Lymphedema Strategies for Investigation and Treatment: A Review

Lymphedema Strategies for Investigation and Treatment: A Review

Oct/Dec 2012

Pankaj Tiwari MD 
Michelle Coriddi MD 
Susan Lamp BSN, RN, CPSN 

Plastic Surgical Nursing

**For information only.  There is much controversery regarding surgical treatment for lymphedema**

Abstract

The goal of this article was to define lymphedema as a disease entity, to introduce the American Lymphedema Framework Project, and to summarize current surgical strategies on the horizon in the surgical treatment of lymphedema.

LYMPHEDEMA DEFINED

Alongside the arterial and venous vasculature, the lymphatic system is a part of the circulatory system. Lymphatic channels primarily regulate the flow of fluid in the interstitium (Ellis, 2006). Under normal conditions, venous capillaries reabsorb 90% of the fluid in the tissues, and lymphatic channels absorb the remaining 10% of lymph fluid, proteins, and other molecules (Warren, Brorson, Borud, & Slavin, 2007). Lymphatic fluid passes to regional lymph node basins. Ultimately, the lymphatic fluid is transported back into the subclavian vein to enter the venous system via the thoracic duct.

Lymphedema is an external or internal manifestation of lymphatic insufficiency and deranged lymph transport (International Society of Lymphology, 2009). This insufficiency causes an accumulation of protein-rich interstitial fluid, leading to distention, proliferation of fatty tissue, and progressive fibrosis. Skin changes such as thickening and hair loss may occur. Progressive lymphedema without adequate management can lead to functional impairment, compromised quality of life, and deformity. Clinically, lymphedema is noted as swelling of the involved extremity. The head and neck, breast, or genitalia may also be affected (McWayne, & Heiney, 2005; Rockson, 2010; Smeltzer, & Stickler, 1985).

Lymphedema is generally classified as either primary or secondary. Primary lymphedema (hereditary) is related to congenital malformation of the lymphatic channels. Secondary lymphedema results from disruption to the lymphatic system. Primary lymphedema can result from any one of a number of disorders that may be sporadic or hereditary. Syndromes such as Milroy's disease and Prader-Willi syndrome have lymphedema as an element of their clinical manifestations to varying degrees. The estimated prevalence of primary lymphedema is 1.15 in 100,000 persons under the age of 20 years Milroy's Disease (Smeltzer & Stickler, 1985). In children, the two main causes are Milroy's disease and lymphedema distichiasis (International Society of Lymphology, 2009).

Secondary lymphedema is a consequence of removal or damage to lymph nodes, fibrosis of the nodes (postradiotherapy), and trauma or infection secondary_lymphedema Rockson, 2010). Upper extremity lymphedema is commonly associated with the treatment of breast cancer. The degree of lymphedema has been well recognized to correlate with the number of lymph nodes that have been removed and the extent of radiotherapy to the axillary region. Lower extremity lymphedema is most often seen in survivors of uterine and prostate cancer, as well as melanoma and lymphoma survivors (Meneses & McNees, 2007). Most cancer survivors develop lymphedema within 3 years of treatment (Petrek, Senie, Peters, & Rosen, 2001).

In addition to cancer ablation, side effects of advanced diseases such as congestive heart failure, neurological and liver disease, and end-stage renal disease can cause chronic edema. An increase in the bariatric population has also seen an increase in lymphedema incidence. Lympedema caused by the parasite wucheria bancrofti and transmitted by mosquitoes remains the most common cause of lymphedema worldwide. Unfortunately, no strategies employed to prevent the onset of lymphedema have proven fruitful to date. The term chronic edema has been adopted by European investigators to define a population of patients with long-standing edema (>3 months). Prevalence estimates for chronic edema are between 1.3 and 1.5 per thousand.

