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Page 2 of 7 Liu et al. Plast Aesthet Res 2020;7:6 I http://dx.doi.org/10.20517/2347-9264.2019.62

INTRODUCTION
Although lymphedema starts off as lymph stasis, the disease is not purely obstructive in nature. The stasis
of protein rich lymphatic fluid in the subcutaneous plane causes infiltration of immune cells and activation
of inflammatory cascade, which in turn lead to chronic inflammation of the subcutaneous plane. The end
results of chronic inflammation include fat hypertrophy and fibrosis of lymphatic vessels and connective
[1-6]
tissue .

Physiological operations, e.g., lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer
[7-9]
(VLNT), aim at the restoration of normal lymphatic flow . However, there is no evidence that these
physiological type operations can reverse fat hypertrophy. Therefore, excisional treatment is mandatory to
achieve a significant limb size reduction in patients with fat hypertrophy.

Liposuction, debulking excision, and Charles operation are the commonly performed excisional operations.
Debulking excision mainly tackles excess skin fold, which is usually seen in lower-limb lymphedema. The
operation also leaves long linear scars on the limb. Charles operation is almost only performed for patients
with late stage, fibrotic lower-limb lymphedema. Therefore, the only sensible option of excisional surgery
for upper-limb lymphedema is liposuction.

In our institute, both physiological and excisional operations are available for lymphedema patients. We
consider liposuction is a valuable tool for breast cancer-related lymphedema (BCRL). In this article, patient
selection and the indocyanine green (ICG) lymphangiography-guided liposuction technique are explained.

METHODS
Patients and patient selection
Institutional review board approval was obtained for this study. For the patient selection, only two groups
of BCRL patients were included for liposuction. The first group was those who had fatty phase of BCRL;
these patients may or may not have received prior surgical treatment of lymphedema. The second group
was the good responders after receiving VLNT in our institute.

Detailed history taking and physical examination were performed during clinic consultation. Special
attention was paid to the softness and the nature of edema of the patient’s diseased limb. Patients with
soft limb and non-pitting edema are the best candidates for liposuction [Figure 1]. At the other end of the
spectrum, patients with tense, fibrotic limb and severe pitting edema were excluded from liposuction.

For patients who were worked up for liposuction, bioimpedance analysis (BIA) was performed as a baseline
measurement before operation. Liposuction was only offered to patients who had BIA value < 50.

Patients
Between January 2015 and December 2018, 32 consecutive patients with BCRL were included in this study.
All patients had unilateral upper-limb lymphedema, i.e., the total number of upper limbs treated was
32. The mean age was 63.4 ± 8.7 years (range, 39-72 years). All 32 patients had axillary dissection. Thirty
patients received adjuvant radiotherapy. The mean duration of lymphedema was 10.4 ± 7.4 years (range,
[10]
6-20 years). The International Society of Lymphology’s staging system was adopted in this series . Twenty-
seven patients had Stage II disease and five patients had late Stage II disease.

Twenty (62.5%) patients had fatty phase lymphedema and none of them had received prior lymphedema
surgery. Twelve (37.5%) patients were the good responders of VLNT. The mean time interval between
VLNT and liposuction was 13.1 ± 2.3 months (range, 11-15 months).