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Overview of Surgical Techniques
Key Points
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Reductive procedures (direct excision with skin grafting or liposuction) alone or as an adjunct are effective in gross reduction of volume; however, they carry significant morbidity.
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Direct excision with skin grafting is reserved for the most extreme cases of lymphedema in which function and activities of daily living are severely affected.
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Liposuction for reduction of excess adipose deposition requires lifelong postoperative compression garments.
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Physiologic methods (lymphovenous anastomosis [LVA] or vascularized lymph node transfer [VLNT]) tend to produce more modest reductions in volume; however, they produce less morbidity to donor and recipient sites.
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LVA seems most effective at early stages of lymphedema before the destruction of lymphatic vessel smooth muscle and the development of irreversible tissue fibrosis.
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LVA may be more effective in addressing upper extremity versus lower extremity lymphedema.
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Vascularized lymph nodes can be harvested from numerous locations such as the groin, axilla, supraclavicular and submental regions. They can also be transferred to proximal (groin/axilla) or distal (wrist/ankle) areas of the affected limb.
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Harvest of vascularized lymph nodes should be performed carefully to prevent donor limb lymphedema.
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VLNT should be considered in patients who are poor candidates for LVA.
Introduction
Lymphedema involves the accumulation of lymphatic fluid leading to progressive fibrosis, fat hypertrophy, and destruction of the lymphatic vessels. The course of lymphedema is chronic, progressive, and debilitating. Although there is no cure, the gold standard for the treatment of lymphedema is manual decongestive lymphatic therapy (MDLT) or complete decongestive therapy (CDT), which is best administered by a certified lymphedema therapist. The use of these therapies, however, is labor intensive and requires strict lifelong patient compliance with compression garments. Surgical treatment of lymphedema follows after failure of such conservative measures. The purposes of surgery are to reduce the weight of the affected region, to reduce frequency of infectious/inflammatory episodes, to prevent progression of lymphedema, and/or to improve cosmesis and function.
Options for surgical treatment of lymphedema can be divided into two categories: excisional and physiological treatment. Excisional treatment usually involves reductive procedures such as liposuction and excisional debulking with skin grafting (Charles procedure). Physiological treatment is aimed at restoring or reconstructing the physiologic drainage of the lymph fluid. Several different strategies to achieve this have been proposed, such as buried flaps, direct repair of lymphatics, bypass grafting of lymphatics, lymphaticovenular anastomosis (LVA), and vascularized lymph node transfers (VLNT). The outcomes of such procedures vary. The aim of this chapter is to present an overview of therapies that have been described and tested.
Excisional Treatment
Liposuction
The accumulation of lymphatic fluid in the limb results in increased deposition and hypertrophy of the adipose tissue. Liposuction, in which a fenestrated metallic cannula connected to a vacuum suction is used to aspirate subcutaneous fat, was originally developed for body contouring but since then has been used for the treatment of lymphedema. O’Brien et al. demonstrated an average 20–23% reduction using liposuction to treat a mixed cohort of patients who had not undergone previous surgeries to treat lymphedema. Brorson and Svensson compared the combined use of liposuction and compression therapy to therapy alone in stage II patients and demonstrated a 115% reduction in volume compared to 54% of patients who had isolated compression therapy. This was maintained at 4 years with average reduction of 106% (66–179%).
One of the theoretical risks of liposuction is further damage to existing lymphatic vessels. Cadaveric and imaging studies have shown that performing liposuction longitudinally to the limb minimizes this damage and that further impairment to already delayed transport of lymphatic fluid does not occur. In addition to volumetric reduction, functional improvement was also reported by Qi et al. when liposuction was combined with physiological treatments. The incidence of cellulitis (6.5±4.3 vs. 0.7±0.8 episodes/year) was drastically improved albeit confounded by the mixture of procedures performed.
In general, treatment of lymphedema with circumferential liposuction is considered safe with quick recovery within 48 hours. Complications are few and usually limited to minor wound healing problems and paresthesias. The use of tumescent technique during liposuction and tourniquets can greatly decrease the blood loss and need for transfusions.
While liposuction can aggressively debulk hypertrophied adipose tissue in a lymphedematous limb, the primary disadvantage of liposuction is the need for continuous (24 hr/day) use of compression garments postoperatively to maintain the new equilibrium. In the Brorson series, patients who discontinued use of compression garments rapidly re-accumulated fluid.
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