Lymphedema is a chronic and progressive disease that affects about 1% of the population, according to American data. Surgical treatments can also be applied in advanced lymphedema patients where conservative treatment is not enough. Surgical treatments in lymphedea have been applied for more than 100 years. Today, surgical treatment methods;
*Tissue Reduction (reductive/excisional) surgeries,
*Physiological surgeries and
*It can be applied in 3 ways as combined surgeries.
For the first time in history, tissue extracted techniques have been applied, and with the progression and spread of microsurgery today, it is becoming increasingly common to apply physiological procedures in the world. Today, we see that physiological procedures are applied alone in appropriate patients or that they are applied as combined therapies together with tissue reduction operations. In our country, we appreciate that some surgeons who are interested in this field and interested in microsurgery have made efforts in this regard and this situation is gradually becoming widespread. There is no center for lymphedema surgical treatment in our country. Tissue reduction surgeries related to lymphedema are partially performed by Plastic Reconstructive and Aesthetic Surgery clinics, while physiological surgeries are performed by a small number of plastic surgery specialists with personal efforts in centers that do not exceed the fingers of one hand. In the United States, Taiwan (China), Japan, The United Kingdom and European countries, there are centers that work especially on the development of physiological methods.
Tissue-reducing surgical treatments include Charles surgery, Homans surgery, Thompson Surgery, Sistrunk surgery and liposuction with surgical methods in which similar skin and subcutaneous tissues are removed. Tissue reduction surgeries are not methods that eliminate the underlying causes. They are methods that help reduce the volume of the extremity so that conservative treatments can be performed more effectively and that the patient can wear printed socks and clothes more easily. In the long term, increases in the comfort of life of patients and reductions in lymphanitis (lymph inflammation) attacks have been reported at different rates in studies conducted in different centers. However, since surgeries require the removal of massive tissue and a limb with impaired lymphatic circulation, the current risks of surgery increase and therefore become surgeries that surgeons do not want to perform. If we look briefly at tissue reduction surgery methods:
By completely removing the affected skin and subcutaneous tissues of the patient’s limb; it is an aggressive operation in which the closure of these wide wounds is tried with skin patches taken from another area. It can cause tissue and blood loss in a very large area of the patient. Due to the fact that it has aggressive surgery and causes aesthetically bad appearance, it is preferable to apply it only as the last option in patients with very advanced lymphedema.
In this method, it is usually a method in which the tissues on the inside or outside of the affected limb are thinned. If surgery is to be performed on both sides of a limb, it is recommended to do it with intervals of 3-6 months. Loss of flexibility in the skin is a method that can be applied in advanced patients who are not fully developed. Like other surgical methods, it is a method that does not completely solve the underlying lymphatic circulatory problem but provides some relief. Surgery risks include unwanted tissue loss, hematoma and wound healing problems.
Similar to Homans surgery, this method is an operation in which less tissue is removed with long incisions applied to one side of the limb. Although the risks are less than homans surgery, they have similar characteristics, but the amount of shrinkage obtained is also less.
Sistrunk surgery is a method of full layer tissue reduction in the simplest way among tissue reduction methods. In this method, a full layer of soft tissue slice from the skin and subcutaneous tissues is reduced and repair is provided afterwards. Today, it is not applied much anymore. The result depends on skin elasticity and is therefore limited.
This method, which was previously developed for aesthetic applications, was also used in the treatment of lymphedema in the 1990s. It has been applied as an alternative to other tissue reduction methods. Unlike other methods, it allows the removal of subcutaneous tissues with a cannula without removing the skin. Since skin integrity is largely maintained, its risks are less than other methods. However, it is unlikely to be applied in end-stage patients where the hardening of the skin increases and the soft tissues also harden. It may be recommended to apply it in middle-advanced patients or to combine it with other physiological surgeries. Although surgical methods for tissue reduction in general do not eliminate the cause of the disease, they reduce the average annual lymphanitis attacks and physical therapy needs of patients and increase their quality of life more or less.
Physiological surgeries performed in lymphedema surgery aim to restore, bypass or increase the continuity of the existing lymphatic current, which is mostly performed without or combining tissue removal operations, to return patients to earlier stages and to ensure its continuity. Physiological surgeries include omental flap transposition, free lymph node phlebi transplantation and lympho-lymphatic/lymphavenous shunt surgeries. Lymphatic vessels are thinner than normal blood vessels, and as the disease progresses, the structures of these vessels gradually deteriorate. For this reason, it is not always possible to perform such surgeries in the very advanced stages of the patient. They are made in the early stages and give higher and more sustained results. If we leg to physiological surgery methods:
Omentum majus is a thin layer of fat containing large vascular mesh, fat and lymphatic tissue that covers the intestines in the abdomen. It is possible to lengthen this tissue by connecting and cutting certain veins and turning it into a thin strip. As such, the entire tissue can be extended without spoiling the blood supply to areas far from the abdomen, one end of which is connected to the main vessels in the abdomen. Due to the lymph nodes in the carried tissue and the soft tissues that bleed well, they have positive effects on the blood and lymph circulation where they are carried. In order to apply omentum flap, an intra-abdominal surgery is required, so General Surgery and Plastic Surgery must perform the operation together. Although it is included in the classic Plastic Reconstructive and Aesthetic Surgery books, the number of studies in the world where omental phlebin is used for lymphedema is small. A study on this subject from our country has not been found in international publications. Since the transport of omentum tissue out of the abdomen in this way naturally causes a hole in the abdominal wall and there is an operation towards the abdomen, there are risks such as abdominal wall infection, fascial separation, ventral herni and even ileus development. I think that’s why it’s not preferred in practice by our country’s plastic surgeons. However, the free movement of some of the omentum tissue from the veins in the abdomen to areas further away from the abdomen has started to become popular again today. These can be applied by laparoscopic methods without even the need for open technique. There are publications from USA, Taiwan, Japan and Spain.