New clinical data suggest that some patients may have a primary disposition to lymphedema but that this first becomes clinically evident after a secondary eliciting event (Rockson, 2010). Lymphedema tarda is defined as debut after the age of 35 years. It is often associated with an eliciting factor such as trauma or an inflammatory reaction (Kerchner, Fleischer, & Yosipovitch, 2008).

Complete text:

Nursing Center

Microsurgical Techniques for the Treatment of Breast Cancer-related Lymphedema: a Systematic Review.

Dec 2012

Penha TR, Ijsbrandy C, Hendrix NA, Heuts EM, Voogd AC, von Meyenfeldt MF, van der Hulst RR.

Source

Department of General Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands.

Abstract

Background 

Upper limb lymphedema is one of the most underestimated and debilitating complications of breast cancer treatment. The aim of this review is to summarize the recent literature for evidence of the effectiveness of lymphatic microsurgery for the treatment of breast cancer-related lymphedema (BCRL).

Methods 

A search was conducted for articles published from January 2000 until January 2012. Only studies on secondary lymphedema after breast cancer treatment and those examining the effectiveness of microsurgery were included.

Results 

No randomized clinical trials or comparative studies were available. Ten case-series met inclusion criteria: (composite) tissue transfer (n = 4), lymphatic vessel transfer (n = 2), and derivative microlymphatic surgery (n = 4). Limb volume/circumference reduction varied from 2 to 50% over a follow-up time ranging from 1 to 132 months. Postoperative discontinuation rates of conservative therapy were only reported after composite tissue transfer, ranging from 33 to 100% after 3 to 24 months. Clear selection criteria for lymphatic surgery and lymphatic flow assessment were absent in most studies.

Conclusion 

We identified important methodological shortcomings of the available literature. Evidence acquired through comparative studies with uniform patient selection is lacking. Consistent positive findings with regards to limb volume reduction and limited complications are reasons to further explore these techniques in methodologically superior studies.

Thieme

The effect of mechanical lymph drainage accompanied by heat

The effect of mechanical lymph drainage accompanied with heat on lymphedema.

Nov 2012

Mariana VF, de Fátima GG, Maria Pde G.

Source

Associate Professor, Godoy Clinic, Paulista University, São Jose do Rio Preto, Brazil.

Abstract

KEYWORDS: Thermotherapy, Lymphedema, Mechanical Lymph Drainage

BACKGROUND:

Thermotherapy has been indicated by some researchers as a treatment for lymphedema. A study comparing temperatures demonstrated that a temperature of 40°C significantly increased the transportation of lymph compared to other temperatures assessed. The aim of this study was to evaluate the possible benefits of mechanical lymph drainage accompanied with heat in the treatment of lymphedema of the lower limbs.

METHODS:

In a cross-over randomized study, the effect of heat on lymph drainage was evaluated in the treatment of leg lymphedema. The study, performed in the Godoy Clinic in São Jose do Rio Preto, Brazil, involved seven patients (two males and five females) with leg lymphedema. The patients' ages ranged from 18 to 79 years old with a mean of 48.5 years. The subjects underwent a total of 38 assessments including 19 evaluations of mechanical lymph drainage alone and 19 combined with thermotherapy. Heat was applied using an electric blanket which was wrapped around the legs of the patients. The volume of legs was evaluated by water plethysmography before and after treatment sessions. The paired t-test was used for statistical analysis with an alpha error of p = 0.05 being considered as acceptable.

RESULTS:

No statistically significant differences were evidenced between mechanical lymph drainage alone and lymph drainage combined with thermotherapy.

CONCLUSIONS:

There was no obvious synergic effect in the immediate post-treatment period when heat was combined with mechanical lymph drainage in the treatment of lymphedema. 

Journal of Research in Medical Sciences

Lymphedema Strategies for Investigation and Treatment: A Review

Lymphedema Strategies for Investigation and Treatment: A Review

Pankaj Tiwari MD 
Michelle Coriddi MD 
Susan Lamp BSN, RN, CPSN 

Plastic Surgical Nursing
October/December 2012  
Volume 32 Number 4 
Pages 173 - 177

Abstract

The goal of this article was to define lymphedema as a disease entity, to introduce the American Lymphedema Framework Project, and to summarize current surgical strategies on the horizon in the surgical treatment of lymphedema.

