It’s not uncommon for patients with breast, gynecologic, prostate, and other cancers to develop congenital or secondary lymphedema after treatment. If cancer spreads to the lymph nodes, patients need to have those nodes surgically removed to help clear their bodies of the cancer. Lymph nodes can be thought of as filters for the circulating lymphatic fluid, and in some cases, when the lymph nodes are removed, the lymphatic drainage system becomes blocked and the fluid leaks into the surrounding tissue. That tissue becomes chronically inflamed and the affected limb becomes swollen and painful. This is stage I lymphedema. If the disorder isn’t treated over time, the inflammation results in deposits of solids that cause the arm or leg to become hard, resulting in stage II lymphedema. Because pathologic solids are now present, an arm or leg with stage II lymphedema will no longer completely reduce in size to match an unaffected arm or leg. Microsurgery and/or conservative therapies drain lymphatic fluid and cannot remove these solids once present.
Though lymphedema is a chronic condition, it can be partially treated and managed with a combination of surgery, therapy, and by wearing compression garments. If left untreated, the swelling and pain caused by lymphedema can have a substantial impact on a patient’s day-to-day life. But with properly selected treatment and/or surgery, the affected limb may return to its normal or near-normal size and the patient may once again resume their typical daily activities.
Finding a lymphedema specialist
Lymphedema is poorly taught during medical education, and many doctors misdiagnose the disorder as obesity or other swelling. And while there are a number of physical therapists and plastic surgeons who claim to treat lymphedema, very few are truly experts in the field. When looking for medical providers to treat their lymphedema, people should look for therapists and surgeons who are certified in lymphedema treatment. Physical and occupational therapists should be a certified lymphedema therapist (CLT), while the surgeon should be board-certified in plastic surgery and a member of the American Society of Plastic Surgeons (ASPS), have additional specialized microsurgery fellowship training and a significant emphasis on lymphedema surgery in their practice.
Treatment for stage I lymphedema
Anyone diagnosed with stage I lymphedema will need to begin with conservative therapies such as physical therapy, occupational therapy, compression garments, and pumps. For some patients, conservative therapies may keep the symptoms at bay and provide the relief they need. Others may benefit from additional treatment that involves microsurgery.
Lymphaticovenous anastomosis (LVA)
Stage I lymphedema patients that may benefit from microsurgery may undergo lymphaticovenous anastomosis (LVA) surgery. In this minimally invasive surgery, a surgeon will take a series of lymphatics in the affected area and connect them directly to veins. This creates tiny shunts to allow the excess lymphatic fluid to drain into the venous system where it belongs. By finding the right lymphatic channels, disconnecting them, and connecting them to tiny, appropriately sized veins with one-way valves, the flow of lymphatic fluid improves and drains appropriately. The lymphatic channels are tiny, typically between 0.1mm and 0.9mm in diameter. LVA allows drainage to happen not just while wearing compression garments, but 24 hours a day, seven days a week.
Vascularized Lymph node transfer (VLNT) Surgery
Depending on the patient, treatment may include a vascularized lymph node transfer (VLNT) surgery, where healthy lymph nodes from other parts of the body are borrowed to replace the cancerous lymph nodes that were surgically removed. Over time, the drainage is expected to improve, which in turn improves the symptoms and swelling. To avoid damage to the donor site, it’s essential to choose a skilled surgeon who has extensive experience in lymph node transfers. Dr.Granzow uses a technique known as reverse lymphatic mapping to minimize donor site risk.
Another benefit of VLNT surgery is that excess scar and constricting bands present after lymph node dissection in the armpit can be release. Additional healthy tissue can then be brought in as part of the VLNT surgery to minimize the repeat formation of scar in the affected areas.
Treatment for stage II lymphedema
Once lymphedema has progressed to stage II and there’s a build-up of permanent solids such as fat and proteins in the affected area, a surgeon needs to start the treatment with a more intensive surgery in which the solids are suctioned out. This will “downstage” the lymphedema to stage I and the patient can continue on with conservative therapies or microsurgery.
The initial procedure of stage II lymphedema is suction-assisted protein lipectomy, in which a very specialized suction device called a cannula is used to suction out the solids through small incisions. Once the solids are removed, the patient will continue wearing compression garments and work with a therapist for about a year until their arm or leg is reduced to a normal size, the inflammation is significantly reduced, vessels are healing, and the patient’s lymphatic system starts to recover.
It should be noted that regardless of whether a patient has stage I or stage II lymphedema, their cancer must be stable, or ideally, they are in remission before they can begin treating the lymphedema.
The role of therapy in lymphedema treatment
Though surgery can provide quick, long-term relief, much of lymphedema treatment revolves around therapy. It’s an important — and often essential — first step in treating lymphedema. Many surgeons, including those at Granzow Lymphedema and Lipedema Center, won’t even see a patient until they’ve been working with a trained therapist.
There are a number of reasons for this. The first being that conservative therapies alone may relieve lymphedema symptoms and eliminate the need for surgery. A patient’s therapist will also have a good understanding of where the biggest problem areas are, which is a big help in the operating room. Therapy decreases inflammation and swelling, making surgery and recovery easier for the patient. Finally, therapy will be necessary post-surgery, and a patient needs to have an existing relationship with a therapist to increase the long-term success of the surgery.
Results of lymphedema surgery
Because most lymphedema surgical sites are so small, patients will be up and walking the day after their surgery. Following lymphedema microsurgery, pain should be minimal and the recovery from surgery should be relatively easy and quick. Patients will continue to need therapy and can expect to wear compression garments for at least a portion of the day most days for the rest of their lives. Because a patient with stage II lymphedema has much more advanced disease and inflammation, SAPL surgical recovery is more involved. But SAPL surgery should significantly reduce the size of the affected limb, reduce the amount of therapy needed as well as the amount of time spent in compression garments, and relieve the pain associated with lymphedema.
Dr. Granzow is a lymphedema surgery pioneer and created the first truly integrated lymphedema surgery treatment system, known as the Granzow SystemSM. Roughly 99+% of patients treated by Dr. Granzow can return to regular clothing sizes without pain, and infections caused by lymphedema go down by 80%.
If you have been diagnosed with lymphedema and are working with a therapist, contact the experts at the Granzow Lymphedema and Lipedema Center today to get the relief you deserve.