LYMPHEDEMA PROGRAM -DEPARTMENT OF PLASTIC ,COSMETIC, RECONSTRUCTIVE MICROSURGERY

We have designed a Lymphedema program to provide a comprehensive solution for all lymphatic related problems.

We at the department of Plastic surgery have collaborated with other departments and devised a wholesome care program which is equipped with the latest technology to establish a diagnosis, stage the disease, devise a patient specific care plan and offer surgical solutions when needed.

OUR TEAM COMPOSITION AND INDIVIDUAL ROLE AND RESPONSIBILITY:

Department of Plastic surgery -Be a team leader and coordinate between various departments to strategise patient specific care plan and provide surgical solutions when required. Major role in analysis of extent of problem: To diagnose extent of tissue excess vs fluid excess.

Department of Physiotherapy- Provide intensive phase care to reduce lymphedema conservatively.Provide , Teach and Monitor the maintainance phase of Lymphedema

Department of Oncology- (Breast cancers axillary dissection ,Gynaec cancers-groin dissection) To predict and prevent the possibility of lymphedema in a patient in whom lymph node resection and or radiotherapy of axilla or groin is done.

Department of Radiology- Diagnostic work up to Stage the disease and monitor the care

Department of nuclear medicine- Lymphoscintigraphy

Department of Internal Medicine- To rule out and treat Secondary causes of Lymphedema

Home Care providers-To spread the outreach to patients in remote areas.

Department of Psychology- To help the patient and relatives cope with the difficulties associated with morbidity and prolonged care.

OUR APPROACH:

• To Prevent Lymphedema when possible by early intervention
• To Establish correct diagnosis in a Lymphedema Patient
• To Cure Lymphedema when detected in early stages.
• To reduce morbidity of Lymphedema when detected in late stages
• To give maximum possible benefit to patients at whatever stage they approach
• To encourage research in the field of lymphedema
• To spread awareness regarding lymphedema and its treatment

WHY CHOOSE US FOR LYMPHEDEMA CARE

AT OUR CENTRE TREATMENT IS TAILORED TO MEET THE NEEDS OF INDIVIDUAL PATIENTS IRRESPECTIVE OF WHATEVER STAGE OF DISEASE THEY ARE IN.

WE HAVE STATE OF ART TECHNOLOGY TO ESTABLISH PRECISE DIAGNOSIS AND VISUALISE THE LYMPHATICS UNDER HIGH MAGNIFICATION

Collaborative approach between experts in multiple fields, including plastic, reconstructive and microvascular surgery ,internal medicine, oncology, radiology, physiotherapy, psychologist and home care team to provide a thorough treatment plan and help in the compliance with the care provided

Advanced treatment options

Robust support services including nurse coordinators to help the patient learn care at home and a good follow up care plan.

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INTRODUCTION OF DISEASE

Lymphedema, also known as lymphoedema and lymphatic edema, is a condition of localized fluid retention and tissue swelling caused by a compromised lymphatic system, which normally returns interstitial fluid to the bloodstream. The condition is most frequently a complication of cancer treatment or parasitic infections, but it can also be seen in a number of genetic disorders. Tissues with lymphedema are at high risk of infection. A number of treatments can ameliorate symptoms.

What Happens in lymphedema.

The lymphatic system is part of your immune system. It moves fluid through your body, picking up waste, bacteria, and viruses. Your lymph nodes filter out the waste and flush it from your body. When something goes wrong, the fluid backs up in your tissue. Most often, lymph nodes get damaged. Sometimes the vessels get blocked. Lymph fluid buildup can worsen over time and cause thickening of tissues, fat accumulation, and lead to infection, so it’s important to get treatment.

LYMPHEDEMA SYMPTOMS – WHEN TO SUSPECT LYMPHEDEMA

It can happen anywhere in your body, including your chest, head, and genitals, but it's usually in just one arm or leg. The swelling might be so minor that you barely notice, or so severe it makes it hard to move that part of your body well. Lymphedema symptoms often begins at the furthest part of the limb, such as the hands, wrists, feet, or ankles and include

• Swelling of part or all of your arm or leg, including fingers or toes
• A feeling of heaviness or tightness
• Restricted range of motion
• Aching or discomfort
• Recurring infections
• Hardening and thickening of the skin (fibrosis)

Causes of Lymphedema

Lymphedema can be either primary or secondary. This means it can occur on its own (primary lymphedema), or it can be caused by another disease or condition (secondary lymphedema). Secondary lymphedema is far more common than primary lymphedema.

