In the world, secondary lymphedema most commonly occurs following treatment of cancer. A variety of conservative therapies have been reported, including complete decongestion therapy(CDT)[9], as well as microsurgical reconstruction including lymhatic venous anastomosis[10] or lymph node transplantation[11, 12].Failure of these treatments to provide complete reduction in patients with long-standing pronounced lymphedema is due to the persistence of excess newly formed subcutaneous adipose tissue in response to slow or absent lymph flow, which is not removed in patients with chronic lymphedema. Liposuction has drawn increased attention in the surgical treatment of lymphedema because it can remove hypertrophied adipose tissue.
Here we have demonstrated that liposuction surgery improved both quality of life and volumetric measurements in patients with lymphedema. Overall, the percent volume difference was significantly lower at post-operation and 3 months follow-up than that at pre-operation. The mean estimated blood loss (EBL) was 828ml, which was much higher than the EBL of 292ml when liposuction was done in obese patients[13]. The reason may be that there is abnormal hyperplasia of subcutaneous adipose tissue in lymphedematous limbs, and that the proliferating adipose layer contains multiple septations, which poses more difficulty during liposuction of lymphedematous limbs, aggravates peripheral vascular injury and increases bleeding than conventional liposuction. Therefore, patients with anemia should be proactively corrected before liposuction. Some patients may need packed red blood cells (pRBC) prepared before surgery. In this study, 3 patients were given intra-operative homologous blood transfusion.
Male had a significantly higher percent volume difference than female at pre-operation, post-operation, and 3 months follow-up, but significantly lower volume of aspirated fat and higher EBL. This suggests that there may be differences between male and female in the occurrence and development of lymphedema.Perhaps the abnormality of the lymphedematous lower extremity in male is more profound than that in female. In addition, subcutaneous tissue hyperplasia and fibrosis may aggravate as the disease progresses. We also found that the liposuction rate in male was significantly lower than that in female during the operation. That is, it was more difficult to extract fat in male. Moreover, the effect of different hormone levels between male and female on the composition of subcutaneous tissue [14, 15]as well as poor compliance of male may also account for the aforementioned differences, which need to be further investigated.
Lymphedema is one of the risk factors for the occurrence of erysipelas [16].Recurrent erysipelas can lead to subcutaneous tissue fibrosis, which in turn can aggravate lymphedema. In the study of Kosenkov[17], a correlation was found between occurrence of erysipelas and the degree of lymphedema, and they aggravated each other.In our study, the erysipelas group was noted to have higher EBL than the non-erysipelas group. This suggests that patients with recurrent erysipelas may have more fibrosis in the subcutaneous tissue, which could increasethe difficulty and risk of the surgery.
The percent volume difference of Stage Ⅲ group was significantly higher than that of Stage Ⅱ group at pre-operation, post-operation, and 3-month follow-up, whereas the volume of aspirated fat and liposuction rate of Stage III group was significantly lower than those of Stage II group. In addition, EBL of Stage III group is greater than that of Stage II group. These results suggest that, the longer the disease period, the more difficult the liposuction may become, and the more blood loss may ensue. It can be deduced that the surgical outcome may also be worse.The reason may be that the degree of fibrosis of subcutaneous tissue gradually elevates along the course of the disease. Sun et al[18] also believe that skin hardness is positively correlated with stage of lymphedema. Consequently, the outcome of liposuction and volume reduction in advanced limb lymphedema may not be as good as those in early lymphedema.
Regarding subjective feelings of the patients, the feeling of heaviness and fatigue of the affected limbs significantly reduced at 3-month follow-up compared with that at pre-operation, but the feeling of stiffness, tenderness and tightness of the lymphedematous limb was more severe than that at pre-operation. This may be related to the injury of subcutaneous nerves and inflammatory reactions after liposuction. It is worth noting that 58.1% of patients still felt stiff, 56.4% felt tight and 54.8% felt heavy 3 months after liposuction.The reason may be that the compression stocking fails to effectively improve lymphatic circulation despite significantly reduced volume of the lymphedematous limb after liposuction.
The data also show that percent volume difference increases significantly at 3-month follow-up after liposuction, which is consistent with the subjective sensory changes of the patients. Qi et al[4] compared outcome of liposuction in 17 patients — 7 upper limb lymphedema and 10 lower limb lymphedema. Substantial limb volume reduction was noted in all cases immediately after operation. This state of volume reduction remained 3 to 12 months with a mean of 6.01 months by applying low-stretch bandages or compression stockings. Subsequently it returned to the preoperative volume level. This implies that liposuction combined with more effective post-operative measures to ameliorate lymphatic circulation could contribute to a better surgical outcome of extremity lymphedema.
In our study, all cases were treated with a second-stage surgery within 3 to 6 months after liposuction to improve lymphatic circulation. All cases are still being followed up.