Surgical procedures and lymphedema of the upper and lower extremity.

BACKGROUND: Lymphedema occurs in the upper and lower extremity, in a minority of patients, following axillary and groin dissections, respectively. Several technical operative factors have been implicated through the years whose relative significance remains unknown.
METHODS: Retrospective review of the author's personal experience with axillary and groin dissections and review of the articles and results written on the author's series of patients. The results, specifically lymphedema, are reported in relation to components of each surgical procedure and the presence or absence of additional surgical procedures, e.g., wide excision of the primary site when performed in the distal leg.
RESULTS: In the axilla, skeletonization of the axillary vein, dissection up to and including Level III nodes, removal of the fat and nodes above the level of the axillary vein (exposing the brachial plexus), removal of pectoralis minor and all the axillary fat, exposing thus serratus anterior, latissimus dorsi and subscapularis are all technical components which do not cause lymphedema. It seems excessively thin flaps in axillary dissections may be the most likely cause for upper extremity lymphedema. The incidence of upper extremity lymphedema, in our experience, after axillary dissection is low (2%). For the lower extremity, skeletonization of the femoral and iliac vessels, in continuity dissection of the femoral and deep nodes (iliac and obturator), do not cause in themselves lymphedema (which occurs in 30% of the patients). The incidence of lymphedema increases with making thin flaps, with wide resection of a primary melanoma below the knee, postoperative incidence of cellulites, failure to follow a prophylactic regimen of leg elevation and compression stockings, and obesity.
CONCLUSIONS: Lymphedema in the upper and lower extremity may be caused by making thin flaps during node dissection, the additional wide excision of primary sites in the distal half of the extremity, postoperative cellulitis, and failure to follow an antilymphedema regimen. (c) 2006 Wiley-Liss, Inc.