In the 1700s, Olof Rudbeck from Uppsala, Sweden (Figure 1) outlined the

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1 Liposuction s tretment for lymphoedem Dr Håkn Brorson, Dr Crolin Freccero Figure 1: Olof Rudeck, Figure 2: Rudeck thesis Novo exercittio ntomic, exhiens ductus hepticos quosus et vs glndulrum seros In the 1700s, Olof Rudeck from Uppsl, Sweden (Figure 1) outlined the function of the lymphtics. In 1653 he wrote thesis out the lymphtic system (Figure 2). Figure 3 shows digrm of the liver nd the lymph vessels entering the cistern chyli nd finlly, vi the thorcic duct, emptying into the venous junctions in the neck. In the 1700s scientists thought tht the lymph vessels drined to the liver. In 1652, Olof Rudeck performed n utopsy to show tht the lymphtic vessels insted drined the liver nd owels s well s the legs (Figure 3). Thoms Brtholin from Denmrk (Figure 4) ws told out these findings nd ws fscinted y this procedure nd likewise strted to do dissections. In 1653, Brtholin presented his thesis four weeks efore Rudeck s, resulting in one of the gret cdemic disputes of the 1700s. Figure 5 shows ptient in the 1960s fter surgery for rest cncer, suffering the effects of hevy irrdition. She hd disturnces of oth the lymph nd lood circultion nd hd to undergo mputtion. Fortuntely tody, ptients do not undergo such high levels of rdition, ut rther more frequent, low-level rdition tht cuses less dmge. Figures 6 nd 7 show typicl ptients who hve presented t the uthors clinic in Mlmö, Sweden. The literture shows tht there hve een numer of surgicl techniques for lymphoedem (Figure 8). Figure 9 shows two ptients with ilterl lymphoedem who were operted on in the 1960s. They were treted y excision of the skin nd sucutneous tissue down to the muscle fsci, which ws covered with split skin grfts (Chrles procedure). In contrst to liposuction, this technique resulted in poor cosmetic outcomes nd ptients often hd prolems with susequent scrring, eczem, lymph fistuls, etc. The uthors hve not performed this procedure for the lst 15 yers. Figure 4: Thoms Brtholin, Figure 3: Novo exercittio ntomic 11 Brorson C, finl 3.indd 11 6/4/09 20:03:35

2 1st Jost Scientific Symposium, 2008 In 1998, the first uthor wrote thesis entitled Liposuction nd controlled compression therpy in the tretment of rm lymphoedem following rest cncer (Brorson, 1998), which further incresed the interest nd knowledge in liposuction s tretment for lymphoedem. This thesis included five different ppers on how to tret lymphoedem with liposuction. The first pper explored how complete reduction of lymphoedem could e gined (Brorson nd Svensson, 1997), nd nother descried rndomised tril where liposuction nd compression were used, versus compression lone (Brorson nd Svensson, 1998). The compressiononly group chieved 47% reduction of excess volume in the lymphoedem, ut the group with surgery s well showed complete reduction (100% reduction). In those erly dys, the pitting test ws not performed s rigorously s it is done tody, thus explining the effect of compression, which moilises fluid ut not ft. In one pper, the uthor showed tht liposuction did not further reduce n lredy decresed lymph trnsport system. This ws importnt ecuse some clinicins thought tht the lymphtics were destroyed y the procedure (Brorson et l, 1998). Figure 5: Ptient suffering the effects of hevy irrdition in the 1960s who hd to undergo mputtion Figure 6: Ptient with excess volume of 2.1 litres Figure 7: Ptient with excess of volume 12.3 litres Another pper found tht skin lood flow incresed fter surgery, which possily explined why ptients hd fewer ttcks of erysipels fter surgery (Brorson nd Svensson, 1997). The lst pper delt with the improvement of qulity of life found fter surgery (Brorson et l, 2006). Pitting test The pitting test is quick nd esy method of deciding which ptients re suitle for surgery. Pitting refers to the depression formed fter pressure is pplied to Figure 8: Exmples of vrious opertive techniques the oedemtous tissue. The thum presses s hrd s possile on the extremity to e investigted for 60 seconds, the mount of depression eing estimted in millimetres (Figure 10). Oedem tht is minly hypertrophied dipose tissue nd/or firosis shows little or no pitting (Figure 10). In 1993, mgnetic resonnce imging scn (MRI) ws tken of the first ptient to undergo liposuction. On nlysis, excess dipose tissue could e seen (Figure 13). Figure 11 shows picture of excess ft volume in the lymphoedemtous rm tken in the 1960s. The uthors hd often een told tht the excess volume ws dominted y firosis. Ft ws never spoken of. Thus, the liposuction spirte in ptients ws nlysed nd % ft ws found. If it hd simply een fluid, it would hve een 90% fluid nd mye 10% ft. Figure 12 shows the spirte, from typicl ptient, in 2-litre cnister. The dipose tissue seprtes into n upper dipose frction (90%) nd lower fluid (lymph) frction (10%). 12 Brorson C, finl 3.indd 12 6/4/09 20:03:37

