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

to achieve better clinical results and allow patients to have a relatively low maintenance of limb after
operation.

We consider patients with fatty phase of lymphedema as the best surgical candidates. The second-best
group includes the patients who responded well after VLNT. The response after VLNT was assessed
clinically with limb circumference measurement and pitting edema detection. BIA and traditional
lymphoscintigraphy were also performed after VLNT. The effect of liposuction in these two patient groups
is usually more long lasting. The limbs can stay soft and the reduction in limb size can remain for a longer
time.

During the follow-up period, eight patients had fluctuation in limb circumferences. There were overall
reductions in limb size after liposuction. However, there was an upward trend of limb circumferences in
the middle of the follow-up period. The possible explanations include: (1) inadequate effort of postoperative
physiotherapy; or (2) recurrence of fat hypertrophy.

[13]
Up until now, there is only one published paper from Campisi et al. describing lymphatic vessel sparing
liposuction. More than 100 lymphedema patients were included in this study. Prior to suction-assisted
liposuction, lymphatic mapping with ICG and blue dye was performed. The group reported that there was
a significant volume reduction after liposuction. The immediate postoperative ICG lymphangiography also
confirmed no lymphatic complications. However, the imaging findings were not listed in detail.

There is no good evidence in the literature to support that: (1) functional lymphatic vessels can be
successfully preserved with this maneuver; and (2) the preserved functional lymphatic vessels can improve
the long-term results after liposuction. To prove these two points valid, it is necessary to compare the pre-
and postoperative (at least mid-term) ICG lymphangiography findings and perform a case-control study to
compare the long-term surgical outcomes between liposuction-only group and the liposuction with ICG
lymphangiography one. In our opinion, it is sensible to preserve as many remaining functional lymphatic
vessels as possible for better lymphatic function. The preserved functional lymphatic vessels can also be
used for future surgery such as LVA.

In conclusion, Liposuction is a valuable treatment for BCRL. The role of ICG lymphangiography in
improving clinical results and long-term outcomes has yet to be has yet to be proven by further study.

DECLARATIONS
Authors’ contributions
Contributed equally to the drafting of manuscript, data collection and analysis: Liu HL, Wong MMK,
Chung JHP

Availability of data and materials
Data were strictly obtained from medical records, in accordance with the privacy policy and code of ethics
at our institutions.

Financial support and sponsorship
None.

Conflicts of interest
All authors declared that there are no conflicts of interest.