Surgical options: Liposuction

Liposuction for Advanced Lymphoedema

Liposuction for the treatment of lymphoedema was pioneered in Sweden by plastic and reconstructive surgeon Professor Håkan Brorson and recently introduced into Australia by Dr Helen Mackie.

Liposuction is not a cure for lymphoedema and ongoing rehabilitation and compression therapy is a necessary component of the long-term management. However, it can have a positive outcome in terms of reducing the swelling in the arm and leg, increasing patient comfort and benefiting patients emotionally and socially.

Surgery

The technique involves removing subcutaneous fat via some 15–20 small incisions (around 2mm each) along the limb. On average, the tissue removed by liposuction contains between 80 and 95% fat. The liposuction treatment is effective because it removes the excess fatty tissue. There is complete reduction of swelling, which decreases pain and heaviness and increases limb mobility.

An absolute requirement for post-operative success is vigilant use of a custom-made compression garment. This garment has to be used at all times or lymphoedema inevitably recurs. The operation and post-operative management will be undertaken at Macquarie University Hospital.

As part of post-operative care, limb volumes will be measured, garments adjusted or renewed and other matters of concern discussed. Patients are also encouraged to contact their team whenever any unexpected problems arise.

The use of a multidisciplinary team during the whole process is a pre-requisite for thorough pre-operative consideration, for fully informing patients about the treatment and for successful maintenance of immediate post-operative improvements.

Follow-up at the clinic

After liposuction, treatment is continued with compression therapy via garmenting. This is very important during the first three months when the most notable changes in volume occur. At the one-month visit, another custom-made compression garment is measured, alternating this with the old one until the three-month visit. At the three-month visit, the limb is measured for new custom-made garments. This procedure is repeated at six, (nine) and 12 months.

The garment may need to be narrowed using a sewing machine to compensate for wear and tear. This may require additional visits in some instances, although patients can often make such adjustments themselves. When the oedema volume has decreased as much as possible and a steady state is achieved, new garments can be prescribed using the latest measurements. This means that garments are renewed three or four times during the first year.

One set of garments for arm lymphoedema comprises a sleeve and a glove or mitten. It is important that two sets of compression garments are always at a patient’s disposal so that one can be washed, every other day, while one is worn. It is imperative that a set of garments be worn constantly, interrupted only by showering and changing of the set. Normally two sets of garments last for six months, but in very active patients they have to be renewed every three to four months. After complete reduction, a patient is normally seen once a year, when garments for the next 12 months are prescribed. Remember that these garments will be the same size as your unaffected arm.

Candidate selection for liposuction

To be considered for liposuction, a patient must have tried conservative therapies such as manual lymph drainage (MLD) and compression therapy by a skilled therapist. MLD includes massage, bandaging during two to four weeks and, thereafter, using compression garments, which have to be worn all the time.

Conservative therapy is performed until all pitting has disappeared or until there is minimal pitting (max 3–4mm). (The ‘pitting test’ involves pressing as hard as possible with the thumb for 60 seconds on the forearm to determine whether the arm shows pits on pressure). If swelling is still present (more than 800–1000ml) after vigorous conservative therapy and no or minimal pitting occurs, liposuction can be performed to remove the excess adipose tissue (only).

An assessment by Dr Mackie and lymphoedema therapist will be undertaken for selection into the program, following the international best practice guidelines established by Professor Broson. (See criteria for selection below).

Measuring the volume of the limbs

Part of patient assessment includes measuring the volume of each limb. Limb volumes can be measured by water displacement pletysmography (volumeter) or by circumference measurements and bio-impedence spectroscopy (L-Dex).

When water volumeter is used, the arm is put into a water tank and the displaced water is measured. As both limbs are measured, the difference in limb volume equals the amount of swelling.

Circumferential measurements can also be used for the calculation of limb volume. For arm measurements, the wrist to the arm pit, the circumference is measured every 4cm on both arms. Using a computer program, the volume can then easily be calculated.

Liposuction surgery does not cure the lymphoedema, but re-shapes the limb to normal size, which is maintained by the use of compression garments.

Criteria for selection for liposuction

  1. Late stage lymphoedema with fatty change and minimal fluid in the limb
  2. Completed and complied with conservative treatment, massage, bandaging and wearing of firm compression garment
  3. An arm-volume difference of 750–1000 ml (or arm ratio above 1:1.3) and a leg-volume difference of greater than 3000ml
  4. The lymphoedema limb must be causing problems such as heaviness or difficulty in use such that a patient wants something done
  5. No recent cellulitis (infection)
  6. No skin lesions or ulcers in the limb
  7. No evidence of active cancer
  8. No surgical or anaesthetic contraindications for liposuction
  9. Patient must be prepared to attend follow up and wear compression garments as instructed, replacing them when needed
  10. Patient must be prepared to undergo a surgical procedure with anaesthetic and to stay at Macquarie University Hospital for up to 10 days and be available for follow up over a 12-month period
  11. Patient must not be obese, and have weight (minus limb extra weight) in normal range for height (calculated BMI < 27)
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