Lymphedema is a chronic medical condition defined by swelling in body tissues caused by a buildup of protein-rich lymph fluid, commonly affecting the arms or legs.
Lymphedema is a chronic medical condition defined by swelling in body tissues caused by a buildup of protein-rich lymph fluid, commonly affecting the arms or legs.
It can occur when lymph nodes are removed or damaged by cancer treatments, blocking the drainage of lymph fluid.
Besides chronic swelling and heaviness of the affected area, there are increased risks of skin infection and skin changes. Treatment includes compression garments, massage and other conservative measures. In some cases, lymphedema surgery in Singapore can help manage swelling and minimise its impact on daily activities.
Swelling in an arm, leg, chest or neck
A heavy, tight or aching feeling in the limb
Thick, hard or leathery skin over time
Restricted range of motion of adjacent joints
Recurrent infections
Caused by damage from cancer treatments (like lymph node removal or radiation), severe infections or trauma.
Caused by rare, inherited genetic problems that affect how the lymphatic system develops.
Caused by damage from cancer treatments (like lymph node removal or radiation), severe infections or trauma.
Caused by rare, inherited genetic problems that affect how the lymphatic system develops.
The most common cause in Singapore is breast cancer–related lymphedema. This refers to arm swelling after axillary clearance (removal of armpit lymph nodes).
In previous studies, the estimated occurrence of lymphedema is about twenty-five to thirty per cent in patients who underwent axillary clearance (AC) and five per cent in patients who underwent sentinel lymph node biopsy (SLNB). Lymphedema of the lower limbs can also occur after lymph node removal or radiation treatment for gynecologic or urologic cancers.
The lymphatic system consists of a network of vessels that carry protein-rich lymph fluid throughout the body. Lymph nodes are found in areas of the body such as the armpit, neck region and groin. They act as filters to clean the lymph of bacteria and waste products before the lymph returns to the blood. They also produce white blood cells and antibodies to help the body fight infections and cancer.
www.scientificanimations.com, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons
OpenStax College, CC BY 3.0
<https://creativecommons.org/licenses/by/3.0>, via Wikimedia Commons
Tissue fluid surrounds our cells and nourishes them. As it accumulates, it is picked up by tiny lymphatic capillaries within the skin (in green). This colourless fluid (“lymph”) flows into progressively bigger lymphatic collectors within the fat and tissues.
These larger channels (more than 15 in each arm) travel upwards in bundles, then drain into the axillary (armpit) lymph nodes. There are 20 to 40 axillary lymph nodes, though the exact number varies among people.
From the lymph nodes, lymph is ultimately collected and funnelled into large neck veins, which then return blood to the heart.
When lymphatic flow is disrupted, there is accumulation of the three Fs:
Lymphedema is a chronic condition that requires lifelong care and attention. In some patients, the arm swelling is well-controlled by therapy and compression garments. They experience a stable course without worsening.
In others, scarring and blockage of the lymphatic channels occur, often progressing from the armpit downwards towards the hand. Patients often notice swelling over the upper arm and forearm before the gradual development of hand and finger swelling.
Due to the blockage of the main lymphatic channels, the lymph fluid backflows into the skin. The analogy is that of a traffic jam on the expressway, which causes congestion all the way into the small roads. The skin then becomes increasingly thickened and no longer pliable. Immune defences are impaired within the abnormal skin.
Patients can develop repeated skin infections (cellulitis), manifesting as red spots or patches. In others, lymphangitis can occur, meaning bacteria travel along the remnant lymphatic tracks, appearing as red lines running up the arm.
Caused by damage from cancer treatments (like lymph node removal or radiation), severe infections or trauma.
Lymphangitis ascending the arm: bacteria travel along the lymphatic channels.
Jmarchn, CC BY-SA 3.0 <https://creativecommons.org/licenses/by-sa/3.0>, via Wikimedia Commons
Prompt treatment is essential to reduce the risk of worsening symptoms and the development of life-threatening conditions such as sepsis (infection in the bloodstream).
