Developing lymphedema – painful swelling in the arm, underarm, hand, chest, abdomen, or back – after breast cancer has traditionally been viewed as a risk worth taking to undergo breast cancer surgery.
Even in skilled surgical hands, about 30% of patients develop lymphedema after lymph node dissection, in which 5-30 lymph nodes are removed during cancer surgery and analyzed for signs that the cancer has spread beyond the breast.
Lymphedema can change how a patient looks and feels about their body – on top of the physical and emotional challenges of breast cancer treatment. But an advanced procedure called immediate lymphatic reconstruction (ILR) can reduce the risk of developing lymphedema by 20% or more.
ILR is a microsurgery performed by a plastic surgeon right after mastectomy is complete. Using a microscope and fluorescein – a dye that illuminates the 0.5mm-wide lymphatic vessels – we can differentiate between the vessels that drain the breast and those that drain the underarm and reroute the flow of lymphatic fluid to be filtered out of the body.
Research has shown that fewer than 10% of patients develop lymphedema within five years after ILR. Working together with UT Southwestern’s Breast Cancer team, the Plastic Surgery team offers this advanced and effective procedure to treat lymphedema and reduce the risk of its recurrence.
ILR is available now and serves as a complement to the nationally recognized skill of our breast cancer surgeons. For patients who qualify, ILR enhances life after breast cancer surgery.
Candidacy for ILR and what to expect
Any patient who qualifies for breast cancer surgery and will have a lymph node dissection may be a candidate for ILR. However, the breast cancer surgeon may not know whether lymph nodes will be removed until lumpectomy or mastectomy begins.
Radiation therapy may also damage healthy lymph nodes in the process of destroying cancer cells. Patients who will need radiation therapy after breast cancer surgery are at increased risk of developing lymphedema and may want to discuss with their surgeon whether ILR is a good option for them.
Recovery from IRL is similar to that of lymph node dissection. Along with care instructions for the mastectomy, patients will go home with a drain in their underarm to help manage swelling and will need to avoid raising their arm above shoulder height for about two weeks.
After one year, we will check the health and function of the lymphatic vessels through lymphoscintigraphy, an exam that uses special dye to show us the reconstructed vessels under a specialized scanner.
While IRL can significantly reduce the chances of developing lymphedema, the risk is not zero. If lymphedema occurs, UT Southwestern offers the most advanced nonsurgical and surgical therapies to manage lymphedema symptoms and improve long-term quality of life.
Related reading: Lymphedema Q&A with Kim Barker, M.D.
Treatment options if lymphedema develops
Every patient who has breast cancer surgery at UT Southwestern will get a referral to our lymphatic therapists. These specialists understand the complexities of lymphedema and can personalize a care plan to a certain area or specific symptoms, such as:
- Swelling that increases over time
- Heavy or bulky feeling
- Blisters that produce clear fluid
- Dull ache
- Recurrent skin infections
- Tighter fitting jewelry and clothing
- Thickened skin that limits range of motion
Many patients with lymphedema can manage symptoms by wearing compression garments that gently press excess fluid into the blood vessels for removal. Compression garments can be difficult to put on, and our lymphedema therapist will demonstrate the best way to wear them.
Lymphedema stresses the skin, making it more susceptible to infections if the area dries out, cracks, or gets cut or scraped. The lymphedema therapist educates patients on strategies to keep the skin hydrated as well as massage and exercise techniques to help drain lymph fluid.
If nonsurgical treatment alone does not adequately control lymphedema symptoms, we offer three surgical options to reduce swelling and improve range of motion:
- Vascularized lymph node transfer (VLNT): This microsurgery involves transplanting healthy lymph nodes, blood vessels, and fat from one area of the body to the area affected by lymphedema. The goal is to restore the lymphatic “pump” function by replacing the lymph nodes and encourage new fluid management pathways to form (lymphagiogenesis). Patients may notice symptom changes around six weeks after surgery. In a 2021 study of 67 patients, 75% experienced fewer pain symptoms after VLNT.
- Lymphovenous bypass (LVB): This newer procedure is similar to IRL in that it involves rerouting flow from healthy lymph vessels to nearby veins for drainage before the lymph encounters the area of blockage. The difference is that it is a form of delayed reconstruction (not at the time of mastectomy) and typically done closer to the hand in the forearm. Early results are promising, and more data are needed to track long-term results.
- Debulking: Clinically advanced lymphedema can cause inflammation, stimulating the growth of fat cells that compound swelling. Debulking through liposuction removes the fat and fibrous tissue, which can help reduce swelling and improve range of motion.
Lymphedema surgery is most effective when performed as early as possible, so talk with your doctor about symptoms as soon as they arise. If you are planning for cancer surgery, talk with your doctor about your risk of lymphedema and strategies to reduce it.
As immediate lymphatic reconstruction becomes more widely used, our cancer surgeons will begin to offer it for other types of cancers that will require lymph node removal. With new and advanced treatments improving every year, we can help more patients function and feel better after surviving cancer.