LYMPHEDEMA DEFINED

Alongside the arterial and venous vasculature, the lymphatic system is a part of the circulatory system. Lymphatic channels primarily regulate the flow of fluid in the interstitium (Ellis, 2006). Under normal conditions, venous capillaries reabsorb 90% of the fluid in the tissues, and lymphatic channels absorb the remaining 10% of lymph fluid, proteins, and other molecules (Warren, Brorson, Borud, & Slavin, 2007). Lymphatic fluid passes to regional lymph node basins. Ultimately, the lymphatic fluid is transported back into the subclavian vein to enter the venous system via the thoracic duct.

Lymphedema is an external or internal manifestation of lymphatic insufficiency and deranged lymph transport (International Society of Lymphology, 2009). This insufficiency causes an accumulation of protein-rich interstitial fluid, leading to distention, proliferation of fatty tissue, and progressive fibrosis. Skin changes such as thickening and hair loss may occur. Progressive lymphedema without adequate management can lead to functional impairment, compromised quality of life, and deformity. Clinically, lymphedema is noted as swelling of the involved extremity. The head and neck, breast, or genitalia may also be affected (McWayne, & Heiney, 2005; Rockson, 2010; Smeltzer, & Stickler, 1985).

Complete article:

Nursing Center.com

How to Cure Lymphedema

How to Cure Lymphedema

Yet another “new” item that seems to be showing up in regards to lymphedema is the claim that you can cure lymphedema.

Use this lotion - take this potion!

In the days of the old West, we always hear the stories of snake oil salesmen traveling through the countryside with their wagons hustling “magical cures” for all ailments.

We are much more sophisticated today, now we use the internet to sell the snake oil.

Please understand that as of this date (Dec. 31, 2011) there is absolutely no “cure” for this condition. Don't be misled by someone who claims to have such cure. Certain techniques that claim to cure lymphedema is exercise and/or microsurgery, lymph node transplant. First, there is absolutely no evidence to support the claim the early intervention and exercise can cure LE. Microsurgery does hold promise and some have had initial good results. However, that is still considered as experimental and there are no studies out showing the long term results (10 years).

Lymph node transplant is also very very early in its use and is considered quite controversial and is very much experimental. Also, because there is mounting evidence that anyone who gets secondary lymphedema was born with a defective lymph system. Yanking out nodes in these individuals to put elsewhere is simply transferring the locale of the potential start of lymphedema. We need honest, clear independent clinical research on outcomes that cover not simply a couple years or even five years, but much further out to include 10 years and 20 years.

Why is there no cure?

The understanding of this, rests in the pathophysiology of lymphedema. Lymphedema is caused by either trauma/damage to the lymphatics and/or being born with a malformed lyhmp system. Those born with it may also be missing lymph nodes throughout their body. This is why I had LE from birth. I am missing critical inguinal lymph nodes as demonstrated by a lymphangiogram I had back in 1966,

The only way to cure lymphedema is to have that lymph system repaired (healed) or to have any missing nodes regrown.

There is no way of doing that, at the moment. There IS promising research going on, but we are still a long way off.

Believe me, if anyone would hope for a cure for this rotten condition it would be me. Mine started from birth some 50 years ago and presently I am having to cope with many complications, some of which includes lymphoma (a lymphatic cancer) and had massive pleural effusions.

Continued:  How to Cure Lymphedema

Experimental Lymphedema: Can Cellular Therapies Augment the Therapeutic Potential for Lymphangiogenesis?

Experimental Lymphedema:  Can Cellular Therapies Augment the Therapeutic Potential for Lymphangiogenesis?

