Surgery for lymphedema is not curative, but it has been used in specific circumstances for control of a severe condition. Circumstances where surgery may be considered are: reducing the weight of the affected limb, minimizing the frequency of inflammatory attacks, improving cosmetic appearance, or fitting the limb into garments. Surgical treatment should be instituted for patients for whom previous medical modalities have failed or for those who have had long-term complications. There are several types of surgical procedures available that have been used for lymphedema: (a) excisional operations, including debulking and liposuction, (b) tissue transfers, and (c) microsurgical lymphatic reconstruction. Previous studies have demonstrated that wound infections and infections of the ipsilateral arm are significant risk facts for the development of lymphedema. Many clinicians presume immediate breast reconstruction to increase the risk of lymphedema as a consequence of increased potential for surgical site infection. In this series , immediate reconstruction was not associated with increased risk of infection. Additionally, those patients who did have infections did not have an increased risk of lymphedema. This last observation must be interpreted with caution. However, as only a small number of patients in the current series had infections complications, thereby limiting the statistical power. In conclusion the study has shown that breast reconstruction with tissue expander following mastectomy does not increase the risk of lymphedema. This information is important for patient counseling.
Chronic lymphedema is a significant problem with limited treatment options . In the United States, the most common cause of lymphedema is axillary lymph node dissection for breast cancer . Most authors categorize arm swelling greater than 5 cm from baseline/contralateral arm or as volume difference of greater than 40% from baseline as severe lymphedema . Moderate lymphedema is usually defined as 2-5 cm arm circumference increases. Some authors have defined mild lymphedema as differences in arm measurements that are less than 2 cm but are associated with subjective sensation of swelling. The use of patient perception in the definition of lymphedema is important and is advocated by the American Cancer Society (ACS). As such, patient-directed interviews and validated instruments that assess lymphedema symptoms have been developed and enable combination of patient perception and objective measurements . The onset of lymphedema relative to surgical intervention is unpredictable and may occur over several years. Large clinical series have identified a number of risk factors for lymphedema. The most consistently identified risk factors include obesity, postoperative weight gain, postoperative surgical site/arm infections, and radiation therapy to the axilla .
Lymphedema is caused by an abnormality of the lymphatic system leading to excessive build up of tissue fluid that forms lymph, known as interstitial fluid. Stagnant lymph fluid contains protein and cell debris that causes swelling of affected tissues. Lymph is responsible for transporting essential immune chemicals and cells. Lymphedema is the accumulation of protein-rich fluid in soft tissues as a result of interruption of lymphatic flow. It occurs most frequently in the extremities, but it can also be found in the head, neck, abdomen, lungs, and genital regions. In post-mastectomy patients, chronic lymphedema has the potential to become a permanent, progressive condition. If it is allowed to progress, the condition can become extremely treatment resistant and in most cases cannot be completely relieved with either medical or surgical means. Left untreated, lymphedema leads to chronic inflammation, infection and hardening of the skin that, in turn, results in further lymph vessels damage and distortion of the shape of affected body parts . Interstitial fluid can build up in any area of the body that has inadequate lymph drainage and cause lymphedema. Lymphedema is a condition that develops slowly and once present is usually progressive . Lymphedema is divided into two forms: and . People can be born with abnormalities in the lymphatic system. This type of lymphedema is known as . Depending on how severe the condition is, swelling can be present at birth or may develop later in life. is associated with developmental abnormalities of the lymphatic system, may be manifested in neonates (congenital), adolescents (praecox), or patients older than 35 years (tarda). is the most common form of lymphedema. This usually occurs after oncologic surgery or radiation therapy. The condition occurs as a result of damage by metastatic disease to the lymphatic system, post-radiation changes to the underlying skin structures, or surgical removal of one or more lymphatic nodal basins. Most lymphedema in the United States is . This type of lymphedema occurs from damage to the lymphatic system, commonly from cancer and its treatment but also from trauma to the skin such as from burns or infections . Lymphedema after breast cancer has been studied the most, but lymphedema can occur as a result of other cancers, including melanoma, gynecologic cancer, head and neck cancer or sarcoma.
Six contributing factors have been shown to influence the incidence of brachial edema after treatment for breast cancer: radiation therapy; obesity; age; operative site; incision type and history of infection. Adding radiation therapy has been shown to increase the incidence of lymphedema from 20% to 52% . The incidence of lymphedema is lessened if transverse rather than oblique incisions are used . The extent of axillary dissection is an important contributing factor. Limiting the axillary dissection to level I and II nodes and preserving the level III nodes and lymphatic collateral channels around the shoulder may decrease the incidence of acute and chronic lymphedema. Recent technology has introduced the concept of lymphatic mapping and SLNB for women with invasive breast cancer. With the hypothesis that the histology of the SLNB reflects the histology of the remaining nodes in the basin, full nodal staging information can be garnered with a simple lymph node biopsy of one or more nodes. This approach may limit the possibility of lymphedema to only those women with histologic evidence of metastatic disease in the axilla.