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More Lymphedema Surgery Questions Answered

December 17, 2014

Last month, we shared with you our answers to . Since then, we’ve continued to receive an outpouring of questions from people affected by this condition, which is characterized by painful swelling in the arms, legs or abdomen.

To set the stage for our next round of questions and answers, recall that lymphedema often occurs after lymph node removal following breast cancer surgery. Until recently, treatment in this country was limited to the use of compression wraps and pumps, as well as specialized massage techniques performed by a lymphedema therapist.

In March of 2013, the plastic and reconstructive surgery group at the UF Health Cancer Center at Orlando Health became the first practice in the state of Florida to perform a new procedure called vascularized lymph node transfer (or VLNT). This highly specialized microsurgery transplants healthy lymph nodes from a donor site to the affected area, eventually causing the lymphatic channels to regrow and reducing or eliminating the symptoms of lymphedema.

Below are the latest reader-submitted questions, along with our answers.

Lymphedema Surgery Q&A—Part II

Q: I have full body lymphedema that is worse on my right side than my left. Can this procedure help me?

A: First, it’s important to distinguish full body lymphedema from lipedema, which is the swelling related to excess adipose tissue, a type of connective tissue. The procedure we offer works best in patients who are healthy and near ideal weight for their age and height. We have seen some of our best results in our breast cancer patients who have had surgery to remove lymph nodes in the armpit or have received radiation.

Moreover, the tissue that we transfer with the lymph nodes entails taking fat and tissue, as well as the lymph nodes and vessels. These vessels are quite small--often one millimeter or less, and so this becomes exceedingly difficult, if not impossible, to accomplish on obese patients.

Q:  I have congenital Milroy’s disease, also known as elephantiasis, in both lower legs and all my siblings have a form of it as well. I would bet each lower leg is a good 20 lbs. I’m a nurse and on my feet 13 hours a day. Am I a candidate for lymphedema surgery?

A: The VLNT procedure can be used on congenital lymphedema patients as well, yielding some improvement, though it is not curative. It depends on the severity of the lymphedema and the quality of the skin. In some patients, we will get a lymphoscintigraphy to determine the extent of the abnormal lymphatics. Some of these patients may require more than one transfer—an initial transfer at the groin level and a second transfer at the knee to try to improve the swelling.

Q: Have you tried this surgery on someone with severe lymphedema with fibrosis? If so, what were the results?

A: We have not performed vascularized lymph node transfer on patients with severe fibrosis of the skin. This is due in part to excess collagen and scar deposition from chronic inflammation and edema, an excess of watery fluid collecting in the cavities of the body. As of right now, it is unclear whether lymphedema surgery will benefit these skin changes.

Q: For over 40 years, I have had lymphedema in my right leg that resulted from a blood clot due to oral contraceptives. I wear compression garments and just started using a pneumatic pump daily. I exercise, walk daily, use weights and the elliptical machine three times a week, and yet my leg is getting larger. I read and am hoping that I would be a good candidate for this.

A: Lymphedema may be the result of issues in the lymphatic system from surgery, infection, injury or congenital causes. It also may be the result of venous issues resulting from damaged valves, as occurs with blood clot formation. Sometimes it is difficult to identify the exact cause of the swelling. It is best to be evaluated in a clinical setting, where we can work together to determine if a particular patient is a good surgical candidate.

Q: I have had left leg stage one lymphedema for several years that is treated with massage and decompression. Recently I had a dynamic ultrasound that showed a moderate greater saphenous reflux.  An ablation has been suggested. If I were to have an ablation for an additional venous issue, would that interfere with a lymphatic transplant in the future?

A: Having the venous ablation will not interfere with the vascularized lymph node transfer procedure. It would be prudent to address the venous issues before exploring lymphedema surgery.

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