Lymphedema is a chronic and progressive disease affecting approximately 1% of the population according to American data. Surgical treatments can also be applied in advanced-stage lymphedema patients where conservative treatment is insufficient. Surgical treatments for lymphedema have been used for over 100 years. Today, surgical treatment methods can be applied in three ways:

Reductive/excisional surgeries,
Physiological surgeries, and
Combined surgeries.

Historically, techniques involving tissue removal were used, but with the advancement and widespread use of microsurgery, the application of physiological procedures is becoming increasingly common worldwide.

Reductive Methods

Reductive surgical treatments include Charles surgery, Homans surgery, Thompson surgery, Sistrunk surgery, and similar surgical methods involving the removal of skin and subcutaneous tissue, as well as liposuction. Reductive surgeries do not eliminate the underlying causes. These methods help reduce the volume of the extremity, thus enabling more effective conservative treatments and making it easier for the patient to wear compression stockings and clothing. In the long term, studies conducted in different centers have reported varying rates of improvement in patients’ quality of life and reduction in lymphangitis (lymph inflammation) attacks with these methods. However, since the surgeries require the removal of massive tissue in a limb with impaired lymphatic circulation, the existing surgical risks increase, making them surgeries that surgeons are reluctant to perform. Briefly, let’s look at tissue-reducing surgical methods:

Charles Surgery

This is an aggressive surgery where the affected skin and subcutaneous tissues of the affected limb are completely removed, and the large wounds are then covered with skin grafts taken from another area. It can cause extensive tissue and blood loss in the patient. Due to its aggressive nature and the resulting poor aesthetic results, it is only considered as a last resort in very advanced lymphedema patients.

Homans Surgery

This method involves thinning the tissues, usually on the inner or outer side of the affected limb. If surgery is to be performed on both sides of a limb, it is recommended to perform them at intervals of 3-6 months. It is a method that can be applied to patients in advanced stages where the loss of skin elasticity is not fully developed. Like other surgical methods, it does not completely solve the underlying lymphatic circulation problem, but it does provide some relief. Risks of surgery include unwanted tissue loss, hematoma, and wound healing problems.

Thompson Surgery

This method is similar to Homans surgery, involving lengthwise incisions on one side of the limb and removal of a smaller amount of tissue. While the risks are lower than Homans surgery, it has similar characteristics, but the amount of reduction achieved is also less.

Sistrunk Surgery

Sistrunk surgery is the simplest method of full-thickness tissue reduction. In this method, a full-thickness soft tissue slice is excised from the skin and subcutaneous tissues, followed by repair. It is rarely used today. The results are limited and depend on skin elasticity.

Liposuction

This method, previously developed for aesthetic applications, began to be used in the treatment of lymphedema in the 1990s. It was applied as an alternative to other tissue reduction methods. Unlike other methods, it allows for the removal of subcutaneous tissues with a cannula without removing the skin. Because skin integrity is largely preserved, the risks are lower than other methods. However, it is not very feasible to apply this method in late-stage disease where skin hardening has increased and soft tissues have also hardened. It is more often recommended for moderate to advanced stage disease or in combination with other physiological surgeries. In general, surgical methods that reduce tissue mass do not eliminate the cause of the disease, but they reduce the average annual incidence of lymphangitis (lymph inflammation) attacks and the need for physical therapy, and improve the quality of life to a greater or lesser extent.

Physiological Surgical Methods

Physiological surgeries applied in lymphedema surgery aim to restore, bypass, or increase the continuity of existing lymphatic flow, either without or in combination with tissue removal operations, thereby allowing patients to return to earlier stages and ensuring the continuity of this process. Physiological surgeries include omental flap transposition, free lymph node flap transplantation, and lympho-lymphatic/lymphovenous shunt surgeries. Lymphatic vessels are thinner than normal blood vessels, and their structure deteriorates as the disease progresses. For this reason, performing these types of surgeries is not always possible in very advanced stages of the disease. Performing them in early stages yields higher and more lasting results.

