LYMPHOEDEMA OF UPPER LIMB

MODERATOR DR G AVINASH RAO .

DR MIR MOHSIN.
FELLOW HAND AND MICROSURGERY.
History
 1622 : Gasper Aselli : 1st description of lymphatics

 1787 : Mascagni : Structural delineation of

lymphatics

 1950: Kinmonth : Direct lymphangiography

 1983 : Loefferer : Lymphoscintigraphy

Surgical Anatomy

Plexus : Subepithelial
Subdermal
Subcutaneous

Lymphatics: Epifascial
Subfascial
Surgical Anatomy
Histology
 No basement membrane
 Wide spaced endothelial cells
 Connective tissue content increases as depth increases
 Communication between deep and superficial system are few
 Don’t function in normal people
 Flow can be deep to superficial
 DEF-

 The cell wall of lymphatic collecting channels contain valves to

prevent backflow of the lymphatic fluid. The sections between these
valves, called LYMPHANGIONS.

 Tissue fluid drainage occurs in distinct regions of the body

called LYMPHOTOMES.
 Factors for lymphatic flow

 Interstitial pressure gradient

 Lymphangions contraction

 Valves

 Muscular contraction

 Compression by adjacent pulsation

 Negative pressure by intrathoracic and intraabdominal respiratiory excursion

 Rapid flow in veins

Course of drainage

Dermis (valveless channels- Prelymphatics)

Subdermal (valved lymphatics)

Large valved Epifascial Channels

Subfascial lymphatics
If obstruction in epifascial system
 Backflow to subdermal plexus

 Cross over to the next quadrant

 Subdermal edema: peau de orange

 Paired axillary system

 No lymphatic circulation across the watersheds

where the direction of lymphatic flow changes

 Minimal communication in midline

 LYMPH VESSELS

The lymph vessels draining the lymph from the upper limb in the
body are split Into 2 groups:

1. Superficial

2. Deep
 SUPERFICIAL LYMPH VESSELS

 The superficial lymph vessels are in the subcutaneous tissue,

accompany the superficial veins.
 They course upwards in the direction of the axilla. Most of them
end in the axillary lymph nodes.
 Those from lateral side of the limb and lateral 2 digits follow the
cephalic vein and drain into the infraclavicular lymph nodes.
 Those from medial side of the limb and medial 3 digits follow the
basilic vein and drain into the lateral group of axillary nodes.
 A number of the medial lymph vessels terminate in the
supratrochlear or epitrochlear nodes, that are situated just above
the medial epicondyle along the basilic vein.
 A couple of lymph vessels drain the thumb end in the
deltopectoral lymph nodes.
 The efferents from these nodes pierce the clavipectoral fascia
to drain in the apical group of axillary nodes
 Just about all the superficial lymph vessels of the upper
limb drain into lateral group of axillary nodes.

 Lymph from palm is drained into the lymph plexus on the

dorsum of the hand.
 Axillary LN dissection should spare infraclavicular
Pathway
 Post ALND important to immobilize operated site with
compression ASD for formation of new
lympholymphatic anastomoses
 DEEP LYMPH VESSELS

 The deep lymph vessels are much less numerous in relation

to the superficial lymph vessels.

 They drain structures being located deep to deep fascia,

i.e. muscles.

 The deep lymph vessels course along the arteries and

drain into the lateral group of the axillary lymph nodes.
 LYMPH NODES

• The lymph nodes draining the upper limb are split into 2
groups:

–(a) Superficial and

–(b) Deep.
 SUPERFICIAL LYMPH NODES

• They are located in the superficial fascia, along with the superficial vein. All these are
as follows:
1. Infraclavicular nodes, 1 or 2 in number, are located on
the clavipectoral fascia along the cephalic vein. They drain lymph from thumb and
upper part of the breast.

2. Deltopectoral nodes, are located in the deltopectoral groove along the

cephalic vein just before it pierces the deep fascia.

– It drains the lymph from the breast and adjoining small structures.
– It’s thought to be displaced infraclavicular node.

