What is Lymphedema?
Lymphedema is a condition during which lymphatic fluid cannot normally circulate, typically from the arms or legs, towards the main veins of the central body where the fluid is typically absorbed.
Lymphedema is typically divided into two separate groups, primary and secondary.
Primary lymphedema is congenital in nature, and can be due to malformations, or syndromic causes. This type of lymphedema is present from birth, and is exceedingly rare, but often worsens throughout life.
Secondary lymphedema is caused by a variety of factors, and causes are largely specific to geographic areas.
In developed countries like the USA, most lymphedema cases are related to prior surgery, radiation, or some form of damage. In the United States, lymphedema is often identified by arm swelling after breast cancer or radiation.
Third world and less developed countries often find parasites and other infections are responsible for the condition.
There is often a significant venous component to lymphedema, which is a surprise to most people. This is because the lymphatic and venous systems are closely intertwined, and the lymphatic system drains into the venous.
Unlike the arterial system (where average pressure is approximately 100mm of mercury and circulation is actively pumped by the heart) the venous and lymphatic systems rely on passive flow due to muscle contraction and gravity to move fluid, and very low pressure systems. Average venous and lymphatic pressures are anywhere from -5mmHg to 10mmHg, depending on the area measured.
Because the lymphatic and venous systems are so low pressure, they require very little pressure to significantly impact their flow. A very small change in anatomy, such as a small scar or any pressure such as an injury, can completely obstruct their flow. This is in contrast to arteries, which require a major obstruction because of the much higher pressure and active pump, the heart.
How Does Venous Circulation Affect Lymphatic Circulation?
Any increase in venous pressure, by default, will cause a slowing of lymphatic circulation. This occurs because the lymphatic system drains into the venous circulation. This is similar to how a problem with your home’s main drain will affect any other drain.
In addition, venous circulatory system problems share many of the same symptoms as lymphatic problems – swelling, fluid buildup, pain, and often redness of the affected area. This is why venous circulation should always be investigated when a lymphatic circulation abnormality is suspected.
Correcting any venous circulatory issues often leads to clinical improvement in many lymphatic problems, due to the same logic. Although it may not solve the issue completely, it often offers a significant benefit, with a much lower risk profile as compared to lymphatic specific surgery, and does not remove the possibility of allowing lymphatic surgery in the future if needed.
Importance of Correcting Venous Problems
Aside from swelling, venous circulatory problems also impact oxygen delivery to the affected area. In doing so, poor healing and infection become more likely.
Venous narrowing is similar to a tourniquet tied around the area (and affects the circulation in much the same way). Venous blood, which is oxygen poor, mixes with arterial blood, which is oxygen rich, and the overall result is like mixing fresh water with dirty water; the overall quality of oxygen is not as bad as pure venous blood, but clearly worse than no trapped venous blood.
Lower that normal oxygen concentration impairs healing and clearance of infection. This is because your body needs a rich supply of oxygen for cellular maintenance, especially when an injury has been inflicted, as it is in surgery of any type.
Other Causes of Lymphedema
While prior surgery or radiation often cause lymphedema, congenital causes also exist.
Congenital causes are most often due to anatomic compression of veins and lymphatics by an abnormal arrangement of internal anatomy. This is typically an artery compressing the veins. This type of lymphedema often has a strong venous component. Unlike post-surgical lymphedema, which is typically one sided, congenital is typically bilateral or affects both sides of the body.
Lymphedema can also occur due to kinking of venous and lymphatic vessels. This often happens in situations where there are “hanging” tissue from certain parts of the body. This can be found in areas where there is hanging skin, or large pendulous breasts.
Lastly, it can occur due to external local compression of venous or lymphatic vessels by benign or malignant masses such as fibroids or tumors that occludes the flow in these vessels.
Ideally, the best treatment plans arise from a multi-system evaluation, and a full understanding of how they relate to each other in order to select the most effective treatment, which is what we are able to provide at NYC Surgical.
