Liposuction of lymphedema: treatment strategy, pathophysiology and long-term outcome (A DOCTORAL DISSERTATION)

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Organization. LUND UNIVERSITY

Department of Plastic and Reconstructive Surgery. Skåne university hospital. Department of Surgery, Blekinge Hospital

Mattias Hoffner, MD

Date of issue January 26, 2018


Lymphedema is a chronic and complex condition that has major physical, psychological and social implications for the quality of life of patients suffering from it. Any disruption of the lymph flow due to disease or iatrogenic damage (surgery, radiotherapy or trauma) can result in failure to transport lymph back to the blood circulation, and secondary to this, fat deposition will occur in the affected extremity resulting in a lymphedema.

Aims: To investigate the incidence of erysipelas in postmastectomy arm lymphedema before and after treatment with liposuction (Paper I), to investigate the quality of life in patients with postmastectomy arm lymphedema before and after treatment with liposuction and in comparison to Swedish norm data (Paper II), to examine the relation of fat and water in the epi- and subfascial compartment of the lymphedema using magnetic resonance imaging (MRI) (Paper III), to investigate the long-term outcome of lymphedema excess volume reduction after liposuction in combination with controlled compression therapy in patients with late stage arm lymphedema (Paper IV).

Methods: Paper I. 130 patients with postmastectomy arm lymphedema underwent liposuction between 1993-2012. Pre- and postoperative bouts of erysipelas were analyzed. The mean duration of lymphedema prior to liposuction was 8.8 years (range1-38, standard deviation (SD) 7.0 years). The mean age at the time of liposuction was 63 years (range 39-89, SD 10 years). The total number of pre-liposuction observation years was 1147, and the total number of post-liposuction observation years was 983. Paper II. Sixty female patients with arm lymphedema were followed for a one-year period after liposuction. The 36-item short-form health survey (SF-36) was used to assess health-related quality of life (HRQoL). Patients completed the SF-36 questionnaire before liposuction, and after one, three, six, and 12 months. The results were compared with Swedish norm data. Paper III. Seven patients with arm lymphedema (median 1239 ml) and six patients with leg lymphedema (mean 4183 ml) were examined with MRI before and after liposuction at four days, and one, three, six and 12 months. Three slices were acquired at eight echo times with voxel size 1.6 x 1.6 x 5 mm3 and fat and water fraction images were reconstructed using a linear least-squares algorithm. Fat and water volumes were calculated within each of the epifascial and subfascial compartments. Paper IV. 105 women with non-pitting edema, a mean age of 64 (range, 41- 89) years and a mean duration of arm swelling of 10 (range, 1-38) years underwent liposuction. The mean age at the time of the breast cancer operation, the mean interval between the breast cancer operation and lymphedema start, and the duration of lymphedema were 51 years (range, 34-86), three years (range 0-32), and 10 years (range 1-38) respectively. Aspirate and arm volumes were recorded.

Results: Paper I. The incidence of erysipelas decreased from 0.47 attacks/year to 0.06 attacks/year, a reduction of 87%. Paper II. Mental health, physical functioning, bodily pain, vitality, social functioning and composite scores showed higher values after surgery. Compared with SF-36 norm data for the Swedish population, only physical functioning showed lower values than the norm at baseline. Paper III. The excess epifascial fat and water decreased. The excess subfascial fat was unchanged. The excess water in the subfascial compartment was reduced over time, which may have represented a decrease of muscle volume after treatment due to less mechanical load after liposuction. Paper IV. The aspirate mean volume was 1831 ml (range 650-3780) with an adipose tissue concentration of 94 % (range 58-100). The preoperative mean excess volume was 1642 ml (range 570-3520). The postoperative mean reduction was 101 % (range 68-189) at three months and more than 100% during the five years’ follow-up when it was 117% (range 25-191), i.e. the lymphedematous arm was somewhat smaller than the healthy arm.

Conclusion: We demonstrate that liposuction removes the excess volume completely, without recurrence, and reduces the incidence of erysipelas by 87%. Also, liposuction seems to improve patients’ HRQoL, possibly due to the reduced volume of fat and the decreased amount of water/muscle shown by MRI.

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