Review of Current Surgical Treatments for Lymphedema
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The current mainstay of lymphedema therapy has been conservative nonsurgical treatment. However, surgical options for lymphedema have been reported for over a century. Early surgical procedures were often invasive and disfiguring, and they often had only limited long-term success. In contrast, contemporary surgical techniques are much less invasive and have been shown to be effective in reducing excess limb volume, the risk of cellulitis, and the need for compression garment use and lymphedema therapy. Microsurgical procedures such as lymphaticovenous anastomosis and vascularized lymph node transfer lymphaticolymphatic bypass can treat the excess fluid component of lymphedema swelling that presents as pitting edema. Suction-assisted protein lipectomy is a minimally invasive procedure that addresses the solid component of lymphedema swelling that typically occurs later in the disease process and presents as chronic nonpitting lymphedema. These surgical techniques are becoming increasingly popular and their success continues to be documented in the medical literature. We review the efficacy and limitations of these contemporary surgical procedures for lymphedema.
A Medline literature review was performed of lymphedema surgery, vascularized lymph node transfer, lymphaticovenous anastomosis, lymphatic liposuction, and lymphaticolymphatic bypass with particular emphasis on developments within the past 10 years. A literature review of technique, indications, and outcomes of the surgical treatments for lymphedema was undertaken.
Surgical treatments have evolved to become less invasive and more effective.
With proper diagnosis and the appropriate selection of procedure, surgical techniques can be used to treat lymphedema safely and effectively in many patients when combined with integrated lymphedema therapy.
Lymphedema is a progressive and debilitating condition associated with dysfunction of the lymphatic system. While a small percentage of cases are congenital, most patients in developed countries present with lymphedema resulting from treatment of malignancy. The true incidence of lymphedema is difficult to determine as a result of significant differences in diagnostic criteria. However, lymphedema is reported to occur in up to 49 % of breast, 20 % of gynecologic, 16 % of melanoma, 10 % of genitourinary, and 6 % head and neck cancer patients after lymph node dissection and/or radiotherapy. Even among patients who undergo isolated axillary sentinel lymph node biopsy, up to 7 % have measurable arm differences, and up to 10 % have subjective symptoms of lymphedema.1, 2, 3, 4, 5, 6, 7, 8
Acquired lymphedema results from the accumulation of lymphatic fluid in the affected limb after interruption of normal lymphatic drainage channels. Initially, swelling is due to excess lymphatic fluid and is characterized by pitting edema. This is the fluid phase of the disease. If untreated or undertreated, the chronic accumulation of inflammatory lymphatic fluids is thought to incite fibrocyte and adipocyte activation and eventually lead to gradual deposition of fat and fibrotic solids.9,10 This solid phase is characterized by nonpitting edema, with solids representing over 90 % of the excess volume in many chronic lymphedema patients.11, 12, 13 The time frame for this transition from fluid to solid can vary considerably between patients.
Surgical procedures to treat lymphedema have existed for over a century. The Charles procedure was first reported in 1912.25 This operation involved an aggressive resection of skin and soft tissue down to the deep fascia, followed by skin grafting over the excised area. The Charles procedure achieved debulking of the limb but was not as effective at managing ongoing lymphatic stasis. The first attempts at preservation of lymphatic function were described by Sistrunk and later Thompson.26, 27, 28 However, the results of these early procedures often were ineffective and disfiguring. These procedures have largely been abandoned except in extreme cases of lymphedema elephantiasis, where massive skin thickening and swelling may necessitate direct tissue excision.
In contrast, contemporary surgical approaches to manage lymphedema are now much less invasive and involve microsurgical approaches to reduce excess lymphatic fluid or minimally invasive approaches to remove accumulated protein solids within the affected limb.
Vascularized Lymph Node Transfer (VLNT)
If simultaneous breast reconstruction is performed, the lymph node flap can be transferred together with a deep inferior epigastric perforator (DIEP) abdominal soft tissue flap. In such cases, a DIEP flap is used instead of a transverse rectus abdominis myocutaneous (TRAM) flap, both to decrease postoperative abdominal morbidity and to allow better geometry of inset for the lymph node flap in the axilla.
In some patients, improvements of lymphedema swelling can be observed immediately in the hospital after VLNT at a time before healing between donor and native lymphatics could have taken place. While the mechanism of improvement is unclear, the release of scar tissue in the previously operated and/or irradiated lymphatic bed has been postulated to account for this observation. Indeed, studies have shown some improvement in lymphedema after breast reconstruction with autologous flaps alone.37 Later in the postoperative period, healing of transplanted lymphatics to native lymphatics at the recipient site and removal of lymphatic fluid by a direct pumping mechanism may provide further fluid drainage. Direct healing of transplanted lymphatics has been shown to occur in animal models and in vivo in transplanted free flaps and likely accounts for some of the improvements observed and the success found by those using recipient sites such as the wrist or ankle.34,38,39
Lymphaticovenous Anastomosis (LVA)
The surgical risks of LVA are low. The lymphatics that are connected are relatively superficial, and only a fraction of the lymphatics present in an affected arm or leg are used for anastomosis.
