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Lymphedema is a disorder of the Lymphatic System. While Lymphedema can occur spontaneously, most cases of lymphedema in the United States result from treatment for cancer with surgery, radiation, or both.
Lymphedema manifests as swelling in either an arm or a leg in most cases. In the cases of arm swelling, lymphedema usually tends to happen after treatment for breast cancer. It’s estimated that between 5% to over 50% of patients who have treatment for breast cancer, which involves surgery to remove the lymph nodes as well as radiation therapy, develop lymphedema in the arm to some degree.
Lymphedema swelling can also occur in the leg. This is most commonly due to treatment for gynecological cancer, such as a cervical or ovarian cancer. This also includes cancer treatment with radiation, surgery to remove lymph nodes or both. It’s estimated that approximately 20% of patients that have surgery to remove lymph nodes and also radiation, will develop some form of leg lymphedema.
Lymphedema swelling first occurs because the lymphatic system is blocked at some point. The lymphatic system is related to the immune system and involves the movement of clear fluid, known as lymph, in the arms and legs. When this lymph fluid can no longer drain properly, such as after surgery or radiation therapy, then the fluid builds up leading to swelling . Congenital or intrinsic problems with the lymphatic vessels can also result in lymphedema.
Initially, most or all the swelling is due to the accumulation of excess fluid. This fluid is very toxic, causes tremendous inflammation and eventually additional solids and fat deposit into the swollen area. The swollen arm or leg then goes from a fluid-predominant state to a more chronic, solid-predominant state.
The traditional therapy for Lymphedema has been non-surgical and involves a course of complete decongestive therapy (CDT) administered by a trained Lymphedema therapist. This involves specialized manual lymphatic drainage, specialized massage, exercises, skin care and compression. Additional non-surgical therapy can include the use of compression garments and other modalities to further reduce the swelling in the limb. Conservative therapy tends to be more effective early in the course of the disease when fluid is predominant.
There is no single procedure that is best suited to all presentations of Lymphedema. In the early, fluid-predominant stages, VNLT and LVAs tend to be most effective. These procedures typically improve the fluid drainage of the limb and are thus most effective early on when swelling is still mostly fluid.
In later stages, when the swelling is mostly solid, the SAPL procedure is more effective. This allows the removal of the excess fat, proteins and other solids that have deposited over months or years in the swollen extremity.
VLNT involves the transfer of lymph nodes from the portion of the body where they are in excess, to another part of the body that is affected by Lymphedema. The lymph nodes are moved with a vascular circulation involving the reattachment of a connected artery and vein to lymph nodes and surrounding fatty tissues allowing them to survive and integrate into the site where they are needed. These transferred lymph nodes allow the built-up fluid to drain and allow the healing of lymphatics in the recipient area into the lymph nodes for additional improved drainage. In some cases, scar release can be performed at the same time as the VLNT, which can further improve drainage of the limb.
LVAs involve the connection of the lymphatics directly into the veins. The lymphatics are quite small, from 0.1 mm up to approximately 0.6 mm in size. The lymphatics are connected to veins that have one-way valves in them to allow excess lymphatic fluid that is returned directly to the venous system, bypassing the areas of blockage. The venous system, even in healthy individuals, is the ultimate outlet for the lymphatic fluid in any case.
SAPL surgery involves the removal of excess fats, proteins and other solids from the affected limb. This is usually performed for patients whose Lymphedema has progressed to a more chronic and solid state. Small incisions are made and a long, thin cannula is introduced to allow removal of the solids. Lifelong use of compression garments is required after the performance of SAPL to prevent the recurrence of swelling.
It is important to note that SAPL surgery is quite different from cosmetic liposuction. Some differences include the requirement for very close work with a trained lymphedema therapist, differences in surgical technique, and the use of a sterile, surgical tourniquet. Specially fitting, custom compression garments are also required and must be worn afterward to prevent the re-accumulation of fluid.
Dr. Granzow has pioneered the use of a VLNT after SAPL to reduce the need for post-operative compression garments. VLNT was introduced by Dr. Granzow after SAPL in selected patients to reduce the need for continuous, compression garment use. The results were very successful and have been published in major medical journals.
Again, it is to be emphasized that not one procedure will help all patients. The procedures must be carefully selected for the right patient at the right time for the best results possible.
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