Lymphoedema is a chronic and progressive disease and, according to American data, it is a problem that affects approximately 1% of the population. Surgical treatments can also be applied to advanced stage lymphedema patients where conservative treatment is not sufficient. Surgical treatments for lymphedema have been performed for more than 100 years. Today's surgical treatment methods;
In history, tissue removal techniques were first applied, and with the advancement and widespread use of microsurgery today, the application of physiological procedures is becoming increasingly common in the world. Nowadays, we see that physiological procedures are applied alone or as combined treatments with tissue-reducing operations in suitable patients.
There is no center for lymphedema surgical treatment in our country. Tissue-reducing surgeries related to lymphedema are partially performed by Plastic Reconstructive and Aesthetic Surgery clinics, while physiological surgeries are performed by personal efforts and a small number of plastic surgeons in a handful of centers.
United States, Taiwan (China). ), there are centers in Japan, England and European countries that work especially on the development of physiological methods.
Tissue-Reducing Methods:
Tissue-reducing surgical treatments. Charles surgery, Homans surgery, Thompson Surgery, Sistrunk surgery and similar surgical methods in which skin and subcutaneous tissues are removed and Liposuction can be listed. Tissue-reducing surgeries are not methods that eliminate the underlying causes. These are methods that help reduce the volume of the extremity, so that conservative treatments can be performed more effectively and the patient can wear compression socks and clothing more easily. In the long term, increases in patients' comfort of life and reductions in lymphangitis (inflammation of the lymph) attacks have been reported at different rates in studies conducted in different centers with these methods. However, surgeries are performed in cases where lymphatic circulation is impaired. Since it requires the removal of limb and massive tissue, the current risks of surgery increase, so they become surgeries that surgeons do not want to perform. If we briefly look at the tissue-reducing surgery methods:
Charles surgery:
Completely removing the affected skin and subcutaneous tissues of the patient's limb; It is a surgery in which large wounds are tried to be closed with skin patches taken from another area. It may cause tissue and blood loss in a very large area in the patient. Since it is an aggressive surgery and causes poor aesthetic appearance, it is preferred to be performed as the last option only in very advanced lymphedema patients.
Homans surgery:
This It is a method in which the tissues generally on the inner or outer side of the affected limb are thinned. If surgery is to be performed on both sides of a limb, it is recommended to perform it at 3-6 month intervals. It is a method that can be applied to advanced stage patients whose skin elasticity loss is not fully developed. Like other surgical methods, it is a method that does not completely solve the underlying lymphatic circulation problem, but provides some relief. Surgery risks include unwanted tissue loss, hematoma and wound healing problems.
Thompson surgery:
This method is applied to one side of the limb, similar to Homans surgery. It is a surgery in which less tissue is removed through incisions. Although its risks are less than Homans surgery, it has similar features, but the amount of shrinkage achieved is less.
Sistrunk surgery:
Sistrunk surgery is the simplest tissue reduction method. It is a method used to reduce full-thickness tissue. In this method, a full-thickness soft tissue slice is excised from the skin and subcutaneous tissues and then repair is provided. Nowadays, it is not practiced much anymore. The result obtained depends on skin elasticity and is therefore limited.
Liposuction:
This method, which was previously developed for aesthetic applications, was also used in the treatment of lymphedema in the 1990s. started to be used. It has been applied as an alternative to other tissue-reducing methods. Unlike other methods, skin removal It allows subcutaneous tissues to be taken out with a cannula. However, it is not possible to apply it in end-stage patients, where the hardening of the skin increases and the soft tissues become hardened. It may be recommended to be applied mostly in middle-advanced stage patients or combined with other physiological surgeries.
In general, surgical methods that help reduce tissue do not eliminate the cause of the disease, but the annual average lymphangitis (lymph inflammation) attacks and physical therapy needs of the patients are reduced.
