By: Håkan Brorson, MD, PhD, Skåne University Hospital, Lund University, Malmö, Sweden
Vol. 28 No. 1 - Lymphlink Reprint, Archived January 2015
Excess Subcutaneous Adiposity and Chronic Lymphedema
There are various possible explanations for adipose tissue hypertrophy in lymphedema. There is a physiological imbalance of blood flow and lymphatic drainage, resulting in the impaired clearance of lipids and their uptake by macrophages.1,2 There is increasing support, however, for the view that the fat cell is an endocrine organ and a cytokine-activated cell,3,4 and chronic inflammation plays a role here.5,6
For more information about relationship between slow lymph flow and adiposity, as well as that between structural changes in the lymphatic system and adiposity, see Harvey et al.7 and Schneider et al.8
Other indications for adipose tissue hypertrophy include:
- The findings of increased adipose tissue in intestinal segments in patients with inflammatory bowel disease (Crohn’s disease), known as “fat wrapping,” have clearly shown that inflammation plays an important role.5,9,10
- Consecutive analyses of the content of the aspirate removed under bloodless conditions using a tourniquet showed a high content of adipose tissue (mean 90%).11
- In Graves’ ophthalmopathy with exophthalmos, adipocyte-related immediate early genes are overexpressed and cysteine-rich, angiogenic inducer 61 may play a role in both orbital inflammation and adipogenesis.12
- Tonometry can distinguish if a lymphedematous arm is harder or softer than the normal one. Patients with a harder arm compared with the healthy one have excess adipose tissue.13
- Volume-rendered computed tomography and dual X-ray absorptiometry have shown adipose tissue excess of 81% and 73%, respectively, in the swollen arm.14-16
The common misunderstanding among clinicians is that the swelling of a lymphedematous extremity is purely due to the accumulation of lymph fluid, which can be removed by use of noninvasive conservative regimens, such as complete decongestive therapy and controlled compression therapy (CCT). These therapies work well when the excess swelling consists of accumulated lymph, but do not work when the excess volume is dominated by adipose tissue.17 The same may apply to microsurgical procedures using lymphovenous shunts and lymph vessel transplantation,18-20 which do not remove adipose tissue.
Today, chronic nonpitting arm lymphedema of more than 4 L in excess can be effectively removed by use of liposuction without any further reduction in lymph transport.21 Complete reduction is mostly achieved in between 1 and 3 months. Long-term results have not shown any recurrence of the arm swelling [Figures 1a, b].17,22-24 Promising results also can be achieved for leg lymphedema [Figures 2a and 2b], for which complete reduction is usually reached at around 6-12 months.25,26
How to Perform Liposuction for Lymphedema
Made-to-measure flat-knitted compression garments (two sleeves and two gloves) are measured and ordered 2 weeks before surgery, using the healthy arm and hand as a template.
Nowadays we use power-assisted liposuction because the vibrating cannula facilitates the liposuction, especially in the leg, which is more demanding to treat.
Initially the “dry technique” was used.27 Later, to minimize blood loss, a tourniquet was utilized in combination with tumescence, which involves infiltration of 1–2 L of saline containing low-dose adrenaline and lignocaine.28,29
Through approximately 15–20, 3-mm-long incisions, liposuction is performed using 15- and 25-cm-long cannulas with diameters of 3 and 4 mm. When the arm distal to the tourniquet has been treated, a sterilized made-to-measure flat-knitted compression sleeve is applied to the arm to stem bleeding and reduce postoperative edema. A sterilized, standard interim glove, in which the tips of the fingers have been cut to facilitate gripping, is put on the hand. The tourniquet is removed and the most proximal part of the upper arm is treated using the tumescent technique.28,29 Finally, the proximal part of the compression sleeve is pulled up to compress the proximal part of the upper arm. The incisions are left open to drain through the sleeve. The arm is lightly wrapped with a large absorbent compress covering the whole arm (60 x 60 cm). The arm is kept at heart level on a large pillow. The compress is changed when needed.
The following day, a standard gauntlet (a glove without fingers but with a thumb) is put over the interim glove after the thumb of the gauntlet has been cut off to ease the pressure on the thumb. Operating time is, on average, 2 h.
Garments are removed 2 days postoperatively so that the patient can take a shower. Then, the other set of garments is put on and the used set is washed and dried. The patient repeats this after another 2 days before discharge. The standard glove and gauntlet is usually changed to the made-to-measure glove at the end of the hospital stay.
The patient alternates between the 3 sets of garments (2 sleeves and 2 gloves) during the 2 weeks postoperatively, changing them daily or every other day so that a clean set is always put on after showering and lubricating the arm. After the 2-week control, the garments are changed every day after being washed. Washing “activates” the garment by increasing the compression due to shrinkage.
