Lymph Node Transfer with DIEP Flap

Lymph node transfer is a relatively new procedure, which is proving to be very successful in the management of lymphoedema as a result of surgical removal of lymph nodes during breast cancer treatment. It was originally described by French surgeon, Corinne Becker, and has shown to be of great benefit to patients plagued by lymphoedema. I am one of the few surgeons in Europe offering this technique and have had very promising results to date with several years follow up.

The procedure involves harvesting several superficial lymph nodes from the groin area attached to the DIEP flap. The superficial lymph nodes are not responsible for draining the leg and therefore it is unlikely that you would develop lymphoedema of your leg. However, to reduce the risk of donor site lymphoedema even further, we use a video fluoroscopy camera to identify which lymph nodes are important for draining the leg. These important lymph nodes are then avoided to reduce the risk of developing leg lymphoedema.

The lymphoedema begins to improve rapidly and many patients will notice a reduction in the size of their affected limb before discharge from the hospital. However the limb will continue to soften and reduce over the following 18 months. The lymph nodes have been shown to release cytokines (cell signaling chemicals) that encourage old lymphatic pathways to open up and new networks to develop. Most patients will notice reduced discomfort and heaviness in their affected limb. Those suffering from recurrent cellulitis should also notice a reduction in the number of episodes. Depending on the severity and length of time you have had lymphoedema, you may need subsequent procedures such as liposuction or lymphatic venous anastomosis. It is essential to continue to wear your lymphoedema garments and be managed by a lymphoedema nurse as you recover. We have our own lymphoedema nurse who will look after you throughout your time with us. She will liaise with your local team following your discharge.

What does the operation involve?

An elliptical area of skin and fat is removed from your tummy by chasing the supplying blood vessels through your rectus muscle to the femoral vessels in your groin. Lymph nodes are identified in you groin with their supplying blood vessels. They are elevated carefully ensuring they remain attached to the DIEP flap via these blood vessels. The tissue is then completely removed and the artery and vein are reattached to small vessels under your arm. The rectus muscle is left completely intact. The abdomen is closed in the same way as a tummy tuck, leaving a horizontal incision in the lower abdomen and a small incision around your new umbilicus (belly button). An incision is made under your arm to release any scarring which may contribute to lymphoedema, create a pocket for your new lymph nodes and identify the blood vessels we are going to attach to. Once the breast flap is reattached to its new blood supply it can be inset to create a breast. The breast skin removed at the time of your mastectomy will be replaced with a leaf shaped area of skin from your abdomen.

Your incisions will be closed with a dissolvable suture that does not need removing. You will have waterproof glue based dressing, which will gradually dissolve at about 3 weeks. You can shower as soon as you want and do not need any dressing changes.

A tube (called a drain) will drain off any excess blood or body fluid from your abdomen and breast.

What are the risks and side effects of surgery?

Having surgery should be a very positive experience. Complications are infrequent and usually minor. However, no surgery is without risk and it is important that you are aware of these potential problems.

Scar – scars tend to settle remarkably well, however some people heal with thick scars and this can make them more noticeable.

Bruising and swelling – bruising and swelling is very common and may take several weeks to settle.

Haematoma – this can happen if a bleed occurs under the skin, allowing a large blood clot to form. If this does occur, it is likely to happen within four to six hours of surgery. Any increase in swelling or pain should be reported immediately so that treatment can be given. Sometimes patients need to have this blood removed with another short operation.

Infection – this is rare. You will be given antibiotics to cover you during the postoperative period and hopefully this will prevent infection.

Seroma / lymphocoele – this is a collection of clear fluid under the skin, which sits in a pocket. This spontaneously reabsorbs over the course of a couple of weeks, although it can be drained with a needle if it feels tight. Vary rarely a surgical procedure may be required if it does not reabsorb.

Lymphoedema of the leg – in theory this should never happen, as we do not harvest the lymph nodes that drain your leg. However there is a small risk that this could happen if the wrong nodes are taken or there is an abnormal lymphatic supply to your leg.

Flap failure – as the flap is relying on small blood vessels to keep it alive, there is a small chance the flap may not work. This is in the order of about 2% risk, so it is very uncommon. The flap may not be possible at the time of surgery or it may stop working within the first 24 hours. It is uncommon that you would have any problems after this. If a flap fails then another reconstructive option would be used.

Wound healing problems – this is rare but can happen if the skin is under tension or the blood supply to the flap has been damaged in any way. These healing difficulties can range from minor problems, such as small areas of wound separation, to major issues, such as area of skin loss. Although very rare, this situation may require a skin graft to close the wound, meaning more surgery. People who have diabetes, smoke, are obese or elderly are at an increased risk of delayed healing.

Fat necrosis – this occurs when small areas of fat within the flap have a reduced blood supply and firm up leaving a palpable thickening under the skin. In most cases this settles with massage but it may require a further procedure to remove the fat.

Dog-ears – these are prominences of soft tissue found where the scar stops. In most cases these settle over the course of 3 months. However a small local anaesthetic procedure may be required to remove any excess that remains.

Numbness, reduced sensation or oversensitivity – this will occur around the scars. This is sometimes temporary, but for most patients these changes will remain to some degree.

DVT/PE – following any surgical procedure it is possible to develop a blood clot in your legs, which could potentially break off and move to your lungs. If the blood clot is large enough it could prove fatal. In order to reduce any risks of this we give you special stockings to wear in bed and a blood thinning injection if you are not mobile.

All the risks will be discussed in detail at your consultation. However, if you have further questions or concerns, do not hesitate to ask. Decisions about surgery should never be rushed.

What happens after the operation?

When you wake up from the anaesthetic, you will have a drain coming under your arm to remove any fluid collecting in your breast and two drains coming out from your abdomen. You will have dissolvable sutures with glue dressing.

The drains are removed at about 3 days and you should expect to be in hospital about 5-7 days.

You will need to wear a support bra and an abdominal corset to help shape your breast and support your abdomen as you are healing. You should purchase this before your operation and I can guide you in your consultation.

Before you leave the hospital, you will be given a follow up appointment to see the nurses at a week to check your wounds. I would normally see you at 2 weeks or sooner should you have any problems. The lymphoedema nurse will also see you to re-measure compression garments as necessary and give advice needed.

What is the estimated time for recovery, absence from work and return to usual activities?

Recovery times vary from one person to another but most patients return to work at 8-12 weeks. You can start driving at 2 weeks, commence gentle exercise at 4 weeks and return to the gym at 6 weeks.