- Swelling of part of your arm or leg or your entire arm or leg, usually including your fingers or toes
- A feeling of heaviness or tightness in your arm or leg
- Restricted range of motion in your arm or leg
- Aching or discomfort in your arm or leg
- Recurring infections in your affected limb
- Hardening and thickening of the skin on your arm or leg
Swelling caused by the condition ranges from mild, hardly noticeable changes in the size of your arm or leg to extreme swelling that can make it impossible to use the affected limb.
Lymphedema caused by cancer treatment may not lead to swelling until months or years after treatment.
Make an appointment with your doctor if you notice any persistent swelling in your arm or leg.
Lymphedema in your arm or leg can lead to serious complications, such as:
- Infections. Lymphedema makes your affected arm or leg particularly vulnerable to infections. Possible infections include cellulitis — a serious bacterial infection of the skin — and lymphangitis — an infection of the lymph vessels. Any small injury to your arm or leg can be an entry point for an infection.
- Lymphangiosarcoma. This rare form of soft tissue cancer can result from the most-severe cases of untreated lymphedema. Possible signs of lymphangiosarcoma include blue-red or purple marks on the skin.
Your doctor may try to rule out other causes of swelling when diagnosing you. Swelling can have many causes, including a blood clot or an infection that doesn’t involve your lymph nodes.
If you’re at risk of lymphedema — for instance, if you’ve recently had cancer surgery involving your lymph nodes — your surgeon may diagnose lymphedema based on your signs and symptoms.
Testing typically begins with vascular and soft tissue ultrasound imaging, which is painless and non-invasive. If ultrasound imaging is inconclusive, we consider MRI, CT scanning, and lymph scanning.
Lymphedema Surgery & Treatment
Lymphedema Treatment Options
Treatment options for lymphedema start with non-surgical options such as compression garments, therapeutic massage and physical therapy. If the disease remains unmanageable with these options, surgery should be considered.
Lymphedema surgery options include a variety of techniques from lymph fluid rerouting by microsurgery and lymph node transposition, to therapeutic liposuction to remove some of the bulky tissue involved. Because NYC Surgical Associates offers the most cutting-edge diagnostic imaging along with the full spectrum of surgical options, we can tailor the plan to each patient’s needs.
Risks of Treatment
The risks of any endovenous treatment is largely the same as any other endovascular surgery. While it is for the most part a very low risk procedure, things like blood vessel damage, and blood clots can form, although this is a rare occurrence.
Most often, especially in the lower limbs, correction of narrowing of veins requires implantation of a small device called a stent, which is permanent. Although this is quite a safe procedure, it is of critical importance that your surgeon clearly illustrates the need for treatment, and discusses all options thoroughly with you prior to treatment. In the right hands, stenting has an extremely high success and satisfaction rate.
Risks of lymphatic specific surgery have additional complications as they often involve an incision unlike endovascular surgery, which is done though an IV. Most additional complications are incision related, such as infection, wound problems, and scarring. As lymphatic specific surgery is typically done where the problem exists, and scarring is one of the causes of lymphedema, there is a small but present risk that it makes the problem worse.
Risks of Non Treatment
In general, risk of non treatment is very low, and largely related to the patient’s unique case. Typically, lymphedema is a progressive disease that worsens with time, although at a very slow rate.
In severe, longstanding cases, scarring occurs due to the chronic inflammation that renders the problem partially irreversible at some point. However, this typically takes time to develop.
Your decision to seek treatment should be well thought out and only made when you have a full understanding and feel comfortable proceeding. It does not need to be an urgent decision. Medical management (non surgical) mostly consists of compression devices of numerous types and options.
Lymphedema Surgery Cost New York & New Jersey
NYC Surgical Associates is committed to helping patients receive the best care possible. That journey always begins with a medical consultation.
No two patients are exactly alike, so consultations allow us to better understand each case and determine the best treatment.
Prior to booking a lymphedema consultation with our surgical practice, our team will collect your insurance information to determine if our providers accept your specific insurance plan.
If we do not accept your medical insurance, we will inform you of any out of pocket costs associated with a lymphedema consultation and help you weigh your options. Either way, a doctor must see you before we can tell you what treatment for your condition will entail, from both a medical and cost standpoint.