Supermicrosurgery for prevention or treatment of lymphoedema

Supermicrosurgery for lymphoedema is a set of highly precise operations that reconnect the body's tiny lymphatic vessels, the channels that drain excess fluid from your tissues, when they've stopped working properly. Surgeons work under a powerful microscope on vessels often less than 0.8mm wide, using stitches thinner than a human hair.

What conditions does it treat?

This surgery treats lymphoedema, a long-term build-up of fluid that causes swelling, usually in an arm or leg. It's considered for lymphoedema caused by:

• damage to, or removal of, lymph nodes during cancer surgery, such as breast, uterine or ovarian cancer treatment
• damage to the lymphatic system from radiotherapy
• other, non-cancer-related causes of lymph node or vessel damage
• lymphoedema that hasn't improved enough with compression garments, bandaging or specialist lymphatic massage
• in some cases, lymphoedema someone has been born with, once other treatable causes of swelling have been ruled out.

What are the benefits of having supermicrosurgery?

Unlike compression garments and bandaging, which only control symptoms, this surgery aims to treat the underlying blockage by creating a new drainage route for lymph fluid. In case series of patients with established lymphoedema, this approach has worked well even for relatively advanced disease.

Many people are able to reduce how much they rely on compression garments and medication after surgery, and some no longer need them at all. Full reversal without any ongoing compression tends to be more achievable for lymphoedema caught early, rather than long-standing or advanced cases, so your surgeon will discuss what's realistic for you.

Are there different types or surgical approaches?

There are two main supermicrosurgical operations. Lymphaticovenular anastomosis (LVA) connects small lymphatic vessels directly to nearby veins, creating a bypass around the blockage; it's generally most suitable for earlier-stage lymphoedema. Vascularised lymph node transfer (VLNT) moves healthy lymph nodes, with their blood supply, from elsewhere in your body to the affected area, and tends to be used for more advanced disease.

A third option, specialised liposuction, removes excess fat and fluid that has built up in a limb over time; this doesn't reconnect the lymphatic system, but can significantly reduce limb volume in suitable patients. Your surgical team will use imaging to help decide which approach, or combination, suits you best.

What happens before the operation?

Before surgery, your team needs a detailed picture of how your lymphatic system is working.

• You'll have imaging such as ICG (indocyanine green) lymphography, where a fluorescent dye is injected and tracked with an infra-red camera to map your lymphatic channels
• This imaging also helps stage how advanced your lymphoedema is, which guides which operation is likely to help most
• Other conditions that cause swelling, such as heart, kidney or vein problems, are usually ruled out beforehand
• You'll be asked about your ability to commit to wearing compression garments both before and after surgery, since this affects how well the operation works
• Your team will check for other health conditions or allergies that might affect your suitability for surgery
• Most LVA procedures can be done under local anaesthetic, so your preparation may be more straightforward than for a general anaesthetic; your team will confirm what applies to you.

What happens during the procedure?

For LVA, a typical operation involves:

1. Locating your lymphatic channels using a fluorescent dye and an infra-red camera to guide where the surgeon will operate
2. Making around four small incisions, roughly 2cm long, on the affected limb at the sites of the detected lymphatic channels
3. Identifying the tiny lymphatic vessels and small veins just under your skin, both typically between 0.2mm and 0.8mm across
4. Joining the lymphatic vessel to the vein under an operating microscope, using stitches thinner than a human hair, so fluid can drain into your working veins instead of pooling in the tissue
5. Repeating this at each site, since more of these joins is linked to better fluid reduction, within an operation that usually takes around 2 hours, and up to about 4 hours for more complex cases.

Vascularised lymph node transfer follows a different pattern, since it also involves preparing and moving healthy lymph node tissue, with its blood supply, into the affected limb, so it's a longer and more involved procedure than LVA.

What does recovery look like?

LVA is minimally invasive, and many patients have it under local anaesthetic, which can mean going home the same day; some units offer it as an overnight stay instead. VLNT is more involved and typically needs a hospital stay of around 3–5 days.

Wearing your compression garments as directed, both before and after surgery, is essential to how well the treatment works, so your team will be very clear about this. Wounds are usually small and heal within around 2 weeks, though you're generally advised to avoid sports or strenuous activity for about 6 weeks.

Improvement in swelling can take time to become noticeable, and your team will monitor your progress at follow-up appointments. It's also important to keep up with any skincare routine you've been given, since keeping the skin healthy helps to lower the risk of infections such as cellulitis.

What are the risks and complications?

This is generally considered a safe procedure, but as with any surgery, there are risks, including:

• the usual risks of any operation, such as infection, bleeding or scarring at the incision sites
• the join between the lymphatic vessel and vein not working as well as hoped, particularly if your lymphoedema is more advanced or your lymphatic vessels have become scarred
• needing to continue with some compression garment use, even if your symptoms improve
• for lymph node transfer, a small risk of developing lymphoedema in the area the healthy nodes were taken from
• a longer operation and hospital stay with lymph node transfer, compared with LVA.