A Selective Microsurgical Approach for Treating Bilateral Lower Extremity Lymphedema

Background

Lower extremity lymphedema is a debilitating condition, posing many challenges for health care professionals. Particularly when both lower extremities are involved. Clinical presentation is usually more severe and reported surgical outcomes tend to be generally less favorable. However treatment modalities continue to evolve. More recently, microsurgical methods including lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) have gained increasing popularity among plastic surgeons. Despite published studies detailing outcomes related to surgical success in treating extremity lymphedema utilizing such methods, limited studies have reported recommendations based on the pattern of lymphatic flow made possible due to a recent advancement in lymphatic imaging technology and is performed with Indocyanine green (ICG) lymphography. Frequently lower extremity edema affects each leg to a variable degree. Therefore, each case of lymphedema should be treated by selecting the best surgical approach likely to give the most favorable long term outcome, taking into account the pattern of lymph flow rather than using the same approach to treat all lymphedema.

Methods

This series includes four patients with chronic bilateral lower limb edema. Either LVA or VLNT was performed simultaneously for each of the affected limbs depending on lymphatic flow mapping in addition to lymphedema grading. Lymphatic imaging was performed using 0.3 to 0.6 mL indocyanine green (ICG) injection. A diffuse ICG pattern of lymphatic flow with stardust appearance and dermal backflow indicates severe obstruction that is unlikely to recover significantly from a simple LVA and therefore a VLNT was required for optimal results. However a linear pattern on ICG indicates the presence of a functional lymphatic duct and performing a LVA is likely to produce a satisfactory reduction of extremity edema without the need for a more complicated intervention. Circumference measurements and ICG lymphography were evaluated pre-and post-op in all patients.

Results

We successfully treated bilateral lower extremity lymphedema in these patients. Regardless of intervention performed, there was a remarkable improvement of edema. Circumference reduction of the each extremity ranged between 40.5% to 50%. ICG appearance within the lymph node flap flap was seen in all cases of VLNT, and was also uses to show a functioning LVA.

Conclusion

This is a novel concept for dealing with extremity lymphedema. The selective application of a VLNT or LVA provides a steady reduction of limb circumference that is sustainable over time and is reflected by lymphatic clearance of ICG.