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Venkatramani et al. Plast Aesthet Res 2020;7:19 I http://dx.doi.org/10.20517/2347-9264.2019.70 Page 7 of 13

only to avoid damage to the vital structures, but also to avoid inducing lymphoedema in the donor limbs.
[48]
Viitanen et al. demonstrated in their series that although none of their patients developed donor site
lymphoedema, lymphoscintigraphy in over half the patients showed a slightly slower lymphatic flow in
the donor limb compared to the non-operated limb. Donor site lymphoedema can be reduced by reverse
[32]
lymphatic mapping . The lymphatic drainage of the flap to be harvested and the potential donor site
lymphoedema area are evaluated by two different methods. For example, before raising the DIEP flap
containing the groin lymph nodes, ICG is injected intradermally in the lower abdomen and technetium
injections in the first and second webspaces of the foot. A gamma probe is used to localise the lymph nodes
draining the lower extremity which is avoided. Similarly, technetium can be injected into the hand and ICG
injected into the back and lateral chest in cases of VNLT.

Postoperatively, the use of drains, antibiotics, anticoagulation and therapy is largely based on anecdotal
experience and surgeon preference, as there is no uniform consensus on this subject, and a conclusive study
can be difficult to devise considering the many variables and confounding issues involved. Compression
over the flap is avoided for 2 to 3 weeks. Later, the patient is advised to wear compression garments
throughout the day. Six months later, the patient can be reviewed, and if necessary, the excess fat in the
limbs can be removed by liposuction.

LIPOSUCTION
In lymphoedema there is a physiological imbalance of blood flow and lymphatic drainage, resulting in
[49]
the impaired clearance of lipids and the uptake by macrophages . Besides, it is believed that chronic
[50]
inflammation in lymphoedema results in adipose tissue hypertrophy . Several studies have found an
association with fat hypertrophy along with lymphatic stasis. The findings are indicated below:

1. In Crohn’s disease, there was increased fat deposition in the areas of the bowel that were inflamed,
[51]
suggesting that inflammation plays an important role in increasing fat .
[52]
2. Analysis of the content of the aspirate from liposuction showed a high content of adipose tissue (90%) .
3. Dual energy X-ray absorptiometry in 18 women with post-mastectomy lymphoedema showed a
[53]
significant increase in adipose tissue in the oedematous limb .
[54]
4. Marked mononuclear cell response was found with adipogenesis in response to lymphatic fluid stasis .
[55]
5. Lymphatic fluid stasis was shown to upregulate fat differentiation markers .
The limbs affected with lymphoedema are swollen due to the accumulation of lymphatic fluid along with
excess fat deposition. The accumulated lymphatic fluid can be decreased by conservative therapies such as
complex decongestive therapy and controlled compression therapy along with microsurgical techniques
such as LVA or VLNT. After lymphatic fluid has been decreased by the above procedures, the accumulated
fat can be removed by liposuction. Liposuction is a method to remove fat and should be used only when
the conservative or microsurgical techniques have been used before. The patient should be on compression
garments. The absence of fluid collection is found when the limbs are not pitting even on applying pressure
to them for a minute. Liposuction should only be done when there is no pitting and when the pitting
[50]
cannot be reduced further even after regular physiotherapy .

Under appropriate anaesthesia, power-assisted liposuction is used to reduce surgeon fatigue and also
[56]
to facilitate liposuction especially in fibrous areas. Initially, the “dry technique” has been used . To
[56]
minimise blood loss, a combination of tourniquet and tumescence liposuction has been used . A sterile
tourniquet is tied proximally on the limb. Through appropriate 3-mm long incisions, liposuction cannulas
15 and 25 cm long and with diameters of 3 and 4 mm are used to aspirate the excess fat. A sterilised
compressive dressing or a glove is worn, and the tourniquet is removed. The proximal part of the limb in
which the tourniquet was removed is infiltrated with tumescence solution containing adrenaline and mild