Advanced treatment of lymphoedema using functional diagnosis, ICG lymphography and microsurgery
Lymphoedema is much more than just persistent swelling. It is a disorder of the lymphatic system that can affect the volume of a limb, mobility, the skin, the risk of infection and, very importantly, quality of life.
For years, treatment focused mainly on managing symptoms, reducing inflammation, relieving heaviness and preventing the condition from getting worse. Today, however, the approach to lymphoedema is changing.
The development of functional diagnostic techniques, advances in lymphatic microsurgery and the use of technologies capable of visualising lymphatic drainage in real time allow each case to be studied with greater precision and more personalised treatments to be devised.
It is no longer simply a matter of observing a limb that is swelling. The aim is to understand how each patient’s lymphatic system functions and, based on that information, to decide on the most appropriate strategy.
“Lymphoedema should not be understood solely as swelling. It is the manifestation of a disorder of the lymphatic system. Therefore, the better we understand how that system functions in each patient, the more precise the treatment can be,” explains Dr Jaume Masià, head of the Plastic and Reconstructive Surgery department at the Publio Cordón Memorial Hospital.
What is lymphoedema and how does it affect the lymphatic system?
The lymphatic system is a network of vessels and nodes that helps maintain fluid balance in the tissues and plays a role in immune functions.
When this network loses its ability to transport lymph properly, this fluid can gradually build up. This is when lymphoedema develops.
In the early stages, it may manifest as a feeling of heaviness, swelling, tightness or subtle changes in a limb. Over time, if it progresses, it can lead to tissue hardening, skin changes, persistent discomfort, functional limitations and episodes of inflammation or infection.
There are two main types of lymphoedema. Primary lymphoedema is linked to developmental abnormalities of the lymphatic system. Secondary lymphoedema occurs following acquired damage, such as cancer surgery, lymph node removal, radiotherapy, trauma, infections or certain surgical procedures.
However, not every increase in volume is due to lymphoedema. For this reason, a specialist assessment is essential to distinguish it from other causes of oedema and to guide treatment appropriately.
From clinical diagnosis to functional diagnosis of lymphoedema
One of the major advances in lymphatic medicine has been the shift from an approach based solely on anatomy or visible volume to a functional assessment.
Two patients may have seemingly similar swelling and yet exhibit very different lymphatic behaviours. One may retain functional drainage pathways, another may have more advanced tissue damage, and yet another may require a combined treatment strategy.
The assessment begins with a detailed clinical evaluation. The specialist analyses the patient’s medical history, the course of the condition, the location of the oedema, tissue consistency, skin condition, symptoms, functional impact and possible associated factors.
Increasingly, this assessment is complemented by techniques that help to understand how lymph actually circulates.
“The diagnosis is not simply a matter of confirming the presence of lymphoedema. We also need to know what stage it is at, what functional capacity the system retains, and which treatment options are appropriate for that particular patient,” explains Dr Masià.
Indocyanine green lymphography: how it reveals lymphatic drainage
One of the most common questions asked by patients is a simple one. How do you know if the lymph is draining properly?
Answering this question has not always been easy. Unlike arteries or veins, lymphatic vessels are extremely fine structures and difficult to observe directly.
One of the techniques that has changed this situation is fluorescence lymphography using indocyanine green, also known as ICG.
Although the name may sound complex, the concept is relatively simple.
The test involves administering a very small amount of a fluorescent tracer via superficial microinjections into the skin, usually near the area to be studied. This tracer enters the lymphatic system and travels along the natural path of the lymph.
The medical team can then use a specialised camera to observe in real time how this fluid circulates beneath the skin.
The result is not limited to a static image. It functions as a dynamic map of lymphatic drainage. It enables the assessment of whether there are preserved pathways, areas where drainage is slowed, blocked regions or alternative routes that the body itself has attempted to develop.
In clinical practice, this information helps to detect early abnormalities in drainage, identify which areas retain lymphatic function, guide surgical planning, locate vessels suitable for microsurgery, and assess the patient’s progress during follow-up.
The usefulness of this technique has been supported by international studies. In a paper published in PLOS ONE, researchers compared indocyanine green lymphography with other imaging techniques in patients with early-stage upper limb lymphoedema. Fluorescent lymphography and magnetic resonance imaging achieved a diagnostic sensitivity of 100 per cent, compared with 62 per cent for lymphoscintigraphy and 33 per cent for computed tomography.
Beyond the technical data, the clinical message is significant. The better we understand how the lymphatic system actually functions, the more personalised the treatment decision can be.
“The great benefit of these techniques is that we are no longer working solely on the basis of what we can see from the outside. We can study how lymphatic drainage is functioning and use that information to make more precise decisions tailored to each patient,” explains Dr Masià.
