It is imperative to ensure patients’ understanding that surgery is not a cure

Advancement in surgical and microsurgical techniques presents promising options for patients. Current research evidence supports that surgical treatment with pre- or post-operative conservative lymphedema therapy (e.g., compression, or MLD, or CDT) resulted in improved limb volume or girth, cellulitis, and quality of life; yet high quality evidence for sustained and long-term surgical results is lacking [1,2,3]. Some case reports demonstrated that lymphedema was substantially reduced from Stage 1 to Stage 0-latent or subclinical lymphedema [4], particularly if surgery was performed on patients with early stage (Stage I) of lymphedema. Still, the need for rigorous research on surgical treatments with or without conservative lymphedema therapy and issues regarding the need for surgical intervention for early stage of lymphedema remain unaddressed. Current evidence does not support that surgical interventions with or without conservative therapy constitute a cure for lymphedema [1,2,3,4,5]. It is imperative to ensure that patients understand that surgical treatment currently is not a cure and post-operative care requires conservative lymphedema treatment. Patients deserve to receive education based on the most recent evidence to make informed decisions along the trajectory of care and manage their treatment expectations accordingly (Fig. 1).

Fig. 1

Recommended essentials for post-operative care following surgical lymphedema treatment

Conservative lymphedema therapy is an essential part of post-operative care

Despite the paucity of evidence in support of a standardized protocol or clinical guidelines for post-operative care of patients following surgical treatment of lymphedema, current research and clinical practice support conservative lymphedema therapy (e.g., compression, CDT, MLD) as an essential part of post-operative care to improve surgical results of limb volume or girth and quality of life [3, 5]. Conservative lymphedema therapy during post-operative care should consider the following:

The compression therapy or CDT after surgery can be initiated at 1–4 weeks after surgery depending on surgery type, patient’s status, and surgeon’s preferences.

The duration of compression therapy or CDT can be from 3 to 12 months or as needed depending on surgery type and patient’s status.

Manual lymphatic drainage (MLD) should be administered by certified therapists after surgery. If patients are required to perform self-MLD, they should be trained by certified lymphedema therapists. MLD can be initiated from 10 days to 4 weeks after surgery and continue for 6 months or longer.

A multidisciplinary care approach is essential for post-operative care

The importance of a multidisciplinary care approach to post-operative care for patients following surgical treatment of lymphedema has been recognized by researchers and healthcare providers [4]. Each profession contributes a unique perspective and set of care skills to the care of patients post-operatively to address patients’ needs, including impairments in physical mobility, metabolism, nutrition, cardiovascular endurance, integument integrity, and emotional health. Post-operative care to meet the complex needs of patients requires a team of well-trained multidisciplinary healthcare providers [6]. The shared-patient-and-patient-centered model is recommended for the multidisciplinary care team. Within the team, each healthcare provider actively listens and addresses each patient’s needs. All the team members should work together to create a personalized patient care plan and clinic workflow that leverages the strengths of each profession to implement a personalized patient care plan and to ensure the continuum of care. The multidisciplinary post-operative care team should consist of:

A primary care physician and/or physiatrist monitoring the patient longitudinally;

A surgeon providing post-operative assessment, including potential adverse effects;

A nurse or other wound specialist to provide post-operative wound care and address other dermatological needs as well as other post-operative needs of the patient;

Physical therapists and/or occupational therapists to evaluate patients and deliver therapy for impaired limb and daily living function as well as strategies for post-operative lymphedema management;

A counselor to provide emotional health support; and

A registered dietitian or nutritionist, or nutrition and dietetics technicians to provide education on diet, nutrition, and weight management.

A multidisciplinary care approach requires leadership support from health systems to build or modify clinical infrastructures to enable effective documentation, patient education, monitoring, scheduling, billing, and reimbursement.

Consistent documentation of a core set of outcomes is imperative

An essential component of post-operative care is to maintain a consistent documentation to evaluate and monitor patient outcomes after surgical treatment of lymphedema. Currently, there is a lack of consistency in the outcomes used and meaningful significant change of the outcomes for patients and healthcare providers. This inconsistent use and documentations of outcomes make it unclear whether lymphedema surgery meets patients’ expectations for success [2]. Using a core set of outcome measures for surgical outcome documentation should be part of clinical practice to allow consistent and longitudinal assessment of the effectiveness of surgical treatment over time. Accordingly, a minimal core set of outcome documentations should include objective and subjective outcome measures.

Objective measures: circumferential measurements of limb volume or limb girth; lymph fluid level, or other appropriate objective measures.

Subjective patient-reported outcome measures (PROMs): lymphedema symptoms, clinical stages of lymphedema, physical or daily living functions, and quality of life [7].

A post-operative care guideline for patient education/expectations is needed

Successful surgical treatment of lymphedema requires accurate and ongoing patient education regarding the expectations for surgical recovery. Targeted post-operative education is essential to enhance patients’ learning and health literacy regarding specific surgical treatment of lymphedema. Moreover, targeted post-operative patient education helps patients to continue shaping their realistic expectations for surgical recovery along the trajectory of care [6, 7]. Minimal patient education for post-operative care should include information regarding:

Conservative lymphedema therapy and self-care;

Outcome measures;

Prevention and treatment of common surgical complications;

Follow-up care and appointments;

Resources addressing patients’ needs along the continuum of care.

Initial and ongoing training/credentialing is required for healthcare providers

The complex nature of lymphedema necessitates a comprehensive understanding of the lymphatic system and proficiency in the specialized techniques involved in conservative lymphedema therapy 8. For lymphedema therapists, the initial certification and ongoing training of certified lymphedema therapists is paramount to provide patients with effective conservative lymphedema therapy (e.g., compression, CDT, or MLD). Initial training equips therapists with foundational skills and knowledge whereas the evolving nature of post-operative care for patients who undergo surgical treatment highlights the importance of ongoing professional development. Advanced training ensures therapists stay abreast of the latest research, techniques, and best practices, thereby enhancing treatment efficacy and patient outcomes.

Ongoing education for members of multidisciplinary post-operative care team plays a critical role in maintaining a high standard of care and ensuring patient safety. As lymphedema can present with various complications, team members must be competent in identifying and managing these challenges. This level of expertise is cultivated through rigorous and continuous training, thereby fostering a deeper understanding of patient-specific needs, such as those arising from different types of surgical procedures. The commitment to ongoing professional development reflects a dedication to patient-centered care from health systems and healthcare providers and aligns with best practice in lymphedema care.