Ask Prof. Dominic Furniss

Areas of Expertise:

  • Surgical treatment of lymphoedema
  • Multiple Lymphaticovenular Anastomoses
  • Liposuction for Lymphoedema
  • Liposuction for Lipodema
  • Lymph node transplant
  • Diagnostic imaging of lymphoedema
  • Screening for patients at risk of lymphoedema

Bio:

Professor Furniss is an Associate Professor of Plastic Surgery at the University of Oxford. He studied medicine at Cambridge University and graduated with a first class degree. He then studied clinical medicine at the Oxford University Clinical School. His clinical interests are in supermicrosurgery for the treatment of lymphoedema and hand surgery. He has undertaken Fellowship training in Supermicrosurgery for Lymphoedema at the University of Tokyo, Japan, with Professor Isao Koshima and Dr Makoto Mihara. Professor Furniss has travelled to New York to undertake training in Vascularised Lymph Node Transfer, and Sweden to train in Liposuction for lymphoedema. He is a full member of the British Lymphology Society.

Professor Furniss has also secured a prestigious Wellcome Trust Intermediate Fellowship — the first awarded to a Plastic and Reconstructive Surgeon — to analyse the genetics of Dupuytren’s Disease, a very common, disabling condition where the fingers of the hand contract into the palm. Professor Furniss has written many papers for academic journals, presented work and lectured at both international and national conferences, and has written several book chapters.


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  1. SAPL surgery primary Lymphedema
    Question (Brenda, ):
    • I have primary lymphedema in both legs. I'm having SAPl surgery on right leg --my lymphedema is not really noticeable in my left leg--but I still maintain compression. Will having surgery on right leg improve the lymphatic system enough that the left leg may improve?

    Answer:
    • Sep 2020

      No, using liposuction does not reconstruct the lymphatic system, it does not improve the lymphatic system - it just physically removes the excess fat that accumulates in lymphoedema - so there is no chance of improvement in lymphatic function. Also, if an operation is on one leg, there will be no effect on a separate anatomical location (eg the other leg).

      I hope this is clear. Your surgeon should explain the difference between reconstructive options and reductive options for lymphoedema so that you are fully informed before giving your consent to undergo surgery.

  2. Preventing lymphedema
    Question (Isabelle, ):
    • Is there anything one can do or take to prevent lymphedema from happening before radiation for breast surgery? I read somewhere that one clinic had 1out of 10 patients suffering from lymphedema after radiation versus 1out of 3 in all other clinics/cancer treatments societies.

    Answer:
    • Jul 2020

      Hi!

      I am not aware of any studies that have been shown to prevent lymphoedema before having radiation therapy or breast surgery.

      However, there is some evidence that performing LVA surgery at the time of having an axillary dissection (removal of lymph glands from the armpit)  reduces the risk of lymphoedema from about 30% to about 5%: see

      https://olp.surgery/outcomes/evidence/

      Click on the link to Boccardo 2011

      Best wishes,
      Dominic

  3. Lymphedema diagnosis
    Question (Susan, ):
    • I had WLE and SLNB with removal of spatial paratiod gland with a total of 43 lymph nodes removed. On my left side of neck. I have 3C Melanoma. I had 1 year of Chemo. Could this of caused my lymphedema? Thank you

    Answer:
    • Jun 2020

      Hi Susan,
      Thanks for your question. Excision of lymph nodes can certainly cause lymphoedema. What I can’t tell from the information you have given is whether that is the case in you - you would really need to be assessed by a medical professional to confirm whether that is the case or not. Neck dissection (removal of the lymph glands from the neck area that you describe) can cause lymphoedema of the face / head, but doesn’t really cause swelling anywhere else.
      I hope this is helpful!
      Dominic

  4. lymphodema from lumbar fusion
    Question (brian, ):
    • Had L5S1 lumbar fusion in 2016, they went in from front-4 inches below naval and the back. I now have suspected Lymphodema, treating it that way. Early stage is what I was told, managing with compression. Can surgery help? Thanks, Brian

    Answer:
    • Jun 2020

      Hi Brian,

      Thanks for your question.