In addition, with each attack, there is further damage to the lymphatics of the affected part, which in turn increases the risk of future infections.
The severity of lymphedema is classified based on the International Society of Lymphology (ISL) grading system as follows.
Stage 0: latent condition where swelling is not evident despite impaired lymph transport.
Stage 1: early accumulation of fluid that subsides with limb elevation. Moreover, pitting may occur at this stage. Pitting oedema is present when a mark is left in the skin by applying finger pressure, indicating fluid in the soft tissues.
Stage 2: limb elevation alone rarely reduces tissue swelling; pitting is obvious. Late in stage 2, the limb may or may not pit as tissue fibrosis increases.
Stage 3: Skin changes such as thickening and warty overgrowths develop (elephantiasis).
Similarly, the lymphatic vessels undergo progressive changes. In stage 1, the vessel is dilated (or widened) due to blockage upstream. In stage 2, there is an increase in smooth muscle cells, which aim to push the lymph upstream, resulting in a thickened wall. Lymphatic stasis causes localised scarring and finally complete blockage of the lymphatic vessel wall in stage 3.
Reprinted with permission from: Mihara, Makoto, Hisako Hara, Yohei Hayashi, et al. 2012.
“Pathological Steps of Cancer-Related Lymphedema: Histological Changes in the Collecting Lymphatic Vessels after Lymphadenectomy.” PLoS One 7, no. 7.
Lymphedema may be diagnosed based on clinical symptoms and limb measurements. Imaging tests can assess the lymphatic system. These include:
1. Lymphoscintigraphy: A small amount of radioactive tracer is injected, and scans are taken to track how the tracer travels through the lymphatic system.
a) Left lower limb dermal backflow with impaired lymphatic clearance
b) Absence of left inguinopelvic lymph nodes and lower limb lymphatic tracks
Ekim H, CC BY 2.5 <https://creativecommons.org/licenses/by/2.5>, via Wikimedia Commons
2. Indocyanine green (ICG) lymphangiography: A small amount of green, fluorescent dye known as ICG is injected into the skin, and a special infrared camera can be used to identify the lymphatic vessels. However, it can only visualise more superficial lymphatics less than 1.5 cm from the surface.
Linear pattern (normal lymph flow through the lymphatic collectors)
Splash pattern: delayed flow and accumulation of dye in the dermis of the skin)
3. Ultrasound: High-frequency ultrasound can show lymphatic vessels.
4. Magnetic resonance lymphangiography (MRL): This is a detailed investigation that can identify lymphatics at varying depths and demonstrate fat and fluid accumulation. MRL requires a small injection of MRI contrast dye into the web spaces of the affected limb, followed by an MRI scan using special settings.
Surgical treatment of lymphedema may be considered for selected patients based on their condition, lymphatic function and treatment needs. To be eligible for consideration for surgical intervention, however, patients must have completed at least three months of complete decongestive therapy (CDT) and continue to be compliant in the long term. Patients should have realistic expectations and be proactive about their treatment.
For patients considering lymphedema surgery in Singapore, assessment will consider the severity of the condition, previous treatment and lymphatic function.
Indications for surgery include:
These procedures can be divided into two types:
a) “Physiologic” procedures
Physiologic procedures aim to create new drainage paths and regenerate lymphatic function. A commonly performed technique is lymphovenous anastomosis (LVA), whereby a lymphatic channel is connected to a nearby small vein. This allows fluid to drain through the bloodstream instead of the blocked lymphatic system.
This is a minimally invasive procedure performed through small incisions in the skin. Recovery varies between patients, and the time required to return to daily activities and work depends on the procedure performed and individual healing. The available data support that lymphovenous anastomosis is effective as a treatment for earlier-stage lymphedema, when lymphatic channels are still present.
With permission from the Lymphedema Society of Singapore, accessed from https://lymphedema.sg/
Vascularised lymph node transfer (VLNT) refers to transplantation of redundant lymph nodes from other areas of the body. It is usually indicated in patients with more advanced disease. It may also be performed in those whose condition did not improve significantly or recurred after lymphovenous bypass.