2012

Stanley G. Rockson

Journal of the American Heart Association

Case presentation on the treatment outcome of CDT in primary lymphedema

Case presentation on the treatment outcome of CDT in primary lymphedema

Primary Lymphedema 

The Unilateral Lower Extremity; Methods and Results

A Case History

By John Mulligan, RMT/CLT-LANA

Clinical Specialist with Lymphedema Depot Ltd
Importer of Solaris lymphedema care products

Article:

Solaris Med

A newly designed SIPC device for management of lymphoedema.

WARNING TO ALL LYMPHEDEMA PATIENTS

This abstract is a prime example of just how bad information can be that is presented even through PubMed.

Lymphology 101 clearly shows that high pressure pneumatic devices can cause serious damage to the good lymphatics, making lymphedema even worse.

Read this for education, but please, please, please, what ever you do never ever ever set the compression level on high if you use a pneumatic device.

A newly designed SIPC device for management of lymphoedema.

PubMed

Pat

Therapeutic lymphangiogenesis with implantation of adipose-derived regenerative cells.

Therapeutic lymphangiogenesis with implantation of adipose-derived regenerative cells.

Aug 2012

Shimizu Y, Shibata R, Shintani S, Ishii M, Murohara T.

Source

Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan.

Abstract

BACKGROUND:

Lymphedema is one of the serious clinical problems that can occur after surgical resection of malignant tumors such as breast cancer or intra-pelvic cancers. However, no effective treatment options exist at present. Here, we report that implantation of adipose-derived regenerative cells (ADRCs) can induce lymphangiogenesis in a mouse model of reparative lymphedema.

METHODS AND RESULTS:

 ADRCs were isolated from C57BL/6J mice. To examine the therapeutic efficacy of ADRC  implantation in vivo, we established a new mouse model of tail lymphedema. Lymphedema was improved significantly by local injection of ADRCs. Histological analysis revealed that lymphatic capillary density was greater in the ADRC group than in the phosphate-buffered saline control group. Tissue expression of vascular endothelial growth factor C mRNA and plasma levels of vascular endothelial growth factor C  ADRCs released vascular endothelial growth factor C, which directly stimulated lymphangiogenesis. Implantation of ADRCs also enhanced recruitment of bone marrow-derived M2 macrophages, which served as lymphatic endothelial progenitor cells.

CONCLUSIONS:

Implantation of autologous ADRCs could be a useful treatment option for patients with severe lymphedema.

PubMed

The Lymphedema Treatment Act

Welcome to the Lymphedema Treatment Act website!

This bill, sponsored by Congressman Larry Kissell of North Carolina, would offer coverage for Medicare beneficiaries with lymphedema from any cause.  Although this legislation relates specifically to a change in Medicare law, it would almost certainly result in all private insurance policies following suit.

WE NEED YOUR HELP!  We have no paid lobbyists; our cause is entirely grassroots and patient driven.  Please explore the site to learn more, then complete as many of the simple steps under the “How You Can Help” menu as you can.  The single most important thing you can do is take just a couple of minutes to 
Contact your members of Congress using our simple submission form.

Untreated lymphedema is progressive and leads to infection, disfigurement, disability and in some cases even death.  Thus, prognosis for the patient is far worse and treatment more costly when the disease is not identified and treated in the earlier stages.

The Lymphedema Diagnosis and Treatment Cost Saving Act of 2011, HR 2499,
will improve coverage for the diagnosis and treatment of lymphedema.

Specific goals of the bill are:

Comprehensive treatment coverage, according to current medical treatment standards, for individuals with and at risk for lymphedema;

The ability to add new treatment modalities to coverage as they become available and are approved;

Preoperative measurements for cancer patients to aid in early detection and diagnosis;

To provide for lymphedema patient education in the procedures for self-treatment so as to transfer the treatment from the clinical to the home setting;

To enable patient self-treatment plan adherence by providing necessary medical supplies for use at home, as prescribed for each patient (compression garments, compression bandages, other compression devices, pneumatic compression pumps, etc);

Reduction in total healthcare costs through avoidance of periodic infections, pain and disabilities resulting from this medical condition.

