Liposuction as a Viable Treatment for End-Stage Upper Extremity Lymphedema

Jaume Masià

Cristhian D. Pomata

Patrícia Martínez-Jaimez

History

Lymphedema is a disabling progressive chronic disease that carries significant physical, functional, and economic consequences which impairs the patient’s quality of life (1). The upper extremity lymphedema, secondary to mastectomy, axillary node dissection, or biopsy, and postoperative irradiation, is a common complication after breast cancer treatment (2). Prospective cohort studies show that 21.4% of women develop lymphedema after breast cancer treatment, but the incidence varies considerably, ranging from 5% to 30% (3).

At the beginning of secondary lymphedema, the obstruction or disruption of the lymphatic system causes accumulation of fluid and plasma proteins in the superficial interstitial space. Later, as the lymph stasis persists, the chronic inflammation response produces fat deposition and fibrosis inducing, a permanent edematous state with sclerotic changes in the subcutaneous tissue, altering progressively the remaining functioning lymphatic channels (4,5). The swelling may generate pain, heaviness, tightness, impaired limb mobility, body image alteration, and anxiety (6).

The clinical management in early breast cancer–related lymphedema involves a wide variety of strategies. Initially, patients are treated by conservative methods such as decongestive lymphatic therapy (DLT) including manual lymphatic drainage, multilayer bandaging, compression garments, lymph-reducing exercises and skincare (7,8).

Over the last five decades, microsurgical techniques such as lymphatic–venous shunt, lymphaticovenous–lymphatic bypass, lymph vessel transplantation, and lymphatic node transfer, have emerged to reconstruct the damaged lymphatic system in early stages of lymphedema (9,10,11,12,13). However, no standardized protocol for lymphedema surgical procedure has been well established.

Despite the revolutionary concept of restoring the lymphatic system functionality is gaining popularity, none of these microsurgical procedures provide a complete reduction of the excess volume in later stages of lymphedema due to the persistence of the fibrotic and hypertrophied adipose tissue that occurs in response to the chronic lymph stasis and inflammation. Therefore, reductive surgical procedures to remove the excess subcutaneous adipofibrotic tissue are necessary to achieve a complete reduction of the swelling and reach similar measures to the healthy contralateral arm.

The excisional technique consisting of circumferential massive resection of skin, subcutaneous fat tissues, and sometimes deep fascia, resurfaced by free split-thickness or full-thickness skin graft, was first reported by Charles (1912). It was first applied to the upper limb, by Macey (1940) and posteriorly, was initially performed in cases of postmastectomy lymphedema by Bunnel (1948), Watson (1953), and McCormack (1954). However, this highly invasive “debulking” procedure may result in pain, wound-healing complications, infections, lymph fistulas, and bizarre cosmetic appearance (14).

Moreover, the modern liposuction method to remove the excess fat tissue, via blunt cannulas attached to a suction machine, was first described by Giorgio and Arpad Fischer in 1976, as a dry technique (15), instead, Illouz is known for developing the wet technique in 1977 (16). Despite, liposuction is the most performed aesthetic surgery in the world, in the late nineties, Brorson introduced the use of liposuction for late breast cancer–related upper extremity lymphedema, reporting favorable overall results in prospectively followed patients, achieving a reduction of 83% at 1 month, 98% at 6 months, and 104% at 1 year; with excellent long-term results (17).

Indications

A surgical approach to remove the hypertrophied fibroadipose tissue is suitable when a complete reduction of the excess volume of the arm has not been achieved by
conservative treatment or microsurgical lymphatic procedures. The main indication for selective liposuction as the treatment of upper extremity lymphedema is the presence of nonpitting lymphedema. Nevertheless, every patient is rigorously independently evaluated based on the clinical examination of the lymphedema stage according to the International Society of Lymphedema (ISL) (Table 32-1) (18), and the results of the preoperative indocyanine green (ICG) lymphography assessment (19). There are two predominant circumstances:

Primary selective liposuction is indicated in cases of volume excess, nonpitting lymphedema ISL stage III, and nonfunctioning lymphatic channels by ICG lymphography assessment.
Secondary selective liposuction is indicated in cases of volume excess, nonpitting lymphedema in late ISL stage II, and functioning lymphatic system by ICG lymphography assessment; in patients with previous microsurgical lymphatics’ derivation, reconstruction, or transplantation techniques.

TABLE 32-1 Staging of Lymphedema of the International Society of Lymphology

ISL Stage	Features
0/IA	Latent or subclinical condition where swelling is not yet evident despite impaired lymph transport.
I	Early accumulation of fluid relatively high in protein content which subsides with limb elevation. Pitting may occur.
II	Limb elevation alone rarely reduces the tissue swelling and pitting is manifest. In late stage II, the limb may not pit as excess subcutaneous fat and fibrosis develop.
III	Lymphostatic elephantiasis where pitting can be absent and trophic skin changes such as acanthosis, alteration in skin character and thickness, further deposition of fat and fibrosis, and warty overgrowths have developed.