Physiological Surgical Methods:
Physiological surgeries applied in lymphedema surgery are performed without tissue removal operations or in combination with them, and are mostly used to restore the continuity of the existing lymphatic flow. It aims to return patients to earlier stages by providing, bypassing or increasing the disease and ensuring its continuity. Physiological surgeries include omental flap transposition, free lymph node flap transplantation and lympho-lymphatic/lymfovenous shunt surgeries. Lymphatic vessels are thinner than normal blood vessels, and as the disease progresses, the structure of these vessels gradually deteriorates. For this reason, it is not always possible to perform this type of surgery in the very advanced stages of the patient. Let's talk about physiological surgery methods:
Omental flap transposition:Omentum majus is a thin fatty layer containing a wide vascular network, fat and lymphatic tissue covering the intestines in the abdomen. It is possible to extend the length of this tissue and turn it into a thin strip by tying and cutting certain vessels. In this form, the entire tissue can be extended, with one end connected to the main vessels in the abdomen, without disrupting the blood supply to areas far from the abdomen. They have positive effects on the blood and lymph circulation in the place where they are transported due to the lymph nodes and well-blooded soft tissues inside the transported tissue. In order to apply the omentum flap, an intra-abdominal surgery is required, so General Surgery and Plastic Surgery must perform the operation together. Although it is included in Classical Plastic Reconstructive and Aesthetic Surgery books, there are few studies in the world using the omental flap for lymphedema. We also want our country to start an international study on this subject. It was not found in publications. Since moving the omentum tissue out of the abdomen in this way naturally causes a defect in the abdominal wall and since it is a surgery directed inside the abdomen, it has risks such as abdominal wall infection, fascial separation, ventral hernia and even development of ileus. I think this is the reason why it is not preferred by the plastic surgeons of our country.
However, today it is practiced to move some of the omentum tissue freely from the abdominal vessels to more distant regions. In fact, these can be applied using laparoscopic methods without the need for open technique. There are publications on studies on this subject from the USA, Taiwan, Japan and Spain.
Lympho-Venous Lympho-Lymphatic Shunt Surgeries:
Structures of lymphatic vessels Since they are very thin and difficult to find, there are difficulties in directly repairing these structures. Among these, super-microsurgical methods, which are advanced techniques of microsurgery, and some special imaging methods need to be used to perform lympho-lymphatic and lympho-venous shunt surgeries. With these methods and technical possibilities, lymphatic vessels that are thinner than the vascular structures that can normally be repaired with microsurgical methods can be found and connected to appropriate structures and the direction of the interrupted lymphatic flow can be changed. Since these are advanced techniques, it is not possible to apply them in all centers. The number of centers and people applying these methods in the world is low. However, it is important to carry out appropriate studies in certain training clinics that will want to apply this method, if appropriate conditions are met, in order to follow the developments in the field of medicine.
Lymph Node Transfer Surgeries:
As it is known, lymphedema occurs due to chronic changes that occur over time as a result of disruption of lymphatic flow. Lymph nodes are constant parts of the lymph system where lymphatic flow is coordinated. Lymph nodes are removed by surgery (regional lymph node dissection), damaged by radiotherapy, their structure is damaged after some infections, or in cases where they are not congenital. Dementia may develop. In these cases, it has been observed that lymph nodes transplanted from other areas with their vascular structures instead of untreated lymph nodes regain the lost function at different rates. However, the exact mechanism or mechanisms by which these lymph nodes transferred to the environment provide benefits has not been clearly demonstrated. For this reason, there is no clear evidence as to which area of the extremities the lymph nodes should be moved to.
Standard microsurgery methods can be used to transplant the lymph nodes to another area with the vessels feeding them. Free tissue transplant surgeries are performed in many training clinics in our country. The areas where lymph nodes can be taken may vary, such as the groin area, the side of the rib cage, the neck and the abdominal area.
Free lymph node transfer surgeries are surgeries that can be performed by Plastic Reconstructive and Aesthetic Surgery physicians who have microsurgery experience and are familiar with regional lymph node surgeries.
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