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 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.
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.
Outcomes of LNT
- 40% definitive normalization
- 98% improvement
- 2% without results
- No worsening of the lymphedema
- 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)
- Huge improvement of all the cases but never complete recovery
- 98% improved, but never normalization. Infections decrease.
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
- 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
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.
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
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.
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.
- 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.