3. Superficial cubital / supratrochlear nodes are located 5 cm above the

medial epicondyle along the basilic vein. They drain the lymph from the ulnar side of
the hand and forearm.
 DEEP LYMPH NODES

• The deep lymph nodes are as follows:

• Axillary lymph nodes are existing in the axilla and are split into
5 sets. These are main lymph nodes of the upper limb.
• A few other deep lymph nodes are located on the following sites:

– Along the medial side of the brachial artery.

– In the cubital fossa, in the bifurcation of the brachial artery (named deep
cubital node).

– Occasionally along the arteries of the forearm.

 LYMPH NODES

• The majority of the upper lymph nodes are located in the

axilla. They can be divided anatomically into 5 groups:

1. Pectoral (anterior)

2. Subscapular (posterior)

3. Humeral (lateral)

4. Central

5. Apical
 Axillary lymph nodes
1. Pectoral (anterior) – 3-5 nodes, located in the medial wall of the axilla.
They receive lymph primarily from the anterior thoracic wall, including
most of the breast.

2. Subscapular (posterior) – 6-7 nodes, located along the posterior axillary

fold and subscapular blood vessels. They receive lymph from the
posterior thoracic wall and scapular region.

3. Humeral (lateral) – 4-6 nodes, located in the lateral wall of the axilla,
posterior to the axillary vein. They receive the majority of lymph drained
from the upper limb.
4. Central – 3-4 large nodes, located near the base of the axilla (deep to
pectoralis minor, close to the 2nd part of the axillary artery). They receive
lymph via efferent vessels from the pectoral, subscapular and humeral
axillary lymph node groups.

5. Apical – Located in the apex of the axilla, close to the axillary vein and
1st part of the axillary artery. They receive lymph from efferent vessels
of the central axillary lymph nodes, therefore from all axillary lymph
node groups. The apical axillary nodes also receive lymph from those
lymphatic vessels accompanying the cephalic vein.
 Efferent vessels from the apical axillary nodes travel through
the cervico-axillary canal, before converging to form the
subclavian lymphatic trunk.

 The right subclavian trunk continues to form the right

lymphatic duct, and enters the right venous angle (junction of
internal jugular and subclavian veins) directly.

 The left subclavian trunk drains directly into the thoracic duct.
 LYMPHOEDEMA

• It is an abnormal swelling of limb due to the collection of excessive

amount of high protein fluid secondary to defective lymphatic
drainage in the presence of normal capillary filteration leading to
painful swelling of the extremity

• Lymphoedema affects around 2% of people and is common cause

of limb swelling.

• It is an abnormal accumulation of proteins in the body’s tissue (unlike

dependent edema).

• Over the period, lymphedema causes tissue proliferation of the affected

areas.
It leads to emotional and psychological distress affecting
relationships, education and work.
Difficulty in fitting garments (Tightening of Garments)
Patient feels emberrassed for seeking treatment.
Early diagnosis and treatment can prevent the development
of disabling late problems.
It is often misdiagnosed and mistreated by doctors thinking it
to be a cosmetic problem only .
 Pathophysiology

 Mechanical Insufficiency - lymphostatic

› Low-flow edema, low-volume insufficiency

› A breakdown in the transport capacity of the lymphatic system

 Dynamic Insufficiency - lymphodynamic

› High-flow edema, high-volume insufficiency

› A high load placed on the lymph system exceeds its capacity

 Combination – Safety Valve Insufficiency
 Mechanical Dynamic Safety valve
Lymphatic
load Normal

Capacity Normal

Protein High protein Low protein High protein

stagnation oedema stagnation
Pathophysiological stages
 LATENT
 Dilated lymphatics
 Oedematous endothelial cells
 Phagocytosis
 Lymphatic neogenesis
 Fibrinoid thrombosis
 Distended medium and marginal sinuses
 CHRONIC
 Dilatation increases
 Collector ducts - thickened walls
 Organized thrombi
 Hyaline changes
 Shrinkage of sinus
 Sclerosis of trabeculae
 Disappearance of lymphatics
 Signs and Symptoms
• Constant dull ache or severe pain
• Burning and bursting sensations in limb
• General tiredness and debility
• Puffiness, heaviness, fullness of limb
• Weakness, fatigue
• Numbness, paresthesias
• Pitting Edema
• Sensitivity to heat, cramps, pins and needles