      The answer as to whether surgery might be helpful or not depends on a number of factors. Firstly, we would need to determine what the cause of the lymphoedema is. It is hard to know exactly what the cause of the lymphoedema is - could the surgery just be a coincidence?

      Secondly, what is the residual lymphatic function? If the lymphatics still have good function, then reconstructive microsurgery might be possible. If they have deteriorated in their function, reconstructive surgery might not be possible.

      The way to determine this is to have an ICG scan. This defines the lymphatic function within the legs to work out whether this is likely to be primary or secondary lymphoedema and also the level of residual function.

      For more details please see: https://olp.surgery/understanding-lymphoedema/icg-lymphography/

      We would be pleased to see you and assess you in our clinic.

      Best wishes,
      Dominic

  5. Lymphatic drainage before cancer surgery
    Question (Sadie, ):
    • I am caught in controversy from different health professionals about whether to have Manual lymphatic drainage before breast cancer surgery or not. Some say yes and others no because the MLD could cause the cancer to spread. Thoughts?

    Answer:
    • May 2020

      Hi!

      If you are talking about MLD on your arm, then there is no risk, either theoretical or with any clinical evidence, that MLD will spread your tumour. If the tumour was already spread to the tissues of your arm (which are the only ones that can be affected by massaging your arm), then that would be at extremely advanced disease already.

      If you are talking about MLD on your breast, then there might be a theoretical risk of “pushing” tumour cells from the primary tumour to the lymph nodes. I am not aware of any actual studies that have looked at this.

      I hope this is helpful.

      Dominic

  6. Lymphedema and Dupuytren’s disease in same hand
    Question (Shannon, ):
    • I have advancing Dupuytren's affecting left palm and pinky, has gotten much worse since diagnosis of left arm Lymphedema after lumpectomy/radiation for BC. Am I able to safely get injections Xiaflex to manage the dupuytren's? Going to hand surgeon soon, would appreciate any input before proceeding.

    Answer:
    • Apr 2020

      Hi, Great question! As it happens, this question encompasses my two great motivations in Medicine - lymphoedema and Dupuytren’s disease!

      Having lymphoedema should not prevent you getting treatment for DD or any hand condition. However, we know that patients with lymphoedema are at increased risk of infection after surgical interventions, and I would include Xiaflex in this. I would recommend that you have a single dose of antibiotics given by mouth around 60mins before your injection. If there is no skin split, this should be all you need. If there is a skin split when the cords are broken, I would recommend you take antibiotics until the skin is healed.
      If you go for open surgery, a 5 day course of antibiotics is appropriate to cover the surgery

      Good luck with your treatment!

  7. Icg vs lymphoscintigraphy
    Question (Shrinjoy , ):
    • If Indocyanine Green Lymphography is considered superior to lymphoscintigraphy, why not replace icg over lymphoscintigraphy as the gold standard protocol for the diagnosis of lymphedema???

    Answer:
    • Jan 2020

      Hi!
      I agree overall, but lymphoscintigraphy does have its place. Sometimes the functional lymphatics are buried slightly deeper in the subcutaneous fat, especially in advanced lymphoedema or obesity. As the camera in ICG can only detect fluorescence down to around 2cm beneath the skin, the radioactive lymphoscintigraphy can be useful.

  8. Carpal tunnel surgery increase risk of lymphedema? Lymph node removal 2 years ago
    Question (Catharine, ):
    • 2 years ago had lumpectomy and 2 nodes removed, left side. 3 months ago cording in underarm, disappeared after a week. Does carpal tunnel surgery (scheduled for left hand in 10 days; symptoms both hands for years, right successfully operated last month) increase risk of lymphedema? Any preventative measures?

    Answer:
    • Jan 2020

      Hi!
      No, having a carpal tunnel decompression will not increase your chance of getting lymphoedema. I hope your operation is a success.

