Surgery has been an option for people dealing with Lymphedema for years, but early surgeries weren’t the most humane. 

Debulking was a technique that involved opening up the skin and removing tissue on the lymphedema area down to the facia and then doing skin grafts. 

In 1912 Sir Richard Henry Havelock Charles was the first to mention using debunking surgery. He reported on 140 scrotal filariasis cases treated by debulking. By the mid twentieth  century the technique was called ‘the Charles procedure’ and it was a surgery done when the patient was stage 4.

Over the years variations of the technique were used but it was highly invasive and extremely painful for the patient.

SAPL or Liposuction

A modern technique which is used for both Lymphedema and Lipedema patients is a modified type of liposuction. This technique allows reducing the lymphatic tissue in the arms or legs. Lymphedema typically leads to an increase in adipose tissue that can be removed with liposuction.

Adipose tissue increases with Lymphedema and it doesn’t depend on the length of time you have had lymphedema.  

Variations of this technique have been in use for over 20 years now. Pioneered by Dr Hakan Brorson (Skane University Hospital, Malmo, Sweden) he has trained teams all over the world in his method. 

Both Lipedema patients and Lymphedema patients have benefitted from this technique. Again - this is not a cure. After surgery you have to remain in compression after the surgery. But Dr Brorson has followed patients for 21 years with Lymphedema and 11 years with Lipedema and they have not had any reocurrances.

Fat cells in Lymphedema patients are larger in areas with Lymphedema compared to unaffected areas. Interesting in animal studies chronic inflammation leads to increased adipose tissue. 

This is not a quick fix as it may take months to recover from the procedure and after care for patients is very important.

It has been reported that after surgery patients quality of life increases. Also with the increased blood flow the cases of cellulitis drop by up to 87%. 

Lymph Node Transfers

As imaging techniques improved more was learned about the lymphatic system. Improvements in micro surgery also brought new ideas and one was Vascularized lymph node transfer surgery (lymphovenous transplant)

The idea seemed simple. Take a section of lymph nodes from a healthy area of the body to the area that has damaged lymph nodes and restore the flow. The surgery is done in hospital and requires a few days of rest before you resume your normal activities. 

It sounds amazing and it has proven life changing for some patients that undergo this surgery. As surgeons become familiar with this technique and combine it with imaging functioning lymph nodes can be transplanted to a new location.

The drawback to this technique is that if the lymph nodes removed from the secondary location can cause lymphedema to occur in the donor location. 

The first transplant of lymph nodes from the groin flap was reported in 1982. Today the groin flap is still the most common location for getting the lymph nodes for transplant. There are other locations that provide lymph nodes suitable for transplant. The choice of location depends on the individual patient.

Although originally it was reported lymph node transfers only helped 30% of patients with the improved methods used now the number is much higher.

Dr Granzow developed a method that showed a reduction in volume of 86% in legs and 111% in arms and statistically significant reductions in the needs for lymphedema therapy and compression garment use. 

Lymphaticovenous anastomosis
(also referred to as lymphovenous bypass) 

We always refer to the lymphatic and venal system as separate, but they actually do intersect on a daily basis. When the system is running properly both systems coexist together. When the lymphatic system is damaged then swelling starts causing lymphedema. 

LVA or lymphovenous bypass uses microsurgery to connect the lymph vessel to the vein. 

LVA was actually tried in the 1960s, but microsurgical techniques using robotic surgery methods were not available then.

Now with the surgical and imaging improvements LVA has become more practised and it now considered one of the gold standard treatments for Lymphedema.

Once the blockage has been identified then using lymphangiography then the surgeon chooses the vein. 

Before the surgeon starts to cut the chosen area local anesthetic containing epinephrine for hemostasis in order to limit bleeding from the dermal edges. Isosulfan blue or Lymphazurin (Covidien) is injected distal to the incision site, which is absorbed into the lymphatic vessel and allows for visualization of the lymphatic during the dissection. 

The size of the lymphatic and venal veins are tiny, some 1 mm, other smaller mean that this is micro surgery. 

When the connection is made then the excess fluid in the lymphatic system starts to drain into the venal system. 

Patients report less heaviness in their limbs, reduction in infections and cellulitis. Studies with a minimum 1 year or longer have shown promising results for treating Lymphedema.

After having surgery patients have to wait for 4 weeks to let the bypass heal before using compression garments or manual lymph drainage.

After surgery patients notice an improvement in dealing with their lymphedema. Reducing the need to wear compression sleeves, using pneumatic pumps or needing to go for manual lymphatic drainage  or massage with Lymphedema therapists.

There is a human component in any surgery you decide to have. That is the expertise of the surgeons and their teams. You want a surgeon who is familiar with the technique that you are getting done. You also want to make sure that proper aftercare has been arranged.