• Skin problems- dehydration, flakiness, weeping excoriation and breakdown

• Skin tension – feeling of “bursting”

• Stiffness, decreased ROM

Sequellae
 Stagnation of protein rich fluid.
 Overload dilation incompetence.
 Chronic swelling
 Excessive tissue proteins
 Fibrotic changes
 Chronic inflammation
 Infections – cellulitis
 Skin changes – “peau d’ orange”
Consequences

 Functional deficits
 Loss of mobility
 Difficulty wearing normal clothing
 Psychological issues
 Classification
• Primary lymphoedema – Born with insufficient or
compromised lymphatic system, cause not known but
presumed to be due to ‘ congenital lymphatic dysplasia’.
• Secondary lymphoedema – May be a result of : Surgery
and/or radiation for cancer, Malignancy, Filariasis, Trauma,
Infection, Chronic Venous insufficiency or Obesity.
 Aetiological Classification
• Primary lymphoedema • Secondary lymphoedema

• Congenital - onset <2 yrs • Parasitic – Filariasis

Sporadic • Fungus -Tinea pedids.
Familial (Milroy’s disease)
• Exposure to silica particles
• Praecox (onset- 2 to 35yrs )
• Primary lymphatic malignancy
Sporadic
• Lymph nodes metastasis
Familial (Meige’s disease)
• Radiotherapy to L N
• Tarda – onset – after 35 yrs
• Surgical excision of LN
old )
• Trauma– Degloving injury
Sup.Thrombophlebitis, DVT.
Primary lymphoedema
Post mastectomy lymphedema
Grade (Brunner)  International Society of Lymphology (2013):

 Subclinical - No apparent lymphoedema, Excess interstial fluid, Histopathological

changes in lymphatics and lymph nodes

 Grade I - Pitting oedema,Swelling subsides on rest or elevation of extremity

 Grade II - Oedema does not pit and does not reduce upon elevation

 Grade III - Oedema associated with skin changes Iike fibrosis, excoriation.

Within each stage, severity based on volume excess as compared to the normal may be sub-
classified as minimal (<20% volume excess), moderate (20–40% volume excess) or severe
(>40%) volume excess.
The volume excess when compared to the contralateral, unaffected, limb or
preferably to the same limb, prior to the onset of lymphedema, when available
is termed Volume differential (VD).

To evaluate patients postoperatively and determine response to an intervention a

Volume Differential Reduction (VDR) is often calculated

Significant changes in BMI, not unusual in lymphedema patients, are

important to consider when assessing a patient’s limb volume change over
time. This is accounted for when applying the weight-adjusted volume
formula (WAC)
Campisi et al. has described a staging system that uses clinical presentation
and lymphoscintigraphic patterns to help classify lymphedema and assist
with clinical management.

Stage IA: No clinical edema despite the presence of lymphatic dysfunction as demonstrated on
lymphoscintigraphy.
Stage IB: Mild edema that spontaneously regresses with elevation.
Stage II: Persistent edema that regresses only partially with elevation.
Stage III: Persistent, progressive edema; recurrent erysipeloid lymphangitis.
Stage IV: Fibrotic lymphedema with column limb.
Stage V: Elephantiasis with severe limb deformation, including scleroindurative pachydermitis and
widespread lymphostatic warts.

Campisi further correlated stage of lymphedema with amount of volume excess:

Stage I: 0–20% volume excess.
Stage II: 21–40% volume excess.
Stage III: 41–60% volume excess.
Stage IV/V: >61% volume excess.
 Chang et al. has devised a classification scheme using ICG
lymphangiography to assist with surgical planning in lymphedema of the
arm

Stage I: Many patent lymphatic vessels, with minimal, patchy dermal backflow.
Stage II: Moderate number of patent lymphatic vessels, with segmental dermal
backflow.
Stage III: Few patent lymphatic vessels, with extensive dermal backflow involving the
entire arm.
Stage IV: No patent lymphatic vessels seen, with severe dermal backflow involving the
entire arm and extending to the dorsum of the hand.
 Conditions mimicking lymphoedema
• Factitious lymphoedema - Caused by application of a tourniquet (a start
and sharp cut off is seen on examination) or hysterical disuse of limb in
pts with psychological or psychiatric problems.

