Lymphovenous Anatomosis (LVA)
Say Goodbye to Compression Garments after Dr. Cheng's Lymphedema Microsurgery
Lymphedema
A common problem cancer survivors face is post-operative lymphedema. Lymphedema is caused by excess fluid that collects in the body’s tissue, causing swelling (edema). The symptoms are typically swollen limbs due to lymphatic circulation blockage. Some patients may also experience skin problems (eczema, rough skin, unidentified protrusion), repeated cellulitis or toe mold infection. Award winning plastic surgeon Dr. Cheng specializes in reconstructive surgery and is an expert in the lymphovenous anatomosis (LVA) technique, a minimally-invasive microsurgery procedure that can address the symptoms of lymphedema. Since lymphedema is not always treatable with non-surgical rehabilitation, LVA surgery can greatly improve the condition.
Anderson,
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Medical Center Specifications and Equipment
The operating room is equipped with Mitaka microscopes, of which there are only four in Taiwan. They have a resolution of up to 16 million pixels and can magnify 42 times optically. They are very suitable for the anastomosis of lymphatic vessels and veins of 0.5 mm and are often used in lymphatic venous anastomosis, such as preoperative evaluation and intraoperative evaluation of the permeability of sutures, making the operation more stable and safe.
Case
Candidates for LVA
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Cancer patients that have had lymph nodes removed due to the disease
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Patients who have not experienced relief from non-surgical therapies
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Cheng’s grading I, and early grade II lymphedema
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Partial obstruction on lymphoscintigraphy
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Patent lymphatic ducts on ICG lymphography
Determining a Treatment Plan
For patients with grade I to IV lymphedema, an individualized treatment plan is determined based on imaging studies. Patients with grade I and early II lymphedema will undergo a lymphodynamic evaluation by indocyanine green (ICG) lymphography. The ICG injection allows Dr. Cheng to evaluate the presence and location of open, functioning lymphatic channels or dermal backflow (obstruction of lymphatic flow). This type of image study is performed via injections into the second and fourth web spaces of the fingers or toes. Images are obtained at 5 minutes, and then again after 20 hours. These image studies enable Dr. Cheng to create a customized treatment plan for each patient depending on their degree of lymphedema.
How Does LVA Surgery Work?
The most advanced, minimally invasive super-microsurgical techniques relieve lymphedema through small incisions (around 3cm). Preoperatively, ICG lymphography is used to map the lymphatic system on the skin and locate the incisions. Once the lymphatic channel and a suitable vein have been identified and prepared, a connection between them is created to give the lymphatic fluid an alternative route to escape from the affected area. The lymph fluid will then drain effectively through the vein.
Surgical Techniques
If LVA surgery is chosen for a patient, Dr. Cheng’s preference is to perform one or two Side-To-End (lymph-to-vein) anastomosis. Using super-microsurgery techniques, Dr. Cheng performs the LVA surgery so that the lymph can drain into the vein from both proximal and distal directions. Into the planned incision, allowing the lymphatic channels to be easily detected. The can then be seen draining from the lymphatic channel into the vein, confirming LVA surgery success. ICG fluorescence may also be used to verify a successful LVA surgery.
Side-to-end (Cheng’s Technique)
End-to-end (Koshima’s Technique)
End-to-end (A and B) end-to-side (C and D) anastomosis are shown. The decision to perform one versus another is based on the intrinsic functionality of the native lymphatic and the inherent pumping mechanism. If the venous pressure is greater than the lymphatic pressure, the blood is regurgitated and causes the anastomosis thrombosis (B and D). Bidirectional lymph will flow into the vein in a side-to-end fashion (C and D).
Data source: Principles and Practice of Lymphedema Surgery. Cheng MH, Chang DW, Patel KM (Editors). Elsevier Inc, Oxford, United Kingdom. ISBN: 978-0-323-29897-1. July 2015, page 63.
Patency test of the side-to-end lymphovenous anastomosis using indocyanine green lymphography (right) and patent blue (left)
Q1
What does the lymphatic system do?
The lymphatic system is vital to ensure a healthy body. It is responsible for circulating protein-rich lymph fluid though the body. During this process, it collects bacteria, viruses and waste. The fluid gets carried through the lymph vessels to the lymph nodes where the waste is filtered out by infection-fighting cells. The lymphatic system is part of the body's immune system and a crucial aspect of a person's health.
Q2
What are the causes of lymphedema?
Lymphedema occurs when your lymphatic system is unable to properly drain lymph fluid. While primary lymphedema occurs on its own, secondary lymphedema, which is more common, is caused by a disease or condition. Secondary lymphedema is usually seen when the lymph nodes are removed, oftentimes as part of a cancer treatment. Lymphedema can also be caused by damage to the lymph nodes, from radiation treatment or infection. Should there be a blockage in the lymphatic system, the lymph fluid will not drain well. This leads to fluid buildup and swelling, which
generally occurs in the arms and legs.
Q3
How can LVA surgery improve lymphedema?
LVA surgical approaches, like Dr. Cheng's advanced LVA technique, are effective in reducing or eliminating lymphedema swelling and discomfort. The LVA method directly connects the lymphatic vessels in the affected area to nearby veins. This allows the built-up lymph fluid to drain, which improves the fluid circulation in the body. Typically, LVA is an outpatient procedure, with most patients returning home the same day as the surgery.
Contact Dr. Cheng For A Consultation
If you have Breast Cancer Related Lymphedema and would like to know more about the most advanced treatments, contact Dr. Cheng. Internationally recognized as a leading lymphedema specialist, Dr. Cheng can discuss treatment options, based on your individual case. Dr. Cheng is a member of the American Society of Reconstructive Microsurgery and has performed numerous VLN surgeries on breast cancer survivors and other lymphedema patients.