Regarding physiological surgical methods:

Lympho-Venous & Lympho-Lymphatic Shunt Surgery

Because lymphatic vessels are very thin and difficult to locate, directly repairing them presents challenges. These procedures, including lympho-lymphatic and lympho-venous shunt surgeries, require the use of advanced microsurgical techniques, such as super-microsurgery, and specialized imaging methods. These methods and techniques allow for the identification and connection of lymphatic vessels—which are thinner than those normally repairable with microsurgical methods—to appropriate structures, thereby redirecting disrupted lymphatic flow. Because these are advanced techniques, their application is not feasible in all centers. The number of centers and individuals worldwide that perform these procedures is also limited. Furthermore, the increasing popularity of free lymph node transfer in recent times has raised further questions about this method, and its long-term success is being questioned. Nevertheless, it is important for certain training clinics wishing to implement this method to conduct appropriate studies under suitable conditions, in order to keep pace with advancements in the medical field.

Lymph Node Transfer Surgery

Lymphoedema, as is known, occurs due to chronic changes that develop over time as a result of impaired lymphatic flow. Lymph nodes are integral parts of the lymphatic system, coordinating lymphatic flow. Lymphoedema can develop when lymph nodes are surgically removed (regional lymph node dissection), damaged by radiotherapy, damaged after certain infections, or are congenitally absent. In these cases, it has been observed that transplanting lymph nodes from other areas, along with their vascular structures, to replace the affected lymph nodes, restores their lost function to varying degrees. However, the exact mechanism(s) by which these transplanted lymph nodes provide this benefit have not been clearly demonstrated. Therefore, there is no definitive evidence regarding which region of the extremities these transplanted lymph nodes should be transferred to. Standard microsurgical techniques can be used to transfer lymph nodes along with their supplying vessels to another area. Free tissue transfer surgeries are performed in many teaching clinics in our country. Lymph node harvesting sites can vary, including the groin, side of the rib cage, neck, and abdominal cavity. Each site presents its own challenges and risks. Free lymph node transfer surgeries are performed by Plastic, Reconstructive, and Aesthetic Surgery physicians with microsurgical experience and expertise in regional lymph node surgeries.

Pressure Ulcers and Wound Care

Closing difficult-to-heal wounds on the skin is a subject of plastic surgery. Deep and large wounds are very difficult to close on their own, requiring appropriate care and closure through certain surgeries. Cleaning and healing damaged tissues begins with wound care. Today, there are many different wound dressing materials and wound care methods specific to wounds. Plastic surgeons will guide you in handling these wounds, choosing the appropriate dressing method, and surgically cleaning and then closing the wound.

Which Methods Are Most Frequently Used in Wound Care?

The first treatment in wound care is the removal of dead tissue from the wound, i.e., debridement. After dead tissue is removed from the wound, a wound care method is chosen according to the type and quality of the remaining tissue. There is a very wide range of wound care methods, from simple dressings to technological biomaterials, complex devices like vacuum therapy, hyperbaric oxygen therapy, and stem cell therapies. Since the variety of these products can be confusing, it is recommended that you trust and follow the method chosen by your doctor.

What Causes Pressure Ulcers?

Pressure ulcers occur in people with reduced mobility due to impaired circulation in the skin caused by constant pressure applied to the same area. Advanced neurological disorders, previous strokes, temporary loss of consciousness, loss of sensation, and improper plaster casts or care after certain surgeries can all lead to pressure on certain areas. Pressure ulcers are generally observed in the skin area between bony prominences and the underlying tissue. Pressure ulcers originate in deep tissues. Therefore, wounds that appear very small from the outside may be much larger than expected deep down.

What Surgery Can Be Performed for Pressure Ulcers?

The treatment for pressure ulcers is determined by the stage of the disease, the size of the ulcer, and the patient’s health condition. For example, superficial ulcers caused by temporary discomfort may heal with wound care alone, while deep ulcers, if the patient’s health condition permits, should undergo flap surgery. Generally, tissues from areas close to the wound are advanced or transferred to close the wound using tissues of appropriate thickness and quality. Previous surgeries and the patient’s general health condition can pose risks during the procedure. Therefore, the patient may need to be evaluated by appropriate specialists for any additional medical conditions.