Thanks for your question Liza. Glad our surgery worked great on the forearm!

The upper arm can be more difficult, especially if you have had an LD flap surgery. Also, swelling above the elbow tends to be more fatty than fluid, so LVA may not be so appropriate.

We would be happy to discuss this with you in clinic, and think about an MRI scan if you wanted to look into it further.

Hi,
I am pleased you have found a diagnosis. Unfortunately, NICE has said that surgery should only be performed by surgeons in the UK if it is part of a research trial, or a National Registry. There are no trials and no Registry currently. Therefore anyone offering surgery is doing so against NICE guidance, which reputable surgeons would not do.
There are some excellent surgeons in Germany if you are willing to travel. Our admin team at Oxford Lymphoedema Practice can provide a recommended name.
Best of luck,
Dominic

Thanks for your question.

LVA surgery relies on the lymphatic capillaries absorbing fluid and passing it down to the lymphatic channels, and then those channels in the leg working well, and being able to transport lymphatic fluid efficiently.

In secondary lymphoedema (post cancer treatment, most commonly), these capillaries and channels are working well, and the problem is in the lymph nodes (removed by surgery, or fibrosed by radiotherapy, usually).

In primary lymphoedema, particularly when swelling starts in the foot and ankle, the problem is usually with either the lymphatic capillaries (meaning fluid can’t get into the lymphatic channels), or in the lymphatic channels themselves. This means that LVA surgery is not usually possible.

There is one rare form of primary lymphoedema called inguinal node sclerosis where the problem is scarring in the lymph nodes. Here, the capillaries and channels are all working well (it is very similar to secondary lymphoedema), and LVA surgery to bypass the problem in the groin lymph nodes is a good option. This form of primary lymphoedema is unusual (I estimate around 1 in 20 cases of primary lymphoedema). The swelling usually starts in the groin, and spreads down the thigh to the knee, and eventually to the calf and ankle.

The best way to know for sure whether you are suitable for LVA surgery is to have an ICG lymphography scan.

Hi,
SAPL is done for patients whose lymphatic function is not reconstructable. This means that the lymphatic function cannot be worsened by the surgery.
Doing SAPL after LVA or VLNT risks damaging the reconstruction, or leaving a strip where SAPL isn’t done, and therefore a ridge inside the arm or leg.
Doing LVA after SAPL may well not be possible (as the lymphatics weren’t functional beforehand, why would they be afterwards.
VLNT after SAPL is possibly, and Dr Graznow in California claims good results.
Hope that helps.

Hello,
It sounds like you would be a candidate for either Lympho-venous anastomosis surgery, or possibly lymph node transfer. For more information and to request an appointment please visits http://www.OLP.surgery

I am afraid I do not know what BodyCombat is. Before re-starting exercise following surgery and radiotherapy, you should consult your treating physicians.

Thank you for your question. Lipedema is a really poor name for the condition, as there is no edema (fluid excess) associated with it, and normal lymphatic function. Lipedema is a condition of abnormal fat deposition.

The first thing to do is make sure that the diagnosis is accurate, from a clinician experienced in lipedema. It is especially important to differentiate from obesity, where the treatment is very different.

If the diagnosis is lipedema, then I agree, the only treatment that is effective is liposuction - this needs careful planning with an experienced surgeon, anaesthetic team, and lymphoedema practitioner to control the postoperative swelling for 6-12 months after the procedure.

Venous insufficiency has no impact on Lipoedema, which is an abnormal deposition of fat. Treatment of VV’s will therefore not change the Lipoedema.

Hi,
This is a difficult issue. The best way to resolve this is to have a thorough evaluation. I would recommend an ICG lymphography scan as well as an MRI to quantify the amount of fluid versus fat in the area that is affected. This will allow an estimate of the degree of swelling, and the amount of lymphatic dysfunction. It would give you the maximum information before planning any treatment (which may well be non-surgical).

Hi! Great question.

The main lymphatics draining the foot run up the medial side of the knee and through the thigh quite close to the long saphenous vein. We have seen a couple of patients who have developed secondary lymphoedema after having endoluminous treatment of long saphenous varicose veins. This must be put in context of probably thousands of people having this treatment every year.

If your problem is truly primary lymphoedema (ie diagnosed by lymphoscintigraphy or ICG lymphography), then unfortunately I can’t see that treating the veins would improve the swelling. If there is a venous element to the swelling, then it might improve things.

Good luck with your treatment.

Hi, This is a good question, but not really relating to surgical management of lymphoedema. Can I suggest you ask another expert on the forum who is a specialist in the non-surgical management of lymphoedema?

Yes of course. The best way to get a comprehensive assessment is to book in for a clinic appointment. Please email .(JavaScript must be enabled to view this email address) or see our website for other contact options, and the team will be delighted to help.

This is a great question, and with the Covid pandemic people are rightly more focussed on their wellbeing, and preserving their quality of life for the future. Early reconstructive microsurgery can indeed do this by reducing the risk of infection, which of course worsens the progression of lymphoedema.

Lymphoedema surgery is not generally funded on the NHS in the UK. To find out if anyone can do this locally, you should speak to the surgeon who operated on you (assuming your lymphoedema is secondary). You could also come for an assessment at Oxford Lymphoedema Practice to see if you would be suitable for reconstructive microsurgery (LVA or VLNT - LVA being as effective but much more minimally invasive), so that you know if the options are worth pursuing.

Thanks for your question! As Prof Brorson says: “If you want to climb Mount Everest, you can!”  The message is that the only restrictions are what your body restricts you from doing. Swimming pools might not want you to use their facilities until wounds are healed (2-3 weeks), but other exercise is fine. In practice, our patients don’t get back to proper exercise until 4-6 weeks after surgery.
I hope this is helpful!

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.

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

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

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

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

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!

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.

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

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.

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.

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.

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).

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.

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.

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!

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.

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