Dr Corinne Becker – Lymphoedema Center

Arm lymphedema

Iatrogenic Arm Lymphedema

Iatrogenic arm lymphedema is a lymphedema of the arm caused by the treatment of an illness (like breast cancer) or by previous surgery.

Lymphatic MRI is the best diagnostic tool for lymphedemaDiagnosis

• Lymphatic MRIs are the best examinations to show the indication for surgery, the new lymphatic vessels, the transplanted nodes and the progress of the lymphatic vessels growth.

• The results observed with the isotopic lymphangiographies are showing uptake of the contrast but they give poor informations on the remaining pathway compared to the lymphatic MRI

Surgical Treatment Options

Lymph Nodes Transfer (LNT)

Autologous Lymph Nodes Transfer (ALNT), also called microsurgical vascularized lymph nodes transfer (VLNT) involves transferring a few healthy lymph nodes from one site to the affected area to restore the lymphatic function in the limb.

ALNT has many advantages. Check out who is a good candidate. All details about ALNT and iatrogenic arm lymphedema are here below.

What about lymphovenous anastomosis?

The indications are actually reserved for very early stages of lymphedema, without any fibrosis and sclerosis of the remaining lymphatic vessels, and lifetime garnments are prescribed.

The identification of good quality lymphatic vessels and the quality of the anastomosis is essential. Compression to maintain hyperpression in the lymphatic system is essential. As a result, numerous failures of this technique have been described.

What about lymphovenous grafts (or lympholymphatic grafts)?

The procedure is extremely difficult to perform. The scar at the donor site is really visible and extended. This procedure is very, very rarely performed and indications are scarce.

Lymph Nodes Transplant (LNT) in details

Pre-ALNT and 10 years after ALNT, without other treatment

Pre-ALNT and 10 years after ALNT, without other treatment

Outcomes of LNT

  • 40% definitive normalization
  • 98% improvement
  • 2% without results
  • No worsening of the lymphedema

Objective results

  • New growing lymphatic vessels are visible on the MRI, 1 year after lymph nodes transfer in the axillary area

    New growing lymphatic vessels are visible on the MRI 1 year after lymph nodes transfer in the axillary area

    New growing lymphatic vessels are visible on the MRI 1 year after lymph nodes transfer in the axillary area

  • Even the 20 years long elephantiasis, with chronic infections, can be improved (like in this case, 4 years after LNT)

    Even the 20 years long elephantiasis, with chronic infections, can be improved like in this case 4 years after LNT

    Even the 20 years long elephantiasis, with chronic infections, can be improved like in this case 4 years after LNT

  • Huge improvement of all the cases but never complete recovery

    Elephantiasis volume reduction

    Elephantiasis volume reduction is very significative 6 months after LNT

  • 98% improved, but never normalization. Infections decrease.

Benefits

Effect on infections

  • Reduction of chronic infections in 90% of the cases
  • Complete disappearance in 68%

Effect on pain

  • The pain appearing after adenomectomy can be solved after surgery if the nevroma are treated
  • The pain and diminution of sensibility in the plexopathies can be improved, but it depends of the lesions of the plexus. The gradual degeneration of the nerves is stopped, but never completely resolved
  • Tendon transfers can be achieved later to restore some functions of the arm

Potential Complications

  • Seroma at the donor sites diminished if compression
  • Slight temporary edema of donor site (0,001%)
  • Infections in 1%
  • Necrosis of the flap 2%

ALNT – Surgical technique in details

Click here for technical details about ALNT

Additional procedure: Liposculpture

  • In some cases, after 1 year, when the fluid disappears, some fat can be removed by local external liposculpture.
  • Temporary compression is applied for the 4 following weeks and then stopped

    External mini liposculpture

    External mini liposculpture

DIEP based on the deep inferior epigastric vessels including the nodes

DIEP based on the deep inferior epigastric vessels including the nodes

Breast reconstruction

The breast can be restored using different operative techniques at the same time as treating lymphedema.

The most common technique is the free transfer of the abdomen to the thorax with microanastomosis of the epigastric vessels on the internal mammary vessels or on branches of the thoracodorsal vessels.

Outcome of an anlarged DIEP on a patient who suffered lymphoedema for 20 years after a mastectomy

25 years after mastectomy and 20 years with lymphedema, then 8 months post enlarged DIEP

8 year and 10 year post-operative outcomes of ALNT combined with breast reconstrction by DIEP

Same results with enlarged ALNT combined with DIEP

Operative technique

Modified DIEP transplant with lymph nodes

Modified DIEP transplant with lymph nodes

The inguinal lymph nodes flap can be incorporated to the flap of the adjacent skin and fat on the lower part of the abdomen, based on the superficial inferior epigastric vessels (SIEA) or the deep inferior epigastric vessels (free TRAM or DIEP).

To harvest the nodes, we lower a little the incision of the abdominal flap, in the region of the iliac crest, going subcutaneous to include the fat containing the nodes vascularized by the circonflex iliac stalk.

If the microsurgical anastomosis of the flap are made to the internal mammary vessels, the lymph node extension should be harvested on the opposite side as the stalk.

If the flap is reattached at the thoracodorsal system, the nodes can be harvested on the same side.

The results can be spectacular, depending of age, radiotherapy and if nipple sparing technique had been achieved.

Postoperative Care & Physiotherapy

  • Hospitalization: 1 to 2 days
  • If the patient is still working, 2 weeks off are recommended
  • The patient is prepared for surgery to reduce the fibrosis
  • After the surgical procedure, manual drainages are immediately performed, combined with iterative bandaging if necessary. The frequency depends on the importance of the edema.
    After 3 months, 1 session every 2 or 3 days can be enough.
    In good cases, after 6 to 12 months, the patients are cured and can have a normal life without sleeves .
    The others can quit the sleeves also but need some physiotherapy.

Congenital Arm Lymphedema

Hypertrophic congenital lymphedema of the arm

Hypertrophic congenital lymphedema

Swollen hand and arm can happen at birth or during the first years of life.

An hypoplasy of the lymphatic vessels and nodes can be observed.

Diagnosis

The clinical examination and the lymphatic MRI are the best techniques to evaluate the lymphatic system. Isotopic lymphangioscintigraphy is only providing informations about a lack or delay of the drainage.

Treatment

  • Compression garments and manual drainages have to be performed immediately.
  • If there is no improvement, surgery will be the only solution: lymph nodes transfer in hypoplasic cases and lymphovenous anastomoses in hyperplasic cases.