lymphedema tarda

measurements at first interview 

Final result as compared to opposite leg

per op photo 

pre op photo

Fasciectomy and debaulking in progress 

Final wound closure

Four layer crepe bandage

Skin marking for autologous lymph node transfer

Superficial lymph node transfer

Vein marked

Lymph node flap dissected

Lymph node vessel connected

lymph node flap with vessel connected

lymph node insetted in groin

First dressing change and result achieved

59 years old female presents with a leg swelling for past 15 years come to my clinic . She was suffering from primary lymphedema tarda. Clinical examination was done , limb measurements were done . MRI leg , lymphoscintigraphy and color doppler  were ordered . MRI leg revealed fluid filled spaces with dilated lymphatics, no lymph nodes. Lymphoscintigraphy revealed absent groin lymph nodes and color doppler was normal. Patient was put on regimen of manual lymphatic drainage and physiotherapy for two weeks .  Physiotherapy helps to mobilize lymphatic fluid and improves results of surgery.
After two weeks surgery was planned over two days , on day one lower leg debulking was done to decrease lower leg volume , I have my known technique. I usually give posterior midline incision with small lateral extensions in at both ends. Skin flaps opened with a copy book style, skin flaps are raised just above fascia . All fascia was excised  with preservation of sural nerve and short saphenous vein upto shin on both sides and extensive debulking of flaps was done . Excess skin was excised and wound was closed in single layer over drain . Four layered bandage was done with leg elevation. It is bloody operation done with tourniquet but not always possible with huge size of limbs , postoperative blood transfusion is mandated . Three units were transfused  in this patient. Next day vascularised lymph node transfer( VLNT) was done . Donor vessels were SCIA superficial circumflex iliac artery and vein .They are really tough vessels to work with . Lymph node flap was dissected from lateral chest wall based on branch of thoracodorsal vessels. Flap was spread over large pocket made in upper thigh , once flap vessel were connected haemostasis was secured . Wound was closed over non negative suction drain. Post was uneventful drain were removed after five days . leg dressing was removed and pressure garments given . Suture removal is after one month. Physiotherapy is started after 15 days once wounds have healed. Walking is encouraged and exercise has beneficial effect. All lymphatic fluid is drained through muscle or skin lymphatics . VLNT flap secretes VGEF vascularised endothelial growth factor which promote lymphogenesis. At last measurements of limb shown near normal with in 10% of normal limb .


Lymphedema is a terrible condition. It has cosmetic ,functional ,psycho social issues which needs to be addressed . Lymphedema is defined as abnormal accumulation of increased amount of high protein ISF secondary to defective lymphatic drainage in presence of normal net capillary filtration. Incidence of primary lymphedema is 1 in 6000 live births.

Lymphedema is classified into primary and secondary lymphedema . Primary lymphedema is of three types congenital, precox and tarda. . Congenita constitute 10 % of cases , precox is most common constitute upto 80% cases tarda is rare is only 10% of problem .
 Congenit manifest before 2 years of age it is called Milroy's disease . Lymphedema precox usually present in teens ,in females ,single leg , upto knees are common presenting senario . Lymphedema precox is also known as Meige's disease. Yellow nail, extradural cyst,vertebral anomaly ,cerebrovascular anomaly and sensorineural hearing loss may be associated with this condition.

Tarda presents after 35 years is rare and affects thigh along with legs .  It is often associated with obesity and lymph nodes being replaced with fibro fatty tissue.










Dr Adhishwar Sharma 8860650846 adhishwar7@gmail.com

Pre op photo

pre op measurements

patient positioning

fascia excision in progress

Foot being addressed

marking for lymphatic flap

patient positioning

vessel being dissected

lateral thoracic lymph node flap harvested

pedicle of flap 

flap connected

6/3/2018
65 year old male a case of lymphedema tarda operated recently first debulking was done . In debulking fascia along with flap thinning is done . Next day patient is again taken up for VLNT .Lateral thoracic nodes on thoraco dorsal pedicle harvested and connected to SCIA vessels in goin.

Dr Adhishwar sharma 8860650846 adhishwar7@gmail.com

32 year old case of lymphedema under went 17 surgery in past now came to us . He was planned for autologous lymph node transfer and liposuction of lower limb.AV loop was formed to connect artery and vein of lymph node flap.

Dr adhishwar Sharma 8860650846 adhishwar7@gmail.com