Lymphedema Treatment Act website

Lymph Node Transfer and Perinodal Lymphatic Growth Factor Treatment for Lymphedema.

Sept 2012

Honkonen KM, Visuri MT, Tervala TV, Halonen PJ, Koivisto M, Lähteenvuo MT, Alitalo KK, Ylä-Herttuala S, Saaristo AM.

Source

*A.I. Virtanen Institute for Molecular Sciences, University of Eastern Finland, Kuopio, Finland †Department of Plastic Surgery, Turku University Central Hospital, Turku, Finland ‡Department of Biostatistics, University of Turku, Turku, Finland §Molecular/Cancer Biology Program and Haartman Institute, University of Helsinki, Helsinki, Finland.

Abstract

BACKGROUND AND OBJECTIVE:  In the lymph node transfer method, lymphatic anastomoses are expected to form spontaneously. However, lymphangiogenic growth factor therapies have shown promising results in preclinical models oflymphedema. Our objective was to define the optimal growth factor treatment to be used in combination with lymph node transfer to normalize lymphatic vascular anatomy. 

METHODS:  The inguinal lymphatic vasculature of pigs was surgically destroyed around the inguinal lymph node. To enhance the regrowth of the lymphatic network in the defected area, adenoviral vascular endothelial growth factor C (VEGF-C) was administered intranodally or perinodally. Control animals received injections of saline or control vector. The lymphangiogenic effect of the growth factor therapy and any potential adverse effects associated with the 2 alternative delivery routes were examined 2 months postoperatively. 

RESULTS:  Both routes of growth factor administration induced robust growth of lymphatic vessels and helped to preserve the structure of the transferred lymph nodes in comparison with the controls. The lymph nodes of the control treated animals regressed in size and their nodal structure was partly replaced by fibro-fatty scar tissue. Intranodally injected adenoviral VEGF-C and adenoviral vector encoding control gene LacZ induced macrophage accumulation inside the node, whereas perinodal administration of VEGF-C did not have this adverse effect. 

CONCLUSIONS:  Lymphangiogenic growth factors improve lymphatic vessel regeneration and lymph node function after lymph node transfer. The perinodal route of delivery provides a basis for future clinical trials in lymphedema patients.

Lippincott, Williams & Wilkins

Editor's Note:

This is presented for information only and should not be mistaken as an endorsement of lymph node transfer.  This experimental treatment technique needs more extensive studies before it can be determined that it is both safe and effective for the patient.  Pat O'Connor

Surgical treatment of congenital lymphedema.

October 2012

Becker C, Arrive L, Saaristo A, Germain M, Fanzio P, Batista BN, Piquilloud G.

Source

Lymphedema Center, Paris, France. Electronic address: corinne.becker.md@gmail.com.

Abstract

Lymphedema is a pathologic condition that results from a disturbance of the lymphatic system, with localized fluid retention and tissue swelling. Primary lymphedema is a congenital disorder, caused by a malformation of lymph vessels or nodes. Major progress has been achieved in the radiologic diagnosis of patients affected by lymphedema. The ideal treatment of the affected limb should restore function and cosmetic appearance. Surgical treatment is an alternative method of controlling chronic lymphedema. Free lymph nodes autologous transplantation is a new approach for lymphatic reconstruction in hypoplastic forms of primary lymphedema. The transferred nodes pump extracellular liquid out of the affected limb and contain germinative cells that improve immune function.

Elsevier

Magnetic Therapy

Magnetic Therapy

Disclaimer: This is presented for information only. Inclusion does not constitute an endorsement of the therapies and/or treatment. Individuals should consult with their physicians as to its applicability in their personal situation.

