MedifocusHealth

Surgery for lymphedema is usually considered as a treatment option only in rare cases that have not responded to conservative treatments and where the size of the limb and the amount of fibrosis is unacceptable (e.g., elephantiasis). Surgery is a palliative treatment and does not eliminate the need for mechanical drainage following the procedure. The goal of surgery is to reduce the volume of the fluid in the limb in order to improve lymphatic function. To date, there has not been any evidence to document long-term favorable results. Surgery may also be effective for removing excess skin following intensive CDP.

There are two general types of surgical procedures that have been used for the treatment of lymphedema:

• Microsurgical techniques - these techniques augment the rate of return of the lymph to blood circulation. There are two methods used that the ILS describes:

  • reconstructive method - which involves lymph vessel transplantation
  • derivative method - which attempts to restore normal flow of lymph with the creation of new anastomoses (openings) using lympho-venous shunts and/or lymphonodal shunts between existing lymph vessels or between lymphatic and venous vessels.

The ISL notes that microsurgery appears promising but long term efficacy has not been clearly proven.

• Excisional procedures (also called debulking) are used to surgically remove excess tissue and skin thereby restoring the affected limb to a more normal size. There are two types of excisional procedures, namely staged excision and liposuction. Both reduce the size of the limb but do not improve lymphatic drainage.

Staged Excision

A portion of the skin and subcutaneous tissue is removed during the initial surgery. After three months, the same procedure is performed in a different area of the extremity. Staged excision has the lowest risk of complications and is considered safe and reliable with consistent improvement.

Potential complications of surgery for lymphedema include:

• Nerve damage
• Skin necrosis
• Ulceration
• Worsening of the edema by causing damage to functioning lymphatic vessels
• Papillomatosis

Liposuction

This technique has shown promise when performed on chronic post-mastectomy lymphedema. Evidence indicates that there are sustained positive results reducing the excess volume of the arm. Some studies suggest that liposuction combined with CDP is more effective than CDP alone. Following surgery, compression therapy must be continued. The ISL recommends modified liposuction for special cases of treating non-fibrotic upper extremity lymphedema following axillary staging for breast cancer and short term results look promising.

The ISL notes that:

• It is imperative that any surgery be done by a surgeon who is highly experienced in performing surgery for lymphedema.
• Resection surgery (excision) should include removal of subcutaneous fat and excess skin.
• The disadvantage of excisional surgery is that, along with removing subcutaneous tissue, there is also a risk of the removal of superficial collateral lymph vessels that may have formed in the course of time under the skin.
• Skin folds may have to be removed following successful CDP.
• Surgery may be helpful for advanced elephantiasis.