Skip to main content

Genital Lymphedema

Genital lymphedema (GL) is the accumulation of protein-rich lymphatic fluid in the interstitial tissues of the external genitalia — penis, scrotum, vulva, and/or perineum — from impaired lymphatic drainage. It is chronic, progressive, and produces discomfort, cosmetic disfigurement, functional disturbances (urinary, sexual, ambulatory), and profound psychosocial impact.[1][2] No standardized treatment algorithm exists; diagnosis and management remain frequently delayed.[3]

For surgical reconstruction technique see Scrotal Reconstruction and Scrotal Flap Reconstruction. For the inflammatory dermatologic condition that may coexist or contribute, see Hidradenitis Suppurativa (GU).

Epidemiology​

  • Lymphatic filariasis (most common cause globally) — Wuchereria bancrofti in 90% of ~120 million LF cases; ~15–16 million live with chronic filarial lymphedema; scrotal elephantiasis and hydrocele are hallmarks. Community prevalence 1.3–7.8% in endemic regions.[5][6][7][8]
  • Prostate cancer treatment — GL in 0–1% after RP + PLND alone; 2–22% after pelvic radiation following PLND.[9]
  • Gynecologic cancer treatment — GL frequently accompanies lower-limb lymphedema after hysterectomy + PLND + pelvic RT.[1][10]
  • Inguinal / ilioinguinal lymphadenectomy for melanoma, anal, penile cancer.[1]
  • Pediatric GL — 0.6% (25/3889) at a vascular-anomalies center; 92% primary / idiopathic; mean onset 4.5 yr; 60.9% in infancy; penoscrotal in 72%; concurrent lower-extremity lymphedema in 76%.[11]
  • Obesity-induced lymphedema (OIL) — BMI > 56 confers 213-fold increased MLL risk; nearly universal above BMI 60; OIL may begin once BMI exceeds 40.[12][13][14]

Etiology and Classification​

Primary GL — developmental lymphatic anomalies; congenital / praecox / tarda; syndromic forms (FOXC2 lymphedema-distichiasis, GATA2 Emberger, Meige, GJC2). 84% primary in the largest male GL series.[17][18]

Secondary GL — filariasis; cancer treatment; obesity (OIL / MLL); recurrent cellulitis / STIs / TB; trauma; non-oncologic surgery; Crohn's / ano-genital granulomatosis (40% have intestinal Crohn's; 80% with combined penile + scrotal edema); HS; idiopathic acquired.[5][9][12][15][20][21]

McDougal 2003 — practical division into self-limited (conservative) vs chronic with pathological skin / tissue changes (surgical).[16]

Pathophysiology​

Lymphatic obstruction → protein-rich interstitial fluid → chronic lymph stasis → inflammation + fibrosis + adipose expansion + dysfunctional lymphangiogenesis + local immunosuppression ("locus minoris resistentiae" predisposing to infection and neoplasia).[22][23] Recurrent cellulitis further damages lymphatics in a vicious cycle.[24] In genital MLL specifically — dartos hyperplasia / hypertrophy with microvascular proliferation at the smooth-muscle–stroma interface.[25]

Staging and Severity​

SystemDetail
ISL Stage 0–3Universal staging; endorsed by NCCN survivorship guidelines.[26][27]
Genital Lymphedema Score (GLS, Yamamoto)0–9 symptom-based score (urinary trouble, edema, lymphorrhea); correlates with Genital Dermal Backflow (GDB) stage on ICG lymphography.[28][29]
Ehrl 2023 treatment-oriented classificationGiant penoscrotal lymphedema; guides whether VLNT is added.[30]
MR-lymphography classification (Lu 2016)Inguinal-node dysfunction mild / moderate / severe → CDP vs microsurgery vs excision.[31]

Clinical Features and Complications​

Progressive genital swelling, heaviness, ambulation / hygiene / voiding difficulty (buried penis), sexual dysfunction, lymphorrhea, cosmetic disfigurement.[1][18][32]

ComplicationDetail
CellulitisLymphedema OR 6.8 for cellulitis; Stage 3 has ~2× the rate of Stage 2 (61.7% vs 31.8%).[24][33]
Papillomatosis / warty overgrowthVerrucous chronic skin changes.
Lymph vesicles / lymphocutaneous refluxSuperficial lymphatic cysts that rupture; retrograde lymph flow.[34]
Recurrent fungal infectionFrom impaired local immunity.
Malignant transformationStewart-Treves lymphangiosarcoma — rare but devastating; immunosuppression also predisposes to non-melanoma skin cancer.[23][35]