• Immobility lymphoedema - Generalised or localised immobility of any cause

leads to chronic limb swellling e.g-elderly person who spendsall day or
night sitting in a chair (arm chair legs ), the hemiplegic stroke patient or
young patient with multiple sclerosis.

• Lipoedema - Seen only in women as B/L symmetrical enlargement of legs

and sometimes lower half of the body due to abnormal
deposition of fat. It may or may not be associated with obesity .It can coexist
with other causes of limb swelling.
 Differential
Diagnosis
• Non vascular or non lymphatics - General disease states - Liver
failure, Hypoproteinemia, CHF, Hypothyroidism, Allergic
(Angioedema), Prolonged Immobilization.

* Local disease processes – Arthritis, Haemarthrosis, Bony (or)

soft tissue tumours, Calf mucle hematoma.
* Retroperitoneal fibrosis
* Drugs – Steroids, Oestrogens, MAO inhibitors.
* Trauma * Obesity * Gigantism
 Differential
Diagnosis
• Venous causes
- DVT(Pain & redness absent)
-Post thrombotic syndrome
-External compression- Pelvic / uterus / abdominal tumour,
Retroperitoneal fibrosis,
-Reperfusion for lower limb ischemia
- Varicose veins (rare)
• Arterial
- A V malformations
- Aneurysm – Popliteal, Femoral, False aneurysm
 Complication
s
Slow wound healing
Infection - Cellulitis
- Lymphangitis
- Lymphadenitis
Skin Ulcers, thickening of skin, follicles forms

Malignancy
- Lymphangiosarcoma ( Stewart Treves Synderome )
- Retiform haemangioendothelioma
(low grade angiosarcoma)
Malignancies associated with lymphoedema

• Lymphangiosarcoma ( Stewart Treves Synderme )

• Kaposi Sarcoma ( HIV, HID virus )

• Squamous cell carcinoma

• Lymphoma

• Liposarcoma

• Malignant melanoma

• Malignant fibrous histiocytoma

• Basal cell Carcinoma

 Investigating Lymphoedema
• Are investigations necessary ?
• It is usually possible to diagnose and manage lymphoedema purely
on the basis of history and examination when swelling is mild and
there are no complicatingfeatures
• In pts with severe, atypical and multifactorial swelling
investigations may help to confirm the diagnosis management and
prognostic information.
 Diagnosis
 Clinical Examination
 Circumferential Measurements.
 Tissue tonometry
 Perometry
 Dermal backflow assessment
 Bioimpedance spectroscopy (BIS) (L-Dex)

 Diagnostic thresholds for upper limb LE - most commonly used thresholds

include: an absolute 200 ml inter-limb volume difference, a 2-cm inter-limb
circumference difference, a 5-cm inter-limb difference of the sum of all
circumference measurements or a relative percentage difference, often 10%
 Investigations

• Routine Tests - TLC,DLC RFT, LFT, Thyroid function tests, total

plasma proeins, albumen, fasting blood sugar, urine exam for chyluria, blood
smear for microfilariae, X ray chest and ultrasound.

• Lymphangiography- Indocyanine green (ICG) lymphangiography) – Direct

method involves injection of contrast medium into peripheral lymphatic channel
followed by radiographic visualisation of the lymphatic vessels and nodes. It is the
gold standard for showing abnormalities of large lymphatics and lymph nodes. It
can be technically difficult , is unpleasant for the pt, may cause further injury to
lymphatics. As a routine it has become obsolete. Indirect lymphangiography
involves intradermal inj. Of water soluble non ionic contrast into a web space it is
taken up by lymphatics and is followed radiographically. It will show distal
lymphatics but not proximal lymphatics and lymph nodes.
• Isotope lymphoscintigraphy - This has become primary diagnostic
technique incase of unccertainty. Radioactive technitium labelled protein or
colloid particles are injected into interdigital web space and taken up by
lymphatics. Serial films are taken by a gamma camera. It provides a qualitative
measure of lymphatic function. Quantitative function is performed using
adynamic (exercise) component and specifically examines the anatomy and
morphology of the lymphatic system. It also provides information on lymphatic
transport.
Based on lymphoscintigraphy-Lymphatic transport index

