About Lymphedema
Lymphedema describes the accumulation of fluids, proteins and fat which can result from a defect in the lymphatic system. This causes an affected extremity slowly to swell, decreasing function, altering appearance and increasing the likelihood of significant cellulitis and infection. The effects can be quite debilitating for affected patients.
In the United States, lymphedema is usually secondary and most commonly the result of cancer treatment with lymphadenectomy and radiation therapy. It is estimated that up to 10-40% of patients who have undergone axillary lymph node dissection followed by radiation therapy develop some degree of ipsilateral upper extremity lymphedema.
Outside the United States, an estimated 140-250 million cases of lymphedema exist, mostly caused by filariasis in developing countries.
Types of Lymphedema
Lymphedema may be classified as primary or secondary, based on underlying etiology. However, this classification usually has little value in determining treatment
Primary lymphedema results from abnormal development of the lymphatic system and is divided into 3 forms. Most are sporadic and have no family history, and are thought to occur secondary to an underlying developmental abnormality which manifests at some point later in life.
Secondary lymphedema describes lymphedema which occurs through damage or dysfunction of normal lymphatics.
The most common causes in developed countries are lymphatic damage from lymphadenectomy, radiation, infection, compression, trauma, burns, insect bites, vascular surgery or tumor invasion. Other causes include vein stripping, peripheral vascular surgery, lipectomy, burns and burn scar excision.
Worldwide, filariasis is the most common cause with damage to the lymphatics caused by invasion by the offending parasite Wuchereria bancrofti.
Lymphedema secondary to surgery and radiation therapy, such as axillary lymph node dissection plus radiation during breast cancer treatment, is thought to occur in patients who, from birth, have less lymphatic channels and collectors in their axilla. This smaller number of channels is then more prone to damage and obstruction from the surgery and radiation, resulting in lymphedema.
Standard Treatment
Currently lymphedema is though by most authorities to be a permanent problem with little hope for a permanent cure.
The mainstay of treatment is non-surgical, massage type therapy. This can be performed by a therapist with special training and may involve the use of special sequential pumps and devices.
Manual lymphatic drainage (MLD) is a massage type therapy designed to move the lymphatic fluid and proteins out of the affected area and back into the circulation.
Complete decongestive therapy (CDT) may combine MDL, bandaging and compression garment therapy, breathing exercises and dietary measures.
Surgical Treatment - History
In the past, surgical methods to treat lymphedema have been radical and largely ineffective. The resulting deformity may be significantly worse than the original lymphedema. Complications are also numerous and include necrosis of the transferred skin flaps, recurrence or worsening of the lymphedema, permanent nerve damage, loss of extremity function and amputation.
The Charles procedure involved debulking of the extremity by debridement of the edematous skin and boggy subcutaneous tissue down to muscle and fascia. The overlying resected skin was used as a skin graft over the affected area. The resulting deformity may be significantly worse than the original lymphedema.
The Thompson procedure is similar but also involves retaining a debulked flap of skin in the extremity. This flap was thought to contain subdermal lymphatics and “wick” fluid to the deeper lymph channels.
Surgical Treatment – Current and future
Effective surgical treatments now exist for lymphedema. Procedures such as vascularized lymph node transfers are relatively new techniques. Others, such as lymphaticovenous anastomoses, have been attempted in the past with mixed results and more recently modified and improved with much better results.
These specialized techniques are performed by only a small handful of highly specialized microsurgeons worldwide. Dr. Granzow is a pioneer in this area and continually works with colleagues from around the world continually to further refine these procedures.
Vascularized Lymph Node Transfer - (click here for more information)
Lymph nodes are taken from the groin and moved to the armpit to improve the clearance of lymph fluid from the affected arm.
Lymphaticovenous Anastomosis - (click here for more information)
Lymphatic channels are connected directly to the veins using supermicrosurgery.
Surgical treatments are most effective in patients whose extremity circumference reduces significantly with compression wrapping, indicating most of the edema is fluid. Patients who do not respond to compression are less likely to fare well with lymphaticovenous anastomoses as a greater amount of their increased extremity volume consists of fibrotic tissue, protein or fat.
Noncompressible limbs may respond to specially performed liposuction followed by lifelong subsequent use of compression garments.
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