QoL improvement after surgery — mean 1.3 → 7.7 on a 1–10 scale in the MLL series.[32]

Diagnosis​

Clinical exam (edema, peau d'orange, fibrosis, Stemmer sign).[2][36]

ModalityRole
LymphoscintigraphyTraditional gold standard; ⁹⁹ᵐTc-colloid; delayed / asymmetric drainage, dermal backflow, collateral channels.[37][38]
ICG lymphographySens 0.97, spec 0.55–0.93; less invasive; characterizes linear → splash → stardust → diffuse progression; differentiates type 1 (leg-to-genital) vs type 2 (non-leg source) genital flow.[38][39][40][41]
MR lymphangiographyFunctional + morphological; grades inguinal-node dysfunction for treatment selection.[31]
UHF ultrasoundExcludes DVT; identifies lymphatics / perforators for surgical planning.[40]
BiopsyFor diagnostic uncertainty / malignancy concern; ano-genital granulomatosis shows non-caseating (50%) and intralymphatic granulomas (14%).[20][25]

Conservative Management​

Complex Decongestive Therapy (CDT)​

The cornerstone — poorly adapted to genital anatomy vs extremities.[1][2][3]

ComponentDetail
Manual lymphatic drainage (MLD)Genital-anatomy-adapted; partner / self-drainage education.[3][43]
CompressionScrotal supports, hip spica bandage, panty girdle, custom compression underwear (40–80 mmHg).[2][3]
ExerciseMuscle / joint pumps; progressive resistance training does not exacerbate.[26]
Skin careMeticulous hygiene; treat fungi; moisturize.[3]

Integrated approach (Torio-Padron n = 51) — perioperative CDP yields a 6% revision rate.[18] Yaman 2024 — six CDT sessions over 14 days achieved significant scrotal reduction in HS-related GL concurrent with ixekizumab.[21]

Pneumatic compression devices​

Recommended by 92% of AVF expert panelists; reduces cellulitis, outpatient services, hospitalization.[24][45]

Pharmacotherapy​

  • Ketoprofen 75 mg TID × 4 mo — Rockson pilot + placebo-controlled (n = 21 + 34): reduced skin thickness, improved histopathology, decreased plasma G-CSF; mechanism via LTB₄ inhibition (Tian 2017). Not FDA-approved.[11][12][13]
  • Low-dose systemic corticosteroids — Fujimoto 2014: prevented acute progression in acquired idiopathic penile lymphedema with histologic lymphocytic inflammation.[15]
  • Immunomodulators (Crohn's / ano-genital granulomatosis) — oral steroids 72% initial response (recurrence common), azathioprine 60%, anti-TNF 3/6 responded.[20]
  • Selenium (sodium selenite) — Micke 2003: VAS reduction 4.3 in radiation lymphedema; Cochrane evidence base weak.[14][15]
  • Antifilarials — DEC, ivermectin, albendazole; mass drug administration programs.[44]
  • Prophylactic antibiotics for recurrent cellulitis — IDSA 2014 recommends after ≥ 3–4 episodes/yr: oral penicillin 250 mg–1 g BID, erythromycin 250 mg BID, or IM benzathine penicillin 1.2 MU q2–4 wk for 4–52 wk. PATCH trial (Thomas NEJM 2013, n = 274): penicillin 250 mg BID × 12 mo significantly reduced recurrence; benefit waned after discontinuation; failure predictors — BMI ≥ 33, ≥ 3 prior episodes, preexisting edema.[18][19][33]

Weight management — fundamental for obesity-induced GL​

OIL is reversible with weight loss (Nitti murine model); BMI > 60 → < 60 normalized leg volume in 50% (Greene). Wisenbaugh — most patients gained 5.2 kg post-excision without a weight-loss program. The BLOOM technique (Sim 2025) combines sleeve gastrectomy with VLNT using repurposed gastroepiploic lymph nodes from the gastrectomy specimen.[12][14][23][24][26][32]

Surgical Management​

Two complementary categories — excisional / debulking and physiologic / reconstructive — frequently combined in modern algorithms.[46][47]

