Lymphedema is a condition where there is accumulation of lymphatic fluid typically in the arms or legs as a result of inadequate return of lymphatic fluid back to the circulation. This can be cause by a congenital absence of lymphatics or acquired from damage to the lymphatic system from infections, cancer surgery or radiation. The common types of lymphedema that we manage are patients with upper limb lymphedema after breast cancer surgery and lower limb lymphedema after pelvic surgery or groin dissections.

There are 2 main surgical options for the treatment  of lymphedema: 

1. Lymphatico-venous anastomosis (LVA) is a procedure where bypasses are made between the lymphatic system and the venous system to enable the lymphatic fluid to return back to the circulatory system. 

2. Lymph node transfer (LNT) is a procedure where lymph nodes are harvested from a donor site and transferred to the affected limb. The postulated mechanism of action is either a pump mechanism that returns lymphatic fluid to the circulatory system or lymphangiogenesis.

An individual who is motivated to undergo physiotherapy for rehabilitation before and after lymphatic reconstruction will likely do well after the surgery. We work closely with the physiotherapist to prepare the patients for surgery and also to optimise patients after surgery. Patients will need to be compliant to pressure garments to optimise results.

Excision procedures can be done to treat lymphedema. However, these procedures are non-physiological and does not restore or correct the altered anatomy. The results would have to be maintained with the use of manual massage or pressure garments.

1. Liposuction can be done to excise both the adipose tissue and also the fibrous tissue associated with lymphedema. Excisional liposuction is done using specialised cannulas. 

2. Charles Procedure is a procedure where the subcutaneous tissue around the affected limb is excised and the skin is harvested and reapplied to the overlying fasia or muscle. Whilst this may be disfiguring it can give dramatic results in patients with advanced lymphedema.

Intra-operatively, indocyanine green (ICG) dye is used to confirm the patency of the anastomosis or to confirm that the lymph node transfer is viable. Limb girth measurements and perometry are done after surgery to document improvement in lymphatic flow. Almost all patients report that the operated limb feels lighter and most will demonstrate a reduction in circumference.

The possible risks of lymphatic reconstruction surgery include:

1. Bleeding, hematoma and bruising 

2. Infection and wound breakdown

3. Scars

4. Complications at the donor site from lymph node harvest

5. Persistent lymphedema

6. Complications from prolonged bedrest such as deep venous thrombosis

7. Risks from general anaesthesia