Lymph Node Transfer

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 plastic surgeon, Corinne Becker, and has shown to be of great benefit to patients plagued by lymphoedema. I am one of a few surgeons in Europe offering this technique and so far 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?

A small transverse incision is made in the skin and the lymph nodes are identified in the harvest site with their supplying blood vessels. A video fluoroscopy camera is used to identify the correct lymphnodes to harvest and protect the lymph nodes that drain the donor limb, thereby minimizing any risk of developing lymphoedema at the donor site. Any scarring in the recipient site is released, as this which may contribute to lymphoedema, as well as creating a pocket for your new lymph nodes and identifying the blood vessels we are going to attach to. The donor nodes are elevated carefully ensuring they remain attached to their supplying blood vessels. The tissue is then completely removed and the artery and vein are reattached to small vessels in the recipient site. Once the lymph node flap is in place, the flap should go pink and have its own blood supply. This can be checked using the video fluoroscopy camera.

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 donor site.

An overnight stay is often necessary and all being well you can go home the following day.

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 the complications associated with this type of procedure.

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

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

Haematoma – 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 4-6hours 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.

Indentation – where the lymph node flap has been removed you may develop a slight depression. Most of this will correct naturally but any remaining indentation can be corrected with a fat transfer.

Infection – is very rare but patients with lymphoedema are prone to infection/cellulitis and you will be given prophylactic antibiotics for a week after surgery.

Seroma/ lymphocoele – is a collection of clear fluid under the skin, which sits in a pocket. This spontaneously re-absorbs 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 donor limb – in theory this should never happen, as we do not harvest the lymph nodes that drain the limb. However there is a remote risk that this occurs.

Flap failure – as the flap is relying on small blood vessels to keep it alive, there is a possibility that the flap will not work. This is in the order of about 2% risk, so it is very unlikely.

Wound healing problems – this is rare but can happen if the skin is under tension. These healing difficulties can range from minor problems, such as small areas of wound separation, to major issues, such as area of skin loss. People who are diabetic, smoke, are obese or elderly are at an increased risk of delayed healing.

No improvement – whilst a lymph node transfer should work in the majority of patients it is possible that there is minimal improvement and another surgical technique would therefore need to be considered.

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.

What happens after the operation?

When you wake up from the anaesthetic, you will have a drain in your donor site. You will have dissolvable sutures with glue dressing.

The drain is removed after 1-2 days and you should expect to be in hospital about 1-2 days.

You will need to wear your normal lymphoedema garment after 1 week and compression shorts for your groin if the nodes are harvested from your leg.

Before discharge from the hospital, you will be given a follow up appointment to see the nurses after a week to inspect your wounds. I would normally see you at 4-6 weeks or sooner should you have any problems. The lymphoedema nurse will also see you to re-measure compression garments as necessary and provide any advice needed.

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

Recovery times vary from person to person but most patients return to work at 2 weeks. You can start driving at 2 weeks, commence gentle exercise at 4 weeks and return to the gym or equivalent activities at 6 weeks.