Excisional / debulking​

ProcedureOutcomes
Modified Charles procedure (excision + STSG)Modolin 2006 n = 17 — symptom regression, 1 recurrence (RT + PLND patient); Salako 2018 n = 11 — hematoma 27.3%, SSI 18.2%, recurrence 9.1%; Singh 2011 n = 48 filarial — all satisfactory cosmesis / function; groin infection 25%.[19][48][49]
Excision + primary closureTorio-Padron n = 51 — 6% complication rate; no flaps or grafts needed; Wisenbaugh n = 11 MLL — mean 21 kg resected, QoL 1.3 → 7.7 but most regained weight.[18][32]
Excision + flap reconstructionGuiotto SR: 54.2% complication rate (highest among approaches), reflects disease severity.[46]
MLL excision in obesityMachol n = 4 — lateral scrotal flaps ± mid-raphe Z-plasty; 50% recurrence without weight loss.[50]
Liposuction / SAPLAddresses the solid (adipose / fibrotic) component of late ISL stage II–III; SR n = 2,334 — standalone reduced volume 99.7% with continuous compression; combined liposuction + LVA / VLNT reduced compression dependence. AAPS Grade 1C.[10][31][32][33]

Physiologic / reconstructive​

ProcedureOutcomes
Lymphaticovenous anastomosis (LVA)Guiotto SR: 9% complication rate — lowest. Hara & Mihara — combined leg-LVA + genital-LVA per ICG flow type to prevent recurrence; Mukenge spermatic-cord LVA. Thomas 2023 n = 150 — cellulitis 4.22 → 0.10 / yr. AAPS Grade 1C.[27][35][37][40][41][46]
Vascularized lymph node transfer (VLNT)Ehrl 2023 n = 9 giant penoscrotal — scrotal VLNT improved lymphatic transport; 0% recurrence at 49 mo; Lindenblatt 2025 — VLNT alone reduced volume in 70% vs LVA 25% (p = 0.035). AAPS Grade 1B.[30][45][51][52]
SCIP Lymphatic Flap Transfer — "3R" (Yamamoto 2022)Radical reduction + reconstruction with pedicled SCIP lymphatic flap + SCIP pure-skin-perforator flap. n = 7 (4 scrotal, 3 penoscrotal); mean resected 1,511 g; 0% complications, 0% recurrence at mean 22.7 mo; GLS 6.7 → 0.3.[53]
Complete Functional Lymphatic System Pedicled Transfer (Abdelfattah 2023)n = 26 advanced scrotal / penoscrotal lymphedema; 100% flap survival; cellulitis dramatically reduced (p < 0.001).[54]
CHASCIP — Combined Charles + Lymphatic SCIP flap (Ciudad 2025)n = 8 ISL Stage III; bilateral pedicled lymphatic SCIP flaps + STSG; mean resected 1,772.7 g; 25% complications; 0% recurrence at 34 mo; sexual dysfunction 87.5% → 0%.[55]
Lymphatic System Transfer (LYST)SCIP flap with both lymph nodes and afferent lymphatic vessels intact; Yoshimatsu 2025 n = 8 — excess volume −11.2% at 39 mo, cellulitis significantly decreased (p = 0.025); Xu 2026 — pedicled SCIP LYST for lymphedema + chronic venous disease, no microsurgical anastomosis needed.[56][57]

Synthesized Treatment Algorithm​

SeverityApproach
Stage 0–1 / GLS ≤ 2CDT, weight management, treat underlying cause (antifilarials, immunomodulators); investigational ketoprofen.[11]
Stage 2 / GLS 3–5Intensive CDT + PCD; prophylactic penicillin if ≥ 3–4 cellulitis/yr; LVA if functional lymphatics on ICG; VLNT if lymphatics sclerosed; excision + primary closure if conservative fails.[18][27][45]
Stage 3 / GLS 6–9 / elephantiasisSCIP lymphatic flap transfer (3R / CHASCIP) — one-stage curative, no postop compression required; modified Charles when lymphatic-reconstruction expertise unavailable; excision + VLNT for documented transport deficiency. Perioperative CDP.[28][43][50][53][55]
Obesity-induced GL / MLLWeight loss is fundamental; BLOOM technique combines sleeve gastrectomy + VLNT; comprehensive weight-loss plan must accompany excision (Wisenbaugh).[12][26][30][50]
Crohn's / ano-genital granulomatosisOral steroids → azathioprine → anti-TNF; circumcision / debulking for refractory cases.[20]

