{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,17]],"date-time":"2026-10-17T12:37:32Z","timestamp":1792240652126,"version":"4.4.0"},"reference-count":37,"publisher":"MDPI AG","issue":"4","license":[{"start":{"date-parts":[[2026,2,7]],"date-time":"2026-02-07T00:00:00Z","timestamp":1770422400000},"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: Lymphedema is a debilitating condition with high morbidity, yet despite advances in management, diagnostic ambiguity and fragmented referral patterns continue to delay appropriate care. We evaluated predictors of accurate diagnosis, microsurgical reconstruction candidacy, and secondary referrals generated during consultation with a lymphatic microsurgeon to highlight the need for a coordinated model of care. Methods: A retrospective chart review was performed for all outpatient referrals for \u2018lymphedema\u2019 from September 2020 to September 2021. Patient demographics, diagnostics, referral patterns, and lymphedema-related clinical data were collected. Results: 94 patients were referred for evaluation of possible lymphedema; lymphoscintigraphy confirmed diagnosis in 69. Following consultation, 23 patients received referrals for physical therapy, 17 for vascular surgery, and 8 for bariatric surgery or medical weight loss. Patients without lymphedema were more often referred to vascular surgery than those with lymphedema. Non-surgical candidates were more frequently referred to therapy or weight loss. Conclusions: Incorporating microsurgical reconstructive expertise into the evaluation of limb swelling improves diagnostic accuracy and refers patients- regardless of lymphedema status or surgical candidacy- to appropriate specialists. We propose a pathfinder model for patient flow that streamlines triage, improves access to accurate diagnosis and treatment, and prevents overburdening microsurgical practices with non-surgical patients.<\/jats:p>","DOI":"10.3390\/jcm15041322","type":"journal-article","created":{"date-parts":[[2026,2,9]],"date-time":"2026-02-09T08:15:54Z","timestamp":1770624954000},"page":"1322","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":1,"title":["Gatekeeper or Pathfinder? The Evolving Role of Lymphedema Surgeons in the Assessment of Limb Swelling"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0497-7866","authenticated-orcid":false,"given":"Judith","family":"Monzy","sequence":"first","affiliation":[{"name":"Division of Plastic and Reconstructive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Yasmina","family":"Samaha","sequence":"additional","affiliation":[{"name":"Division of Plastic and Reconstructive Surgery, Department of Surgery, Stony Brook University Hospital, Stony Brook, NY 11794, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0008-9201-1810","authenticated-orcid":false,"given":"Shelby","family":"Chun Fat","sequence":"additional","affiliation":[{"name":"Division of Plastic and Reconstructive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eileen","family":"Lu","sequence":"additional","affiliation":[{"name":"Division of Plastic and Reconstructive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3035-6476","authenticated-orcid":false,"given":"Christopher","family":"Pham","sequence":"additional","affiliation":[{"name":"Department of Orthopedic Surgery, University of California Los Angeles Health, Los Angeles, CA 90095, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Edward C.","family":"Ray","sequence":"additional","affiliation":[{"name":"Division of Plastic and Reconstructive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philip S.","family":"Brazio","sequence":"additional","affiliation":[{"name":"Division of Plastic and Reconstructive Surgery, Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,2,7]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1177\/1358863X231215329","article-title":"Advances in lymphedema: An under-recognized disease with a hopeful future for patients","volume":"29","author":"Carroll","year":"2024","journal-title":"Vasc. Med."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"202","DOI":"10.1111\/j.1742-7924.2012.00220.x","article-title":"Health-related quality of life and associated factors in patients with primary lymphedema","volume":"10","author":"Okajima","year":"2013","journal-title":"Jpn. J. Nurs. Sci."