Causes of secondary lymphedema

Any condition or procedure that damages your lymph nodes or lymph vessels can cause lymphedema. Causes include:

• Surgery. Removal of or injury to lymph nodes and lymph vessels may result in lymphedema. For example, lymph nodes may be removed to check for spread of breast cancer.
• Radiation treatment for cancer. Radiation can cause scarring and inflammation of your lymph nodes or lymph vessels.
• Cancer. If cancer cells block lymphatic vessels, lymphedema may result. For instance, a tumor growing near a lymph node or lymph vessel could enlarge enough to block the flow of the lymph fluid.
• Infection. An infection of the lymph nodes or parasites can restrict the flow of lymph fluid. Infection-related lymphedema is most common in tropical and subtropical regions .Filariasis is the most common infection causing lymphedema
• Trauma- If there is circumferential loss of skin and subcutaneous tissue then the distal part develops lymphedema.
• Cardiovascular disease: People with cardiovascular diseases, like deep vein thrombosis or varicose veins, may have a higher risk of developing lymphedema.

Causes of primary lymphedema

Primary lymphedema is a rare, inherited condition caused by problems with the development of lymph vessels in your body. Specific causes of primary lymphedema include:

• Milroy's disease (congenital lymphedema). This disorder begins in infancy and causes lymph nodes to form abnormally.
• Meige's disease (lymphedema praecox). This disorder often causes lymphedema around puberty or during pregnancy, though it can occur later, until age 35.
• Late-onset lymphedema (lymphedema tarda). This occurs rarely and usually begins after age 35.

Risk factors

Factors that may increase your risk of developing lymphedema after cancer, from cancer treatment or from other secondary causes include:

• Older age
• Excess weight or obesity
• Rheumatoid or psoriatic arthritis

Complications

Lymphedema in your arm or leg can lead to serious complications, such as:

• Infections. Possible infections that can result from lymphedema include a serious bacterial infection of the skin (cellulitis) and an infection of the lymph vessels (lymphangitis). The smallest injury to your arm or leg can be an entry point for infection.
• Lymphangiosarcoma. This rare form of soft tissue cancer can result from the most-severe cases of untreated lymphedema. Possible signs of lymphangiosarcoma include blue-red or purple marks on the skin.

prevention of lymphedema

Rest your arm or leg while recovering. After cancer treatment, exercise and stretching are encouraged. But avoid strenuous activity until you've recovered from surgery or radiation

Prevention of complications of lymphedema

• Protect your arm or leg. Avoid injury to your affected limb. Cuts, scrapes,drawing blood samples and burns can invite infection. ..
• Avoid heat on your arm or leg. Don't apply ice or heat, such as with a heating pad, to your affected limb. Also, protect your affected limb from extreme cold.
• Elevate your arm or leg. Whenever possible, elevate your affected limb above the level of your heart.
• Avoid tight clothing. Avoid anything that could constrict your arm or leg, such as tightfitting clothing and, in the case of your arm, blood pressure cuffs. Ask that your blood pressure be taken in your other arm.
• Keep your arm or leg clean. Make skin and nail care high priorities. Inspect the skin on your arm or leg daily, watching for changes or breaks in your skin that could lead to infection. Don't go barefoot.

STAGING LYMPHEDEMA

We use the lymphedema staging classification developed by the International Society of Lymphology. In early-stage lymphedema (Stages 0–2), the condition may be reversible if detected and treated early. The earlier you get medical intervention, the better the outcome will be.

Stage 0: You may notice a heavy feeling in the affected area but not see any physical changes.

Stage 1:

• The limb becomes enlarged or swollen.
• Swelling improves at night and worsens during the day.
• Elevating your limb helps temporarily reduce swelling.
• If you push your finger on the affected area, it leaves an indentation. This type of swelling is known as pitting edema and results from fluid collection.

Stage 2:

• Pitting subsides, and the skin takes on a sponge-like appearance.
• The swelling no longer changes from morning to night, and elevation does not help. This problem happens because the swelling is no longer from fluid, but from the formation of scar tissue.

Stage 3:

• The skin is dry and flaky.
• Fluid-filled blisters may form, which can increase the chance of infection.
• The swollen, heavy limb may become difficult to move, affecting normal function and activities.