See Also​

References​

1. Vignes S. Genital lymphedema after cancer treatment: a narrative review. Cancers (Basel). 2022;14(23):5809. doi:10.3390/cancers14235809

2. Grada AA, Phillips TJ. Lymphedema: pathophysiology and clinical manifestations. J Am Acad Dermatol. 2017;77(6):1009–1020. doi:10.1016/j.jaad.2017.03.022

3. Borman P, Noble-Jones R, Thomas MJ, Bragg T, Gordon K. Conservative and integrated management of genital lymphoedema. J Wound Care. 2021;30(Sup12a):6–17. doi:10.12968/jowc.2021.30.Sup12a.6

5. Taylor MJ, Hoerauf A, Bockarie M. Lymphatic filariasis and onchocerciasis. Lancet. 2010;376(9747):1175–1185. doi:10.1016/S0140-6736(10)60586-7

6. Sawers L, Stillwaggon E. Economic costs and benefits of community-based lymphedema-management programs for lymphatic filariasis in India. Am J Trop Med Hyg. 2020;103(1):295–302. doi:10.4269/ajtmh.19-0898

7. John W, Mushi V, Tarimo D, Mwingira U. Prevalence and management of filarial lymphoedema in Lindi District, Tanzania. Trop Med Int Health. 2022;27(8):678–685. doi:10.1111/tmi.13792

8. Walsh V, Little K, Wiegand R, Rout J, Fox LM. Evaluating the burden of lymphedema due to lymphatic filariasis in Khurda District, Odisha. PLoS Negl Trop Dis. 2016;10(8):e0004917. doi:10.1371/journal.pntd.0004917

9. Clinckaert A, Callens K, Cooreman A, et al. The prevalence of lower-limb and genital lymphedema after prostate cancer treatment. Cancers (Basel). 2022;14(22):5667. doi:10.3390/cancers14225667

10. Mimura T, Hasegawa T, Okada Y, et al. Exercise interventions for lower-limb lymphoedema after treatment for gynaecological cancers. Cochrane Database Syst Rev. 2025;6:CD015669. doi:10.1002/14651858.CD015669

11. Schook CC, Kulungowski AM, Greene AK, Fishman SJ. Male genital lymphedema: clinical features and management in 25 pediatric patients. J Pediatr Surg. 2014;49(11):1647–1651. doi:10.1016/j.jpedsurg.2014.05.031

12. Maclellan RA, Zurakowski D, Grant FD, Greene AK. Massive localized lymphedema: a case-control study. J Am Coll Surg. 2017;224(2):212–216. doi:10.1016/j.jamcollsurg.2016.10.047

13. Kurt H, Arnold CA, Payne JE, et al. Massive localized lymphedema: a clinicopathologic study of 46 patients. Mod Pathol. 2016;29(1):75–82. doi:10.1038/modpathol.2015.135

14. Sudduth CL, Greene AK. Lymphedema and obesity. Cold Spring Harb Perspect Med. 2022;12(5):a041176. doi:10.1101/cshperspect.a041176

15. Fujimoto N, Honda S, Nakanishi G, Tachibana T, Tanaka T. Acquired idiopathic penile lymphedema: successful prevention of acute phase progression with low-dose corticosteroids. J Dermatol. 2014;41(2):157–159. doi:10.1111/1346-8138.12357

16. McDougal WS. Lymphedema of the external genitalia. J Urol. 2003;170(3):711–716. doi:10.1097/01.ju.0000067625.45000.9e

17. Connell FC, Gordon K, Brice G, et al. The classification and diagnostic algorithm for primary lymphatic dysplasia. Clin Genet. 2013;84(4):303–314. doi:10.1111/cge.12173

18. Torio-Padron N, Stark GB, Földi E, Simunovic F. Treatment of male genital lymphedema: an integrated concept. J Plast Reconstr Aesthet Surg. 2015;68(2):262–268. doi:10.1016/j.bjps.2014.10.003

19. Singh V, Sinha RJ, Sankhwar SN, Kumar V. Reconstructive surgery for penoscrotal filarial lymphedema. Urology. 2011;77(5):1228–1231. doi:10.1016/j.urology.2010.10.026

