Lymphedema Treatment in Ankara, Turkey

Lymphedema is a chronic condition that occurs as a result of fluid accumulation in the tissues due to insufficiency of the lymphatic system. It usually develops after breast cancer surgery, radiotherapy, or trauma. Treatment is planned to reduce edema, prevent infection, and improve quality of life.

Conservative treatment methods include manual lymph drainage, compression bandages, special lymphedema stockings, and skin care. These approaches control fluid accumulation and slow the progression of the disease. Regular application provides long-term benefits.

In advanced cases, surgical treatments may be considered. With microsurgical methods such as lymphatic bypass (lymphovenous anastomosis) and vascularized lymph node transfer, lymph drainage can be re-established. These procedures are planned individually according to the degree of lymphedema.

The treatment process requires a multidisciplinary approach; physiotherapists, plastic surgeons, and dermatologists work together. With early intervention, the risk of complications is reduced, patients’ daily life activities become easier, and long-term permanent improvement can be achieved.

What Is Lymphedema Treatment?

Lymphedema treatment is the combination of methods aimed at reducing swelling caused by the accumulation of lymph fluid in tissues, lowering the risk of infection, and improving quality of life. In treatment, manual lymph drainage, compression bandages or stockings, exercise programs, and skin care are the main approaches. Surgical options may be considered in advanced cases. Early diagnosis and regular follow-up are of great importance for treatment success.

What Are the Causes of Lymphedema and Who Is at Risk?

We examine the causes of lymphedema mainly in two groups. The first is congenital structural disorders, and the second is damage acquired later. The vast majority of our patients, almost all of them, apply to us due to causes that develop later.

Congenital, or primary lymphedema, results from errors that occur during the development of the lymphatic system in the womb. In these patients, lymph vessels either have not developed at all, are insufficient in number, or are structurally defective. It usually manifests during adolescence or young adulthood with swelling in the leg or arm without any obvious trauma. This condition is seen more frequently in women and genetic factors may play a role.

Today, the main large patient group we encounter consists of secondary lymphedema cases. In developed countries, the most common cause is unfortunately cancer treatments. Removal of lymph nodes during cancer surgery or radiotherapy applied to the region may create the risk of lymphedema.

Factors that prepare the ground for or cause this condition are as follows:

• Breast cancer surgery
• Lymph node dissections
• Radiotherapy applications
• Gynecological tumor surgeries
• Melanoma surgeries
• Recurrent infections
• Severe traumas
• Chronic venous insufficiency
• Obesity
• Sedentary lifestyle

Especially obesity is an independent and serious risk factor in the development of lymphedema. A body mass index above 30 causes excess fat tissue to exert external pressure on lymph channels and slows the flow. In addition, weight gain in patients who have undergone cancer treatment significantly increases the existing risk.

Which Symptoms Are Warning Signs for the Diagnosis of Lymphedema?

Lymphedema is generally a slowly progressing process, and detecting it in the early stage greatly increases the success of treatment. Most of our patients feel something unusual in their limbs long before visible swelling occurs. A feeling of heaviness in the arm or leg that cannot be clearly described, tension, or clothes and jewelry feeling tighter than before are the first signals given by the body. In this early stage, swelling may increase during the day and decrease with rest at night. This indicates that the disease is still in the “reversible” stage and is the most valuable time for intervention.

During examination, we perform a simple but very reliable test called the “Stemmer Sign.” The skin on the back of the fingers or toes is pinched to see if it can be grasped. If the skin cannot be grasped and feels thickened and tight, this test is positive and indicates lymphedema. The presence of pitting is also an important indicator for us. When you press on the swelling with your finger and release it, if the indentation does not disappear immediately, it shows that there is significant fluid accumulation between tissues. As the disease progresses and the tissue hardens, this indentation disappears.