It is a physiologic procedure where the lymph nodes work as a lymphatic pump while promoting lymphatic regeneration.
It is recommended that patients continue CDT long-term even after surgery. In some cases, they may be able to reduce reliance on compression garments and wear them three to five times a week instead of 23 hours every day. CDT is critical in countering the effects of gravity and the large amounts of fluid leaving the blood vessels daily.
With permission from the Lymphedema Society of Singapore, accessed from https://lymphedema.sg/
b) “Debulking” procedures
In advanced cases, the focus moves towards debulking procedures to improve movement and comfort. Liposuction is used when the excess is mainly fat accumulation. In severe cases where fibrosis prevents effective liposuction, direct removal of the tissue becomes necessary.
On their own, these debulking procedures cannot restore lymphatic function. The patient may still suffer from recurrent infections due to reduced immunity, poor skin quality and recurrence of swelling. Combining debulking with physiologic procedures is thus advised for many patients.
With permission from the Lymphedema Society of Singapore, accessed from https://lymphedema.sg/
Patients who develop breast cancer-related lymphedema may experience swelling when breast cancer treatment affects the lymphatic pathways. The location and severity of swelling can vary depending on which lymphatic pathways are affected and the extent of the impairment. Treatment is therefore tailored to the individual’s symptoms and lymphatic function.
Breast cancer lymphedema treatment may include conservative therapy, with surgical options considered for selected patients to improve lymphatic drainage. Upper limb swelling may require arm lymphedema treatment, depending on the patient’s symptoms, lymphatic function and previous cancer treatment.
Lower limb lymphedema can occur following lymph node removal or radiation treatment for gynaecological or urological cancers. Leg lymphedema treatment may be considered based on the underlying cause and extent of lymphatic impairment.
Lymphedema is an evolving field with continued research into modern methods of supporting patient outcomes. These include the concept of immediate lymphatic reconstruction, which tries to prevent lymphedema by identifying cut lymphatic vessels at the time of axillary clearance. If they are of sufficient length, they can be joined to small vein branches in the armpit, thus restoring lymph flow.
It is important to diagnose lymphedema and begin CDT early with a qualified therapist. Self-management is the key to lymphedema maintenance: being compliant with compression garments and carrying out self-drainage. Exercising, eating a low-fat diet and maintaining a healthy weight are also critical.
Disease progression leads to long-term physical and psychosocial consequences for the patient. However, modern physiologic approaches aim to support lymphatic drainage in patients. Debulking techniques also have a role to play by removing tissue that has already accumulated and reducing the weight of the arm.
Assessment by our lymphedema specialist in Singapore can help determine whether surgical treatment may be appropriate based on the patient’s condition and lymphatic function.
Videos/resources
The Lymphedema Society of Singapore helps to spread awareness about lymphedema amongst the public and multidisciplinary professionals.
Helpful videos about donning a compression garment or bandaging are available at: https://lymphedema.sg/educational-resources.
There are also many resources available online, such as at https://lymphaticnetwork.org/ and https://lymphnet.org/.
Lymphedema is a condition where impaired lymphatic drainage causes persistent swelling in the affected area.
You can consult our lymphedema specialist in Singapore at The Aesthetic & Plastic Surgery Clinic for an assessment of your condition, lymphatic function and suitable treatment options.
Yes, breast cancer lymphedema can develop after treatment that affects the lymphatic system.
Lymphatic surgery may be considered when swelling persists despite appropriate conservative treatment.
Lymphedema microsurgery may be suitable for selected patients whose swelling persists despite conservative treatment.
Yes. Lymphovenous anastomosis (LVA), also known as lymphovenous bypass (LVB), uses microsurgery to create an alternative pathway for lymphatic drainage.
Lymphatic imaging and a clinical assessment may be used to evaluate lymphatic function and guide treatment planning.
