Complete decongestive therapy (CDT) has been the standard of care for the treatment of lymphedema. CDT includes manual lymph drainage, compression bandaging, exercises, and skin and nail care. The goals of CDT are to reduce the accumulated fluid maximally, reduce the risk of infections, and soften fibrotic tissue.

Manual lymphatic drainage is a gentle, hands-on technique that stimulates the lymphatic system to absorb fluid from the tissue spaces and move the fluid in the appropriate direction. The effects of MLD are to increase lymph production, increase the rate of contraction of the lymph angion, reverse lymph flow to reroute around the areas that have been damaged, and increase venous return. There is also a soothing and analgesic effect of MLD, as it promotes a parasympathetic response [12].

Compression for lymphedema is provided via bandages and/or garments. Short-stretch bandages are utilized during the treatment phase of CDT. They work with the muscle pump to facilitate movement of lymph fluid. The bandages exhibit a high working pressure on the tissues to promote fluid uptake. They are applied in layers, with more layers being applied distally to facilitate uptake and movement of lymph fluid back into the lymphatic system.

Once maximal reduction in limb volume has been achieved, or if the swelling was mild enough initially not to warrant CDT, compression garments are utilized to maintain the limb volume. There are a variety of daytime and nighttime garments available depending on the needs of the patient.

There is some discrepancy in the literature as to the efficacy of the individual components of CDT. A meta-analysis conducted by Huang et al. found that the addition of MLD to compression and exercise for the treatment of breast cancer-related lymphedema is unlikely to produce significant limb volume reduction. The reviewed studies were, however, poor in quality [13].

Multilayer compression bandaging has been found to be an effective means of reducing limb volume, either with or without the addition of MLD and/or exercise.

Intermittent pneumatic compression (IPC) devices have been used as an adjunct to lymphedema treatment. These devices utilize multichamber intermittent compression to facilitate the uptake and movement of lymph fluid. There has been shown to be improvement in reduction and/or maintenance of limb volume as well as increased tissue elasticity and quality of life in those who use IPC at home.

A systemic review and meta-analysis by Rogan et al. compared the effects of compression bandages, compression sleeves, IPC, and active exercise on the reduction of breast cancer-related lymphedema (BCRL) . Exercise was found to contribute to volume reduction. IPC has been shown to be an effective adjunct to traditional therapy, but not as a stand-alone treatment. A compression sleeve, unless worn at a subclinical onset of lymphedema [11], is to maintain limb volume, not reduce. Compression bandaging was found to be an effective means of reducing limb volume [14].

There are a variety of other adjunct treatment options, including but not limited to low-level laser, kinesiotaping, and acupuncture. None of these have been shown to be stand-alone therapies but have been shown in some cases to enhance the effects from CDT.

A variety of surgical procedures are currently offered for lymphedema patients suffering from mild to severe symptoms. Surgical procedures fall into two broad categories: ablative and physiologic. Both can offer symptomatic relief from pain, infection, and/or swelling; improve limb range of motion; facilitate hygiene; and improve cosmesis. However, patients must be optimized on nonsurgical management prior to consideration for any lymphedema surgery and to maximize success. Surgical options are not considered curative and must be customized based on each patient’s etiology, comorbidities, symptoms/staging, physical examination, surgeon’s preference for debulking versus physiologic procedures, and occasionally preoperative imaging (lymphoscintigraphy and/or MRI). Timing of surgical intervention may correlate to efficacy, as early and mild symptoms may respond to physiological procedures better and late-stage lymphedema may only be amenable to debulking or ablative procedures [15]. Also, patients with lymphedema secondary to obesity should first consider bariatric surgery.

Early surgical interventions consisted primarily of direct excision of the areas of enlarged skin and subcutaneous tissue. Today, two commonly used ablative procedures are direct excision and liposuction. Large pendulous masses are more easily amenable to direct excision. Often, debulking procedures were performed in series to slowly but effectively decrease the size of the limb [16]. Complications include wound healing problems, infection, and recurrence. The Charles procedure is reserved often for the most severe or advanced disease. A radical debulking is performed by removing all of the abnormal skin and subcutaneous tissue completely to the epimysium or deep fascia, and applying skin grafts from either the resected specimen or alternate donor sites. The superficial lymphatic system is completely disrupted, and any foot lymphedema may be exacerbated. The resulting limb may suffer from hyperkeratoses, papillomatosis, graft contracture, infection, and ulceration with a cosmetically poor but functionally acceptable result [17, 18].