TI = 0 optimal flow
TI =45 no flow
<10 normal
• Computed tomography - A single axial CT slice through the midcalf is
a useful test for lymphoedema (coarse, non enhancing reticular
honeycombpattern in an enlarged subcutaneous compartment), Venous
oedema (increased volume of the muscular compartment and lipoedema
(increased sub cutaneous fat). CT will diagnose a pelvic or abdominal
mass lesion.
 Investigation
s
• MRI – It can provide clear images of lymphatic channels and lymph
nodes and is useful in assessment of lymphatic hyperplasis, MRI scan
differentiate between venous and lymphatic causes of a swollen limb and
can detect tumours causing lymphatic obstruction

• HR Ultrasound - It can provide information about venous function

like DVT and venous abnormalities

• Pathological examination - If malignancy is suspected FNAC , neddle

cone biopsy or surgical excision from lymph nodes is useful. Skin biopsy will
confirm the diagnosis of lymphangiosarcoma.
 Management – Conservative
Complex Decongestive Therapy (CDT)

• Skin care to treat infections (nail – fungal) and optimise condition of the
skin (skin – cellulitis) + Patient Education.

• Manual Lymphatic Drainage (MLD) to enhance lymph flow.This precedes bandaging

and directs lymph fluid to functional territories and helps to form collateral pathways
• Multi Layer Compression Bandaging

• Exercise to increase lymphatic & venous flow- Massage and swimming are
beneficial. Avoid vigrous exercises.

• A compressive garment therapy is used to preserve the reduction acieved by

treatment and prevent progression of lymphoedema Education and Psychosocial
support.
Adjuvant Therapy

 Myofascial Release
 Kinesiotaping
 Aquatic therapy
 Wound Care
 Pneumatic pumps
 COMPLETEX DECONGESTIVE THERAPY

Complex Decongestive Therapy (CDT) as the method of

choice- includes two phases
 Decongestion phase
 Maintenance phase
Manual Lymphatic Drainage (MLD)

• Increase lymphatic uptake

• Increase lymph vessel pulsation
• Promotes movement of fluid from edematous areas to regions of
normal lymphatic drainage
Goals of technique:
• Promotes relaxation
1. Increase peristalsis of lymphangion
• Analgesic effect
2. Break down fibrotic tissues
3. Increase lymph volume in lymph
vessels
4. Decrease congestion in interstitium
Treatment begins proximal, to “clear” proximal lymphotomes before
moving to affected lymphotomes
 Massage is directed towards the cleared lymphotome
 Pressure is very light
 Strokes are rhythmic
Massaging lymph nodes
› Firmer pressure, circular motion
 “Clearing”
› Begin farthest from the affected area
› Clears the way for fluid drainage
› Moves proximal to distal
 “Flowing”
› Begin closest to the affected area
› Always done after clearing
› Moves distal to proximal
 Medical Compression Bandaging
Low stretch bandages
› Provides low stretch when no contraction
› Higher compression when muscles contract
 Prevent re-fill of lymphatics
 Work with muscle pumping
 Follow “Law of Laplace” – the smaller the radius the greater the pressure
 Help break up fibrotic areas
 Bandaging Guidelines

Worn 23 hrs/ day (off only for bathing)

 Should re-wrap daily to prevent loosening
 Should have more compression (more layers) distally
 Bandages should be washed frequently
 Compression Therapy

Use of compression garments is very important in treatment of

lymphoedema - maintains reduction gained during therapy
- Transition to garments when reduction plateaus.
- They apply medically proper pressure to the swollen region to reduce
pooling of fluid.
 These garments are available in a variety of styles, sizes, colours and grades of
compression (Class I- IV).
 More swelling needs stronger support. They come as Pre–sized (ready to wear) or
custom made design. They are worn during day and removed at night.
 Therapeutic Exercises

 Exercises facilitate muscle pumping

 Should be done with compression
 Progress proximally to distally
 Very low resistance, few repetitions, rests as needed
Pneumatic compression devices
 Not to be used without preparing contralateral limb

 Else edema increases and worsens

Goals of surgical therpay
 Improve function
 Prevent further complications
 Facilitate conservative therapy
 Indications : failed medical management.
size is impairing normal function.

