Lymphoedema Surgery, Brachial Plexus and Pectus Correction

Lymphoedema surgery treats chronic limb swelling that conservative care cannot control. Dr. Pradeep Kumar Singh's approach is staged: lymphography to find functioning lymphatic channels, lymphovenous anastomosis to drain lymph into veins, excisional surgery to remove the excess tissue, and a free vascularised lymph node transfer to prevent recurrence. In one patient this brought a 120 cm limb girth down to 65 cm.

Dr. Pradeep Kumar Singh, Head - Cosmetic & Plastic Surgery, Artemis Hospitals, Gurugram, India, describes four areas as the most specialised part of his practice: lymphoedema, brachial plexus injury, pectus chest wall deformities and gender-affirming surgery. All four came later in his career, after years of trauma, cancer and aesthetic work, and each depends on specialised equipment and skills. This article covers what each involves, how patients are assessed and what results look like. The complete guide to plastic surgery from reconstruction to aesthetics gives the overview of the specialty, and the replantation and microsurgical reconstruction article covers the free flap techniques these operations build on.

What lymphoedema is and when it needs surgery

Lymphoedema is chronic swelling caused by a failure of the lymphatic system to drain fluid from the tissues. Lymph collects under the skin, and over time the tissue thickens with fat and fibrous tissue, so the limb grows heavier and firmer. It can be primary, from abnormal development of the lymphatics, or secondary, after injury, surgery, radiotherapy or infection damages them. In its most advanced form the limb becomes massively enlarged, a picture often called elephantiasis.

Conservative treatment, with elevation, compression and specialised massage, is the first line. Dr. Singh's referral trigger is specific: leg oedema that does not settle with limb elevation and conservative management needs a surgical opinion from a plastic surgeon.

Lymphoedema surgery step by step: one patient's staged treatment

In the case that first took Dr. Singh into lymphoedema surgery, staged treatment reduced the girth of a 45 kg leg from 120 cm to 65 cm, and the girth held at about 65 cm one year after the lymph node transfer. That case arrived during the COVID-19 lockdowns. A man in his mid-forties had developed lymphoedema of the left leg after an injury to the groin about ten years earlier. He could barely walk, had only slight movement at the ankle and had lost his work. Dr. Singh, who was not treating lymphoedema at the time, referred him to a centre that was, but it had closed during the pandemic and the patient returned.

Dr. Singh's department acquired a specialised microscope and lymphography equipment and treated him in stages:

1. Lymphography. Imaging of the lymphatic system showed that a few lymphatic channels were still functioning.
2. Lymphovenous anastomosis at three sites. Functioning lymphatics were joined to nearby small veins. The limb girth fell from 120 cm to 102 cm.
3. Excisional surgery. Multiple operations removed the excess fibrous and fatty tissue. The girth fell to 65 cm.
4. Free vascularised lymph node transfer. To prevent recurrence, supraclavicular lymph nodes from the neck were transferred with their blood supply from the transverse cervical artery, which was joined to the anterior tibial artery in the leg.

One year after the lymph node transfer, the limb girth was maintained at about 65 cm despite walking and work. The patient had taken a job and could ride his scooter.

Lymphovenous anastomosis and lymph node transfer explained

Lymphovenous anastomosis (LVA) connects lymphatic vessels directly to small veins so that trapped lymph drains into the venous circulation. Lymphatic vessels in the limb are often less than a millimetre wide, so the operation is supermicrosurgery: joins made under high magnification with sutures finer than a hair. It works only where some lymphatics still function, which is why lymphography comes first.

Vascularised lymph node transfer (VLNT) moves a small cluster of healthy lymph nodes, with the artery and vein that supply them, to the affected limb. The transferred nodes are thought to draw lymph into the venous circulation and to stimulate new lymphatic channels.

Excisional (debulking) surgery removes tissue that drainage procedures cannot shrink. Once lymphoedema has turned the limb into solid fat and fibrous tissue, reconnecting the lymphatics alone will not restore its shape.

