Lymphedema after a mastectomy is an extremely difficult problem. The mainstay of treatment has been lymphatic massage and physical therapy. Lymphedema usually progresses over time and the tissues become more and more recalcitrant to physical therapy and massage. Because of the inadequate lymphatic flow, tissue that is lymphedematous is more at risk for infections. This sets up the extremity into a downward spiral as the remaining lymphatic vessels are further destroyed by subsequent nfections. This then causes further lymphatic obstruction and edema and causes a worsening of the inflammation and scarring process, which leads to further fibrosis of the extremity.
The only true way to treat this condition is to restore the lymphatic flow where the obstruction is sitting. Previously, this has been done by lymphovenous bypass procedures. They have been only moderately successful. This requires extremely delicate microvascular anastomoses to reconnect lymphatics to the veins so that the lymphatics have a channel to leave the swollen extremity.
A more novel approach and more anatomically correct operation would be to replace the lymphatic channels with lymph tissue, and lymph nodes to help re-create new lymphatic channels. This can be accomplished by lymph node transplantation with a vascularized skin flap. This is a cutting-edge operation and the worldwide literature is quite sparse. The preliminary findings after this operation have been extremely promising. There has been a dramatic decrease in the number of infections as well as a significant increase and the diameter of the extremity after this surgery. These results are far better than the previous lymphovenous bypass surgeries and represents a new paradigm in treating extremely difficult lymphedema. This operation will likely serve as a more permanent solution to an extremely difficult and debilitating problem.
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