The methods we use in the diagnostic process are as follows:

• Clinical examination
• Circumference measurements
• Water displacement test
• Bioimpedance analysis
• Lymphoscintigraphy
• ICG lymphography
• MR lymphangiography

Especially during the surgical planning stage, ICG (Indocyanine Green) Lymphography technology is like our hands and feet. In this method, a special dye is injected under the skin and the map of the lymph channels is displayed live with an infrared camera system. This mapping shows the surgeon with millimetric precision which vessel is functioning, which is blocked, and in which direction the flow occurs. In this way, we avoid performing procedures “blindly” and plan targeted treatments.

Why Is Complex Decongestive Therapy Necessary Before Surgery?

Many patients want to go straight to surgery and get rid of the swelling as soon as they receive the diagnosis. However, lymphedema surgery may end in disappointment if performed without proper preparation. For this reason, the preparation process called “Complex Decongestive Therapy” (CDT) in the preoperative period is indispensable for treatment. The main purpose of CDT is to minimize the amount of edema in the limb, soften the tissue, and eliminate possible infection risks.

Reducing the swelling as much as possible before surgery improves the quality of the tissue on which the surgeon will work. Performing microsurgery on an arm with reduced fluid load is technically much easier and the chance of success is higher. In addition, this process is also a critical educational period for the patient to learn to live with lymphedema and to adapt to the use of bandages and compression garments. Surgery is not a magic wand but the strongest complement to this disciplined process.

The main components of this therapy are as follows:

• Manual lymph drainage
• Multilayer bandaging
• Skin care
• Special exercises
• Use of compression garments

How Is the Lymphatic-Venous Anastomosis (LVA) Method Applied?

In the treatment of lymphedema, the group we call “physiological methods” focuses on repairing the body’s disrupted natural drainage mechanism. One of the leading methods is Lymphatic-Venous Anastomosis (LVA). LVA is one of the most delicate points reached by medical technology and surgical skill. In this procedure, “super-microsurgery” techniques are used. The reason it is called super-microsurgery is that the diameter of the vessels worked on is usually thinner than a strand of hair.

The working principle of LVA is actually similar to a “bypass” surgery in the heart. Imagine that an accident has occurred on a highway and traffic is blocked; vehicles cannot move forward and congestion occurs behind. In LVA surgery, the surgeon finds the functioning lymph vessels just before the blocked area and connects them to nearby small veins. Thus, instead of using the blocked path, lymph fluid is transferred directly into the bloodstream. As a result, the pressure within the tissue decreases, fluid is drained, and swelling is reduced.

The advantages of this method are as follows:

• Minimally invasive structure
• Low risk of complications
• Fast recovery process
• Possibility of local anesthesia
• Short hospital stay

The greatest advantage of this surgery is that the recovery process is quite rapid because no muscle or deep tissue is cut. LVA provides excellent results especially in early-stage patients where lymph vessels have not yet been completely damaged and retain their contraction ability. Patients in whom vessels appear as smooth lines in ICG lymphography are the most ideal candidates for this surgery.

In Which Situations Is Vascularized Lymph Node Transfer (VLNT) Preferred?

In cases where lymph pathways are completely destroyed or damaged to the extent that LVA cannot be performed, another physiological method called Vascularized Lymph Node Transfer (VLNT) comes into play. This procedure is similar to installing a new water pump system in a dried agricultural field. Our aim is to initiate drainage in the area from scratch.

In this surgery, a group of healthy lymph nodes is taken from another region of the body along with their blood vessels without affecting lymphatic function in that region. This tissue piece is then transplanted to the lymphedematous area, such as the armpit or wrist, using microsurgical techniques. The vessels of the transplanted tissue are sutured to vessels in the recipient area to ensure blood supply. The transferred lymph nodes function through two main mechanisms. First, they act like a sponge, absorbing excess fluid from surrounding tissues and delivering it into the bloodstream through their own vascular network. Second, and more importantly in the long term, they trigger the formation of new lymph vessels in the transplanted area by releasing growth factors.

The regions used as donor sites are as follows:

• Submental region
• Groin region
• Intra-abdominal omentum
• Lateral chest wall

VLNT is generally preferred in more advanced stages where fibrosis has begun or lymph pathways are completely blocked. Sometimes it can be combined with LVA in the same session to achieve the highest efficiency. However, when removing lymph nodes from the donor site, it is vital to use protective techniques called “reverse mapping” to avoid creating new lymphedema in that area.

