Lymphedema Assessment

Millions of people worldwide suffer from lymphedema, which in non-infective causes is a chronically progressive disease awaiting development of a definitive cure. In developed nations, secondary lymphedema most commonly stems from cancer treatment, but may also result from trauma or secondary to surgical treatment of other conditions.

Regardless of the etiology, the underlying pathophysiology depends on blockage of lymphatic flow, resulting in lymph stasis, triggering a cascade of inflammation resulting in fibrosis and adipose deposition. Recent advances in technique have allowed the refinement of physiologic and reductive surgeries – including lymphovenous anastomosis or free functional lymphatic transfer, which collectively encompasses a variety of flap designs including lymph node transfer, lymph channel transfer, and lymphatic system transfer.

Management of lymphedema aims to prevent fluid stasis and prevent progression of the resulting inflammatory cascade. Due to the progressive nature of lymphedema, noninvasive management should begin as early as possible in suspected cases. This includes compression garments, pneumatic lymphedema pumps, and referral to lymphedema therapy for comprehensive decongestive therapy.

Initial management begins with examination and work-up for other causes of extremity swelling. frequent misdiagnoses include venous stasis, lipedema, obesity, trauma, vascular malformation, and rheumatologic disease – and these must be ruled out prior to proceeding with lymphedema management to avoid mistreatment.

Schedule an appointment with one of our lymphedema surgical specialists for further evaluation — whether to confirm diagnosis of lymphedema; to determine the severity and staging of disease; or to discuss treatment options.

When patients find first-line measures to be intolerable, or have insufficient symptom management, then consideration for surgical treatment may be given. In general, a minimum of 4-6 months of noninvasive measures are trialed due to the possibility for spontaneous regression, which is uncommon but has been observed.

Treatment options depend on the disease severity. The most common system used to grade severity is likely the International Society of Lymphology (ISL) staging system, which utilizes clinical criteria describes the presence of fluid versus fibroadipose dominance.

Stage 0: Subclinical lymphedema, in which patients experience symptoms but have no measurable edema.

Stage 1: Reversible limb swelling and pitting edema, indicating fluid predominance.

Stage 2: Irreversible limb swelling, without pitting edema, indicating fibrotic or adipose dominance

Stage 3: End stage lymphedema with severe swelling, trophic skin changes, and elephantiasis.

Procedure selection depends on disease staging and degree of fibrofatty deposition, both of which reflect the working condition of the remaining functioning lymphatics. As the severity of lymphedema progresses, the remaining lymphatic channels demonstrate progressively decreased function. Conceptually, when determining treatment options, it may be simplest to determine whether the edema is clinically primarily a dominance of fluid, versus fibrotic and adipose tissue. In general, surgical management falls within physiologic versus debulking techniques as discussed in the associated sections of this website (click to explore):

Lymphovenous bypass

Free functional lymphatic tissue transfer

Liposuction debulking

For further evaluation and discussion with one of our specialist, please schedule a consultation.