Post-traumatic lymphedema: review of the literature and surgical treatment options

Abstract

Post-traumatic lymphedema (PTL) is a complex, debilitating, and potentially common disease which has received limited attention to date. The available literature is reviewed to identify injury patterns and critical lymphatic areas associated with the disease. A deeper understanding of these critical anatomic regions allows the reconstructive surgeon to potentially identify PTL patients earlier in order to apply surgical and nonsurgical interventions in the acute phase, improving lymphatic physiology and, ultimately, patient outcomes. Current diagnostic and treatment approaches are discussed in detail, with a focus on lymphatic microsurgical techniques developed and applied to PTL within the last decade.

Keywords

Post-traumatic lymphedema / traumatic lymphedema / secondary lymphedema / lymphatic reconstruction / lymphatic restoration

References

[1] Tsai RJ,Lynch CF,Zamba GK.The risk of developing arm lymphedema among breast cancer survivors: a meta-analysis of treatment factors.Ann Surg Oncol2009;16:1959-72

[2] Warren LE,Horick N.The impact of radiation therapy on the risk of lymphedema after treatment for breast cancer: a prospective cohort study.Int J Radiat Oncol Biol Phys2014;88:565-71 PMCID:PMC3928974

[3] Kasper DA.Lymphedema of the hand and forearm following fracture of the distal radius.Orthopedics2008;31:172

[4] Pereira N,Kufeke M.Prevention and treatment of posttraumatic lymphedema by soft tissue reconstruction with lymphatic vessels free flap: an observational study.Ann Plast Surg2021;86:434-9

[5] Szczesny G.The pathomechanism of posttraumatic edema of lower limbs: I. The effect of extravasated blood, bone marrow cells, and bacterial colonization on tissues, lymphatics, and lymph nodes.J Trauma2002;52:315-22

[6] Szczesny G.The pathomechanism of posttraumatic edema of the lower limbs: II--Changes in the lymphatic system.J Trauma2003;55:350-4

[7] Thomas C,Benson E.Managing lymphedema in fracture care: current concepts and treatment principles.J Am Acad Orthop Surg2020;28:737-41

[8] Hettrick H,Ward S.Incidence and prevalence of lymphedema in patients following burn injury: a five-year retrospective and three-month prospective study.Lymphat Res Biol2004;2:11-24

[9] Engeset A.Letter to editor: trauma and lymphatic injury.Lymphology2002;35:130

[10] van Zanten MC,Suami H.The lymphatic response to injury with soft-tissue reconstruction in high-energy open tibial fractures of the lower extremity.Plast Reconstr Surg2017;139:483-91

[11] Mihara M,Hayashi Y.Pathological steps of cancer-related lymphedema: histological changes in the collecting lymphatic vessels after lymphadenectomy.PLoS One2012;7:e41126 PMCID:PMC3404077

[12] International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2013 Consensus Document of the International Society of Lymphology.Lymphology2013;46:1-11

[13] Pereira de Godoy AC, Ocampos Troitino R, de Fátima Guerreiro Godoy M, Pereira de Godoy JM. Lymph drainage of posttraumatic edema of lower limbs.Case Rep Orthop2018;2018:7236372

[14] Itzchaki M,Ashur H.Lymphedema of the hand following a fracture of the distal radius.Int Surg1978;63:29-30

[15] Aköz T,Görgü M.Persistent lower eyelid lymphedema after Le Fort III maxillary fracture.Plast Reconstr Surg1998;101:858-9

[16] Freeman BG.Treatment of traumatic secondary lymphedema of the upper extremity.Ann Plast Surg1981;7:411-4

[17] Casley-Smith JR.A case of localised traumatic lymphoedema: observations concerning the obstruction of initial lymphatics and tissue channels by fibrin, and Menkin's hypothesis.Lymphology1983;16:143-9

[18] Osada A,Kamei W,Sakurai H.A case of traumatic intractable leg ulcer with lymphorrhea diagnosed using ICG lymphography.Plast Reconstr Surg Glob Open2021;9:e3489 PMCID:PMC8062140

[19] Mihara M,Todokoro T.The effect of lymphatico-venous anastomosis for an intractable ulcer at the lower leg in a marked obese patient.Microsurgery2014;34:64-7

[20] Whatley JM,Greene CC,Tatum DM.Effect of lymphedema treatment for management of acute pilon fractures.Orthopedics2017;40:e668-74

[21] Lohrmann C,Felmerer G,Schaefer O.Posttraumatic edema of the lower extremities: evaluation of the lymphatic vessels with magnetic resonance lymphangiography.J Vasc Surg2009;49:417-23

[22] Bourgeois P,Van Mieghem A,Giacalone G.Edemas of the face and lymphoscintigraphic examination.Sci Rep2021;11:6444 PMCID:PMC7979859