First described in 1986 by Baumeister et al.,49 this procedure involves the transfer of healthy, functioning lymphatic vessels from a donor area, usually the inner thigh, and sewing the lymphatic vessels of the donor site directly to the lymphatic vessels of the affected limb. Although the authors reported improvements in both limb volumes and the lymphatic transport index, volume reductions were easier to achieve in arms than legs. Moreover, this type of procedure also presents the theoretical risk of new lymphedema at the donor collection site.50
Suction-Assisted Protein Lipectomy (SAPL)
A successful SAPL outcome cannot be achieved without the integral involvement of a trained lymphedema therapist who is well versed in the procedure and its pre- and postoperative care. Custom-fit flat-knit compression garments are measured by the therapist and must be placed immediately after surgery in the operating room. Otherwise, if lymphedema bandaging is performed by the therapist in the operating room after surgery, then the custom compression garments can be placed by the therapist 1–2 days after the procedure. After surgery, patients remain in the hospital for several days until they can ambulate and remove and replace their compression garments independently.
While effectively removing excess volume, SAPL does not address the pathophysiology causing the lymphedema. Therefore, patients must continue postoperative compression to prevent reaccumulation of excess fluid. Additional postoperative therapy and manual lymphatic drainage can reduce swelling more rapidly, and new, custom-fit flat-knit garments must be remeasured and placed by the lymphedema therapist as the volume decreases in the months after surgery.
When performed correctly, the safety of SAPL has been established and has been found not to further damage the already impaired lymphatic flow in the affected patients studied.54 The technique of SAPL is a significant departure from that of conventional cosmetic liposuction and should not be attempted by surgeons not trained in the procedure. Damage to nerves and vessels, worsening of lymphatic flow, increased swelling and excess volume, and disruption of lymphatics by overaggressive or incorrect suctioning are risks if performed by an inexperienced surgeon. The postoperative compression garment protocol and lymphedema therapist treatment are also completely different than in cosmetic liposuction and are integral to the procedure’s success.
We have combined the use of VLNT, LVA, and SAPL together with appropriate lymphedema therapy into an integrated treatment system. To our knowledge, this is the first comprehensive system to integrate traditional therapy and contemporary surgical techniques in order to address specifically the fluid and solid components of lymphedema.11 We find that patients whose disease is in the fluid phase are best treated with a physiologic procedure that promotes drainage of fluid from the extremity, such as VLNT or LVA. These patients are usually early in the disease process or may show some improvement with compression garment therapy. Lymphaticolymphatic bypass would apply to this phase but has not been used by our group. Patients in whom lymphedema has progressed to the solid phase, characterized by the deposition of excess lymphedema fat and proteins, are better treated with SAPL to remove this excess solid material.
Proper diagnosis and patient selection for the appropriate therapy and/or surgical procedure are central to the system’s success. We think that selective application of the appropriate technique to treat fluid or solid phase lymphedema greatly improves overall patient outcomes. It is important to perform physiologic procedures such as VLNT or LVA while the patients are still in the fluid phase of their condition, before the depositions of excess solids occurs. A delay in treatment may allow solids to accumulate and may require patients to undergo SAPL treatment instead.
It should also be noted that procedures that address the fluid component of lymphedema, such as VLNT or LVA, are less likely to achieve the large reductions of excess volumes observed after SAPL.48,55,56 Rather, the procedures will significantly decrease the postoperative need for compression garments and lymphedema therapy. Conversely, SAPL results in large volume reductions because it can remove the large amounts of solid fat and proteinaceous material, but it does not address ongoing lymphatic stasis and obstruction.11 Therefore, SAPL and VLNT procedures have been combined in a staged approach to manage chronic solid-phase lymphedema. First SAPL is performed to remove the proteinaceous solids and reduce volume excess. After postoperative swelling stabilizes, VLNT is used to improve lymphatic drainage and address subsequent fluid reaccumulation. This combined approach has resulted in volume reductions of over 83 % with compression garment use required only in the evenings and at night.57
In conclusion, surgical techniques to treat lymphedema have evolved tremendously from the disfiguring procedures of the past. Together with integrated lymphedema therapy, proper diagnosis, and the appropriate selection of procedure, safe surgical techniques can be used to treat lymphedema effectively in many patients. The techniques described have been demonstrated to be effective in multiple studies and are no longer considered experimental. Standard precautions, such as vigilance with cuts and scratches in the affected limb and bandaging or compression with flying or at-risk activities, should be continued in all lymphedema patients, regardless of whether they have undergone surgical treatment. We are optimistic that further research and investigation will continue to improve our understanding and ability to treat this complex disease process.
The authors declare no conflict of interest.
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