Dr. Singh's sequence used all three, each for a different job: LVA to drain, excision to reduce, and lymph node transfer to keep the limb from swelling again. Since that case his department has performed multiple LVAs for other patients, including post-traumatic lymphoedema. Reducing the risk of arm lymphoedema at the time of breast cancer surgery is a separate, preventive approach, covered in axillary management in breast cancer and the LYMPHA technique.

Brachial plexus injury: nerve transfer and its timing

The brachial plexus is the network of nerves, from the fifth cervical to the first thoracic spinal nerve roots, that supplies the shoulder, arm and hand. Injury, usually from traction in a road accident, a fall or a difficult birth, can paralyse part or all of the limb. An upper plexus injury, involving the C5 and C6 roots, typically takes away the ability to lift the arm at the shoulder and to bend the elbow.

A nerve transfer takes a working nerve, or some fascicles of one, whose function the patient can spare and connects it to the nerve of a paralysed muscle, so that the muscle is reinnervated close to where it needs to work. Nerve transfers are most effective when performed within months of the injury, before the paralysed muscle loses its capacity to accept a new nerve supply; when that window has passed, a free functional muscle transfer can still restore movement.

Two of Dr. Singh's cases illustrate the approach:

• A young boy with an upper brachial plexus injury could not lift his shoulder or bend his elbow. After multiple nerve transfers, he had regained a fairly good amount of shoulder abduction and elbow flexion at one year, and was still recovering.
• A man with an upper brachial plexus injury of the right arm, affecting the shoulder and elbow, was presented six months after multiple nerve transfers.

Pre-surgical evaluation for brachial plexus injury

Dr. Singh's workup has three parts, each with a distinct purpose:

1. Clinical examination, to map the deformities and deficits the patient has after the injury and to plan the procedure around them.
2. Nerve conduction studies and electromyography (EMG), to establish how many donor nerves and donor muscles are available for transfer.
3. Magnetic resonance imaging (MRI), which he regards as essential, to map the brachial plexus itself.

Birth, traumatic and oncological brachial plexus injuries

His department manages birth brachial plexus injuries as well as traumatic and oncological injuries in adults. Birth brachial plexus palsy usually follows a stretching injury, when traction is applied to the arm during a difficult delivery. Klumpke's palsy, a lower plexus injury affecting the hand, is one form. Shortly before the session, Dr. Singh operated on a two-year-old child with a birth brachial plexus injury.

Pectus excavatum and pectus carinatum surgery

Pectus excavatum is a sunken breastbone that gives the chest a hollow appearance; pectus carinatum is the opposite, a breastbone that protrudes outward, sometimes called pigeon chest. Both can be purely cosmetic concerns, but a deep pectus excavatum can compress the chest cavity.

Dr. Singh's department now treats a steady flow of pectus patients. A young patient from Central Asia with pectus excavatum came for correction because the deformity made him breathless while running, from compression of the chest. Ten days after surgery the depression had gone and the chest contour had clearly improved, and his lung capacity improved markedly as he recovered. In a young boy with pectus carinatum, the improvement in the chest wall contour was visible immediately after surgery. The thoracic surgery view of chest wall deformities is covered in chest wall tumours, reconstruction and deformities.

Gender-affirming surgery

Dr. Singh's department performs gender reassignment surgery in both directions, male-to-female and female-to-male. Gender-affirming genital surgery draws on the same flap and microsurgical techniques used in penile reconstruction after trauma or cancer, which is one reason it sits within plastic surgery. The specialty's link with this work is long: Sir Harold Gillies, one of the founders of modern plastic surgery, performed one of the earliest male-to-female operations in 1951. Internationally accepted practice, set out in the WPATH Standards of Care, places surgery after a multidisciplinary assessment.

Why these four areas need a specialist centre

What lymphoedema, brachial plexus, pectus and gender-affirming surgery share is that each needs equipment, experience and teamwork beyond routine plastic and reconstructive surgery: a supermicrosurgical microscope and lymphography for lymphoedema, electrodiagnostics and plexus imaging for nerve surgery, and staged planning for reconstruction that may take several operations.

For referring doctors, the practical points are the oedema that will not settle with elevation and conservative care, and a paralysed shoulder or elbow after a brachial plexus injury, where earlier referral keeps more options open. Questions doctors asked on brachial plexus evaluation and birth palsy are answered in the Live Discussion.