Surgical Approaches to Lymphedema Therapy
Physiologic Procedures using Microsurgery and Supermicrosurgical Techniques
Lymphatic surgery is at the cutting edge of reconstructive microsurgery, a specialty within plastic surgery. Using highly specialized and state-of-the-art techniques, we are able to surgical treat lymphedema. These operations are most beneficial in patients with earlier stage disease where the swelling of the extremity is still largely due to fluid rather than fat deposition. Examples of these procedures are listed below.
Lymphovenous Bypass (LVB)
Through multiple small and superficial incisions in the affected arm or leg, the small lymphatic channels are run under the skin are identified and connected to a nearby superficial vein. The entire surgery is performed under a specialized microscope with “supermicrosurgery” techniques that allow us to sew vessels and lymphatics smaller than 0.8 mm in diameter. This procedure re-routes the flow of lymph fluid into the venous system in the forearm or lower leg to “bypass” the area of lymphatic damage, which is often in the armpit or groin. The flow of lymph fluid out of the extremity is then re-established. As a result, patients see significant improvement in the risk of infection, decreased need for compression garments, and reduction in the limb circumference and weight.
Vascularized Lymph Node Transfer (VLNT)
Lymph nodes are harvested from another area of the body — often the abdomen, groin, neck, or armpit — and are transferred to the extremity with lymphedema as a free flap. The lymph nodes are taken with an artery and a vein to keep them alive. Those blood vessels are then re-connected to vessels where the nodes are placed. In the short term, the transferred lymph nodes act like a sump pump to absorb excess fluid in the nearby soft tissues. Over time, they stimulate new lymphatic channels to grow. As with lymphovenous bypass, patients see significant improvement in the risk of infection, decreased need for compression garments, and reduction in the limb circumference and weight.
Preventative Lymphatic Surgery
Immediate Lymphatic Reconstruction (ILR)
Patients who require lymph node dissections are at high risk for lymphedema. The most common scenario is breast cancer related lymphedema (BCRL) after axillary lymph node dissection. These patients have a 15-35% chance of developing lymphedema, depending on radiation status and other risk factors. Immediate lymphatic reconstruction (ILR) decreases the risk of lymphedema to 4-10%, which is about a four-fold risk reduction.
Lymphovenous bypasses (LVB) are performed in the armpit after the breast surgeon has completed the lymph node excision. The lymphatic channels that drain the arm are stained with a blue dye, identified, and sewn into a nearby vein to allow the flow of lymph fluid to no longer be obstructed. The entire procedure is performed through the same incision as the lymph node removal and with minimal additional risk to the patient.
Debulking Lymphatic Surgery
In patients with more advanced disease, the tissues have become firm and fatty without any functional lymphatic channels. These patients are no longer candidates for physiologic surgeries such as lymphovenous bypass or vascularized lymph node transfers. Therefore, the surgical goal is to remove as much bulk from the extremity as possible to decrease the limb circumference and weight to improve overall quality of life.
Minimally Invasive Tissue Excision (MITE)
Using liposuction techniques, large amounts of tissue can be removed from the arm or leg between the skin and muscle with very small incisions. In some cases, the limb can be reduced by many pounds after liters of fat and fluid are removed. The results are maintained with strict compression garment use.
In the most severe cases, patients benefit most from a direct excision of skin and fat in the affected extremity to reduce the bulk of the limb, increase its mobility, and significantly improve quality of life.