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Lymphoedema — diagnosis and surgery
Lymphoedema is first treated with complete conservative therapy (manual lymphatic drainage, compression bandaging, exercise and skin care); physiological surgery — lymphaticovenular anastomosis (LVA) or vascularised lymph node transfer (VLNT) — suits early disease with still-functioning lymphatics, and liposuction suits late disease in which excess fat predominates.
Why it matters in the exam
Primary lymphoedema: Milroy (congenital, FLT4/VEGFR3), praecox (Meige — appearing around puberty, the commonest primary form) and tarda (after age 35); secondary — worldwide mainly filariasis, and in Western countries mainly after axillary node dissection and radiation for breast cancer. ISL staging: stage 0 — latent; 1 — pitting oedema that resolves with elevation; 2 — does not resolve with elevation, and in late stage 2 already non-pitting fibrosis; 3 — elephantiasis with skin changes. The Stemmer sign — inability to pinch the skin on the dorsum of the second toe — points to lymphoedema. Diagnosis: lymphoscintigraphy, and ICG lymphography, which shows "dermal backflow"; on the MD Anderson scale stages 0 to 5 are set by flow pattern — splash, stardust and diffuse.
Complete decongestive therapy (CDT) includes a reduction phase with bandaging and a maintenance phase with compression garments, and it is the foundation for any surgery. LVA connects subcutaneous lymphatics to small veins by supermicrosurgery and suits cases where ICG shows functional lymphatics. VLNT transfers vascularised lymph nodes (from the groin, neck or omentum) to the affected area; donor-site risk — new lymphoedema in the donor limb. Liposuction removes the fat tissue accumulated in advanced non-pitting disease and requires lifelong compression garments. The Charles procedure (radical excision and skin grafting) is reserved for severe elephantiasis. LYMPHA — preventive anastomosis during axillary node dissection — reduces the risk of lymphoedema. Recurrent cellulitis is managed with penicillin prophylaxis. Long-standing lymphoedema can develop lymphangiosarcoma (Stewart-Treves).
Key points
- CDT — the foundation of all treatment.
- ISL 0 to 3; positive Stemmer sign.
- Early — LVA; without lymphatics — VLNT.
- Late and fatty — liposuction and permanent compression.
- LYMPHA — prevention during node dissection.
Summary table
| Stage or situation | Finding | Suitable treatment |
|---|---|---|
| ISL 0 to 1 | Latent, or pitting oedema that resolves with elevation | CDT; LVA with functional lymphatics |
| ISL 2 | Does not resolve with elevation | CDT, LVA or VLNT |
| Late ISL 2 to 3 | Fibrosis and fat, non-pitting | Liposuction and lifelong compression |
| Severe elephantiasis | Skin changes, infections | Charles procedure |
| Prevention | During axillary node dissection | LYMPHA |
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Sources
- International Society of Lymphology Consensus Document: Diagnosis and Treatment of Peripheral Lymphedema, 2020 — Staging and complete decongestive therapy
- MD Anderson ICG lymphography staging (Yamamoto and Chang), 2016 — Dermal backflow patterns
- Plastic Surgery (Neligan), 5th edition (2023) — Lymphoedema surgery: LVA, VLNT and debulking
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.