However, recently, indocyanine green (ICG) imaging has allowed for advances in both preoperative selection and intraoperative mapping. ICG imaging can differentiate between patients who still have some degree of functioning lymphatics, evidenced by proximally progressing lines on the extremity, and those who do not, evidenced by a diffuse pattern (personal communication, Barcelona lymphedema group). In those with functioning lymphatics, the ICG imaging provides direct data on the patient to indicate the location of surgery. In a study from MD Anderson Cancer Center, Chang et al. performed a prospective study in 100 patients; symptom improvement was noted by 96 % and quantitative improvement by 74 %. He also noted a significant improvement in identification of lymphatics within the study through the use of preoperative ICG imaging [27].

Another surgical modality for the treatment of lymphedema is free lymph node transfer. In this procedure, lymph nodes from the groin or chest wall are isolated with their blood supply and microsurgically transferred to the axilla or groin. In the axilla, the artery and vein of the pedicle is anastomosed to the thoracodorsal vessels using microsurgical techniques. In the groin, the vessels are anastomosed to the superficial branches of the femoral artery and vein. Corinne Becker in France pioneered this procedure and has published the largest series of patients [28, 29]. In her landmark paper in the Annals of Surgery, she reported a series of 24 patients who underwent groin to axillary lymph node transfer. Ten patients had complete resolution of their lymphedema, and 12 patients had decreased lymphedema of their upper extremity [29] (Fig. 26.2).

For patients who are not candidates or do not wish for LVA or lymph node transfer, e.g., patients with “late stage” lymphedema or advanced fibrotic disease, liposuction may potentially reduce the subjective “weight” and objective circumference of the arm, leading to improvements in functioning. This can also be performed after LVA or node transfer surgery. Brorson is one of the most prolific authors in this field and has good reported patient outcomes [30, 31]. In a 5-year prospective study of 12 patients from another group, the final volumes of the affected and unaffected arms were virtually equivalent after liposuction, and this reduction was stable with up to 5 years of follow-up. These patients also had significant reductions in anxiety scores (p < 0.05) as well as an improvement in overall well-being [32]. The major limitation of this method is the guaranteed continued need for compression garments. If the compression garments are discontinued, the lymphedema is likely to recur [31].

There is a possibility that upper extremity lymphedema may be improved through release of the contracture and interposition of soft tissue. Two patients with severe postmastectomy lymphedema of the upper extremity were treated with a latissimus dorsi muscle flap. Complete disappearance of edema was achieved by 11 months postoperatively in one case and 50 % reduction by 8 months in the other case [33]. The tissue was transposed through the axilla to make a new breast, and there is a distinct possibility that the transposition of healthy, living tissue into the axilla provides a means of improving lymphedema by promoting lymphatic vessel ingrowth. In another larger retrospective review of 38 patients, 23.7 % demonstrated significant improvement in their lymphedema after free flap breast reconstruction, with none demonstrating worsening [34]. Because the tissue was transferred as a free flap directly to the breast, the patients who did not improve may not have had a sufficient amount of tissue transferred to the axilla. In an animal model, lymphatic continuity was noted to be restored with transfer of a rectus abdominis myocutaneous flap, providing an experimental model to explain the lymphedema improvement [35]. Furthermore, even if the lymphedema does not improve, the patient should benefit in terms of shoulder range of motion and improvement in functioning from release of the axillary contracture alone.