History
A female patient in her 40s was initially diagnosed with bilateral ER+ and PR+ invasive lobular carcinoma of the breast. She underwent neoadjuvant chemotherapy, followed by bilateral mastectomy with axillary lymph node dissection and immediate breast reconstruction with permanent silicone implants.
Additionally, she received adjuvant radiation therapy targeting the chest wall and axillary regions. Approximately five months post-mastectomy, the patient presented with complaints of swelling, numbness and pain in her left upper extremity.
Presentation and Examination
The patient exhibited notable swelling in the left upper extremity without signs of cellulitis. Lymphoscintigraphy highlighted delayed uptake and dermal backflow, which suggested grade 2 lymphedema. The results of an upper left extremity MRI corroborated these findings.
Preoperative assessment of the patient’s left extremity lymphedema demonstrated increased swelling, erythema and limb volume compared to her right extremity.
Treatment
The patient's surgical history and presentation were indicative of secondary grade 2 lymphedema, likely secondary to her breast cancer axillary lymphadenectomy and radiation management. Secondary lymphedema is a condition marked by acquired lymphatic dysfunction resulting in protein-rich fluid accumulation, subsequent swelling, fat hypertrophy, tissue fibrosis and limb hypertrophy.
Lymphedema is a progressive and debilitating disease. Treatment of this condition should be centered on palliative symptom relief and disease progression management. After unsuccessful conservative treatment that involved manual lymphatic drainage and compressive garments, I believed surgical intervention was necessary to treat this patient’s early-stage lymphedema.
To achieve both symptomatic improvement and aesthetic outcomes, I incorporated a combination of physiologic and debulking procedures in a staged fashion. Initially, the patient underwent three lymphovenous anastomoses (LVA), while we simultaneously connected functional lymphatic channels to nearby subdermal venules to redirect lymphatic flow into the venous system; this allowed drainage of the lymphatic fluid from the distal arm. Intraoperative SPY imaging fluoroscopy with indocyanine-green (ICG) was used to identify these lymphatic channels and to confirm improved lymphatic flow post-intervention.
Post-lymphovenous anastomosis showed significant improvement of the swelling distally with the wrist bone, which was notable, given that it was the first time this was observed since her lymphedema ensued.
I performed liposuction as a debulking procedure to further reduce excess adipose tissue and limb volume while enhancing the extremity's cosmetic appearance. I repeated this again about six months later.
Outcome
Following surgery, the patient reported a marked improvement in her lymphedema symptoms, including reduced swelling, enhanced limb mobility, improved cosmetic appearance and an overall increase in her quality of life. Recognizing the chronic nature of her condition, a comprehensive, long-term management strategy that includes ongoing lymphedema therapy was established to ensure the continued preservation of these benefits.
Post-operative assessment of the left upper extremity demonstrated significant reduction in limb swelling and size with excellent aesthetic outcome. Given the extent of dermal backflow in the proximal arm, we discussed monitoring her symptoms and potentially offering vascularized omental transfer to the left upper extremity as an additional physiologic procedure to help with lymphangiogenesis and drainage of the excess lymphatic fluid.
Analysis
Breast cancer-related lymphedema represents the most common cause of non-infectious lymphedema in the United States, occurring in up to 25-40% in patients who undergo a combination of axillary lymphadenectomy and radiation therapy.
This case highlights the successful management of lymphedema through a combination of physiologic and debulking procedures. The postoperative outcomes showcase significant symptom improvement, enhanced limb mobility and improved cosmetic appearance. Together, these underscore the potential benefits of surgical intervention in early-stage lymphedema along with lymphedema therapy.
Additionally, the patient may require an additional physiologic procedure (i.e., vascularized omental transfer to the left upper extremity) to further improve her lymphatic drainage and optimize her long-term extremity volume.
