Surgical approaches for the management of lymphedema

Rates of breast cancer-related lymphedema range from 5% to 8% with sentinel node biopsy, 20% with axillary node dissection or radiation and >50% for patients treated with surgery and radiation.Recent advances in surgical management of lymphedema have provided options for patients for whom conservative management has failed, but questions remain about timing, technique, postoperative care and mechanism of action. In mild-to-moderate cases of lymphedema, microsurgical techniques including autologous lymph node transfer (LNT) and lymphovenous anastomosis (LVA) are being performed. Medical liposuction is well established for patients with advanced lymphedema.LNT harvests healthy lymph nodes from one region (e.g. superficial inguinal nodes) and transplants them either to the original site of injury (e.g. axilla or groin) or to other areas within the lymphedematous limb. Studies are limited to case reports or series, often with limited follow-up.LVA, a safe, minimally invasive, microsurgical technique performed via small limb incisions is for patients whose condition cannot be managed conservatively or who suffer from recurrent infection. Fine anastomotic connections between a functioning lymphatic selected by advanced infra-red imaging and a subdermal venule are created. Results vary so standardized diagnostic, assessment and surgical treatment protocols are required.As lymphedema progresses, adipogenesis from mesenchymal stem cells results in large depositions of fat. The indications for liposuction include nonpitting edema that has not responded to conservative management; arm volume differences of at least 600 cc; and no evidence of cancer recurrence. Significant physical, functional and psychological improvements occur after treatment, which has a near 100% volume reduction success rate, although life-long wearing of compression sleeves is required.Further, human, cadaver, animal and basic research is required to understand the underlying pathophysiological mechanisms of lymphedema and associated surgical interventions.