Dysfunction of the lymphatic system causes lymphedema, a chronic disease that can lead to cellulitis. However, the optimal treatment modality for preventing cellulitis has not yet been established. This cohort study investigated the outcomes of cellulitis by treatment modality in lymphedema of the extremities. A meta-analysis was conducted to evaluate the change in frequency of cellulitis episodes according to the surgical procedure.

This single-center retrospective cohort study included patients with extremity lymphedema who were treated at our department. We performed a comprehensive search of PubMed, Scopus, and Web of Science for studies published from 2000 to March 2025 with a primary outcome of change in the frequency of cellulitis episodes before and after treatment. The meta-analysis was conducted using a random-effects model.

Our cohort study included 183 patients (nonsurgical treatment: 91; surgical treatment: 92). The change rate in frequency of cellulitis episodes before and after treatment increased by 27.0% in the nonsurgical group but decreased by 85.4% in the surgical group. Thirty-five studies, comprising 2,241 patients, were included in the meta-analysis. The mean reduction rates of cellulitis episodes per year before and after surgery were 84.8, 78.2, 80.6, and 87.6% for lymphaticovenous anastomosis, vascularized lymph node transfer (VLNT), liposuction, and combined surgery, respectively. Compared to before surgery, the number of cellulitis episodes per year was significantly reduced after lymphaticovenous anastomosis, VLNT, liposuction, and combined surgery, with standard mean differences of 0.91 (I 2 = 87%), 1.78 (I 2 = 94%), 0.68 (heterogeneity not calculable), and 1.66 (I 2 = 88%), respectively.

The findings of this cohort study showed that surgical treatment was superior to nonsurgical treatment in preventing the development of cellulitis in extremity lymphedema. The meta-analysis results demonstrated that surgical procedures tailored to the severity of lymphedema can significantly reduce the development of cellulitis.

This study was approved by the Research Ethics Committee of Hiroshima Prefectural Hospital, Japan (approval number: 202304-4).

Received: 10 May 2025

Accepted: 16 February 2026

Accepted Manuscript online:
23 February 2026

Article published online:
07 March 2026

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