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Reconstructive Procedures

Reconstructive Procedures

Reconstructive Procedures

Lymphedema Surgery

Lymphedema Surgery_1

What is lymphedema?

The lymphatic system is a system of vessels and nodes in your body which are responsible for fluid and fat transport, along with flushing toxins and infectious agents from your body. Alongside the veins in the body, the lymphatic system returns lymph fluid to the heart and circulation. The lymphatic vessels drain into lymph nodes, which form part of the immune system and help to fight infections in the body.

Lymphedema is the abnormal accumulation of fluid in the compartments of the body due to dysfunction in the lymphatic system. This can be primary, where there is an inherent underlying problem with the lymph vessels or nodes, or secondary, where an infection, trauma, surgery or even radiation has resulted in a disruption to the lymphatic flow. The most common cause of lymphedema in developed nations is cancer treatment-related. This is either due to surgery to the lymph node basins, or from radiotherapy causing damage to the lymphatic system. For example, up to 30% of patients who have received breast cancer treatment and axillary lymph node clearance will develop lymphedema in their lifetime.

What are the clinical features of lymphedema?

Lymphedema can develop soon after the disruption to the lymphatic system, or many years later. In early lymphedema, there is mild swelling and heaviness in the limb. As lymphedema progresses, there may be more obvious swelling in the affected limb, the occurrence of infections, and/or reduced function including reduced hand dexterity or difficulties with walking. In the later stages of lymphedema, the persistent swelling can lead to fibrosis of the fat and chronic skin changes and hardening. In severe and long-standing cases, there may even be the development of a cancer known as angiosarcoma.

The International Society of Lymphangology (ISL) classified lymphedema into 3 stages according to the clinical features. Briefly, they are:
 
Stage 1: Reversible swelling of the involved body part
Stage 2: Irreversible swelling of the involved body part
Stage 3: Chronic fibrosis and irreversible skin changes; elephantiasis
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What treatments are there for lymphedema?

Traditionally, lymphedema has been managed conservatively with skin care and lymphedema therapy. Lymphedema therapies include manual decongestive therapy, lymphatic massage, pressure garments, and in some cases, serial wrapping of the involved limb to encourage fluid egress back to the circulation. However, whilst helpful in alleviation of symptoms and preparation for surgery, oftentimes conservative management is more of a temporary fix and does not solve the underlying disruption in lymphatic flow.

In terms of medication, therapies such as diuretics to offload fluid from the body have been tried, without much success. Moreover, if used in excess these diuretics can lead to imbalances in the body’s electrolytes and even kidney problems.

In the past decade, surgical treatments for lymphedema have garnered increasing attention and have improved significantly. Most of the developments have been in physiological treatments aimed at restoring the dysfunctional lymphatic system and include lymphaticovenous bypass/anastomosis (LVB/LVA) surgery and vascularized lymph node transfer (VLNT).

How can surgery help with lymphedema?

In LVB, special machines and techniques are used to identify the superficial, clogged lymphatics, and divert their flow by suturing them to neighboring veins. This is akin to relieving a traffic jam on a main thoroughfare by creating a diversion to a parallel highway. The advantage of this procedure is that they are extremely low risk, can be performed under local anesthesia if desired, and require very small incisions and minimal downtime.

For VLNT, lymph nodes are taken from a part of your body where lymph nodes are in excess and transplanted to the affected limb. In select patients, VLNT can be performed together with other procedures such as extremity or breast reconstruction to achieve dual aims simultaneously. VLNT procedures usually require a few days of hospital stay and about 1 to 2 weeks downtime.

In severe cases of ISL stage 3 lymphedema, physiological techniques may no longer be possible due to the amount of fibrosis and skin changes. For these situations, excisional surgery such as liposuction or removal of fibrotic skin can be performed to debulk the affected body part.

Post-surgery, patients will still have to continue taking care of their lymphedema, as none of these treatments can be said to be 100% effective. However, many patients report reduced symptoms and weight of the affected limb, and there are some who completely stop lymphedema therapy altogether.

What happens before surgery?

The best way to start on your journey for lymphedema treatment is to seek a consult with a plastic surgeon who specializes in lymphedema treatment. He can perform a thorough assessment and recommend the appropriate therapy/sequence of therapies for you. This may involve first seeing a lymphedema therapist and having a trial of conservative therapy before surgery can be considered.