  9. use of blue dye instead of ICG
    Question (ahmed, ):
    • Dear Dr Why do you use ICG instead of methylene blue in visualization of Lymphatic disorder I. e. what are disadvantages of blue dye? Sincerely

    Answer:
    • Jan 2020

      Hello! They are completely different and used for different purposes.

      ICG is a diagnostic and pre-operative planning technique. It is injected into the limb, and then visualised through the skin with an infrared camera. This will diagnose lymphoedema, and can show the location of functioning lymphatics for planning surgical incisions. It doesn’t colour the lymphatics, so can’t be seen during the operation.

      Patent blue (not methylene blue) is injected during the operation. It is bright blue coloured, and gets taken up into the lymphatics, and allows us to visually see the lymphatics during the operation. It is not visible through the skin, so would be useless in the outpatient clinic.

  10. Lymphedema after mastectomy - problems
    Question (Anni, ):
    • Hello! My mom had a mastectomy a year ago (without reconstruction) and she has developed a lymphoedema in the area where the breast was. Doctors punctured it every two weeks and now the fluids have gone from yellow to dark bloody. Doctors don't know why. Need help! Thank you!

    Answer:
    • Nov 2019

      Hi,
      This is not lymphoedema. What your mum had sounds like a seroma. She needs to discuss this with her breast surgeon and oncologist.
      Best of luck.

  11. Sluggish lymphatics
    Question (Katie , ):
    • Hi there, My lymphadema nurse has told me a sluggish lymphatic system can recover, is this correct? Thanks

    Answer:
    • Oct 2019

      Hi! That is a great question. There are two parts to the answer: firstly, how have your sluggish lymphatics been diagnosed? Have you had ICG lymphography or lymphoscintigraphy? If not, they may not be sluggish at all.
      Second: if you have damaged lymphatic leading to secondary lymphoedema, then the pressure inside the lymphatic is increased. This leads to secondary changes in the structure of the wall of the lymphatics, which then lose their pumping function, leading to further progression of the lymphoedema. This vicious cycle is why lymphoedema tends to be progressive. The only way to break this downward spiral is LVA surgery which can decompress the system, stopping the degeneration of the lymphatics.

  12. Facial LE
    Question (Katie , ):
    • Is there any surgery available to improve primary facial lymphedema

    Answer:
    • Sep 2019

      Thank-you for your question! I have not come across primary facial lymphoedema previously. We have successfully used LVA to treat people with secondary lymphoedema (usually caused by having bilateral neck dissection and radiotherapy for head and neck cancer).

  13. Risk & avoidance
    Question (Debbie, ):
    • I just had 10 nodes removed as part of a mastectomy. I will require radiation. After radiation, what is my risk for developing lymphedema? And, besides avoiding constriction and injury in that arm, is there anything I can do to reduce the risk of lymphedema? Like exercises, prophylactic compression, etc.

    Answer:
    • Jul 2019

      Great question! There is no way of precisely estimating your risk, as it depends on lots of factors, but it is clear that you will be at high risk of developing lymphoedema.

      There is a nice systematic review written in the Lancet Oncology (a really high quality medical journal) in 2013 (https://www.sciencedirect.com/science/article/pii/S1470204513700767?via=ihub).

      This looked at the risk factors for developing lymphoedema after breast cancer treatment. It showed that around 21% of women get lymphoedema overall, and the risks were increased by having a mastectomy, and an axillary clearance with a greater number of lymph nodes removed, and if more of those nodes were positive for cancer. Post-operative chemotherapy and radiotherapy were also associated with higher risk. The other major factor was obesity, which was strongly correlated with developing lymphoedema.

      Prevention: There are no non-surgical interventions that have been shown to reduce the risk of developing lymphoedema. Massage, wearing compression, exercising or not exercising, tapes etc do not prevent lymphoedema.

