Final Remarks and Future Applications

In the complex therapy for lymphedemas, the role to be played by surgery versus medical-physical conservative treatment can be easily defined.10 Combined physiotherapy is the treatment of choice for most lymphedemas. In nonresponsive cases

Fig. 14.1. Multiple lymphatic-venous anastomoses performed by microsurgical technique, using the operating microscope at 30x magnification.

(up to 30-40%), the drainage function of the lymphatic circulation can, at least partially, can be recovered by lymphatic microsurgery performed as early as possible. The rather constant outcome can further be improved with subsequent conservative treatment. Major resective surgery is no longer justified. Only in rare cases, as soon as the results of microsurgical and medical conservative treatment have become stable, does minor resective surgery still find some indications for aesthetic-reductive purposes.

Lymphedema Anastomoses
Fig. 14.2. Lymphatic-venous-lymphatic interpositioned vein graft carried out by means of the operating microscope (25x): a) distal anastomoses and b) proximal anastomoses, below and above the inguinal region.
Fig. 14.3. Primary leg lymphedema (a) in pediatrics. Microsurgical derivative lymphatic-venous drainage was performed at the inguino-crural region. Microsurgery allowed to obtain a rapid reduction of the edema at both sides (b).

With regard to prevention of secondary lymphedemas, finally, early diagnosis plays an important role as well as the selection of high-risk patients for the onset of lymphostatic disease after oncological lymphadenectomies, especially if associated with radiotherapy. In these cases, early microsurgery is a valid suggestion in order to treat, from their very onset, lymphedemas which, based on a reasonable statistical probability, are expected to show unrelenting progression.

Fig. 14.4. Left arm lymphedema (a) secondary to breast cancer treatment. Lymphatic-venous microsurgical anastomoses at the arm allowed to achieve a very good result, stable with time, controlled at over 5 years (b).
Fig. 14.5a. Primary right leg lymphedema.
Fig. 14.5b. Primary right leg lymphedema, treated by derivative lymphatic-venous microsurgery, and controlled at long distance of time from operation.

Based upon over 25 years clinical experience, we can conclude by emphasizing the efficacy of microsurgery for the treatment not only of patients with acquired lymphedema, but also with primary lymphostatic pathology, even in pediatrics, and moreover for the prevention of secondary lymphedema.

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