982-1950","authenticated-orcid":false,"given":"Joseph M.","family":"Escand\u00f3n","sequence":"additional","affiliation":[{"name":"Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1968","published-online":{"date-parts":[[2024,8,30]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1196\/annals.1413.013","article-title":"Phenotypic characterization of primary lymphedema","volume":"1131","author":"Connell","year":"2008","journal-title":"Ann. N. Y. Acad. Sci."},{"key":"ref_2","first-page":"206","article-title":"Primary lymphedema in children and adolescents: A follow-up study and review","volume":"76","author":"Smeltzer","year":"1985","journal-title":"Pediatrics"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"R140","DOI":"10.1093\/hmg\/ddm211","article-title":"Genetic causes of vascular malformations","volume":"16","author":"Brouillard","year":"2007","journal-title":"Hum. Mol. Genet."},{"key":"ref_4","first-page":"91","article-title":"Lymphoedema: Pathophysiology and classification","volume":"26","author":"Browse","year":"1985","journal-title":"J. Cardiovasc. Surg."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1196\/annals.1413.014","article-title":"Estimating the population burden of lymphedema","volume":"1131","author":"Rockson","year":"2008","journal-title":"Ann. N. Y. Acad. Sci."},{"key":"ref_6","first-page":"6","article-title":"Lymphatic dysplasia in paediatrics. A new classification","volume":"18","author":"Papendieck","year":"1999","journal-title":"Int. Angiol."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"409","DOI":"10.3400\/avd.ra.12.00080","article-title":"Recent advancement on surgical treatments for lymphedema","volume":"5","author":"Koshima","year":"2012","journal-title":"Ann. Vasc. Dis."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"222","DOI":"10.1002\/micr.30079","article-title":"Comprehensive review of vascularized lymph node transfers for lymphedema: Outcomes and complications","volume":"38","author":"Scaglioni","year":"2018","journal-title":"Microsurgery"},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1148","DOI":"10.1002\/jso.24969","article-title":"Staged surgical treatment of extremity lymphedema with dual gastroepiploic vascularized lymph node transfers followed by suction-assisted lipectomy\u2014A prospective study","volume":"117","author":"Agko","year":"2018","journal-title":"J. Surg. Oncol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"771","DOI":"10.1002\/micr.30168","article-title":"Double gastroepiploic vascularized lymph node tranfers to middle and distal limb for the treatment of lymphedema","volume":"37","author":"Ciudad","year":"2017","journal-title":"Microsurgery"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"439","DOI":"10.1002\/jso.25360","article-title":"Combined double vascularized lymph node transfers and modified radical reduction with preservation of perforators for advanced stages of lymphedema","volume":"119","author":"Ciudad","year":"2019","journal-title":"J. Surg. Oncol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"430","DOI":"10.1002\/jso.25356","article-title":"Comprehensive multimodal surgical treatment of end-stage lower extremity lymphedema with toe management: The combined Charles,\u2019 Homan\u2019s, and vascularized lymph node transfer (CHAHOVA) procedures","volume":"119","author":"Ciudad","year":"2019","journal-title":"J. Surg. Oncol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"446","DOI":"10.1089\/lrb.2017.0061","article-title":"Complex Decongestive Therapy Enhances Upper Limb Functions in Patients with Breast Cancer-Related Lymphedema","volume":"16","author":"Dalyan","year":"2018","journal-title":"Lymphat. Res. Biol."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1097\/SAP.0b013e31802ca54c","article-title":"Radical reduction of lymphedema with preservation of perforators","volume":"59","author":"Salgado","year":"2007","journal-title":"Ann. Plast. Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"302","DOI":"10.1097\/SAP.0b013e31818d45aa","article-title":"Radical reduction of upper extremity lymphedema with preservation of perforators","volume":"63","author":"Salgado","year":"2009","journal-title":"Ann. Plast. Surg."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1097\/SAP.0000000000000022","article-title":"Management of Primary and Secondary Lymphedema: Analysis of 225 Referrals to a Center","volume":"75","author":"Maclellan","year":"2015","journal-title":"Ann. Plast. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"883","DOI":"10.1097\/PRS.0000000000001631","article-title":"Indication of Lymphaticovenous Anastomosis for Lower Limb Primary Lymphedema","volume":"136","author":"Hara","year":"2015","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1055\/s-0029-1243299","article-title":"Comparison of primary and secondary lower-extremity lymphedema treated with supermicrosurgical lymphaticovenous anastomosis and lymphaticovenous implantation","volume":"26","author":"Demirtas","year":"2010","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_19","first-page":"454","article-title":"Diagnosis and treatment of primary lymphedema. Consensus document of the International Union of Phlebology (IUP)-2009","volume":"29","author":"Lee","year":"2010","journal-title":"Int. Angiol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1016\/j.cps.2012.08.001","article-title":"Surgical treatment of congenital lymphedema","volume":"39","author":"Becker","year":"2012","journal-title":"Clin. Plast. Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"669","DOI":"10.1097\/SAP.0b013e318180cd24","article-title":"Modified Charles procedure using negative pressure dressings for primary lymphedema: A functional assessment","volume":"62","author":"Perks","year":"2009","journal-title":"Ann. Plast. Surg."},{"key":"ref_22","first-page":"541","article-title":"Diagnosis and treatment of primary lymphedema. Consensus document of the International Union of Phlebology (IUP)-2013","volume":"32","author":"Lee","year":"2013","journal-title":"Int. Angiol."