Lymphatic Microsurgical Preventive Healing Approach (LYMPHA)

LYMPHA is a relatively new and promising technique aimed at reducing the risk of lymphedema development in patients undergoing lymph node dissection surgeries, particularly for cancer treatment. This approach involves the use of microsurgery to re-route lymphatic vessels and prevent the accumulation of lymph fluid that leads to lymphedema. The breakdown of this approach is as follows:

1. Patient Selection: Patients who are at high risk of developing lymphedema due to planned lymph node dissection surgeries, such as those undergoing treatment for breast cancer or melanoma, are typically considered for this approach.

2. Preoperative Evaluation: At the time of surgery, I inject Indocyanine green (ICG) into the arm and by using a special camera (PDE NEO 2), I can map out the lymphatic system and identify healthy lymphatic vessels that can be used for microsurgical intervention.

3.Microsurgical Technique: Once the lymph nodes have been removed, the cut ends of the lymphatic vessels are connected directly to nearby veins using microsurgical techniques. This allows excess lymph fluid to drain into the venous system, bypassing the removed lymph nodes.

4. Postoperative Care: After the microsurgical procedure, patients need comprehensive postoperative care, including compression therapy, lymphatic drainage massage, and exercises to promote lymphatic flow and prevent complications.

5. Long-term Monitoring: Patients undergo long-term monitoring to assess the effectiveness of the microsurgical intervention and detect any signs of lymphedema development. Regular follow-up appointments are essential to ensure optimal outcomes, and I image the lymphatic system in the clinic every 3 months for the first year to ensure there is no deterioration.

6. Benefits and Considerations: The microsurgical preventative healing approach offers several potential benefits, including reduced risk of lymphedema development, improved quality of life, and better preservation of limb function. However, it's essential to weigh the potential risks and benefits of surgery before deciding to proceed.

There are no specific complications of LYMPHA itself, as the lymphatics will already have been divided by the lymph node dissection. There is a chance that lymphedema may occur despite the surgery, although the risk will be reduced from lymph node dissection alone. The procedure will add approximately an hour to the length of the surgery.

Having surgery should be a very positive experience. Complications are infrequent and usually minor. However, all surgery has risk, and it is important that you are aware of the possible complications in relation to LYMPHA. All the risks will be discussed in detail with you at your consultation. However, if you have further questions or concerns, please do not hesitate to discuss them with me. Decisions about surgery must never be rushed and requires personal research.

These risks can be divided into those specific to the surgery and those that relate to the anaesthesia.

General Anaesthetic risks: An anaesthetic is very safe, however, should a complication arise, the relevant medical expertise is immediately available to deal with this.

The risks increase if you have certain medical problems, which will be discussed at length during the consultation. The risks include:

• Unintended intraoperative awareness, which is very rare.
• Dizziness and nausea.
• Sore throat.
• Damage to teeth or mouth.
• Nerve injury due to body positioning.
• Allergic reaction or anaphylaxis.
• Malignant hyperthermia, which is a rare life-threatening condition.

The anaesthetist will go through these risks in more detail prior to your surgery.

Scars: Scars tend to settle remarkably well. However, some people heal with thickened scars, and this can make them more noticeable.

Bruising and swelling: This is very common and may take approximately 3 weeks to resolve.

Haematoma: This is clotted blood that collects under the skin. If a haematoma develops, it is likely to do so within 4 to 6 hours post-surgery. Any increase in swelling or pain should be reported immediately so that treatment can be given. Sometimes patients need to have this collection of blood removed with another short operation. This does not normally delay your recovery or change the cosmetic result.

Infection: Patients having lymph node removal are at a higher risk of developing an infection after surgery, therefore, I prescribe you a course of antibiotics to take for 2 weeks, whilst everything is healing.

Numbness, reduced sensation or oversensitivity:  A reduction in sensation occurs in most patients around the abdomen and possibly the upper thigh. This is usually temporary, but occasionally these changes can remain to some degree.

Lymphocele: This is a collection of clear fluid under the skin, at the surgical site, which sits in a pocket. It is because of cutting some of the lymphatics from where the nodes are removed. This normally reabsorbs spontaneously over the course of a couple of weeks, although it can be drained with a needle if it feels tight. Vary rarely a surgical procedure may be required if it does not reabsorb.

Wound healing problems: These are rare but can range from minor problems, such as small areas of wound separation, to major issues, such as skin loss. Although very rare, skin grafting to close the wound may be required thus resulting in further surgery.

People who have diabetes, smoke, are obese or elderly are at an increased risk of delayed healing.

Dog-ears: These are soft tissue prominences where the scar stops. In most cases these settle over the course of 3 months. A small local anaesthetic procedure may be required to remove any excess that remains.

Indentation: You may develop a slight depression where the lymph nodes have been removed. The majority of this will correct naturally but any remaining indentation can be corrected with a fat transfer.

Lymphoedema of the limb: Even if the LYMPHA technique is performed, there is a small risk that this could occur because of the lymph node removal.

Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE): Following any surgical procedure it is possible to develop a blood clot in your legs, which could potentially break off and travel to your lungs. If the blood clot is large enough, it could prove fatal.

The overall risk for surgery is less than 1%, but to reduce any risks of a DVT/PE, you will be provided with special stockings to wear in bed together with a blood thinning injection, if you are not mobile or have previously had a DVT or PE.

All the risks will be discussed in detail at your consultation. However, if you have further questions or concerns, do not hesitate to discuss these with me.

Your incisions will be closed with a dissolvable suture that does not need removing. You will have waterproof glue-based dressing, which will gradually dissolve at about 3 weeks. You can shower as soon as you want and do not need any dressing changes.

A tube (called a drain) will channel away any excess blood or body fluid from your donor site. This is removed as soon as the fluid is less than 30ml/24 hours, which is normally about 3 days post-surgery.

You can go home with the drain, and we will show you how to empty it. As soon as it is ready to be removed, we will see you in clinic to remove it.

You need to be measured for full length Class 1 compression of the arm prior to surgery and I will put you in the garment after the operation. You need to wear this continuously for 2 weeks, but it can be removed for washing and replaced after. After 2 weeks you only need to wear the garment during higher-risk activities such as flying.

I recommend that you commence manual lymphatic drainage with the physiotherapist 2 weeks after surgery to encourage the swelling to settle and the limb to drain in the initial post-surgery period.

Before you leave the hospital, you will be given a follow up appointment to see the nurses at one week to check your incisions and an appointment to see me in 2 weeks. You will not be able to drive yourself home from hospital and, ideally, you should have someone to stay with you for a few days to assist you. If you have any concerns during this period, do contact the clinic for advice.

When you return home, you should take it easy for the first week or so. Most people take around 1 to 2 weeks off from work. You should be able to drive from 2 weeks, commence gentle exercise at around 2 weeks and return to the gym or equivalent activities at around 4 weeks.

For lymphoedema surgery the fees are normally cover by your health insurance, however most patients have a co-pay of 20%. This means you are likely to have to pay towards the cost of your surgery. Any fees will be calculated, and you will be informed of the potential fees just after your consultation.

LYMPHA - Nicotine and Surgery

LYMPHA - Pre-Op Instructions

LYMPHA - Post-Op Instructions