 Relative : cosmetic .
Recurrent lymphangitis.
 10 year conversion rate into lymphosarcoma is 10 %
 AIM OF SURGERY

 Reduce swelling

 By pass lymphatic blockage

 Surgical Management

 Early 1990s
 Early methods of managing lymphedema surgically involved
using a silk suture that was threaded in a subcutaneous plane
along the affected extremity.
lymphangioplasty
 Handley
 Introduced silk thread across lymphatic barrier
 Capillary action drain fluid
 But later dense fibrosis around thread prevents
capillary action

 Proposed improvement : Teflon thread & steroid

injection
 Suami and Chang classified the surgical management

- Ablative

- Physiologic
 Ablative Surgery
 In Ablative surgery - The soft tissues, which are edematous and fibrotic,
above the level of the deep fascia, are surgically removed with either
direct excision or by liposuction.
 Aim at surgical removal of the tissue layers affected by lymphedema, the
deep fat compartment above the deep fascia, the superficial fat
compartment above the superficial fascia and below the dermis, and to
varying degrees the skin itself.
 Ablation surgery

Basis : reduce lymph producing tissue

 Sistrunk : removal of ellipses of skin and subcutaneous
tissue with primary closure
 Homans : Staged excision of subcut tissue under flaps.
 Charles : radical excision with STSG
 Gibson : radical excision with FTG
 Teimourian : lipectomy
 Jaju : arterial ligation
 Thompson et al. utilized modifications of Homan technique for the upper
extremity.
 These modifications include excising affected tissue, then creating de-
epithelialized dermal flaps and folding these in toward, and suturing them to the
deep investing fascia,

- postulating that these dermal bridges would act as connections between

deeper lymphatics and vessels and superficial lymphatics facilitating fluid
transport.

There is no evidence to support that this takes place.

 92 % of 72 cases of thompson improved
 No e/o communication between dermal and muscle lymphatics
 Improvement was attributed to excision
 More recently, suction-assisted lipectomy / liposuction has been utilized as
an ablative method to remove the hypertrophied fat of the affected extremity.
- Much less morbid.

- No skin grafting is involved .

- External scarring at surgical sites is minimal.

 Compression garments or wraps must be worn throughout the day following
liposuction to continue to control the excess fluid component and maintain
the volume reduction that was achieved
 Currently, all these ablative methods should be reserved for more
advanced lymphedema that has undergone architectural changes in the
soft tissue and would thus be unresponsive to physiologic methods of
intervention.
 Currently, most practitioners - combining physiologic procedures and
liposuction – in later stages of lymphedema with significant amounts of fat
hypertrophy and/or fibrosis.
 Most physiologic methods - used for secondary lymphedema.
 Physiological Surgery
 Physiologic methods are those that recreate normal or alternate route
for lymph fluid to flow out of the affected limb.
 Two main physiologic interventions are currently employed to treat
lymphedema.
 1) Based on the creation of shunts between the congested lymphatic
channels and the venous system proximal to the site of lymphatic
obstruction.
 2) Relies on the introduction of vascularized soft tissue flaps which
frequently include vascularized lymph nodes to the affected extremity
 Jackobsen and Suarez - Lymphaticolymphatic bypass
 Olszewski : Lymphnodovenous
 O’brine : lymphaticovenous
 Vascularized lymph node transfer (VLNT)
 Vascularized omental flap transfer.
 Simultaneous microsurgery breast reconstruction and
vascularized lymph node transfer
 First described by Jackobsen and Suarez in 1962.
 Baumeister et al.- used health lymphatic grafts from the lower extremity as
a means of bypassing upper arm lymphatics into healthy neck lymphatics
across the scarred axilla.
 Campisi et al - instead of using lymphatic vessels as graft conduits, vein
grafts from the thigh were used.
 This helped alleviate potential disruption of the lymphatic system and the
risk of additional secondary lymphedema at the donor site
Microvascular
 O’brine : lymphatic vessels in a lymphedematous limb are connected
to nearby small veins and venules using microsurgical and super-
microsurgical techniques min of 3 anastomoses needed