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"249","DOI":"10.1177\/026835550702200604","article-title":"Terminology and classification of congenital vascular malformations","volume":"22","author":"Lee","year":"2007","journal-title":"Phlebology"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"562","DOI":"10.1097\/00006534-199004000-00011","article-title":"Long-term results after microlymphaticovenous anastomoses for the treatment of obstructive lymphedema","volume":"85","author":"Mellow","year":"1990","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"8","DOI":"10.3322\/caac.20001","article-title":"Lymphedema: A primer on the identification and management of a chronic condition in oncologic treatment","volume":"59","author":"Lawenda","year":"2009","journal-title":"CA Cancer J. Clin."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"799","DOI":"10.1016\/j.jacc.2008.06.005","article-title":"Diagnosis and management of lymphatic vascular disease","volume":"52","author":"Rockson","year":"2008","journal-title":"J. Am. Coll. Cardiol."},{"key":"ref_27","first-page":"4476","article-title":"Three-dimensional laser scanning as a reliable and reproducible diagnostic tool in breast cancer related lymphedema rehabilitation: A proof-of-principle study","volume":"24","author":"Losco","year":"2020","journal-title":"Eur. Rev. Med. Pharmacol. Sci."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"209S","DOI":"10.1097\/PRS.0000000000002683","article-title":"Lymphedema: Surgical and Medical Therapy","volume":"138","author":"Chang","year":"2016","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"220","DOI":"10.1089\/lrb.2017.0007","article-title":"Surgical Treatment of Primary Lymphedema","volume":"15","author":"Lee","year":"2017","journal-title":"Lymphat. Res. Biol."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"417","DOI":"10.1002\/micr.30569","article-title":"Combined radical reduction with preservation of perforators and distal lymphaticovenular anastomosis for advanced lower extremity lymphedema","volume":"40","author":"Ciudad","year":"2020","journal-title":"Microsurgery"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"437","DOI":"10.1002\/micr.20772","article-title":"Types of lymphoscintigraphy and indications for lymphaticovenous anastomosis","volume":"30","author":"Maegawa","year":"2010","journal-title":"Microsurgery"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1016\/j.ejvs.2014.10.023","article-title":"Indocyanine Green Lymphography Findings in Primary Leg Lymphedema","volume":"49","author":"Yamamoto","year":"2015","journal-title":"Eur. J. Vasc. Endovasc. Surg."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"368","DOI":"10.1016\/j.bjps.2015.10.042","article-title":"Proximal and distal patterns: Different spreading patterns of indocyanine green lymphography in secondary lower extremity lymphedema","volume":"69","author":"Tashiro","year":"2016","journal-title":"J. Plast. Reconstr. Aesthet. Surg."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"671","DOI":"10.1002\/jso.24730","article-title":"Comparison of long-term clinical outcomes among different vascularized lymph node transfers: 6-year experience of a single center\u2019s approach to the treatment of lymphedema","volume":"116","author":"Ciudad","year":"2017","journal-title":"J. Surg. Oncol."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1002\/micr.30508","article-title":"Comparisons in long-term clinical outcomes among patients with upper or lower extremity lymphedema treated with diverse vascularized lymph node transfer","volume":"40","author":"Ciudad","year":"2020","journal-title":"Microsurgery"},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"197","DOI":"10.1002\/micr.22450","article-title":"The laparoscopic right gastroepiploic lymph node flap transfer for upper and lower limb lymphedema: Technique and outcomes","volume":"37","author":"Ciudad","year":"2017","journal-title":"Microsurgery"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"175","DOI":"10.1002\/jso.25583","article-title":"Surgical treatment of Milroy disease","volume":"121","author":"Bolletta","year":"2020","journal-title":"J. Surg. Oncol."},{"key":"ref_38","first-page":"156","article-title":"Liposuction reduces arm lymphedema without significantly altering the already impaired lymph transport","volume":"31","author":"Brorson","year":"1998","journal-title":"Lymphology"},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"545","DOI":"10.21037\/gs.2020.01.13","article-title":"Single-stage VASER-assisted liposuction and lymphatico-venous anastomoses for the treatment of extremity lymphedema: A case series and systematic review of the literature","volume":"9","author":"Ciudad","year":"2020","journal-title":"Gland Surg."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"117","DOI":"10.1089\/lrb.2013.1132","article-title":"The lymphatics and the inflammatory response: Lessons learned from human lymphedema","volume":"11","author":"Rockson","year":"2013","journal-title":"Lymphat. Res. Biol."},{"key":"ref_41","first-page":"23","article-title":"Immune cells in peripheral lymph and skin of patients with obstructive lymphedema","volume":"23","author":"Olszewski","year":"1990","journal-title":"Lymphology"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"7","DOI":"10.4269\/ajtmh.1997.57.7","article-title":"Bacteriologic studies of skin, tissue fluid, lymph, and lymph nodes in patients with filarial lymphedema","volume":"57","author":"Olszewski","year":"1997","journal-title":"Am. J. Trop. Med. Hyg."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/17\/5161\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T15:45:52Z","timestamp":1760111152000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/13\/17\/5161"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,8,30]]},"references-count":42,"journal-issue":{"issue":"17","published-online":{"date-parts":[[2024,9]]}},"alternative-id":["jcm13175161"],"URL":"https:\/\/doi.org\/10.3390\/jcm13175161","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2024,8,30]]}}}