20. Alexakis C, Gordon K, Mellor R, et al. Ano-genital granulomatosis and Crohn's disease. J Crohns Colitis. 2017;11(4):454–459. doi:10.1093/ecco-jcc/jjw173

21. Yaman A, Borman P, Eşme P, Çalışkan E. Complex decongestive therapy in hidradenitis suppurativa-related genital lymphoedema. J Wound Care. 2024;33(Sup2a):xxviii–xxxi. doi:10.12968/jowc.2024.33.Sup2a.xxviii

22. Wu T, Pu J, Yao Q, et al. Advances in etiology, pathophysiology, diagnosis, and management of lymphedema. Front Med (Lausanne). 2025;12:1666522. doi:10.3389/fmed.2025.1666522

23. Carlson JA. Lymphedema and subclinical lymphostasis facilitate cutaneous infection, inflammatory dermatoses, and neoplasia. Clin Dermatol. 2014;32(5):599–615. doi:10.1016/j.clindermatol.2014.04.007

24. Lurie F, Malgor RD, Carman T, et al. AVF / AVLS / SVM expert opinion consensus on lymphedema diagnosis and treatment. Phlebology. 2022;37(4):252–266. doi:10.1177/02683555211053532

25. Lee S, Han JS, Ross HM, Epstein JI. Massive localized lymphedema of the male external genitalia: a clinicopathologic study of 6 cases. Hum Pathol. 2013;44(2):277–281. doi:10.1016/j.humpath.2012.05.023

26. National Comprehensive Cancer Network. Survivorship guidelines. 2026.

27. Davies C, Levenhagen K, Ryans K, Perdomo M, Gilchrist L. Interventions for breast cancer-related lymphedema. Phys Ther. 2020;100(7):1163–1179. doi:10.1093/ptj/pzaa087

28. Yamamoto T, Yamamoto N, Furuya M, Hayashi A, Koshima I. Genital lymphedema score (GLS). Ann Plast Surg. 2016;77(1):119–121. doi:10.1097/SAP.0000000000000360

29. Yamamoto T, Narushima M, Doi K, et al. Characteristic ICG lymphography findings in lower-extremity lymphedema. Plast Reconstr Surg. 2011;127(5):1979–1986. doi:10.1097/PRS.0b013e31820cf5df

30. Ehrl D, Heidekrueger PI, Giunta RE, Wachtel N. Giant penoscrotal lymphedema — what to do? J Clin Med. 2023;12(24):7586. doi:10.3390/jcm12247586

31. Lu Q, Jiang Z, Zhao Z, et al. Assessment of the lymphatic system of the genitalia using MR lymphography. Medicine (Baltimore). 2016;95(21):e3755. doi:10.1097/MD.0000000000003755

32. Wisenbaugh E, Moskowitz D, Gelman J. Reconstruction of massive localized lymphedema of the scrotum. Urology. 2018;112:176–180. doi:10.1016/j.urology.2016.09.063

33. Raff AB, Kroshinsky D. Cellulitis: a review. JAMA. 2016;316(3):325–337. doi:10.1001/jama.2016.8825

34. Liao SF, Huang MS, Chou YH, Wei TS. Successful CDP for lymphedema and lymphocutaneous reflux of the female external genitalia after RT. J Formos Med Assoc. 2003;102(6):404–406.

35. Szuba A, Rockson SG. Lymphedema: classification, diagnosis and therapy. Vasc Med. 1998;3(2):145–156. doi:10.1177/1358836X9800300209

36. Rockson SG. Diagnosis and management of lymphatic vascular disease. J Am Coll Cardiol. 2008;52(10):799–806. doi:10.1016/j.jacc.2008.06.005

37. Basavalingu D, Elojeimy S, Mercer MK, et al. Nuclear medicine lymphoscintigraphy. Radiographics. 2025;45(7):e240207. doi:10.1148/rg.240207

38. Akita S, Mitsukawa N, Kazama T, et al. Comparison of lymphoscintigraphy and ICG lymphography. J Plast Reconstr Aesthet Surg. 2013;66(6):792–798. doi:10.1016/j.bjps.2013.02.023