3 Liposuction s tretment for lymphoedem Figure 9: Typicl results fter excision of skin nd sucutneous tissue followed y split skin grfting Figure 10. Mrked lymphoedem of the rm fter rest cncer tretment, showing pitting severl centimetres in depth. The rm swelling is dominted y the presence of fluid, i.e. the ccumultion of lymph. Figure 10. Pronounced rm lymphoedem fter rest cncer tretment. There is no pitting in spite of hrd pressure y the thum for one minute. A slight reddening is seen t the two spots where pressure hs een exerted. The oedem is completely dominted y dipose tissue. The term oedem is improper t this stge since the swelling is dominted y hypertrophied dipose tissue nd not y lymph. At this stge, the spirte contins either no, or miniml mount of lymph Figure 11: Cross-sections of lymphoedemtous (right) nd norml rm (left) showing undnce of excess dipose tissue in the ffected rm Figure 12: The spirte contins % dipose tissue in generl Evidence of dipose tissue in lymphoedem Indictions for dipose tissue hypertrophy include: Consecutive nlyses of the content of the spirte removed under loodless conditions using tourniquet showed tht high content of dipose tissue in 44 women with postmstectomy rm lymphoedem (men 90%, rnge ) ws found (Brorson et l, 2004) Anlyses with dul X-ry sorptiometry (DXA) in 18 women with rm lymphoedem following rest cncer tretment showed 73% increse in volume of dipose tissue in the non-pitting swollen rm efore surgery (Brorson et l, 2009) Preopertive investigtion with volume rendered computer tomogrphy (VR-CT) imges in eight ptients, following rest cncer tretment, showed significnt preopertive increse of dipose tissue in the swollen rm, the excess volume consisting of 81% ft (Brorson et l, 2006) Tonometry findings in 20 women with postmstectomy rm lymphoedem showed postopertive chnges in the upper rm, ut not in the forerm, which lso showed significntly higher solute vlues thn in the upper rm. This is proly cused y the high dipose tissue content with little or no free fluid, just like the sitution in the norml rm. The thinner sucutneous tissue in the forerm my lso ply prt. Tonometry cn 13 Brorson C, finl 3.indd 13 6/4/09 20:03:39

4 1st Jost Scientific Symposium, 2008 Figure 13: Preopertive. Figure 13: One yer postopertively Right lymphoedemtous rm Left norml rm Figure 14: Volume rendering computer tomogrphy (VR-CT) imges showing 1.3 litres of excess ft in the right rm Figure 15: Aspirted ft versus VR-CT excess ft volume. Reproduced y kind permission of Lymphtic Reserch nd Biology (Brorson et l, 2006) distinguish if lymphoedemtous rm is hrder or softer thn the norml one. If lower tissue tonicity vlue is recorded in the oedemtous rm, it indictes tht there is ccumulted lymph fluid in the tissue, nd these ptients re cndidtes for conservtive tretment. In contrst, ptients with hrder rm compred with the helthy one, hve n dipose tissue excess tht cn successfully e removed y liposuction (Bgheri et l, 2005) The findings of incresed dipose tissue in intestinl segments in ptients with Crohn s disese, known s ft wrpping, hve clerly shown tht inflmmtion plys n importnt role (Jones et l, 1986; Sheehn et l, 1992; Borley et l, 2000) In Grves ophthlmopthy, mjor prolem is n Lymphoedem Norml increse in the introritl dipose tissue volume leding to exopthlmus. Adipocyte relted immedite Figure 16: Dul energy X-ry sorptiometry (DXA) erly genes (IEGs) re overexpressed in ctive ophthlmopthy nd cysteine-rich, ngiogenic inducer 61 (CYR61) my hve role in oth oritl inflmmtion nd dipogenesis nd serve s mrker of disese ctivity (Lntz et l, 2005). Mesurement techniques In the uthors opinion, the prolem with non-pitting lymphoedem is ft, not lymph. Looking t n MRI scn efore nd fter surgery, there is considerle reduction of the excess volume (Figures 13, ). However, to chieve ojective mesurements further nlysis with VR-CT cn e performed. This involves tomogrphy of oth rms with the computer eing progrmmed only to show pixels for ft. Ft volume cn e clculted y mesuring the ft pixels. Figure 14 shows ptient with n excess ft volume of 1.3 litres. This is n ojective sign of excess dipose tissue. The mount of spirted ft cn lso e correlted to the excess ft volume mesured with computer tomogrphy (Figure 15). 14 Brorson C, finl 3.indd 14 6/4/09 20:03:40