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"70","DOI":"10.1038\/s41523-021-00276-y","article-title":"The impact of lymphedema on health-related quality of life up to 10 years after breast cancer treatment","volume":"7","author":"Toyserkani","year":"2021","journal-title":"Npj Breast Cancer"},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"1009","DOI":"10.1016\/j.jaad.2017.03.022","article-title":"Lymphedema","volume":"77","author":"Grada","year":"2017","journal-title":"J. Am. Acad. Dermatol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"421","DOI":"10.1002\/micr.22254","article-title":"Lymphatic Microsurgical Preventing Healing Approach (LYMPHA) for primary surgical prevention of breast cancer-related lymphedema: Over 4 years follow-up","volume":"34","author":"Boccardo","year":"2014","journal-title":"Microsurgery"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"201","DOI":"10.1007\/s10549-016-4089-0","article-title":"Radiation therapy targets and the risk of breast cancer-related lymphedema: A systematic review and network meta-analysis","volume":"162","author":"Shaitelman","year":"2017","journal-title":"Breast Cancer Res. Treat."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Brenner, E., H\u00e4gerling, R., Schacht, V., Schrader, K., and Wilting, J. (2025). Definition, Epidemiology and Pathophysiology of Lymphoedema. Cells, 14.","DOI":"10.3390\/cells14241955"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"72","DOI":"10.1055\/s-0035-1564608","article-title":"Indocyanine Green Lymphography Findings in Limb Lymphedema","volume":"32","author":"Narushima","year":"2015","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"541","DOI":"10.1097\/01.sap.0000244977.84130.cf","article-title":"The Use of Bioimpedance Analysis to Evaluate Lymphedema","volume":"58","author":"Warren","year":"2007","journal-title":"Ann. Plast. Surg."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"1003e","DOI":"10.1097\/PRS.0000000000003218","article-title":"Current Concepts in the Surgical Management of Lymphedema","volume":"139","author":"Kung","year":"2017","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"286","DOI":"10.1177\/14574969241300101","article-title":"Modern surgical treatments for lymphedema","volume":"114","author":"Kearns","year":"2025","journal-title":"Scand. J. Surg."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"1360","DOI":"10.1097\/JS9.0000000000000210","article-title":"Outcomes after microsurgical treatment of lymphedema: A systematic review and meta-analysis","volume":"109","author":"Meuli","year":"2023","journal-title":"Int. J. Surg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"982","DOI":"10.1016\/j.jamcollsurg.2021.03.002","article-title":"Outcomes of Vascularized Lymph Node Transplantation for Treatment of Lymphedema","volume":"232","author":"Schaverien","year":"2021","journal-title":"J. Am. Coll. Surg."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"947","DOI":"10.1002\/micr.30246","article-title":"Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema","volume":"37","author":"Scaglioni","year":"2017","journal-title":"Microsurgery"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1007\/s10549-020-05839-4","article-title":"Outcomes following lymphaticovenous anastomosis (LVA) for 100 cases of lymphedema: Results over 24-months follow-up","volume":"184","author":"Qiu","year":"2020","journal-title":"Breast Cancer Res. Treat."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"522","DOI":"10.1097\/SAP.0000000000004508","article-title":"Lymphovenous Anastomosis and Vascularized Lymph Node Transfer Reduce Long-term Cellulitis Events in Patients With Secondary Lymphedema: A Systematic Review and Meta-analysis","volume":"95","author":"Solomon","year":"2025","journal-title":"Ann. Plast. Surg."},{"key":"ref_17","doi-asserted-by":"crossref","unstructured":"Chen, J., Feng, X., Zhou, Y., Wang, Y., Xiao, S., and Deng, C. (2025). Outcomes after liposuction-based treatment of lymphedema: A systematic review and meta-analysis. Front. Oncol., 15, Available online: https:\/\/www.frontiersin.org\/journals\/oncology\/articles\/10.3389\/fonc.2025.1651472\/full.","DOI":"10.3389\/fonc.2025.1651472"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"464","DOI":"10.1097\/01.sap.0000257149.42922.7e","article-title":"Lymphedema: A Comprehensive Review","volume":"59","author":"Warren","year":"2007","journal-title":"Ann. Plast. Surg."},{"key":"ref_19","first-page":"3806150","article-title":"Healthcare Practitioners\u2019 Knowledge of Lymphedema","volume":"2021","author":"Yarmohammadi","year":"2021","journal-title":"Int. J. Vasc. Med."},{"key":"ref_20","first-page":"e2670","article-title":"Building a Multidisciplinary Comprehensive Academic Lymphedema Program","volume":"8","author":"Schaverien","year":"2020","journal-title":"Plast. Reconstr. Surg.-Glob. Open"},{"key":"ref_21","unstructured":"(2025, November 08). Lymphedema Network of Excellence [Internet]. Department of Surgery. Available online: https:\/\/uwsurgery.org\/lymphedema-network-of-excellence\/."