A new and ever increasingly popular method of treating a myriad of diseases is magnetic therapy. I have included a section on it because of reader interest, questions and a simple desire to bring as much information as I can to those with lymphedema.

I must admit however, I was a skeptic before research and I am still unconvinced that the use of magnetic fields, magnetic polarities etc has any real medical value. In presenting the articles that follow, the reader is free to form their own conclusions.

What bothers me the most is the lack of solid double blind clinical studies that will substantiate evidence that this type of therapy actually works. The one done at Baylor University is itself, clouded in controversy. I have found not concrete evidence that it improves lymphatic flow, resolves lymphatic blockages, reverses fibrosis of subcutaneous tissues or prevents any of the other complications associated with lymphedema.
Not long ago, a member of an online support group proudly announce she was going to buy a magnetic bracelet because she had heard it would help lymphedema.  Her reasons were three fold.  First, she felt, as a patient she was "taking control" of her medical condition, Secondly, she was giving a black-eye to the terrible world of evidence based medicine by seeking a treatment outside their dark domain and finally, she felt this would be a repudiation to those monster "big-money" pharmaceutical companies.

How sad, I thought that this person, any person would place their health in danger to pursue such a dangerous course.  It is estimated by now that magnetic sales are reaching a half billion dollar mark in the US alone.  To me that equals big money, especially since it comes at the expense of the health of so many desperate people seeking effective treatment for their medical condition.  Also, every bit of information we have learned about the lymph system, lymphedema and such comes directly from this "terrible"  world of evidence based medicine and its research.

Ever more important is that we once and for all need to recognize that there is no magic bullet, no magic pill, no magic cure for lymphedema.  Indeed, if there were, we would all be lined up to buy it.  There simply is no replacement at the present time for a treatment protocol of manual decongestive therapy, compression bandages, compression garments and a compliant patient who is willing to take the time necessary for proper management...a patient who does so because they as a person are worth it.

However, please do not abandon your physician or your lymphedema therapist to undergo this therapy. This is not meant to take their place.

Pat O'Connor
Lymphedema People
Dec. 26,2011

As of today's update, there is still no clinical evidence to support the claim the magnetic therapy is of any value to lymphedema patients.  Therefore, I  simply can not recommend this therapy to anyone.

What is Magnetic Therapy ?

During the past few years, magnetic devices have been claimed to relieve pain and to have therapeutic value against a large number of diseases and conditions but what is the scientific evidence ?

Pulsed electromagnetic fields -- which induce measurable electric fields -- have been demonstrated effective for treating slow-healing fractures and have shown promise for a number of other conditions. However, few studies have been published on the effect on pain of small, static magnets marketed to consumers

Pulsed electromagnetic field therapy has also been evaluated in the treatment of soft tissue injuries, with the results of some studies providing evidence that this form of therapy may be of value in promoting healing of chronic wounds (such as bedsores), in neuronal regeneration, and in many other soft tissue injuries.
Different Types of Magnets

Both ferrite and rare-earth magnets, unlike earlier magnetic materials such as steel, have great resistance to demagnetization, allowing thin disks to be magnetized. This feature allows modern magnets to be mounted in a variety of thin products that can be applied to the body with the magnetic field emanating from the surface.

Article Continuation

Reflexology

Reflexology

What is Reflexology?

Reflexology is an alternative treatment therapy which deals with the principle that there are reflex areas in the feet and hands which correspond to all of the glands, organs and parts of the body. Stimulating these reflexes properly can, according to practitioners help many health problems in a natural way, a type of preventative maintenance.