39. Brezgyte G, Mills M, van Zanten M, et al. A SR of ICG lymphography for the diagnosis of primary lymphoedema. Br J Radiol. 2025;98(1168):517–526. doi:10.1093/bjr/tqaf006

40. Kadle RL, Chao AH. Imaging modalities in lymphatic surgery. Expert Rev Med Devices. 2025. doi:10.1080/17434440.2025.2554760

41. Hara H, Mihara M. Genital LVA and leg LVA to prevent the recurrence of genital acquired lymphangiectasia. Microsurgery. 2021;41(5):412–420. doi:10.1002/micr.30733

43. Ezzo J, Manheimer E, McNeely ML, et al. Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database Syst Rev. 2015;(5):CD003475. doi:10.1002/14651858.CD003475.pub2

44. de Souza DK, Bockarie MJ. Current perspectives in the epidemiology and control of lymphatic filariasis. Clin Microbiol Rev. 2025;38(2):e0012623. doi:10.1128/cmr.00126-23

45. Karaca-Mandic P, Hirsch AT, Rockson SG, Ridner SH. Cutaneous, clinical, and health-economic benefits of advanced PCDs in lymphedema. JAMA Dermatol. 2015;151(11):1187–1193. doi:10.1001/jamadermatol.2015.1895

46. Guiotto M, Bramhall RJ, Campisi C, Raffoul W, di Summa PG. A SR of outcomes after genital lymphedema surgery. Ann Plast Surg. 2019;83(6):e85–e91. doi:10.1097/SAP.0000000000001875

47. Barbon C, Imholz C, Zurfluh CE, et al. Longitudinal evaluation of lymphatic reconstruction: 10-year practice data. J Plast Reconstr Aesthet Surg. 2026. doi:10.1016/j.bjps.2026.03.024

48. Salako AA, Olabanji JK, Oladele AO, et al. Surgical reconstruction of giant penoscrotal lymphedema in sub-Saharan Africa. Urology. 2018;112:181–185. doi:10.1016/j.urology.2016.09.064

49. Modolin M, Mitre AI, da Silva JC, et al. Surgical treatment of lymphedema of the penis and scrotum. Clinics (Sao Paulo). 2006;61(4):289–294. doi:10.1590/s1807-59322006000400003

50. Machol JA 4th, Langenstroer P, Sanger JR. Surgical reduction of scrotal MLL in obesity. J Plast Reconstr Aesthet Surg. 2014;67(12):1719–1725. doi:10.1016/j.bjps.2014.07.031

51. Chang DW, Dayan J, Greene AK, et al. Surgical treatment of lymphedema: a SR and meta-analysis. Plast Reconstr Surg. 2021;147(4):975–993. doi:10.1097/PRS.0000000000007783

52. Lindenblatt N, van den Wildenberg R, Barbon C, et al. Lymphatic reconstructive surgery in primary and secondary lymphedema. J Surg Res. 2025;316:8–17. doi:10.1016/j.jss.2025.10.023

53. Yamamoto T, Daniel BW, Rodriguez JR, et al. Radical reduction and reconstruction for male genital elephantiasis: SCIP lymphatic flap transfer. J Plast Reconstr Aesthet Surg. 2022;75(2):870–880. doi:10.1016/j.bjps.2021.08.011

54. Abdelfattah U, Elbanoby T, Hamza F, et al. Treatment of advanced male genital lymphedema with a complete functional lymphatic-system pedicled transfer. Urology. 2023;175:190–195. doi:10.1016/j.urology.2023.02.006

55. Ciudad P, Escandón JM, Escandón L, Mayer HF, Manrique OJ. Surgical management of genital lymphedema using the combined Charles' procedure and lymphatic SCIP flap transfer (CHASCIP). Microsurgery. 2025;45(5):e70075. doi:10.1002/micr.70075

56. Xu KY, Finkelstein ER, Wu S, Tadisina K, Mella-Catinchi J. LYST with pedicled SCIP for patients with lymphedema and concomitant chronic venous disease. Plast Reconstr Surg. 2026. doi:10.1097/PRS.0000000000012927

57. Yoshimatsu H, Cho MJ, Karakawa R, et al. The role of LYST for treatment of lymphedema: long-term outcomes of SCIP flap incorporating LN + afferent lymphatic vessels. J Plast Reconstr Aesthet Surg. 2025;101:15–22. doi:10.1016/j.bjps.2024.11.052