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Page 4 of 7 Liu et al. Plast Aesthet Res 2020;7:6 I http://dx.doi.org/10.20517/2347-9264.2019.62

Figure 3. The same patient as in Figure 1: suction-assisted liposuction was performed until the overlying skin could be lifted with ease

Clinical measurement
Limb circumferences of both upper limbs were measured before operation and at a six-month intervals
after operation. The circumferences were measured at five levels, i.e., mid-palm, wrist, 10 cm above the
wrist, elbow, and 10 cm above the elbow. Readings were taken twice to reduce measurement error.

The circumference difference before and after liposuction was expressed in terms of reduction rate.
The numerator was: (pre-liposuction lymphedema limb circumference - pre-liposuction healthy limb
circumference) - (post-liposuction lymphedema limb circumference - postop healthy limb circumference).
The denominator was: (pre-liposuction lymphedema limb circumference - pre-liposuction healthy limb
circumference).

Statistical analysis
All values are reported as mean ± standard deviation. All statistical analyses were performed with IBM
SPSS Version 22.0 (IBM Corp., Armonk, NY).

RESULTS
The mean volume of aspirated fat was 1137 ± 126 mL (range, 1000-1400 mL). At a mean follow-up of 24.5
± 6.5 months (range, 12-46 months), all (100%) patients had a reduction in limb circumferences [Figure 4].
Throughout the follow-up period, 24 (75%) patients had progressive reduction and reached a plateau in limb
size, while eight (25%) patients had fluctuation of limb circumference. Of these eight patients, three patients
were those with fatty phase of lymphedema and five were the good responders after VLNT.

The mean circumference reduction rates were 40.2% ± 29.3% (range, 35.4%-50.8%) at mid-palm, 36.5% ± 31.2%
(range, 30.3%-45.7%) at wrist, 57.7% ± 22.4% (range, 41.6%-71.3%) at 10 cm above the wrist, 70.1% ± 25.5%
(range, 68.2%-76.5%) at elbow, and 85.7% ± 27.8% (range, 73.2%-92.3%) at 10 cm above the elbow. The overall
mean circumference reduction rate was 67.6% ± 27.9% (range, 30.3%-92.3%).

DISCUSSION
The rationale of treating lymphedema with liposuction is the fat hypertrophy caused by chronic
[5,6]
inflammatory process . In lymphedema, the increase in limb size is contributed by the fluid component
due to lymphatic obstruction and the fatty component due to chronic inflammation. However, not every
patient has the same proportion of fluid retention and fat hypertrophy. We believe that fluid predominant
lymphedema is more commonly encountered in the daily practice of most lymphedema practitioners.
Therefore, the International Society of Lymphology has devised its staging system according to the nature