Since the structures of lymphatic vessels are very thin and difficult to find, there are difficulties in repairing these structures directly. These include the use of super-microsurgery methods, which are advanced techniques of microsurgery, and some special image methods for the application of lymphatic and lymphedean-venous shunt surgeries. With these methods and technical facilities, lymphatic vessels that are thinner than vascular structures that can normally be repaired by microsurgery methods can be found and connected to the appropriate structures and the direction of the disrupted lymphatic current can be changed. Since these are advanced techniques, they cannot be applied in all centers. There are few centers and people in the world who apply these methods. In addition, as free lymph node transfer has become increasingly popular recently, questions about this method are increasing. Its long-term success has also been called into question. Nevertheless, it is important to carry out appropriate studies in order to follow the developments in the field of medicine in case of favorable conditions in the major training clinics that will want to apply this method.
Lymphedema, as it is known, occurs due to chronic changes that occur over time as a result of the deterioration of lymphatic current. Lymph nodes are immutable parts of the lymphatic system, where lymphatic current is coordinated. Lymphedema may develop if the lymph nodes are surgically removed (regional lymph node dissection), damaged by radiotherapy, their structure deteriorates after some infections or they are not congenital. In these cases, it has been observed that the lymph nodes, which are transplanted together with vascular structures from other areas instead of untreated lymph nodes, restore the lost function in different proportions. It is not clear exactly what mechanisms or mechanisms benefit these lymph nodes, which are carried into the environment alone. Therefore, there is no conclusive evidence of which area of the extremities the carried lymph nodes should be transported to. Standard microcerahi methods can be used to transplant lymph nodes into another area with the vessels that feed them. Free tissue transplantation surgeries are performed in many educational clinics in our country. Areas where lymph nodes can be removed may vary such as groin areas, rib cage side, neck and abdomen area. Each site has its own challenges and risks. Free lymph node transfer surgeries are surgeries that have microsurgery experience and can be performed by Plastic Reconstructive and Aesthetic Surgery physicians who are familiar with regional lymph node surgeries.
Closing the wounds that occur on the skin that are difficult to heal is the subject of plastic surgery. Since deep and wide wounds will be very difficult to close on their own, these wounds need to be properly cared for and closed with some surgeries. Cleaning and healing of health-impaired tissues begins with wound care. Today, there are many different dressing materials and wound care methods specific to wounds. Plastic surgeons will guide you through the stages of handling these wounds, which dressing method should be selected and cleaning the wound with surgery and then closing it with surgery.
The first treatment of wound care is the removal of dead tissues from the wound, i.e. the Debridement process. After the dead tissues are removed from the wound, a wound care method is selected in accordance with what the remaining tissue is and its quality. There is a wide range of wound care methods ranging from simple dressing methods to technological biomaterials, complex devices such as vacuum closure therapy, hyperbaric oxygen treatments and stem cell treatments. Since you will be confused by the large variety of these products, it is advisable to trust and follow the method that your doctor has chosen for you.
Pressure sores are caused by impaired circulation of the skin due to the constant pressure applied to the same area in people whose mobility has disappeared. After advanced neurological disorders, past strokes, temporary blackouts, loss of sensation and some surgeries, pressure exposure may occur in some areas due to inappropriate plaster or care. Pressure wounds are usually observed in the area of skin between the bone protrusions and the floor. Pressure wounds start with deep tissues. Therefore, wounds that look very small from the outside may be much larger in width than previously estimated.
The treatment to be applied to the pressure wounds is decided according to the stage of the disease, the dimensions of the wound and the health status of the patient. For example, while superficial wounds caused by a temporary disorder can only be healed with wound care, Flap Surgery should be performed if the patient’s health conditions allow in deep wounds. Usually, tissues will be moved or moved from areas close to the patient’s wound area to close the wound with tissues of appropriate thickness and quality. The fact that the patient has undergone surgeries before and general health condition may cause risks in the surgery to be performed. Therefore, it may be necessary to evaluate the patient by the appropriate branches in terms of additional diseases.