Controlled Compression Therapy
A prerequisite to maintaining the effect of liposuction and, for that matter, conservative treatment, is the continuous use of a flat-knitted compression garment.17,22 After initiating compression therapy, the custom-made garment is taken in at each visit using a sewing machine to compensate for reduced elasticity and reduced arm volume. This is most important during the first 3 months when the most notable changes in volume occur, but even later it is important to adapt the garment to compensate for wear and tear. This can often be managed by the patient him or herself. At the 1- and 3-month visits the arm is measured for new custom-made garments. This procedure is repeated at 6, 9, and 12 months. If complete reduction has been achieved at 6 months, the 9-month control may be omitted. If this is the case, garments are prescribed for the next 6 months, which normally means double the amount that would be needed for 3 months. When the excess volume has decreased as much as possible – usually the treated arm becomes somewhat smaller than the normal arm – and a steady state is achieved, new garments can be prescribed using the latest measurements. In this way, the garments are renewed 3 or 4 times during the first year. Two sets of sleeve and glove garments are always at the patient’s disposal: one is worn while the other is washed. Thus, a garment is worn permanently, and treatment is interrupted only briefly when showering and, possibly, for formal social occasions.
The life span of 2 garments worn alternately is usually 4–6 months. Complete reduction is usually achieved after 3–6 months, often earlier. After the first year, the patient is seen again after 6 months (1.5 years after surgery) and then at 2 years after surgery. Then the patient is seen once a year only, when new garments are prescribed for the coming year, usually 4 garments and 4 gloves (or 4 gauntlets). For active patients, 6–8 garments and the same amount of gauntlets/gloves a year are needed. Patients without preoperative swelling of the hand can usually stop using the glove/gauntlet after 6–12 months postoperatively.
For legs, the author’s team often uses up to 2 or 3 compression garments on top of each other, depending on what is needed to prevent pitting. A typical example is flat-knitted compression class 3 (or 3 forte), round-knitted
compression class 2 (or flat-knitted compression class 2), and flat-knitted compression class 2; the latter being a below-the-knee garment. Thus, such a patient needs 2 sets of 2–3 garments. One set is worn while the other is washed. Depending on the age and activity of the patient, 2 such sets can last for 3–4 months. That means that they must be prescribed 3–4 times during the first year. After complete reduction has been achieved, the
patient is seen once a year when all new garments are prescribed for the coming year.
Volumes of both extremities are always measured at each visit using water plethysmography, and the difference in volumes is designated as the excess volume.17,22
When to Use Liposuction to Treat Lymphedema
A surgical approach, removing the hypertrophied adipose tissue, seems logical when conservative treatment has not achieved satisfactory reduction of the excess volume and the patient has subjective discomfort of a heavy arm or leg.
Liposuction should never be performed in a patient with a pitting edema, as it is dominated by accumulated lymph, which can be removed by conservative treatment.
The first and most important goal is to transform a pitting edema into a nonpitting one by conservative regimens like complete decongestive therapy or CDT. “Pitting” means that a depression is formed after pressure on the edematous tissue by the fingertip, resulting in lymph being squeezed into the surroundings. To standardize the pitting test, one presses as hard as possible with the thumb on the region to be investigated for 1 min, the amount of depression being estimated in millimeters. A swelling, which is dominated by hypertrophied adipose tissue, shows little or no pitting.23
Around 4–5 mm of pitting in an arm lymphedema, and 6–8 mm in a leg lymphedema can be accepted. The reason for not performing liposuction for a pitting edema is that liposuction is a method to remove fat, not fluid, even if theoretically it could remove all the accumulated fluid in a pitting lymphedema without excess adipose tissue formation.
Liposuction improves patients’ quality of life17,30 and reduces the incidence of erysipelas.31
There need be no tension between those who favor conservative treatment and proponents of liposuction. Accumulated lymph should be removed using the well-documented conservative regimens until minimal or no pitting is seen. If there is still significant excess volume, it can be removed by the use of liposuction. Continuous wearing of a compression garment prevents recurrence. To date, the author has trained and approved several teams from several countries. A recent publication from the Dutch team shows the same favorable outcome as from our clinic.32
- Excess volume without pitting means that adipose tissue is responsible for the swelling.
- Adipose tissue can be removed with liposuction. Conservative treatment and microsurgical reconstructions cannot do this.
- As in conservative treatment, the lifelong use (24 h a day) of compression garments is mandatory for maintaining the effect of treatment.
- Vague J, Fenasse R. Comparative anatomy of adipose tissue. In: Renold AE, Cahill GF, eds. American Handbook of Physiology, Section 5. Washington DC: American Physiology Society; 1965:25-36.
- Ryan TJ. Lymphatics and adipose tissue. Clin Dermatol. 1995;13:493-498.
- Mattacks CA, Sadler D, Pond CM. The control of lipolysis in perinodal and other adipocytes by lymph node and adipose tissue derived dendritic cells in rats. Adipocytes. 2005;1:43-56.
- Pond CM. Adipose tissue and the immune system. Prostaglandins Leukot Essent Fatty Acids. 2005;73:17-30.
- Borley NR, Mortensen NJ, Jewell DP, Warren BF. The relationship between inflammatory and serosal connective tissue changes in ileal Crohn’s disease: evidence for a possible causative link. J Pathol. 2000;190:196-202.
