Areas of Expertise:
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.
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.
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.
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?
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:
This should help guide the doctors who are treating your mother - as you say, many doctors don’t know very much about lymphoedema.
Why do some people have LVA surgery and some people have liposuction for their lymphoedema? And how should you choose a surgeon?
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!
What is the risk of developing Lymphedema after a lymphovenous anastamosis ? & what are the symptoms to watch out for? Anything to do for prevention?
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.