If a patient or a loved one has been diagnosed with lymphedema, a condition that occurs when there is damage to the lymph system, causing a collection of fluid in one or more areas of the body, it’s critical that they learn everything possible about this condition so that they can make informed decisions about their treatment. This may be especially important after cancer treatment, during a patient’s recovery process, when lingering health issues can be frustrating.

A Baylor College of Medicine plastic surgeon discusses lymphedema, a disruption to the lymphatic system often caused by cancer surgery or treatment and increased infection risk and discomfort in the limbs. [1]

Jessie Z. Yu, M.D. is an assistant professor of surgery at Baylor College of Medicine. She is a fellowship-trained reconstructive microsurgeon and provides a comprehensive spectrum of plastic surgical care, ranging from cosmetic to trauma surgical needs. Yu has specialized interests in complex free flap reconstruction after breast, head and neck, and orthopedic surgeries, as well as the surgical treatment of lymphedema. Yu is dedicated to providing compassionate and personalized patient care while optimizing safe and long-lasting aesthetic and functional outcomes. Photo Courtesy: ©1998-2021 Baylor College of Medicine®, Houston, TX. Used with permission.

A constant reminder
“Lymphedema can be a constant reminder to a patient of their cancer journey and is a lifestyle-limiting health issue that persists long after they are past the treatment portion of their cancer care,” noted Jessie Z. Yu, MD., assistant professor in the Division of Adult Plastic Surgery in the Michael E. DeBakey Department of Surgery at Baylor.

The role of the lymphatic system
The lymphatic system is part of the body’s natural immune defense system and plays an important role in cancer. Lymphatic channels and lymph nodes are present throughout the body and work to remove excess fluid and ultimately pump it back to the heart. Lymph nodes are found in specific areas, such as the armpits, groin, and elbow, where the lymphatic channels converge.

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If the lymphatic system is injured or lymph nodes are removed by surgery, this can cause a backup in how lymph fluid drains from the limb. Lymphatic fluid leaks out of damaged lymph channels into the healthy surrounding tissue and can cause tissue edema or swelling, thickening, and even scarring or fibrosis. Over time, these changes result in the hallmark signs of lymphedema, including swelling, redness, recurrent infections, and limb heaviness.

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The most common reason patients in the United States develop lymphedema is after surgery, particularly if lymph nodes are removed for cancer staging or treatment. This is called ‘secondary lymphedema.’ Radiation therapy also has been associated with lymphedema.

“Interestingly, most patients do not notice signs or symptoms of lymphedema until two to three years after their initial procedure,” Yu said.

“Why and how some people get lymphedema and others do not is a huge area of research, but we do know that risk factors for lymphedema include being overweight and undergoing chemotherapy or radiation in that area,” she added.

Treatment Options
Treating lymphedema early is best, but matching the right procedure with the right type of lymphedema is key, she said.

Yu explained that it’s important to start with non-invasive treatments to achieve limb volume reduction using compression dressings that are customized to the patient. Lymphatic massage or home lymphatic pumps also can be used with compression.

“If the limb volume goes down using these initial steps, it not only tells me that the patient is an excellent candidate for the next step, which is surgery, but it also will improve this patient’s ultimate outcome after the surgery,” Yu further noted

Lymphovenous bypass
In patients with early-stage lymphedema where they have some functional and some nonfunctional lymphatics, one of the available surgeries is the lymphovenous bypass (LVB), also known as lymphovenous anastomoses, an intricate microsurgical procedure where surgeons use a 1 to 2-centimeter (0.4 – 0.8 inch) incision to create a ‘bypass’ of the blocked lymphatic system to connect the part of the lymphatic vessel that’s not blocked to a nearby vein.  With advancements in technology and microsurgical techniques, lymphovenous anastomoses has become a popular reconstructive procedure in the treatment of chronic lymphedema. This approach results in a detour that allows for the lymphatic fluid to flow away from the affected limb and return to the heart via the venous system. [2][3]

Vascularized lymph node transfer surgery
For more advanced stage lymphedema patients who have non-functioning lymphatic channels, a vascularized lymph node transfer surgery is an option. Using this approach, surgeons ‘borrow’ healthy lymph nodes from another part of the body, usually the abdomen or groin, to replace lymph nodes damaged or removed by previous breast cancer treatment.  This approach helps to stimulate new lymphatic growth and pump out the extra fluid in the diseased area. This is a particularly good option for patients who also want to undergo breast reconstruction using their own tissue since lymph nodes and tissue can be transferred in one surgery.

Those with extremely advanced lymphedema who may not be candidates for the other procedures may benefit from surgical debulking surgery or liposuction to decrease limb size.

Continued outpatient lymphedema therapy is required after all of these procedures. The goals of surgery include eliminating or reducing the use of compression garments in patients and improving symptoms, such as feeling less heavy, having fewer infections, and being more nimble with that limb.

“Lymphedema is a complicated problem and can be difficult to treat,” Yu explained.

“Our plastic surgeons at Baylor are committed to providing the most cutting edge and comprehensive lymphedema care to our patients. The field of lymphedema research is also actively exploring and developing new treatments and interventions for our patients,” she concluded.

[1] Principles and Practice of Lymphedema Surgery. Cheng MH, Chang DW, Patel KM (Editors). Elsevier Inc, Oxford, United Kingdom. ISBN 978-0-323-29897-1. July 2015.
[2] Tourani SS, Taylor GI, Ashton MW. Long-Term Patency of Lymphovenous Anastomoses: A Systematic Review. Plast Reconstr Surg. 2016 Aug;138(2):492-498. doi: 10.1097/PRS.0000000000002395. PMID: 27064227.
[3] Scaglioni MF, Fontein DBY, Arvanitakis M, Giovanoli P. Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema. Microsurgery. 2017 Nov;37(8):947-953. doi: 10.1002/micr.30246. Epub 2017 Oct 3. PMID: 28972280.

Featured image: Upper limb lymphedema.


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