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"111e","DOI":"10.1097\/PRS.0000000000002258","article-title":"Diagnosis and Management of Obesity-Induced Lymphedema","volume":"138","author":"Greene","year":"2016","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"12600","DOI":"10.1038\/s41598-024-63145-1","article-title":"The lymphedema patient experience within the healthcare system: A cross-sectional epidemiologic assessment","volume":"14","author":"Bowman","year":"2024","journal-title":"Sci. Rep."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"315","DOI":"10.1089\/lrb.2017.29033.sr","article-title":"Lymphatic Medicine: Paradoxically and Unnecessarily Ignored","volume":"15","author":"Rockson","year":"2017","journal-title":"Lymphat. Res. Biol."},{"key":"ref_25","first-page":"292\u2013307; quiz 308\u2013311","article-title":"Lymphedema: Current issues in research and management","volume":"50","author":"Petrek","year":"2000","journal-title":"CA. Cancer J. Clin."},{"key":"ref_26","unstructured":"(2026, January 14). Primary Lymphedema-Symptoms, Causes, Treatment|NORD [Internet]. Available online: https:\/\/rarediseases.org\/rare-diseases\/hereditary-lymphedema\/."},{"key":"ref_27","first-page":"18","article-title":"Post-traumatic lymphedema: Review of the literature and surgical treatment options","volume":"9","author":"Minasian","year":"2022","journal-title":"Plast. Aesthetic Res."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"626","DOI":"10.1016\/j.jvsv.2023.01.005","article-title":"The efficacy of stenting in the iliofemoral vein of patients with venous obstruction and secondary lymphedema from malignancy","volume":"11","author":"Li","year":"2023","journal-title":"J. Vasc. Surg. Venous Lymphat. Disord."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"331","DOI":"10.1177\/1358863X17714884","article-title":"Specialized consultations in a hospital-based referral center for patients suspected of having limb lymphedema: Impact on diagnosis","volume":"22","author":"Vignes","year":"2017","journal-title":"Vasc. Med."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"574","DOI":"10.1002\/micr.30753","article-title":"Lymphatico-venous anastomosis in chronic ulcer with venous insufficiency: A case report","volume":"41","author":"Cigna","year":"2021","journal-title":"Microsurgery"},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"275","DOI":"10.1007\/s40257-022-00753-5","article-title":"Stasis Dermatitis: An Overview of Its Clinical Presentation, Pathogenesis, and Management","volume":"24","author":"Yosipovitch","year":"2023","journal-title":"Am. J. Clin. Dermatol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"185","DOI":"10.1055\/a-2530-5875","article-title":"Lipedema: Clinical Features, Diagnosis, and Management","volume":"52","author":"Mortada","year":"2025","journal-title":"Arch. Plast. Surg."},{"key":"ref_33","doi-asserted-by":"crossref","unstructured":"Nagy, B.I., Mohos, B., and Tzou, C.H.J. (2023). Imaging Modalities for Evaluating Lymphedema. Medicina, 59.","DOI":"10.3390\/medicina59112016"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"145","DOI":"10.1177\/1358836X9800300209","article-title":"Lymphedema: Classification, diagnosis and therapy","volume":"3","author":"Szuba","year":"1998","journal-title":"Vasc. Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1089\/lrb.2020.0118","article-title":"From Bench to Bedside: The Role of a Multidis-ciplinary Approach to Treating Patients with Lymphedema","volume":"19","author":"Lentz","year":"2021","journal-title":"Lymphat. Res. Biol."},{"key":"ref_36","first-page":"253","article-title":"Agreement between telerehabilitation involving caregivers and face-to-face clinical assessment of lymphedema in breast cancer survivors","volume":"22","year":"2014","journal-title":"Support. Care Cancer"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"218","DOI":"10.12968\/bjon.2021.30.4.218","article-title":"Guidelines for managing people with lymphoedema remotely: A post-COVID-19 response document","volume":"30","author":"Thomas","year":"2021","journal-title":"Br. J. Nurs."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/4\/1322\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,2,9]],"date-time":"2026-02-09T08:41:41Z","timestamp":1770626501000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/4\/1322"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,2,7]]},"references-count":37,"journal-issue":{"issue":"4","published-online":{"date-parts":[[2026,2]]}},"alternative-id":["jcm15041322"],"URL":"https:\/\/doi.org\/10.3390\/jcm15041322","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,2,7]]}}}