June 17, 2025
Lymphedema is a lifelong condition, typically managed with conservative measures or complex decongestive therapy. While standard lymphedema treatments may reduce swelling, improve mobility and prevent cellulitis, daily treatments and ongoing discomfort can pose health risks and affect quality of life.
Lymphedema surgery continues to gain momentum as an immediate and longer lasting way to reduce volume in affected extremities. Debulking through liposuction produces significant and immediate volume reduction by removing excess adipose tissue due to lymphedema. However, microsurgical reconstruction using lymphovenous bypass (LVB) or vascularized lymph node transfer (VLNT) can restore lymphatic flow and drainage in select patients with lymphedema.
"Lymphatic reconstruction for lymphedema is relatively recent and is only performed by plastic surgeons with microsurgical training," says Kunle I. Elegbede, M.D., Ph.D., a plastic surgeon at Mayo Clinic in Jacksonville, Florida. Microsurgery relies on powerful microscopes providing magnification of up to 40 times. Sutures used during microsurgery are extremely fine — much thinner than the thickness of most human hair. "Even though all plastic surgeons train in microvascular anastomosis, lymphatics are much more delicate and technically challenging than the vessels and nerves we handle in non-lymphatic surgery."
Diagnostic protocol and patient selection for lymphatic microsurgery
Physiological microsurgeries for lymphedema are complex procedures requiring microsurgical expertise and specialized instruments, imaging, and operating microscopes. However, Dr. Elegbede says the diagnostic process and patient selection are critical for successful outcomes.
"There is an overlap between vascular insufficiency and lymphedema," says Dr. Elegbede. "Many of the patients who come in don't have true lymphedema. They have vascular insufficiency, but the swelling can mimic lymphedema. Other patients have true lymphedema and some component of vascular insufficiency."
Imaging studies, including lymphoscintigraphy, help surgeons evaluate the extent of lymphedema and the lymphatic system to identify bypassable lymphatic vessels. Patients also undergo duplex ultrasound of the extremity to rule out deep vein thrombosis (DVT) and check for venous insufficiency.
Microsurgery is not indicated for every patient. Discerning appropriate treatment requires close collaboration with lymphedema therapists, vascular surgeons and other specialists. Surgical limitations may include:
- Obesity.
- Uncontrolled venous insufficiency or DVT.
- Previous noncompliance with conservative treatment.
Lymphovenous bypass for rerouting lymphatic drainage
During LVB, also known as lymphaticovenular anastomoses, the surgeon uses small incisions to connect lymphatics to nearby veins of similar size. The new connections create a detour for lymphatic drainage to avoid damaged or missing lymph nodes.
The minimally invasive operation is performed as an outpatient procedure. Following LVB, some patients may still need to pump but may do it less often and only when swelling occurs.
"With successful lymphovenous bypass, we expect to have limb volume reduction of 20% to 30% a year after surgery," says Dr. Elegbede. "It's our first choice for microsurgical treatment of lymphedema because it is relatively safe and effective."
Restoring lymphatic drainage through vascularized lymph node transfer
VLNT involves the transfer of healthy lymph nodes and their blood supply from other parts of the body to the limb that is affected by lymphedema. It is more invasive than LVB and may be indicated when there are no available functional lymphatic vessels for bypass or when LVB is unsuccessful.
"VLNT may involve close collaboration between two specialists," says Dr. Elegbede. "For example, when the donor site is from the abdomen, we work closely with our robotic surgeons who harvest the lymph nodes from the omentum using the surgical robot. We then need to move that lymphatic vessel to the affected site and connect it."
Lymph nodes also can be taken from other donor areas, including the groin, back and chin. "Many areas outside the abdomen have limitations though, such as a limited number of lymph nodes that can be removed," says Dr. Elegbede.
When VLNT is successful, patients notice an improvement in their lymphedema symptoms months after the operation. A study published in Plastic and Reconstructive Surgery — Global Open followed patients for 70 ± 17 months after VLNT. In that time, 42% of patients were able to discontinue use of compression garments, and subjective pain symptoms decreased in 75%. The incidence of cellulitis was reduced by a factor of 10.
Understanding and enhancing outcomes of microsurgery for lymphedema
Mayo Clinic surgeons and researchers continue to study and improve upon microsurgical techniques for lymphedema. Dr. Elegbede says it begins with tracking patient outcomes.
"We are looking closely at the timing of the surgery, the number of vessels we bypass and the comparative efficacy of the different modes of reconstruction," says Dr. Elegbede. "These are the areas that can impact surgical treatment for lymphedema going forward."
For more information
Rannikko EH, et al. Long-term results of microvascular lymph node transfer: correlation of preoperative factors and operation outcome. Plastic and Reconstructive Surgery – Global Open. 2021;9:e3354.
Refer a patient to Mayo Clinic.