Beyond Swelling: A Review of Postoperative Lymphedema in Aesthetic Surgery
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsThe authors conducted a narrative review of postoperative lymphedema in aesthetic surgery. They performed a literature search with terms related to edema or lymphoedema after elective aesthetic or cosmetic surgery. They selected 18 articles for this review. The manuscript described types of surgical procedures, imaging analysis of lymphedema, and interventional strategies.
Lymphoedema in post-aesthetic surgery is an important topic because secondary lymphedema is generally considered an incurable condition, and aesthetic surgery is elective. Aesthetic surgery should avoid causing iatrogenic lymphedema. Though the number of selected articles was small, the authors covered the overall topic.
I would like to provide several suggestions to the authors.
- Title (on page 1, line 2)
The current manuscript is not a systematic review. The subtitle needs to be changed to “A review of…” or “A narrative review of …”.
- The authors’ affiliation (on page 1, lines 5-8)
The affiliation should be numbered by the institution’s name instead of the email address.
- Facial transplantation (on pages 4-5, lines 167-201, and on page 8, lines 366-374)
Though this paragraph provides interesting information, facial transplantation is not an aesthetic procedure but reconstructive surgery. This paragraph is outside of the scope of the topic.
- Surgical intervention for lymphoedema (on pages 6-7, lines 277-295)
Lymphovenous anastomosis (LVA) is one of the surgical interventions for lymphedema. However, I don’t think any connection between reference 23 and aesthetic surgery. Did the authors find any articles that applied LVA for post-aesthetic lymphedema cases?
- Sclerotherapy (on page 7, lines 296-314)
This paragraph describes sclerotherapy for veno-lymphatic malformation. This is not an aesthetic procedure but a treatment of malformation. Discard the paragraph.
- Retinoic acid (on pages 8-9, lines 385-407, and page 10, lines 446-449)
Several potential drug therapies have been introduced, and their outcomes have been investigated in animal and clinical studies. I don’t know why the authors suddenly described a retinoic acid study published by one group. If there are any particular reasons, they should be explained in context with aesthetic surgery.
Author Response
Hello. Thank you for your review. Please see the attachment for our team's responses.
Author Response File: 
Author Response.pdf
Reviewer 2 Report
Comments and Suggestions for AuthorsI would like to thank the authors for their valuable efforts in conducting this study. The manuscript addresses an important and relatively underexplored topic, which renders the subject matter particularly relevant. However, several aspects require clarification and improvement to enhance the rigor and clarity of the article:
The authors state that a systematic review was conducted; nevertheless, the Methods section (which is placed in the wrong place, before the conclusion section) lacks critical details such as the keywords used, adherence to PRISMA guidelines, and the quality assessment of included studies. It is essential that these elements be clearly described if a systematic review is performed. Furthermore, in the Results section, it is advisable to report the total number of articles identified through the systematic search and to include a summary table of the selected studies. Currently, the presentation of the results resembles more a narrative literature review than a systematic one. The authors should better define the specific objectives of the study.
For instance, reference number 16 refers to a cadaveric study describing the lymphatic anatomy of the upper third of the face. While such anatomical studies may support discussion points, they are not typically appropriate for inclusion in a systematic review focused primarily on clinical evidence.
Regarding the studies evaluated, it would be important to clarify how lymphedema was diagnosed. Was diagnosis based solely on clinical evaluation, or was it confirmed through objective measures such as lymphoscintigraphy to demonstrate lymphatic drainage impairment? This diagnostic approach should be explicitly addressed for each included study.
Given that the article focuses on lymphedema following aesthetic surgical procedures, the rationale for including discussions on facial transplantation or hyaluronic acid (HA) fillers is unclear and should be reconsidered or better justified.
On line 296, the mention of sclerotherapy for the treatment of low-flow venous-lymphatic malformations appears to fall outside the stated scope of the review (“This review systematically examines the literature from the last 15 years on postoperative edema and lymphedema”). The relevance of this content to the manuscript’s primary focus should be reassessed.
Self-citations should be avoided as much as possible and included only when strictly necessary to support the article’s thesis. Regarding references 25 and 26, they do not contribute to substantiating the argument and therefore it would be appropriate to remove the corresponding portion of the text (line 385-407) along with these references. The authors include this paragraph to describe a potential treatment hypothesis; however, given that this is a review article, such inclusion is not justified.
In conclusion, while the topic of the article is of significant interest, the manuscript would benefit from a more structured and comprehensive approach to the review process and clearer delineation of its scope and aims.
Author Response
Hello. Thank you for your review. Please see the attachment for our team's responses.
Author Response File: Author Response.pdf
Round 2
Reviewer 1 Report
Comments and Suggestions for AuthorsThe authors addressed all my concerns. The edited manuscript is read well.
Author Response
Thank you very much for your feedback. We greatly appreciate you taking the time to review our manuscript. We have also included an article that was recently published in May of 2025, months after we had conducted our initial search of articles. The article is titled "Postoperative Edema Following Rhytidectomy: A New System for Quantifying Lymphedema after Facelift." We concluded that this article was relevant to our manuscript and should be included in this narrative review. I have made adjustments to the manuscript as shown in the word document reviewer edits.
Reviewer 2 Report
Comments and Suggestions for AuthorsI would like to thank the authors for their efforts modifying the manuscript.
The article is interesting and in this form could be considered for publication. I would just suggest to revise the numbering of the subparagraphs.
Author Response
Thank you very much for your feedback, and we greatly appreciate you taking the time to review our manuscript. We have revised the numbering of the subparagraphs as recommended. Additionally, we have included an article that was recently published in May of 2025, months after we had conducted our initial search of articles. The article is titled "Postoperative Edema Following Rhytidectomy: A New System for Quantifying Lymphedema after Facelift." We concluded that this article was relevant to our manuscript and should be included in this narrative review. I have made adjustments to the manuscript as shown in the word document reviewer edits.