The treatment consists of using different massage and pressure techniques to relax and loosen muscles in the feet and hands. Treatment is done with the patient lying down on a treatment bed with foot massage the main focus and hand massage after that.   According to the British Reflexology Association, “In the feet, there are reflex areas corresponding to all the parts of the body and these areas are arranged in such a way as to form a map of the body in the feet with the right foot corresponding to the right side of the body and the left foot corresponding to the left side of the body. By having the whole body represented in the feet, the method offers a means of treating the whole body and of treating the body as a whole. This latter point is an important factor of a natural therapy and allows not only symptoms to be treated but also the causes of symptoms.”(1)

Brief Background of Reflexology

Modern Reflexology is based on the work of two American physicians, Dr. William Fitzgerald and Dr. Joe Shelby Riley of the 1920's and on that of physiotherapist Eunice D. Ingham who developed Fitzgerald and Riley's knowledge into a usable therapy, calling it Foot Reflexology and took it to the public in the late 1930's through the early 70's.(2)

Does Reflexology Work for Lymphedema?

In the website Reflexology Presents, there is a section on forty-five clinical studies done on this treatment concept. However, none of them involve lymphedema. I have also not been able to locate any controlled studies anywhere, so there is nothing that conclusively demonstrates this is beneficial to lymphedema patients as far as their lymphedema is concerned.

There is a slight bit of evidence that reflexology may be useful in pain management,and in some limited types of dementia, but even then the below studies indicate more research is needed.

I was unable to find a single article that supports the efficacy of using Reflexology in the treatment of lymphedema.

Pat O'Connor

As of this update of Jan. 15, 2012, there are no independent clinical studies or evidence based medical news to substantiate the claim that reflexology is beneficial for lymphedema. Thus, this continues to be a supposed tretment method that I can simply not support or encourage anyone to have. Pat

Read More: Reflexology

π-Shaped lymphaticovenular anastomosis for head and neck lymphoedema: A preliminary study.

Oct 2012

Ayestaray B, Bekara F, Andreoletti JB.

Source

Department of Plastic and Reconstructive Surgery, Nimes University Hospital, pl Pr Robert Debré, 30000 Nimes, France; Department of Plastic and Reconstructive Surgery, Breast Institute, 15, av Jean Jaurès, 90000 Belfort, France. Electronic address: bayestaray@yahoo.fr.

Abstract

BACKGROUND:

Head and neck lymphoedema secondary to jugular lymphadenectomy is a severe issue, without efficient solution. Successful treatment of lymphoedema of the upper and lower limbs has become possible with supermicrosurgical lymphaticovenular anastomosis. The technique based on two end-to-side anastomosis is named π-shaped lymphaticovenular anastomosis. We have evaluated this method for chronic head and neck lymphoedema.

METHODS:

From November 2010 to April 2011, four patients with a chronic head and neck lymphoedema were treated by π-shaped lymphaticovenular anastomosis. Three patients had a unilateral lymphoedema, and one patient had a bilateral lymphoedema. The mean age of the patients was 63.2 years (range, 46-77 years). The mean duration of the lymphoedemawas 2.6 years (range, 1-5). Every patient was operated under local anaesthesia through a face-lift skin incision. One π-shaped lymphaticovenular anastomosis was performed at each operative site.

RESULTS:

The average operative time to perform one π-shaped lymphaticovenular anastomosis was 1.9 h (range, 1.8-2.5). The calibre of lymphatic vessels used for lymphaticovenular anastomosis ranged from 0.3 to 0.7 mm (average, 0.5). A venous back-flow was found in seven lymphaticovenular anastomosis (70%). Three patients (75%) had a qualitative improvement of skin tissue and a significant circumferential reduction after surgery. The average circumferential differential reduction rate was 3.7% (range, 0.6-7.8) (p = 0.006). The average cross-sectional area differential reduction rate was 7.2% (range, 1.2-15.1) (p = 0.007). The average volume differential reduction rate was 6.9% (range, 2-14.8) (p = 0.05).

CONCLUSIONS:

The authors present a new option to treat head and neck lymphoedema. π-Shaped lymphaticovenular anastomosis is an effective method to reduce the severity of skin tissue fibrosis and lymphoedema volume. Further studies with larger groups of patients are required to confirm the outcome of this preliminary study. EBM Level = level 4.

Elsevier