American Society of Lymphology staging system helps to identify the severity of lymphedema. With the assistance of medical imaging apparatus, such as MRI or CT, staging can be established by the physician, and therapeutic or medical interventions may be applied:

• Stage 0:The lymphatic vessels have sustained some damage that is not yet apparent. Transport capacity is sufficient for the amount of lymph being removed. Lymphedema is not present.
• Stage 1 :Swelling increases during the day and disappears overnight as the patient lies flat in bed. Tissue is still at the pitting stage: when pressed by the fingertips, the affected area indents and reverses with elevation. Usually upon waking in the morning, the limb or affected area is normal or almost normal in size. Treatment is not necessarily required at this point.
• Stage 2: Swelling is not reversible overnight, and does not disappear without proper management. The tissue now has a spongy consistency and is considered non-pitting: when pressed by the fingertips, the affected area bounces back without indentation. Fibrosis found in Stage 2 lymphedema marks the beginning of the hardening of the limbs and increasing size.
• Stage 3: Swelling is irreversible and usually the limb(s) or affected area become increasingly large. The tissue is hard (fibrotic) and unresponsive; some patients consider undergoing reconstructive surgery, called "debulking". This remains controversial, however, since the risks may outweigh the benefits and the further damage done to the lymphatic system may in fact make the lymphedema worse.
• Stage 4: The size and circumference of the affected limb(s) become noticeably large. Bumps, lumps, or protusions (also called knobs) on the skin begin to appear.
• Stage 5: The affected limb(s) become grossly large; one or more deep skin folds is prevalent among patients in this stage.
• Stage 6: Knobs of small elongated or small rounded sizes cluster together, giving mossy-like shapes on the limb. Mobility of the patient becomes increasingly difficult.

ESTABLISHING A DIAGNOSIS

Diagnostic Tests for Lymphedema Accurate diagnosis and grading are fundamental to successful treatment extremity lymphedema patients. The new Taiwan Lymphoscintigraphy Staging is a reliable approach for the assessment of lymphatic obstruction and is significantly correlated with Cheng’s Lymphedema Grading, which could be applied to guide appropriate effective treatment for unilateral extremity lymphedema

Diagnosis

Accurate diagnosis and staging are fundamental to the management of lymphedema patients.[18] A swollen limb can result from different conditions that require different treatments. Diagnosis of lymphedema is currently based on history, physical exam, limb measurements, and imaging studies such as lymphoscintigraphy and indocyanine green lymphography.

We evaluate your symptoms, take girth measurements and volume assessment. If required we may use diagnostic tests to confirm it. These tests include:

• Lymphatic mapping using Fluoptics: We inject a fluorescent dye into the webspace of your hand or foot. Infrared imaging allows us to visualize your superficial lymphatic system in real time.
• Lympho-MRI: This detailed imaging study provides a look at the entire lymphatic system and aids in planning management.
• Lymphoscintigraphy: We inject a small, safe amount of a radioactive substance iinto the web space of your hand or foot. A special imaging device can detect the gamma rays created by the substance, which helps us identify lymphedema in its earliest stage.
• Venous duplex: An ultrasound of the veins is done to rule out blood clots and check the function of the blood vessel valves. Venous hypertension can exacerbate the lymphedema.

Treatment

Treatment focuses on reducing the swelling and controlling the pain, preventing the complications and maintaining the reduction achieved. Lymphedema treatments include:

Nonsurgical Treatment for Early-Stage Lymphedema:

WE GIVE INTENSIVE CARE FOR 6 WEEKS FOLLOWED BY MAINTAINANCE CARE FOR WHICH PATIENTS ARE TRAINED TO PRACTISE AT HOME. DURING THE INTENSIVE PHASE WE PREFER ADMITTING PATIENTS FOR 2-3 DAYS TILL THEY UNDERSTAND AND ACCLIMATISE THEMSELVES FOR THE CARE PROTOCOL

THE ENTIRE PROTOCOL OF self CARE INCLUDES:

• Physiotherapy: THIS IS INITIATED BY Physical therapists who specialize in treating lymphedema using manual lymphatic drainage, a massage technique that can reduce swelling. This gentle therapy moves excess fluid to areas where the lymphatic system is working, for proper drainage. The patients and attendants are trained and gradually encouraged to manually drain the excess fluids.
• Exercises. Light exercises in which you move your affected limb to encourage lymph fluid drainage. Exercises should focus on gentle contraction of the muscles in your arm or leg
• DYNAMIC COMPRESSION THERAPY-A sleeve worn over your affected arm or leg connects to a pump that intermittently inflates the sleeve, putting pressure on your limb and moving lymph fluid away from your fingers or toes. – The pressure settings are adjusted to mimic gentle massage to activate the lymph pump and return of lymphatic fluid to venous circulation.
• BANDAGING- IN THE INITIAL INTENSIVE PHASE 4 layer bandaging is done to achieve maximum reduction in girth of limb, followed by compression garment .The bandage should be tightest around your fingers or toes and loosen as it moves up your arm or leg.

