Lymphedema

One of the most commonly occurring causes of lymphedema in the United States is the disruption of lymphatic drainage due to surgery for breast cancer. When cancer has spread to the lymph nodes in the axilla and they must be removed, the normal pathway for fluid drainage from the arm on that side is damaged. When the arm subsequently develops swelling as a result, this is lymphedema. When a patient undergoes radiation to that area, it can increase the chances that lymphedema will occur. Even patients that only undergo a simple lymph node biopsy can ultimately develop this condition. And while lymphedema may occur very soon after surgery, it can also take years for the cumulative effects of the damaged lymphatics to result in noticeable symptoms.

For many years now, the mainstay of treatment for lymphedema has been a combination of techniques collectively known as complex decongestive therapy. These are generally overseen by a specially trained physical or occupational therapist and include in-person therapy sessions, custom-fitted compression garments, and home-administered pumping. While these techniques remain essential in the overall treatment of lymphedema, they are not able to address the physiologic cause of the problem.

Over the last several decades, plastic surgeons have been working to develop techniques through which the physiologic drainage of lymphatic fluid could be reconstructed in order to correct the cause of the problem and can actually reverse the symptoms of lymphedema. In the last ten years these surgical procedures and treatment protocols have been refined, and now when performed successfully provide positive results in up to 90% of patients suffering from this condition. There are several different procedures used in these cases, and depending on the stage of lymphedema and severity of symptoms, an individual surgical plan should be developed for each patient.

One component of the surgical treatment of lymphedema is the restoration of functional lymph nodes to the area where they were previously damaged or removed. Using microsurgical techniques we are able to “borrow” some lymph nodes from one area of the body and transfer them to another. Over time these newly placed lymph nodes will reestablish tiny new lymphatic channels, and also act to take up lymphatic fluid and redirect it back into the bloodstream. The lymph nodes are usually transferred either from taking extra nodes from the groin or harvesting extra lymph nodes from fat inside the abdomen using minimally invasive techniques. This procedure is an essential part of maintaining long-term results of the surgical restoration of lymphatic flow.

The second important component of the surgical treatment of lymphedema is lymphaticovenous bypass. This is a technically challenging procedure in which some of the remaining functional or partially functional lymphatic channels in the affected extremity are rerouted to drain fluid into adjacent veins. These new connections act as a bypass around the damaged area of the lymphatic system and help remove accumulated fluid to reduce swelling. These tiny lymphatic channels are usually 0.3 to 0.8 millimeters in diameter and must be mapped out prior to the operation using special imaging techniques. This procedure can provide more immediate symptomatic relief when compared to vascularized lymph node transfers, but when performed in combination with that procedure can prove to be a lasting solution for this complicated problem.

In some patients that have had longstanding lymphedema, the damage done to the tiny lymphatic channels may simply be irreversible. These patients will have experienced significant changes to the composition of the affected extremity and will have accumulated fatty deposits that prevent the swelling from being treated with either complex decongestive therapy or attempts at surgically reconstructive the lymphatic drainage. In these patients, the best approach may be a procedure aimed at directly debulking the accumulated fatty tissue through liposuction. This can help to alleviate the heaviness and functional difficulties associated with these chronic changes, although these patients will still require compression garments and therapy to maintain lasting results.