To aid in diagnosis of lymphedema and to stage the severity of the condition, your doctor may order advanced imaging techniques such as lymphoscintigraphy, indocyanine green lymphangiography, and MR-lymphangiography. These investigations will help to confirm the diagnosis of lymphedema, as well as plan for potential surgical interventions. In addition, certain pre-operative blood tests and X-rays may be performed if surgery is planned.

During the procedure

You will either be admitted to the hospital the day before or on the day of surgery. If a general anaesthetic is planned, you will be asked to fast for at least 8 hours before surgery. LVBs can often be performed under local anaesthesia with or without sedation, in a day surgery setting. If a VLNT or excisional techniques are planned, you may require a few days’ hospital stay. In general, lymphedema surgery can last from 3 to 6 hours.

Post-operative care

LVA/LVB procedures can be performed as day surgery, and if comfortable, patients may be discharged on the same day. For VLNT and excisional procedures, you may have post-surgical drains and a urinary catheter for comfort. You may also be asked to rest in bed for a few days. Close attention will be given to the success of the procedure, any post-operative infection as well as your surgical wounds. Most patients are discharged from hospital after 5 to 7 days, and full recovery is generally expected after 1 to 2 months.

Potential risks and complications

As with any surgery, general risks include pain, bleeding, and infection. Post-operative pain is usually well controlled after surgery with medication, and the risk of bleeding and infection leading to the need for another procedure is low. There is also the general anaesthetic risk, which will be explained to you by the anaesthetist, and is typically low especially if you are healthy. Specific to VLNT, if there is any sign of problems with the blood supply to the transferred lymph nodes, you may be brought back to the operating theatre expediently. Other known sequelae include scarring and numbness at the operative sites, which are usually managed well in the post-operative period.

Why choose Polaris Plastic Surgery?

Also the Honorary Secretary of the Lymphedema Society of Singapore, Dr Adrian is a trained specialist who can perform all types of lymphedema surgery. He has published numerous articles on the topic and has been invited to lecture on the topic locally, regionally and internationally. Most importantly, he has years of experience and works closely with other specialists such as lymphedema therapists to achieve satisfactory outcomes for his patients.

Schedule a consultation with Dr Adrian to assess your needs and goals. He will communicate with you regarding your concerns, and in discussion formulate and perform the reconstructive procedure for appropriate outcomes.

FAQ

What is lipedema? How is it different from lymphedema?

Lipedema is the abnormal accumulation of subcutaneous fat in the body. It can cause social embarrassment, difficulty walking, and can even be painful. Whilst obesity can also cause fatty accumulation, lipedema predominantly affects only the buttocks and the legs, with the rest of the body being of normal size. It is refractory to exercise and diet, and affects only women, with incidences reported at up to 11%. Physiological lymphedema techniques are ineffective for pure lipedema, which usually requires liposuction or excisional techniques to treat. However, in some cases, both conditions can co-exist. See a specialist plastic surgeon who is trained in these techniques and he can advise you accordingly.

Will I need to continue wearing my pressure garments for lymphedema post-operatively?

The short answer is yes. Lymphedema surgery does not treat 100% of the condition, therefore it is always recommended to continue your lymphedema maintenance and garments post-operatively. However, there are some patients who, after a while, find that they no longer need their pressure garments.


References
1. Ooi, A., Chang, D. (2017). 5-step harvest of supraclavicular lymph nodes as vascularized free tissue transfer for treatment of lymphedema. Journal of surgical oncology 115(1), 63 - 67.

2. Chang, D. W., Suami, H. & Skoracki, R. A Prospective Analysis of 100 Consecutive Lymphovenous Bypass Cases for Treatment of Extremity Lymphedema. Plastic and Reconstructive Surgery 132, 1305–1314 (2013).

3. Garza, R., Ooi, A., Falk, J., Chang, D. (2019). The Relationship Between Clinical and Indocyanine Green Staging in Lymphedema Lymphatic Research and Biology 17(3), 329-333.

4. Nguyen, A., Chang, E., Chang, D. (2013). Simultaneous Vascularized Lymph Node Transfer with Microvascular Breast Reconstruction Plastic and Reconstructive Surgery 132(), 22.

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