Treatment of lymphoedema: a personalised, stepwise approach
Modern treatment for lymphoedema is usually approached in a stepwise and individualised manner. Not all patients require surgery, and not all benefit from the same measures.
In many cases, conservative treatment remains an essential part of the approach. This may include complex decongestive therapy, compression garments, adapted exercise, skin care, patient education and specialist follow-up.
These measures can help to reduce symptoms, control progression, improve function and minimise complications.
In selected patients, particularly where there is a clear indication following clinical and functional assessment, advanced surgical treatments may be considered.
Lymphatic microsurgery: when it may be indicated
Lymphatic microsurgery acts on the functioning of the lymphatic system. Its aim is not merely to reduce volume, but to promote new drainage pathways or improve lymphatic function in carefully selected patients.
One of the most commonly used techniques is lymphatic-venous anastomosis. This involves connecting small-calibre lymphatic vessels to nearby veins to enable the lymph to find an alternative route out. It is a highly precise surgical procedure, carried out using advanced magnification, as the vessels involved may measure less than one millimetre.
In certain cases, the transfer of vascularised lymphatic tissue may be considered. This technique involves transferring tissue that contains lymphatic structures and their blood supply, with the aim of promoting the functional recovery of drainage in selected areas.
In more advanced stages, where there is significant fibrosis or an increase in fatty tissue secondary to lymphoedema, techniques aimed at reducing volume and improving function may be considered, always within the context of a specific medical indication.
These options should not be viewed as isolated or interchangeable procedures. They form part of a strategy that depends on the stage of the condition, the lymphatic anatomy, the condition of the tissues and the clinical objectives for each patient.
One of the key European studies in this field was published by Dr Jaume Masià and his team in the *Journal of Reconstructive Microsurgery*. In what is known as the Barcelona algorithm, the authors analysed 200 patients with breast cancer-related lymphoedema and applied different surgical strategies according to the clinical and functional characteristics of each case.
The value of this type of study lies not only in the results in terms of volume reduction, but also in the approach itself. The surgical treatment of lymphoedema must be based on appropriate patient selection and individualised planning.
“Surgery for lymphoedema is not indicated solely on the basis of the volume of a limb in isolation. It requires an understanding of how the lymphatic system functions and a clear definition of the actual benefit we can offer each individual,” notes the specialist.
Follow-up as an essential part of treatment
The management of lymphoedema does not end with a surgical procedure or an initial course of physiotherapy or compression therapy.
Follow-up allows for the assessment of changes in volume, symptoms, skin condition, limb function and the patient’s adaptation to their daily life.
It also helps to adjust conservative measures, detect complications, review expectations and support a process that often requires continuity.
In this context, the success of treatment should not be measured solely in centimetres. It is also important that the patient experiences less heaviness, less discomfort, improved mobility, a lower risk of inflammatory episodes and a more comfortable daily life.
Frequently asked questions about lymphoedema and its treatment
Does lymphoedema always require surgery?
No. Many patients can benefit from conservative treatment and specialist follow-up. Surgery is considered only in selected cases, following a clinical and functional assessment.
Is fluorescence lymphography necessary in all cases?
Not always. Whether it is indicated depends on the clinical situation, the stage of the lymphoedema and whether advanced or surgical treatment is being considered.
Does surgery always eliminate the need for compression?
It depends on the individual patient. In some cases, it may reduce the need for compression or improve symptoms, but in others, compression remains part of the treatment.
Can lymphoedema that has been present for many years be treated?
Yes, but the options may vary depending on how long the condition has been present, the condition of the tissues and the residual lymphatic function. That is why an individualised assessment is important.
Why is it important to seek advice early?
Early diagnosis can help identify the initial stages, guide treatment more effectively and prevent changes in the tissues from limiting certain treatment options.
Towards more precise and personalised lymphatic medicine
The treatment of lymphoedema is evolving towards a more precise, functional and personalised model.
The combination of clinical experience, advanced diagnostics, fluorescent imaging, microsurgery and specialised follow-up allows for a better understanding of each case and the design of strategies tailored to the patient’s actual needs.
For years, lymphoedema was mainly managed by treating its visible consequences. Today, progress lies in studying the lymphatic system, understanding how it works and deciding with greater precision when to monitor, when to treat conservatively and when surgery may be indicated.
“The future of lymphoedema treatment lies in precision: diagnosing more effectively, intervening when indicated, and supporting the patient with a personalised strategy maintained over time,” concludes Dr Jaume Masià.
This information is for general guidance only and is not a substitute for an individual medical assessment. If you experience symptoms consistent with lymphoedema or have any doubts about the most appropriate treatment, you should consult a specialist.
The information in this article is provided for general awareness and does not replace an individualised medical assessment.