Surgical Treatment for Early-Stage Lymphedema

Based on diagnostic tests, when indicated we discuss the surgical options with you, including:

• Lymphovenous bypass: In this minimally invasive procedure, we connect healthy lymph vessels to venules to reduce swelling by rerouting drainage around obstructed vessels.

Lymph node transfer: We transplant healthy lymph nodes from other parts of the body to the area with lymphedema. Vascularized lymph node transfer

Vascularized lymph node transfers (VLNT) can be an effective treatment of the arm and upper extremity. Lymph nodes are harvested from the groin area or the supraclavicular area with their supporting artery and vein and moved to the axilla (armpit) or the wrist area. Microsurgery techniques connect the artery and vein to blood vessels in the axilla to provide support to the lymph nodes while they develop their own blood supply over the first few weeks after surgery.

Advanced Stage Lymphedema Treatment

NON SURGICAL CARE REMAINS THE SAME

• LIPOSUCTION OR DEBULKING SURGERY- The first step in treating advanced-stage lymphedema is to restore function to the limb by reducing its size through debulking or liposuction . This is because the affected area is very large and swollen due to accumulation of fluid, fat and thick fibrous tissue. and the skin develops a leathery appearance.

• lymph node transfer or lymphovenous bypass. These options can help reduce symptoms for the long term and give you a better quality of life.

• The lymph nodes act as “lymph pumps,” wherein the steep pressure gradient between the high-pressure arterial inflow and the low-pressure venous outflow draws fluid from the interstitial to the undamaged lymphatic tissue and into the venous system by means of lymphaticovenous channels around the nodes in the transferred flap.

• The “catchment effect” may recruit more lymph from the surrounding tissue into the transferred lymph nodes as the subcutaneous interstitial pressure in the lesion limb decreases.

• A “gravity effect” may gradually drain from the upper arm to the forearm, and from the forearm to the wrist.

• Further investigation is mandatory to support this hypothesis.

The newly transferred lymph nodes then serve as a conduit or filter to remove the excess lymphatic fluid from the arm and return it to the body's natural circulation.

This technique of lymph node transfer may be performed together with a DIEP flap breast reconstruction. This allows for both the simultaneous treatment of the arm lymphedema and the creation of a breast in one surgery. The lymph node transfer removes the excess lymphatic fluid to return form and function to the arm. In selected cases, the lymph nodes may be transferred as a group with their supporting artery and vein, but without the associated abdominal tissue for breast reconstruction.

Lymph node transfers are most effective in patients whose extremity circumference reduces significantly with compression wrapping, indicating most of the edema is fluid.

VLNT significantly improves the fluid component of lymphedema and decrease the amount of lymphedema therapy and compression garment use required.

Lymphaticovenous anastomosis

Lymphaticovenous anastomosis (LVA) uses supermicrosurgery to connect the affected lymphatic channels directly to tiny veins located nearby. The lymphatics are tiny, typically 0.1 mm to 0.8 mm in diameter. The procedure requires the use of specialized techniques with superfine surgical suture and an adapted, high-power microscope.

LVA is most effective early in the course of the disease in patients whose extremity circumference reduces significantly with compression wrapping, indicating most of the edema is fluid.

Indocyanine green fluoroscopy is a safe, minimally invasive and useful tool for surgical evaluationSuction assisted lipectomy

People whose limbs no longer adequately respond to compression therapy may be candidates for suction assisted lipectomy (SAL). Lymphatic liposuction combined with controlled compression therapy is more effective than controlled compression therapy alone.

Lymphatic vessel grafting

With advanced microsurgical techniques, lymph vessels can be used as grafts. A locally interrupted or obstructed lymphatic pathway, mostly after resection of lymph nodes, can be reconstructed via a bypass using lymphatic vessels. These vessels are specialized to drain lymph by active pumping forces. These grafts are connected with main lymphatic collectors in front and behind the obstruction. The technique is mostly used in arm edemas after treatment of breast cancer and in unilateral edemas of lower extremities after resection of lymph nodes and radiation.

Low level laser therapy

Low-level laser therapy (LLLT) may be effective in reducing lymphedema in a clinically meaningful way for some women. Two cycles of laser treatment were found to be effective in reducing the volume of the affected arm, extracellular fluid, and tissue hardness in approximately one-third of patients with postmastectomy lymphedema at 3 months post-treatment.