Lymphedema remains one of the most challenging aspects of breast cancer treatment. Lymphedema is defined as swelling of the arm due to a blockage in the lymphatic drainage of that arm. This can often occur for a variety of reasons. These reasons include removal of lymph nodes from the axillary region, radiation of the lymphatics or constriction of the brachial veins with scar tissue. Whatever the cause, lymphedema can be debilitating and a constant reminder of the breast cancer struggle.
Lymphedema, however, is not without hope. Many procedures can be used to improve lymphedema. Older techniques that were unsuccessful in treatment have been replaced with newer microsurgical procedures resulting in significant improvements in lymphedema.
Two therapies remain the main stay of treatment for lymphedema.
- Lymphovenous bypass
- Vascularized lymph node transfers
In a natural state, the lymphatics all coalesce into one large lymphatic and empty into the venous system through a large lymphatic vessel called the thoracic duct. This natural drainage of lymphatics is interrupted in many lymphedema patients. One of the solutions is simply rewrap the lymphatics directly into the venous system prior to the area of obstruction. The lymphatic fluid is simply bypassing the area of obstruction and entering into the venous system in the arm itself. Lymphovenous bypass is an excellent treatment and can result in significant improvement in lymphedema.
This treatment requires advanced microsurgical techniques. The size of the lymphatic vessels are significantly smaller than the majority of microsurgical vessels that are typically reconnected; resulting in much more technical difficulty in the reconnection.
We at HPCS provide patients with imaging postoperatively, which demonstrates patient lymphovenous anastomosis. These can be either functional lymphatic dumping with indocyanine green fluorescent mapping or, in some cases visual confirmation when patient lymphovenous anastomosis is demonstrated through the operating microscope. Our surgeons show dedication and effort by the willingness to demonstrate the success of these technically difficult operations as seen in these short attached videos.
Lymphovenous bypass is best performed within the first year of the onset of lymphedema. After the first year, the lymphatics themselves become scarred and the success of lymphovenous bypass decreases due to the fibrosis in the lymphatic system itself. In these patients, we choose instead, to use vascularized lymph node transfers. The vascularized lymph node transfer transplants viable lymphatic and viable lymph nodes in a vascularized manner to areas of edema. These lymph nodes act as pumps absorbing surrounding lymphatic fluid and pushing the lymphatic fluid through the efferent veins directly into the venous system. This mechanism of action is extremely useful as it can be performed at any stage of lymphedema even in patients with longstanding lymphedema.
The location of the vascularized lymph node transfer can be customized to patient needs and overall desires. These can be placed in the wrist of patients with predominantly wrist and hand edema, in the area around the elbow of patients with forearm edema or in the axilla in patients with total arm edema. Axillary placement has the advantage of nonvisible scars and secondary benefit of exploration of the axilla for any constriction of the drain veins.
The two modalities of lymphovenous bypass and vascularized lymph node transfer can often be incorporated at the same time. By incorporating both of these techniques simultaneously, patients are left with the highest likelihood of success for lymphedema management.
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Consultation with a surgeon at Houston Plastic, Craniofacial and Sinus Surgery will determine the feasibility of lymphatic treatment for you. Our surgeons will be able to customize a surgical plan for treatment of your lymphedema. Please contact us at 713-791-0700, or click the button below.