Lymphedema is a side effect of cancer treatment that can cause swelling in the arms and legs. It happens when lymphatic fluid doesn’t drain properly from the limbs. That may be because nearby lymph nodes were removed to look for the spread of cancer or the lymphatic system itself was damaged during radiation therapy or other cancer treatments.
To learn more about the surgical options that can help relieve lymphedema, we talked with plastic surgeon Edward Chang, M.D.
Why is lymphedema such a problem?
For one thing, it can really impact patients’ quality of life. Many report feeling a heaviness or a tightness in the affected limbs that’s very uncomfortable. It can also be upsetting not to be able to wear your wedding ring or a wristwatch because your fingers or forearms are swollen. In some cases, patients might have trouble finding clothing that fits, because one arm or leg is so much bigger than the other. They may also have problems walking, holding a coffee cup or using a pen.
The other concern is that lymphedema gets worse over time, and can lead to permanent damage if left untreated. When lymphatic fluid doesn’t drain properly, it starts backing up and leaking out of the vessels into the surrounding tissues. That can trigger an inflammatory response in the body, which sometimes results in the buildup of scar tissue. And that, in turn, may cause lymphedema to progress. So, it becomes a vicious cycle.
How can surgery relieve lymphedema?
At its core, lymphedema is a plumbing issue. Surgery helps us restore the connection that allows fluid to drain properly from patients’ extremities. We do this in one of two ways:
Lymphovenous bypass surgery: surgeons “go around” blockages by rerouting functional lymphatic vessels into healthy blood vessels, allowing them to drain back into the bloodstream
Vascularized lymph node transfer: surgeons transfer healthy and functional lymph nodes from one area of the body to another and reconnect them in the new location
How do surgeons decide which procedure to use?
That really depends on the patient and their individual situation. We have discovered, though, that when we combine a bypass with a transfer, we’re often able to achieve much better results than if we did one or the other by itself.
How do you decide where to take donor lymph nodes from for the transfer procedure?
Obviously, we don’t want to cause lymphedema in a new location in order to treat it in its original one. But it turns out we can take lymph nodes from a number of different locations without doing any harm:
Inguinal (in the groin area)
Supraclavicular (above the collar bone)
Submental (beneath the jaw)
Omentum/gastroepiploic (around the abdomen)
There are advantages and disadvantages to each one, of course, but it’s really up to the patient, once the surgeon lays out their options. Scars are going to be more visible in certain locations, so that’s a consideration, but we feel like they’re all equally effective in terms of function. And that’s important, because not every patient is going to be a candidate for every donor site.
How soon can patients expect to see improvement in lymphedema symptoms after having these procedures done?
With a bypass, the effect is almost immediate. The backed-up fluid is usually under pretty high pressure, so it starts to drain immediately. Patients can sometimes see a difference the very next day. They may notice more wrinkles on their hand, for instance, or more definition in the tendons on their feet.
With a transfer, it usually takes about a year to reap the full benefits. That’s because it takes time for the transferred lymph nodes to grow more vessels to help absorb the fluid. It’s like planting a seed. You have to give it ample time to grow.
That’s another reason we like to do both of these at once. Combining procedures offers patients the most potential for improvement. Often, they will see an immediate effect from the bypass, and then a second wave of improvement about a year later from the transfer.
Can lymphedema be made worse by a failed bypass or caused in a new location?
Yes, though I can’t think of a single patient whose lymphedema got worse after a transfer at MD Anderson. Our surgeons are very cautious. You can’t just go in there willy-nilly and harvest lymph nodes from anywhere.
In fact, one donor site that I won’t even consider anymore is the side of the chest. That’s because it’s very close to the lymph nodes that are often removed during breast cancer surgery. Early studies showed that lymph nodes taken from that location came with the highest risk of complications. So, I don’t offer that option anymore. I think the risks are too great.
Are either of these procedures ever used to prevent lymphedema?
Yes. We sometimes use a process called axillary reverse mapping in conjunction with a bypass during breast surgery. The goal is to prevent lymphedema in the arm by proactively connecting healthy lymph vessels to veins in the axilla (armpit).
We also sometimes do prophylactic lymph node transfers when we’re using the patient’s own tissue to reconstruct their breast. If we take the lymph nodes from the groin area, it doesn’t add any additional time to the surgery, and it doesn’t prolong the patient’s recovery period at all.
How can I find out if I’m eligible for one of these surgical procedures?
Talk to your doctor. Anyone who is experiencing lymphedema should at least consider having one of these procedures done if they’re eligible.
We can’t cure lymphedema once it’s started, but we can definitely offer some improvement. And patients will get much better results if they do it sooner rather than later, once the condition is more advanced.