- Sadler D, Mattacks CA, Pond CM. Changes in adipocytes and dendritic cells in lymph node containing adipose depots during and after many weeks of mild inflammation. J Anat. 2005;207:769-781.
- Harvey NL, Srinivasan RS, Dillard ME, et al. Lymphatic vascular defects promoted by Prox1 haploinsufficiency cause adult-onset obesity. Nat Genet. 2005;37:1072-1081.
- Schneider M, Conway EM, Carmeliet P. Lymph makes you fat. Nat Genet. 2005;37:1023-1024.
- Jones B, Fishman EK, Hamilton SR, et al. Submucosal accumulation of fat in inflammatory bowel disease: CT/pathologic correlation. J Comput Assist Tomogr. 1986;10:759-763.
- Sheehan AL, Warren BF, Gear MW, Shepherd NA. Fat-wrapping in Crohn’s disease: pathological basis and relevance to surgical practice. Br J Surg. 1992;79:955-958.
- Brorson H, Åberg M, Svensson H. Chronic lymphedema and adipocyte proliferation: clinical therapeutic implications. Lymphology. 2004;37(Suppl):153-155.
- Lantz M, Vondrichova T, Parikh H, et al. Overexpression of immediate early genes in active Graves’ ophthalmopathy. J Clin Endocrinol Metab. 2005;90:4784-4791.
- Bagheri S, Ohlin K, Olsson G, Brorson H. Tissue tonometry before and after liposuction of arm lymphedema following breast cancer. Lymphat Res Biol. 2005;3:66-80.
- Brorson H, Ohlin K, Olsson G, Nilsson M. Adipose tissue dominates chronic arm lymphedema following breast cancer: an analysis using volume rendered CT images. Lymphat Res Biol. 2006;4:199-210.
- Brorson H. Adipose tissue in lymphedema: the ignorance of adipose tissue in lymphedema. Lymphology. 2004;37:135-137.
- Brorson H, Ohlin K, Olsson G, Karlsson MK. Breast cancer-related chronic arm lymphedema is associated with excess adipose and muscle tissue. Lymphat Res Biol. 2009;7:3-10.
- Brorson H, Svensson H. Liposuction combined with controlled compression therapy reduces arm lymphedema more effectively than controlled compression therapy alone. Plast Reconstr Surg. 1998;102:1058-1067. discussion 1068.
- Baumeister RG, Siuda S. Treatment of lymphedemas by microsurgical lymphatic grafting: what is proved? Plast Reconstr Surg. 1990;85:64-74. discussion 75-76.
- Baumeister RG, Frick A. The microsurgical lymph vessel transplantation. Handchir Mikrochir Plast Chir. 2003;35:202-209.
- Campisi C, Davini D, Bellini C, et al. Lymphatic microsurgery for the treatment of lymphedema. Microsurgery. 2006;26:65-69.
- Brorson H, Svensson H, Norrgren K, Thorsson O. Liposuction reduces arm lymphedema without significantly altering the already impaired lymph transport. Lymphology. 1998;31: 156-172.
- Brorson H, Svensson H. Complete reduction of lymphoedema of the arm by liposuction after breast cancer. Scand J Plast Reconstr Surg Hand Surg. 1997;31:137-143.
- Brorson H. Liposuction in arm lymphedema treatment. Scand J Surg. 2003;92:287-295.
- Brorson H, Ohlin K, Olsson G, Svensson B. Liposuction of postmastectomy arm lymphedema completely removes excess volume: a thirteen year study (Quad erat demonstrandum). Eur J Lymphol. 2007;17:9.
- Brorson H, Freccero C, Ohlin K, Svensson B. Liposuction normalizes elephantiasis of the leg. A prospective study with a 6 years follow up. Eur J Lymphol. 2009;20:29.
- Brorson H, Ohlin K, Svensson B, Svensson H. Controlled compression therapy and liposuction treatment for lower extremity lymphedema. Lymphology. 2008;41:52-63.
- Clayton DN, Clayton JN, Lindley TS, Clayton JL. Large volume lipoplasty. Clin Plast Surg. 1989;16:305-312.
- Klein JA. The tumescent technique for liposuction surgery. Am J Cosm Surg. 1987;4: 263-267.
- Wojnikow S, Malm J, Brorson H. Use of a tourniquet with and without adrenaline reduces blood loss during liposuction for lymphoedema of the arm. Scand J Plast Reconstr Surg Hand Surg. 2007;41:243-249.
- Brorson H, Ohlin K, Olsson G, Långström G, Wiklund I, Svensson H. Quality of life following liposuction and conservative treatment of arm lymphedema. Lymphology. 2006;39:8-25.
- Brorson H, Svensson H. Skin blood flow of the lymphedematous arm before and after liposuction. Lymphology. 1997;30:165-172.
- Damstra RJ, Voesten HG, Klinkert P, Brorson H. Circumferential suction-assisted lipectomy for lymphedema after surgery for breast cancer. Br J Surg. 2009;96:859-864.