What Are Volume-Reducing Surgical Methods in Advanced Stages?

If the disease has continued for many years and has not been treated, the character of lymphedema changes completely. The problem is no longer only fluid accumulation; dense fat accumulation and fibrosis, meaning tissue hardening, develop within the tissue. At this stage, physiological surgeries aimed only at increasing drainage are not sufficient because the accumulated fat tissue and hardened structures do not disappear on their own. At this point, “reductive,” or volume-reducing, surgeries come into play.

The most modern and effective representative of this group is Suction-Assisted Protein Lipectomy (SAPL), a liposuction method customized for lymphedema. However, this should not be confused with classical liposuction performed for aesthetic purposes. While aesthetic liposuction aims for regional contouring, the aim of SAPL is to remove nearly all pathological fat and fibrotic tissue in the extremity. The surgeon works meticulously by using cannulas parallel to the long axis of the limb in order not to damage the remaining few lymph pathways.

The gains obtained with this method are as follows:

• Significant volume reduction
• Lightening of the limb
• Reduction in infection risk
• Increase in mobility
• Improvement in aesthetic appearance

After SAPL, patients notice that the limb becomes lighter and thinner immediately after the operation. A volume reduction of 80–90% can be achieved in the arm or leg. However, the continuity of success with this method is strictly dependent on the patient’s compliance after surgery. Since the lymphatic system is still insufficient, patients must use compression garments for life after the operation. Otherwise, the emptied areas may fill with fluid again. In much more severe cases called “elephantiasis,” radical methods such as the Charles Procedure, in which the skin and tissue are completely removed, may rarely be required.

How Does the Postoperative Recovery and Care Process Progress?

Lymphedema surgery is not a process that ends when the patient leaves the operating room; on the contrary, postoperative care is at least as important as the surgery itself and is the key to success. The recovery process varies greatly depending on the method applied. After microsurgical procedures such as LVA or VLNT, the first weeks are critical. During this period, the limb must be protected from sudden movements so that the delicate vascular connections made with hair-thin sutures are not damaged.

Points to consider after microsurgery are as follows:

• Keeping the limb at heart level
• Avoiding sudden movements
• Not lifting heavy objects
• Avoiding tight bandaging (initially)
• Regular wound care

The process after liposuction (SAPL) is completely different. Here, a tight compression application begins immediately after leaving the operating room to prevent the spaces within the tissue from filling with fluid again. The patient must use these compression garments day and night for the specified period. During the rehabilitation process, we work closely with our physiotherapists. In the first weeks, light joint movements are started, and as the tissue heals, lymph drainage massages are introduced.

The activities we recommend to our patients in the long term are as follows:

• Regular walking
• Swimming exercises
• Aquatic aerobics
• Low-resistance weight training
• Diaphragmatic breathing exercises

Swimming is especially strongly recommended for our patients because the natural pressure created by water supports lymph circulation. In addition, infection control is very important; in case of the slightest redness, increase in temperature, or fever, a doctor should be consulted without delay.

What Should Expectations from Treatment and Future Perspective Be?

When starting lymphedema treatment, expectations should be clearly discussed between the patient and the physician. Lymphedema is a chronic disease that needs to be managed, similar to diabetes or hypertension. The main goal of surgery is not to completely “eliminate” the disease but to re-establish physiological balance, relieve symptoms, and stop the progression of the disease.

In patients detected in early stages and operated on with appropriate techniques, we can see results where the need for compression garments completely disappears and the limb returns to normal. This is a very encouraging point reached by medicine. However, in advanced-stage cases our goal should be more realistic; reducing the volume of the limb, eliminating the unbearable feeling of heaviness, ending recurrent infection attacks, and enabling the patient to wear the clothes they want are major achievements.

Factors affecting treatment success are as follows:

• Stage of the disease
• Patient’s age and general condition
• Compliance with treatment
• Weight control
• Smoking