Oct-Dec 2007: Surgery And LE

LymphLink Question Corner - Archived Oct-Dec 2007

By Bonnie B. Lasinski, MA, PT, CLT-LANA (Questions 1 & 2); Paula J. Stewart, MD, CLT-LANA (Question 3)

Q:  I have primary lymphedema in my legs that is under good control since I had successful CDT treatment. I wear knee-high compression stockings and toe gloves, do my self- MLD and lymphedema exercises daily. I am normal weight for my size, but since my pregnancies, I have a "pot belly" that makes me feel very self-conscious. I have been exploring having plastic surgery - a tummy tuck - to remove this fat and excess skin. One therapist that I spoke to suggested that having this type of surgery could worsen my lymphedema since the incision will cut across the collateral lymph pathways that connect from my legs to the upper part of my torso. Is this true? I found a surgeon who only operates on the skin, not the muscle; would that be safer?

A:  You have asked a controversial question that is probably on the minds of many people who have lymphedema. First of all, the decision to have elective plastic surgery is a complex one that involves both physical and psychological issues that are very specific to the individual. No one can tell you what is right for you.

Post-operative infection is a risk with any surgery, even in individuals who don't have lymphedema. However, the risk for post-op infection in a limb at risk for or a limb with lymphedema is greater because of lymph stasis. Lymph fluid is high in protein and is a perfect culture medium for bacteria to multiply. The white blood cells in the lymphedema fluid in a lymphedematous limb don't work effectively and this can allow bacteria to multiply rapidly, resulting in infection. Any surgery results in some post-op swelling and inflammation- it is a "controlled" trauma, but a trauma nonetheless. This combination of factors can worsen a pre-existing lymphedema or trigger a lymphedema in a limb at risk.

You mention a surgery that only cuts and tightens skin, not muscle. The superficial lymph pathways are located in the dermal layer of the skin so cutting the skin will cut through those pathways that were utilized during your CDT treatment to mobilize the excess lymphatic fluid from your legs into your torso. There is no way to know whether the incisions that will be made to complete your "tummy tuck" will further reduce the lymph transport from your legs to cause significant worsening of your leg swelling. There are no clinical studies of which I am aware that examine the effects of this surgery on leg lymphedema. Only you can assess how well you function now, how much the appearance of your "tummy" bothers you in relation to how much it would bother you if your leg swelling were to become significantly worse following this procedure. It is a question of checks and balances that only you can weigh.

Q:  I have had lymphedema in my right arm since my lumpectomy, lymph node dissection and radiation treatment in 2005. I have not had any treatment for the lymphedema and have had two cellulitis infections in my right arm in the past year, one requiring hospitalization for IV antibiotics.

Recently, I developed severe pain in my right shoulder and I can't lift my right arm over my head or hook my bra in the back anymore. My orthopedist diagnosed me with a partial tear of my right rotator cuff and tendonitis and recommended that I have a cortisone injection in my shoulder and physical therapy to strengthen my arm. Is it safe to have a cortisone injection in my lymph- edematous arm? The doctor assures me that it is a sterile procedure and I should not worry about infection. Is that true? I am desperate-the pain is getting worse and I can't do the things I need to do. I am right handed. What should I do? Help!

A:  There is no right or wrong answer to this question. However, your last sentence about the severity of your pain tells me that you need pain relief and you needed it yesterday! If you develop a frozen shoulder from the pain and inflammation that you are experiencing, it can worsen your lymphedema, not to mention how negatively it will impact on all your activities of daily living. Although the NLN Risk Reduction Guidelines caution against injections into a lymphedematous limb if they can be avoided, in this case, your orthopedist is trying to quickly reduce the inflammation in your shoulder so that you will be able to participate in physical therapy exercises to strengthen your shoulder and regain the mobility you are losing due to the pain.

Some lymphedema specialists recommend taking an oral antibiotic (specifically prescribed for the individual) before the procedure and two to three days following the procedure to minimize the chance of developing an infection in the affected limb. There have been no clinical studies done to support or refute this recommendation and you would have to discuss this with your physician prior to the procedure. However, your past history of cellulitis makes your risk for developing infection greater than the individual who has never had an infection in their affected limb. In fact, you should make sure that your pain is not caused by an acute cellulitis infection combined with your tendonitis. Severe inflammation in a lymphedematous limb can trigger a cellulitis in a limb that has significant lymph stasis. You would benefit from the guidance that a LE specialist has to offer concerning your current acute condition and how to best manage your untreated lymphedema, once this acute inflammation is under control. They can best advise you how to safely participate in a rehab program for your shoulder without exacerbating your lymphedema. Good communication between you, your orthopedist, LE specialist and physical therapist is essential for the best outcome.

Q:  I am a 56-year-old overweight female with primary lower limb lymphedema (just diagnosed 2 months ago) and varicose veins. I have lost 30 pounds since winter, walk about 3 miles a day, and am seeing a lymphedema therapist. A few months ago I had a small varicose vein on my ankle open up and bleed profusely. It had appeared as a "bubble" above the skin surface about a year earlier. After applying pressure and a bandage, it seemed fine. It opened up and bled again in the shower one week ago. I am keeping it wrapped until I decide what to do. My vein doctor wants to do radio frequency ablation on the lesser and greater saphenous veins in my legs, plus some phlebectomy and sclerotherapy on the surface veins. She says that the only way to prevent future bleeds like I have had is to take care of the "root" of the problem (the incompetent saphenous veins). I understand this but it seems a drastic amount of procedure just to stop a small bleeder (the scabbed opening is only 3 mm in size). I am concerned about doing this much surgery, especially with the existence of primary lower limb lymphedema. All the information I can find on the internet says that vein surgery is contraindicated with lymphedema. Yet, my physician says it may help the lymphedema and she has no reservations about going ahead with the procedures. What do you recommend?

A:  I have had a number of patients with phlebo-lymphedema and I have had them get ablation procedures for their varicose veins. Not only are the procedures safe and effective for the venous disease, but they also aid the treatment of the LE by reducing the impact of the venous insufficiency on the lymphatics. I usually speak to the physician doing the procedure and we agree on the administration of antibiotics prophylactically and on the application of compression after the procedure.

Please address questions to: Editor c/o NLN, 116 New Montgomery Street, Suite 235, San Francisco, CA 94105 or e-mail: nln [at] lymphnet.org. Deadlines for submissions (for the following issue) are: Feb 1, May 1, Aug 1, Nov 1.