Lymphedema FAQ

Say Goodbye to Compression Garments after Dr. Cheng’s Lymphedema Microsurgery

FAQS About Lymphatic System & Lymphedema

Lymphedema FAQ
▲The flow diagram represents the impact of both physiologic and nonphysiologic methods of surgical treatment on the lymphatic system.

Data source: Principles and Practice of Lymphedema Surgery. Cheng MH, Chang DW, Patel KM (Editors). Elsevier Inc, Oxford, United Kingdom. ISBN: 978-0-323-29897-1. July 2015, page 218.

What is the Lymphatic System?

As part of the immune system, the lymphatic system helps the body activate a specific immune response against viruses and bacteria. It retains fluid homeostasis in all different compartments of the body. It is made by channels called lymphatic vessels. These collect lymph from all over the body and deliver lymph to the regional lymph nodes or thoracic ducts and then back to the cardiovascular system.

FAQS About Lymphatic System and Lymphedema - schema lymphatic system

What is Lymph fluid?

Lymph is a colorless protein-rich fluid that physiologically collects waste products and pathogens. It is present in tissue and transported through the lymphatic system to regional lymph-nodes. The venous flow carries 90% of arterial blood back to the heart and the remaining 10% becomes lymph fluid in the interstitial. Peripheral lymph nodes drain approximately 4-8 liters of lymph fluid per day. The lymphocytes (infection-fighting cells) that reside in the lymph nodes activate a specific immune response against infection.

What are Lymph Nodes?

Lymph nodes are bean-shaped organs of the lymphatic system that are distributed widely throughout the body. They are composed by lymphoid tissue enclosed by a capsule of connective tissue. Lymph nodes are major sites of B cells, T cells, and other immune cells. They serve as filters for the blood and provide specialized tissues where foreign antigens and cancer cells can be trapped and exposed to cells of the immune system for destruction. They are typically found concentrated near junctions of the major lymphatic vessels and most prominently found in the neck, groin, and armpits.

Why is the lymphatic system important?

The lymphatic system has two important roles: activating the immune response against antigens and transporting lymph fluid. Both functions are important to preserve body homeostasis. When the lymphatic system is compromised by cancer, infections, surgery, trauma, or congenital issues, the affected part of the body is prone to swelling (lymphedema) and recurrent infection due to the faulty surveillance mechanism. The functions of the lymphatic circulation include prevention and resolution of edema, maintenance of interstitial fluid homeostasis, immune trafficking (the regulated transit of antigen-presenting cells to the lymphoid organs), and lipid absorption from the gastrointestinal tract.

Prepare vascularized submental lymph node flap transfer surgery


1) How long is the stay, to comfortably prepare for surgery and complete postoperative care?

One week.

2) At which hospital or facility would the surgery actually be performed?

A+ Surgery Clinic has the state of art 42X Mitaka microscope, 3 operation rooms, and professional anesthesiologists, full-time RNs, and 7 private rooms for admission.

3) Will you and your office coordinate all aspects of care?

Yes. All of our patients are well cared for.

4) Who will be the point person before, during, and after the surgery?

Miffy Lin, Ph.D.,

5) Do you have any logistical leaflet you could share that is aimed at international patients like us?

No. You may check our website:

Surgical procedure, from planning to post-operative care


1) Do you need MRI, lymphoscintigraphy, and ICG, OR are one or two of those sufficient? If so, which is/are preferable in terms of balancing accuracy of diagnosis /surgical course vs radiation or other risks?

Lymphoscintigraphy and ICG are required to make an accurate diagnosis and staging for the treatment, either LVA or VLNT. MRI does not help for the treatment.

2.1) Before travel to Taiwan, are other tests (beyond imaging) needed to determine the appropriate surgical procedure?

Please check platelet count, since the heparin-induced thrombocytopenia and thrombosis is the most common complications post VLNT, specially for those patients with heparin exposure such as the Port-A insertion for chemotherapy.

2.2) Before travel to Taiwan, are there any medical records that we should be sending you?

Surgical record, pathology reports, Lymphoscintigraphy and ICG.

3) Upon arrival in Taiwan: what are the salient pre-operative steps?

CBC/DC, Chest X-ray, EKG, Lymphoscintigraphy and ICG.

4) Would you personally be performing the surgery, irrespective of the surgical path you deem best?

I personally perform the surgery through the entire procedure.

5) What other specialists, if any, would be part of my medical team?

No need.

6) How long does the surgical procedure itself last?

LVA: 2 hours, VLNT 4-5 hours.

7) How long is the hospital stay?

LVA: 2 days, VLNT 5-7 days.

8) How much pain should my reasonably expect and for how long?

Not much pain immediate postoperatively, most patients do not need intravenous pain killer.

9) What are the salient risks of undergoing the surgery itself? How likely are they?

The heparin-induced thrombocytopenia and thrombosis (HITT) is the most common complication post VLNT, about 15 %, especially for those patients with heparin exposure such as the Port-A insertion for chemotherapy. HITT will develop the local pedicle artery or vein thrombosis, which will affect the survival and function of the VLNT. Infection is rare.