- proven results in post mastectomy lymphedema

 Baumester’s technique bridging the lymphatic block with autologous
graft

Both are for localized blocks

 Campisi - vein interposition graft between the lymphatic
vessel bundles above and below the site of lymphatic
blockage to bypass.
The ventromedial lymphatic bundle of the thigh consists of
about 16 lymphatic channels\ this region is useful for
harvesting.
knee and the inguinal region are avoided.
Lymphatic grafts can be harvested up to about 30 cm in
length.
Lymphatic - vein anastomosis
 Lymphnodovenous anastmosis
 Basis : normal lymphovenous shunts open in
lymphedema
 Pulp of node is removed and subcapsular sinus is
sutured to the vein
 Best result with dilated sinuses and with max LN
transfer
 Indication : palpable LN
 Lymphovenous Anastmosis

 Indication : nonpalpable LN
 Sedlacek - end-to-side
 Yamada - end-to-end anastomosis

 Better in hyperplastic forms - Because after decompression

chances of thrombosis increases in them.

 Degni designed a special needle to facilitate the insertion of

lymphatic vessels into veins.
 Vascularized lymph node transfer
 Vascularized lymph node transfer is useful in reducing lymphedema. One of the
larger studies by Becker et al. evaluated 1500 patients with stage I, II, and III
lymphedema who had undergone vascularized lymph node transfer. The minimum
follow up was 3 years. Findings included a 98% subjective improvement.
 40% of patients with stage I and stage II lymphedema had significant improvement
and required no further conservative therapy. For patients withstage III
lymphedema, 95% had some improvement and 98% remained infection free.
However, the stage III patients still required conservative therapy to help control
edema in the limb.
 One of the major drawbacks to lymph node transfers is the potential for iatrogenic
secondary lymphedema at the donor sites.
 Vascularized omental flap transfer
 Because of the risk of donor site lymphedema, clinicians have sought out
other sources of vascularized lymphatic tissue.
 The omentum’s function as lymphatic organ has been explored for
possible applications in lymphedema management.
 Surgeons began using the omentum as a pedicled flap attached to its
gastroepiploic vascular supply to aid with lymphatic drainage in upper
extremity lymphedema
 Results from this approach have yet to be fully validated, but early reports
show promising results similar to vascularized lymph node transfers
 Simultaneous microsurgery breast reconstruction and
vascularized lymph node transfer

 Recently, the use of a combined abdominal and groin lymph

node flap has been utilized to treat lymphedema in the upper
extremity for patients who have undergone mastectomy and
axillary lymph node sampling and have developed refractory
lymphedema. Results from this approach are limited due to
the lack of data currently available, but some improvement
has been noted
 The most commonly performed surgical procedures for
lymphedema are LVA and Free vascularized lymph node
transfer.
 Lymphatic Microsurgical Preventative Healing Approach
(LYMPHA). This method, championed in Italy, utilizes
lymphovenous anastomoses of upper extremity lymphatics
at the time of the axillary node dissection to bypass any
severed arm lymphatics immediately.
 Points to remember
 Current practices dictate that conservative measure be utilized first
when patients are initially diagnosed with lymphedema.
 Most surgeons recommend physiologic procedures for patients that
have stage II or early stage III lymphedema.
 Becker et al., results from vascularized lymph node transfer suggested
that patients who had surgical interventions earlier in the course of their
disease had better outcomes.
 Explain the patient the actual condition
 Avoid false assurances
 In breast cancer pts.
 To avoid intravenous blood draws and intravenous catheter
placements in the at risk limb.
 Avoid blood pressure measurements in the limb
 Encourage Use of compression garments during air travel are
sometimes recommended.