Surgeons at the Center for Human Appearance at Penn Medicine are performing microsurgical vascularized lymph node transfer surgery (VLNTx) procedures for patients with lymphedema following cancer surgery.
Lymphedema manifests as the accumulation of protein-rich fluid in the interstitial spaces at the cellular level, particularly in the extremities, and is a common side effect of surgery and radiation therapy for cancer. In its advanced stages, the condition is characterized by chronic edema, cellulitis, inflammation, fibrosis, pain and disfigurement.
The Lymphedema Treatment Program of the Center for Human Appearance at Penn is designed to manage lymphedema at every stage. The Program team comprises lymphedema therapists, physical medicine and rehabilitation specialists, radiologists, medical and surgical oncologists and plastic surgeons. The Program offers compression garments, massage therapy and lymphedema pumps to patients with mild-to-moderate lymphedema to provide symptomatic relief and inhibit the progress of the disease.
Autologous vascularized lymph node transfer surgery (VLNTx) is available at Penn for patients with more advanced lymphedema. VLNTx relieves the symptoms of lymphedema by transferring healthy lymphatic tissue from a donor site in the patient’s body to a recipient site at the affected extremity to augment the drainage of lymph. Because the tissue is the patient’s own, immunosuppressants are unnecessary.
During the surgery, scarred and fibrotic tissue is first removed from the recipient site. Healthy vascularized lymphatic tissue is then obtained from a supraclavicular flap, transferred to the recipient location and microsurgically anastomosed there to an artery and vein. Over time, the transposed tissue stimulates reconnections between the obstructed and healthy lymphatic systems, promoting lymph flow and reducing inflammation and infection in the limb. Typically, a substantial reduction in limb diameter occurs within two to three weeks.
Mrs. M, a 54-year-old woman, came to Penn Plastic Surgery for evaluation of severe, advanced lymphedema in her right leg three years after a right-sided mastectomy for breast cancer followed by radiation therapy.
When her lymphedima became apparent in the weeks after surgery, Mrs. M began a course of therapy that included massage, compression sleeves and the use of a lymphedema pump. While these treatments were efficacious in the short term, Mrs. M’s lymphedema became resistant to therapy over time and was exacerbated by repeated episodes of cellulitis. Distressed by the progressive disfigurement of her leg, Mrs. M contacted her oncologist and was referred to Penn Medicine.
On physical examination at Penn, Mrs. M’s right leg circumference exceeded that of her left by almost 40%. After a thorough review of the available options for treatment, Mrs. M opted for a VLNTx procedure.
During her surgery, scarred and fibrotic tissue was first removed from Mrs. M’s groin until what remained was healthy tissue. An estimation from the incision site was then made to determine the dimensions of the tissue to be transferred. A flap comprised of superficial lymph nodes and their vasculature was then harvested from the base of her neck, transferred to the recipient site and microsurgically anastomosed to an artery and vein.
Mrs. M went home two days after surgery. Her recovery was unremarkable. At her first follow-up visit three weeks after surgery, her edema and swelling was substantially diminished (Figure 1) and she reported that she had returned to a moderate exercise regimen. She continues to use compression garments, and visits Penn Medicine’s Lymphedema Services for regular monitoring and assessment.
Penn Plastic Surgery performs more than 1,800 cosmetic and reconstructive procedures each year, and is the hub for the largest volume of breast reconstruction surgeries (including latissimua and DIEP flaps) in the region.
As a result of its expertise in breast reconstruction, plastic surgeons at Penn are actively involved in the management of the adverse cosmetic effects related to cancer treatment, including lymphedema. Treatments embrace both non-surgical and surgical techniques, including microsurgery, a technology that permit surgeons to perform anastomoses on minute blood vessels, nerves and other tissues.
Performing Autologous Vascularized Lymph Node Transfer Surgery at Penn Medicine
Suhail K. Kanchwala, MD
Assistant Professor of Surgery
Joy C. Cohn, PT, CLT-LANA
Team Leader, Lymphedema Services
AccessCenter for Human Appearance
Perelman Center for Advanced Medicine
East Pavilion, 1st Floor
3400 Civic Center Boulevard
Philadelphia, PA 19104