10) What are the post-operative risks or adverse effects of the procedure? How likely are they?

See above answer.

11) Can you briefly describe anew (our notes are a bit confusing) the salient difference between your approach and the “main US alternative” we discussed (Cleveland Clinic)?

The side-to-end lymphovenous anastomosis is the better drainage for extremity lymphedema without wearing compression postoperatively. The lymphatic vessels require contraction to push the lymph from distal to proximal, from dependent site to axilla. If the lymphatic vessels are divided and lost its continuity during end-to-end anastomosis, all the segments of lymphatic vessels will lose their continuity and contraction function, which lost the drainage function eventually.

12.1) What are the key benefits of your approach compared to the main US alternative? Is your approach substantially less invasive than the main US alternative?

Yes, one side-to-end LVA at the distal forearm is less invasive, no trauma to other healthy lymphatic vessels. No compression garments are required postoperatively.

12.2) What are the key benefits of your approach compared to the main US alternative? Is your approach substantially lower risk?


12.3) What are the key benefits of your approach compared to the main US alternative? Is the reduction in lifetime risk of infection /cellulitis substantially greater?

Yes. Once the lymph has been adequately drained into venous system through side-to-end LVA daily, estimated 500 cc per day, the infection and cellulitis has significantly decreased.

12.4) What are the key benefits of your approach compared to the main US alternative? Is the reduction in other lymphedema-related risks /co-morbidities substantially greater?

Yes, mainly the infection, swelling, and appearance.

12.5) What are the key benefits of your approach compared to the main US alternative? Is reduction in arm circumference substantially greater?


12.6) What are the key benefits of your approach compared to the main US alternative? Is the absence of need for post-surgical compression unique to your approach?


13) Taking into account the unique benefits of your approach, are there any countervailing potential risks or disadvantages that we should consider, relative to the main US alternative?

No countervailing potential risks in side-to-end LVA. The temporary cosmesis in the distal recipient site, the potential HITT in VLNT.

14) You indicated a 98% success rate for the procedure, which is remarkable and very comforting. Are there clinical indicators that can determine if my is at high risk of being in the 2%?

If the ICG demonstrating the lymphatic vessels are available at the forearm.

15.1) About post-operative care, what does the post-operative care in Taiwan involve?

You may visit the testimonials my patients via Youtube at, and

15.2) About post-operative care, once we are back home, is there someone you trust in NYC to collaborate with, so as to ensure any follow up care is performed to your standards of excellence?

Dr. Joseph Dayan at Memorial Sloan Kettering Cancer Center.

15.3) About post-operative care, how likely is it that we would need to travel to Taiwan anew for follow up care or procedures?

One year post-operatively.

16) Is there a risk that the two long flights from /to NYC might defeat the benefits of the surgery itself?

No. I have quite a few international patients from US, Canada, Rusia, Sweden, Dubai, Saudi Arabic, India, and Iraq.

17) I am on Anastrozole, Verzenio, Minoxidil. Are any of those of concern as it relates to surgery?


18) Considering the most promising current /known avenues of research for an actual cure over the next 5 to 10 years, is the surgery likely to foreclose applicability of such potential cures?

In my opinion, the side-to-end LVA can cure the early grade lymphedema, and VLNT can cure the late grade lymphedema without wearing compression garments. I think there may be some innovation for the treatment of lymphedema in the next 5-10 years.

Managing symptoms & caring for my lymphatic system today


1) We followed your advice not to bandage. Can you briefly provide anew the key rationale for your recommendation? (Please forgive our anxiety; bandaging seems to be the standard of care in the US.)

Bandage and compression garments are not helping the drainage of lymph in the extremity daily. 10% of arterial blood become the lymph (estimated 500 cc /day in the upper limb) in the interstitial, then the lymph accumulates through the lymphatic vessels to axillary lymph nodes, which continuously drains to thoracic ducts, and to venous system. Bandage and compression garments will affect the contraction of the lymphatic vessels. Although the lymphedematous limb seems not swelling, but the lymphatic vessels will be fibrotic changed quickly.

2) Are there demonstrably helpful non-surgical treatments or routines that I can start now to manage symptoms or protect her lymphatic system (e.g.: exercises, lymphatic massage by certified therapist, acupuncture, diet, arm elevation)?

Exercises including yugo, biking, swimming and golfing within 3 hours each time are helpful for circulations. Lymphatic massage is helpful too. Please remember the lymph production is 10% of the arterial flow. Diet control is good. Arm elevation with one pillow during sleep is good.

Financial aspects


1) What is the all-in cost of the procedure?

Please ask Miffy for the details of the cost of possible procedures.

2) Is this cost fixed /guaranteed?

Please ask Miffy for the details of the cost of possible procedures.

3) Are you amenable to working with our insurance (BUPA in the United Kingdom) to ensure they provide us with pre-authorization, so that we can be reimbursed.

I am not familiar with the BUPA insurance policy.

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