      This was shown in a Cochrane Review (the highest quality review of all of the medical literature) - https://www.cochrane.org/CD009765/BREASTCA_interventions-for-preventing-lymphoedema-swelling-of-the-arm-after-breast-cancer-treatment

      It would, however, be sensible to keep control of weight, so that your BMI is <25.

      What about surgery? There is evidence that using reconstructive supermicrosurgery (LVA) can decrease the development of lymphoedema after breast cancer treatment.

      My recommendation would be to undertake screening with ICG lymphography (see:  http://olp.surgery/screening.php) to detect the earliest signs of lymphoedema and then choose an intervention if it develops. This intervention could be LVA surgery, but some patients don’t want an operation, so they choose non-surgical treatment such as compression sleeve.

  14. Lypmhedema wounds and ulcers
    Question (Lilas , ):
    • mum has been suffering from lyphedema for more than 5 years in both legs, we live in Egypt and the doctors here are not very familiar with this disease, the problem her lymphedema causes cellulitis a lot, she always has open wounds, deep ulcers and suffers from fever, what canwedo?

    Answer:
    • Apr 2019

      Thank-you for asking this question. It is a difficult problem, especially when you live in such a hot country. The most important thing will be for your mum to be seen by a qualified lymphoedema practitioner, who can do bandaging to get the swelling down, and then prescribe regular compression garments to keep the swelling down. This will help with the leaking and the ulcers.

      In addition, because she is getting regular attacks of cellulitis, she should be taking regular antibiotics as a preventative (prophylactic) measure. In the UK, we have guidelines for the treatment of cellulitis in lymphoedema, including prophylactic antibiotics. A copy of the guidelines can be found here:

      https://www.lymphoedema.org/images/pdf/CellulitisConsensus.pdf

      This should help guide the doctors who are treating your mother - as you say, many doctors don’t know very much about lymphoedema.

  15. LVA surgery and liposuction
    Question (Antonia, ):
    • Why do some people have LVA surgery and some people have liposuction for their lymphoedema? And how should you choose a surgeon?

    Answer:
    • Mar 2019

      Thank-you for your question - it is a really important one! I am going to answer its from the point of view of secondary lymphoedema (lymphoedema usually caused by a doctor treating cancer by surgery or radiotherapy). If anyone wants to know about primary lymphoedema, go ahead and ask another question!

      I think to really understand the answer to this question, we first need to understand about why lymphoedema happens in the first place. Blood is taken into your arm (or leg, but for this answer I will just use arm) by an artery, and drains out by veins. In between the two are tiny, microscopic capillaries. As the blood flows through the capillaries, some fluid leaks out and bathes all of your cells. This fluid has come from the bloodstream, and has to find its way back into the bloodstream - that is where the lymphatic system comes in! It also has tiny capillaries that take up the fluid ad pump it to larger and larger lymphatic vessels (a bit like the branches of a tree coming together to form a trunk). Eventually, it finds its way to larger (about 0.5mm!) channels that run up the arm, through the armpit, and drain the fluid back into the circulation deep inside the neck.

      Now, if someone has had their lymph glands in their armpit (or groin/pelvis is the leg is the problem) removed, or treated with radiotherapy, there is now a blockage in that drainage system, so the fluid builds up - lymphoedema. Because the lymphatic channels are now pumping fluid against higher pressure, the muscles in the walls get bigger, and the walls become scarred, so eventually the pumping mechanism fails. This is why lymphoedema progresses over time.

      One more thing! The fluid that builds up contains proteins and growth factors, and over a period of time causes the normal fat in the arm to grow, and excess fat to be deposited. This means that some lymphoedema is mainly fluid, some is mainly fat, and some is a mixture of the two.

      OK, back to the question! LVA surgery (Lymphaticovenular anastomosis), is a kind of delicate plumbing operation. Under local anaesthesia, we make small incisions in the arm, find the lymphatic channels (0.5mm) and some tiny veins and suture the lymphatics into the veins. This means that the fluid no longer has to be forced past a blockage in order to get back to the bloodstream, its gets directly back into the bloodstream in the arm. This decompresses the system, and reduces the swelling.

