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Liu et al. Plast Aesthet Res 2020;7:6 I http://dx.doi.org/10.20517/2347-9264.2019.62 Page 5 of 7

A B

Figure 4. The same patient as in Figure 1: (A) clinical photo before liposuction; and (B) clinical photo 40 months after liposuction. The
limb size was maintained with only regular use of Class I compression sleeve. When liposuction is performed in the right patients, i.e.,
patients with fatty phase of lymphedema, only low maintenance is required for the control of limb size

[10]
of fluid retention .

On the other hand, there are patients who have predominately fat hypertrophy. Some lymphedema
surgeons called it the fatty phase of lymphedema. This entity is not well documented in textbooks
and literature. It also does not fit into any modern lymphedema staging system. In the fatty phase of
lymphedema, the limb is often soft without pitting edema. BIA value is usually less than 40. We also
observed that this fatty phase of lymphedema is more likely to be associated with severe brachial plexus
neuropathy in BCRL patients.

In theory, physiological operations such as LVA and VLNT aim at restoring normal lymphatic flow, which
[7-9]
in turn decrease the fluid retention . These operations are not effective in reducing the fat content of limb.
[11]
Dr. Brorson et al. has advocated liposuction since late 1990s [11,12] . He and his team treated lymphedema
with circumferential liposuction. Preoperative ICG markings were not documented in his studies. Patients
need to wear long-term pressure garments after operation lifelong.

Dr. Brorson’s liposuction protocol is difficult to follow in our locality. The main reason is the high
maintenance after surgery, i.e., regular physiotherapy and long-hour pressure garment. In Hong Kong,
the hot and humid weather during summertime discourages the regular use of pressure garment and
frequent limb bandaging. Moreover, from our earlier experience when liposuction was performed more
liberally for upper-limb lymphedema patients, we noticed the outcome of liposuction for fluid predominant
lymphedema, i.e., patients with pitting, tense limb, and high BIA value, is less satisfactory. In the short
term, the wound usually remained tense and firm for a longer postoperative period. In the long term, the
limb size reduction was not as significant as for patients with limbs that contained less fluid. A relatively
higher maintenance, i.e., more intense physiotherapy and more regular use of pressure garment, is also
required to keep the reduced limb size.

To utilize liposuction as a treatment and at the same time knowing that the compliance of pressure
garment and physiotherapy will be low after operation, we have to tighten the patient selection criteria