Axillary Scar Release
Extremity lymphedema is a painful and functionally limiting complication of breast cancer treatment, most likely due to lymphatic thrombosis after lymph node resection and radiation. When lymph nodes are removed, the adjacent lymph vessels, which are now non-functional, become fibrosed. The prevailing theory is that surgery to the underarm and chest area traumatizes the connective tissue that encases nearby bundles of blood vessels, lymph vessels, and nerves. This trauma leads to inflammation, scarring, and eventually hardening of the tissue. Over time, this may cause more serious problems with function and mobility. The cause of this condition is interruption of the axillary lymphatics during either surgical procedures or as the effect of post-surgical radiation treatment to the axilla. Thrombosed lymphatics go through an inflammatory phase with thickening of the vessels and temporary shortening and tightening. Often, this leads to lymphedema where the stasis gives rise to a protein rich exudate into the interstitium which can become fibrotic.
Cord-like structures can form in the axilla, extending into the distal arm causing pain, limited shoulder range of motion (ROM) and functional compromise. These become attached to the axilla or chest via scar tissue. While the cording process is distinct from lymphedema, both seem to be a manifestation of the lymph stasis. Even in patients without symptoms of lymphedema, many believe axillary webbing is a sign of injury to the lymphatic system, which could suggest an increased risk of lymphedema developing at a later time.
Axillary webbing is known to be an independent risk factor for lymphedema, and patients with early webbing symptoms should likely be evaluated for surgical and non-surgical management. Moving and stretching under the guidance of an experienced therapist can help resolve the condition and stop the pain, although some patients do not improve despite all attempts at therapy. For these patients, surgical release of the skin and scar tissue in the axilla can help improve the lymphatic drainage from the arm. Dr. Barbour has had good results with release of scar tissue and significant improvements in arm motion, less heaviness, and some decrease in the size of the arm. This procedure has very little risk and frequently results in an immediately noticeable improvement for the patient.
Suction-Assisted Protein Lipectomy (SAPL)
The body has a tendency to deposit fat in areas of the arm affected by lymphedema. Suction-Assisted Lipectomy (SAPL) has been found to be successful in treating excess fat and protein-rich solids found in advanced stages of lymphedema. It must be emphasized the SAPL technique is NOT the standard cosmetic liposuction technique. The procedure must be performed using specific parameters, methods, and protocols. Patients are candidates if the swelling in the limb is due to deposits of fat, protein, and fibrotic tissue with non-pitting edema. Studies throughout the medical literature indicate a long-term and reproducible reduction in the size of the affected arm or leg and a tremendous decrease in the rate of cellulitis or infections in the affected limb. This procedure does not appear to damage lymphatics. Published studies in the medical literature have specifically looked at the lymphatic system before and after SAPL, and no decrease in function has been found. This doesn’t cure the lymphedema, but it can get the arm down to a size the patient would then have to maintain. Volume reduction is maintained with the use of compression garments after surgery.
Lymphedema vs. Lipoedema
Lymphedema and lipoedema (lipedema) are two distinct disorders even though both involve swelling in the arms and legs. In short, lymphedema is a disorder of the lymphatic system and is commonly caused by dysfunction in the flow of lymph fluid through the arms or legs. Lipoedema, in contrast, does not involve the lymphatic system, but a pathologic, symmetric deposit of fat that most often affects the lower extremities and almost exclusively occurs in women. Lymphedema is a disorder of the lymphatic system. It involves circulation of lymph fluid and is related to the immune system. When blockages occur in the circulation of lymphatic fluid, then swelling in an arm or a leg can result. In most cases, lymphedema in the United States occurs following radiation therapy and/or removal of lymph nodes as cancer treatment. In a small number of cases, lymphedema can be spontaneous in onset or congenital. Typically, one extremity, either and arm or a leg, is effected.
Lymphedema in the arms typically occurs after treatment for breast cancer and lymphedema in the legs typically occurs after treatment for gynecologic malignancies such as cervical cancer. Lymphedema is treated with therapy such as complete decongestive therapy, which is administered by a trained lymphedema therapist. Highly technical surgeries can also be used to treat lymphedema. Fluid-based lymphedema can be treated with vascularized lymph node transfer (VLNT) or lymphatic venous anastomosis (LVA). In chronic, solid-predominant cases, lymphedema can be treated with suction-assisted protein lipectomy (SAPL). These procedures have been shown to be very effective in significantly decreasing excess volume, compression garment use and therapy required for patients with lymphedema in the arms or legs.
The type of procedure must be matched to the type of patient for the best result. In contrast, lipoedema is a disorder that involves the deposit of pathologic fat mostly in the legs. The fat distribution is disproportionate to the normal distribution of fat. These fatty areas often resemble fatty tumors and are typically quite painful to the touch. The fat mainly deposits on the insides of the legs and knees, causing pain when the legs touch and rub together. This causes the legs to be pushed further and further out during walking, causing eventual damage to the knees and ankles, with significant wear on the insides of the feet and shoes.
The typical treatment for lipoedema is initially conservative therapy with complete decongestive therapy by a trained lymphedema therapist. Otherwise, some patients may be candidates for tumescent liposuction aspiration and removal of the pathologic fat. In some cases, lipoedema and lymphedema disorders may overlap and the excess fat deposited in lipoedema may even cause lymphedema. Therefore, some patients who have been treated for lipoedema with either complete decongestive therapy or tumescent liposuction may require long-term treatment with compression garments as well.