      However, it can only work if the lymphatics are still pumping well (not too scarred), and the swelling is mainly fluid, not fat. It therefore needs to be done as soon as possible after developing lymphoedema. In fact, we have developed a lymphoedema screening programme to detect it as early as possible after cancer treatment. I have seen several patients who have had this done early, and no longer have any swelling, and no longer have to wear any compression.

      So, what about patients whose lymphatics are no longer working well, or who have mainly fat rather than fluid? These patients tend to have had lymphoedema for longer, and be more severely affected. For them, the best operation is liposuction for lymphoedema. This accepts that reconstruction of the lymphatics is no longer possible, and aims instead to treat the consequences and improve quality of life. Under a general anaesthetic, we use special liposuction cannula to remove all of the excess fatty tissue from the arm through tiny incisions (around 5mm). The amount of fat to remove is calculated based on the size of the normal arm. The patient is then placed immediately into a compression sleeve that they wear day and night. This is a really good operation, as patients who need to wear compression anyway, can now do so with a normal sized arm.

      How should you choose a surgeon? This is another very good question. Firstly, your surgeon should be a fully qualified Plastic Surgeon (have the FRCS(Plast) in the UK, or be Board Certified in the USA). Secondly, they should have a substantial commitment to lymphoedema surgery - these operations are not to be undertaken by the ‘occasional’ lymphoedema surgeon, they need specialist training and equipment. Thirdly, they should be specially trained - for LVA surgery, they should have been to Japan to work with Prof Koshima, Dr Mihara, or Dr Yammamoto. For liposuction, they should have trained with Prof Brorson in Sweden. Ask your surgeon who they trained with and how long they have been doing lymphoedema surgery for. Finally, lymphoedema surgery is a team effort, especially liposuction. Your surgeon should have a therapist who works closely with them and is responsible for the intensive aftercare required.

      I hope this answers your questions!

  16. Lymphedema after lymphovenous anastamosis
    Question (Claudia, ):
    • What is the risk of developing Lymphedema after a lymphovenous anastamosis ? & what are the symptoms to watch out for? Anything to do for prevention?

    Answer:
    • Mar 2019

      Thanks for this question! Lymphovenous anastomosis surgery (LVA for short) is a technique used tot treat lymphoedema, usually in the early stages of the disease (up to stage 2a).

      The lymphatic fluid is formed from the blood when it passes through the capillaries of the arm or leg. This fluid usually recirculates through the lymphatic system back into the blood stream at a vein in the neck. When this re-circulation is blocked - for example by surgery or radiotherapy to the lymph glands in the armpit or groin - the fluid backs up causing lymphoedema. LVA creates a bypass around that blockage by stitching the lymphatics into veins in the arm or the leg. This surgery is highly technically demanding (the lymphatics are only around 0.5mm in diameter) and requires specialist training and experience. If you want to see a video of an LVA (not too graphic!), please click here: https://vimeo.com/133984132

      As you can see, LVA is designed to treat lymphoedema. However, sometimes LVA surgery doesn’t work, and in that case, lymphoedema can progress. For a nice video explaining why lymphoedema progresses over time please click here: https://vimeo.com/316799941

      The symptoms of lymphoedema are well known - swelling is the key. This swelling is usually transient initially, going down overnight, but can become permanent, and can also be replaced by fatty deposits.

      The best way of preventing lymphoedema is by using LVA at the time of surgery to remove lymph nodes. This has been proven to be effective in a randomised controlled trial of surgery versus no surgery. The scientific paper can be viewed here: https://olp.surgery/perch/resources/boccardo-et-al-2011.pdf

      I hope this answers your questions! If you need more clarification, please do get back in touch.

  17. Test for Prof. Furniss
    Question (, ):
    • Test question.

    Answer:
    • Feb 2019

      Test successful!