[23] Balakrishnan C,Khalil AJ.Lymphedema of the upper extremity following circumferential burns.Can J Plast Surg2004;12:79-80 PMCID:PMC3792813

[24] Eren T,Orman S,Özemir İA.Isolated chylous injury due to blunt abdominal trauma: report of a case and a review of the literature.Turk J Surg2017;33:119-22 PMCID:PMC5508236

[25] Ferguson EJ,Lowe S.Appearance of retroperitoneal lymphedema on CT scan after penetrating neck injury.Am Surg2011;77:799-801

[26] Agrawal V,Minhas S.Paint ball injury resulting in penoscrotal lymphedema.Urology2006;67:1288-9

[27] Scaglioni MF,Fritsche E.Lymphovenous anastomosis (LVA) for treatment of isolated penile lymphedema: a case report.Microsurgery2020;40:692-5

[28] Ito T,Ishiura R.Diagnosis of trauma-induced lymphedema using indocyanine green lymphography.J Plast Reconstr Aesthet Surg2015;68:e177-8

[29] Mihara M,Murai N.Severe lymphedema caused by repeated self-injury.Lymphology2011;44:183-6

[30] Unno N,Suzuki M.Preliminary experience with a novel fluorescence lymphography using indocyanine green in patients with secondary lymphedema.J Vasc Surg2007;45:1016-21

[31] Chang DW,Skoracki R.A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema.Plast Reconstr Surg2013;132:1305-14

[32] Yamamoto T,Doi K.Indocyanine green-enhanced lymphography for upper extremity lymphedema: a novel severity staging system using dermal backflow patterns.Plast Reconstr Surg2011;128:941-7

[33] Cohen MD.Complete decongestive physical therapy in a patient with secondary lymphedema due to orthopedic trauma and surgery of the lower extremity.Phys Ther2011;91:1618-26

[34] Loskotová A,Suchanek I,Lipový B.Myofascial-manual lymphatic drainage for burn trauma: a service evaluation.Br J Community Nurs2017;22 Suppl 5:S6-S12

[35] Becker C,Levine JL.Microlymphatic surgery for the treatment of iatrogenic lymphedema.Clin Plast Surg2012;39:385-98

[36] Becker C,Mangiameli G,Randrianambinina F.Post-traumatic massive hand lymphedema fully cured by vascularized lymph node flap transfer.SICOT J2018;4:53 PMCID:PMC6256967

[37] Koshima I,Urushibara K.Supermicrosurgical lymphaticovenular anastomosis for the treatment of lymphedema in the upper extremities.J Reconstr Microsurg2000;16:437-42

[38] Seki Y.Fundamental and essential techniques for supermicrosurgical lymphaticovenular anastomosis: the art of Isao Koshima’s supermicrosurgery.Plast Aesthet Res2021;8:44

[39] Cheng MH,Wu CW.The mechanism of vascularized lymph node transfer for lymphedema: natural lymphaticovenous drainage.Plast Reconstr Surg2014;133:192e-8e

[40] Saaristo AM,Viitanen TP,Hartiala P.Microvascular breast reconstruction and lymph node transfer for postmastectomy lymphedema patients.Ann Surg2012;255:468-73

[41] Gazyakan E,Kneser U.Chimeric thoracodorsal lymph node flap with a perforator-based fasciocutaneous skin island for treatment of lower extremity lymphedema: a case report.Microsurgery2020;40:792-6

[42] Schaverien MV.Surgical treatment of lymphedema.Plast Reconstr Surg2019;144:738-58

[43] Maheshwari M,Maheshwari S.Elephantiasis nostras: complication of third degree acid burn.J Assoc Physicians India2006;54:713

[44] Jia W,He W,Zhao F.Engineering the lymphatic network: a solution to lymphedema.Adv Healthc Mater2021;10:e2001537 PMCID:PMC8483563

[45] Schoenle P,Kremer T,Kneser U.The chimeric versatility of the subscapular system revisited: backup options, coverage for bone transplants and vascularized lymph nodes.Plast Reconstr Surg Glob Open2018;6:e1765 PMCID:PMC5999433

[46] Pereira N,Kufeke M.Post-traumatic lymphedema treatment with superficial circumflex iliac artery perforator lymphatic free flap: a case report.Microsurgery2019;39:354-9

[47] Yamamoto T,Yoshimatsu H,Hayashi A.Lymph flow restoration after tissue replantation and transfer: importance of lymph axiality and possibility of lymph flow reconstruction without lymph node transfer or lymphatic anastomosis.Plast Reconstr Surg2018;142:796-804

[48] Brazio PS.Combined liposuction and physiologic treatment achieves durable limb volume normalization in class II-III lymphedema: a treatment algorithm to optimize outcomes.Ann Plast Surg2021;86:S384-9