5 Liposuction s tretment for lymphoedem Figure 17 Lymph mkes you ft. Reprinted y permission from Nture Genetics, Octoer, 2005 (Schneider et l, 2005) Figure 18: Preopertively, ml; Figure 18: four weeks postopertively Figure19: A 74-yer-old womn with non-pitting rm lymphoedem for 15 yers. Preopertive excess volume ws 3.1 litres. Figure 19: One yer postopertively Figure 20: Preopertively,1.335 ml; Figure 20: One yer postopertively Figure 21: Preopertively, ml; Figure 21: Five yers postopertively Figure 22: Preopertively, ml; Figure 22: 14 yers postopertively Another mesurement technique is DXA, where ft, muscle nd one re mesured in grms nd trnsferred to volumes y density. Figure 16 shows typicl ptient where DXA shows n excess of 510 grms in the lymphoedemtous rm. The sme reltionship with spirted ft nd excess ft volume mesured with VR-CT ws found. The mount of excess dipose tissue in the lymphoedemtous rm showed men excess mount of ft of 73% using DXA (Brorson et l, 2009), nd of 81% using VR-CT (Brorson et l, 2006). Both VT-CT nd DXA re methods to ojectively show excess dipose tissue merely for reserch purposes. This is not necessry in the clinicl sitution where the pitting test is sufficient. In 2005, Hrvey et l cited in Nture Genetics one of the uthors erlier works regrding findings of excess dipose tissue (Hrvey et l, 2005). Figure 17 shows tht in the wild type (WT) mouse fluid leks from lood cpillries nd is collected y the lymph vessels nd is trnsported ck to the lood circultion (left-hnd imge). In the Prox 1 +/- mice, impired lymph dringe cused ccumultion of lymph fluid in the tissues, where it induced excess differentition of ft cell precursors nd ft cell hypertrophy (right-hnd imge). The fctors determining the dipogenic potency of lymph re not known (Schneider et l, 2005). Inflmmtion is proly one of the cuses of excess ft deposition. The gol of liposuction should e to remove excess ft nd chieve complete reduction. Figures show some typicl results. Initilly, liposuction ws done s dry technique, no dilute drenline or nesthetics eing injected into the dipose tissue eforehnd (Clyton et l, 1989). A disdvntge of the dry technique ws the lrge mount of lood lost (Courtiss et l, 1992). Most surgeons recommended tht no more thn 1500ml of ft should e removed to void the need for lood trnsfusions. Illouz ws the first to infiltrte the sucutneous ftty tissue when doing liposuction (Illouz, 1983). In the erly 1980s most surgeons used the wet technique (Goodpsture nd Bunkis, 1986), which involves infiltrtion of ml of 15 Brorson C, finl 3.indd 15 6/4/09 20:03:42

6 1st Jost Scientific Symposium, 2008 Men lood loss/volume spirte (%) No tourniquet, no drenline (n=19) p< Tourniquet, no drenline (n=33) p<0.01 Tourniquet + drenline (n=10) Figure 23: Men lood loss (ml) in the groups with lymphoedem. Reproduced y kind permission of the Scndinvin Journl of Plstic Reconstructive Surgery nd Hnd Surgery (Wojnikow et l, 2007). Aville online t: norml sline with or without lignocine, drenline, or comintion, into the surgicl re efore liposuction. In 1986 the superwet technique ws introduced, which involves infiltrtion of solution of norml sline contining drenline nd lignocine in n mount equl to tht of the ft tht is to e removed (Rohrich nd Mthes, 1990). The following yer, Klein descried the tumescent technique, which involves somewht lrger mounts of sline contining oth low-dose drenline nd lignocine in rtio of 2 3:1ml (infiltrte:spirte) eing injected (Klein, 1987). These techniques enled surgeons to remove lrge quntities of dipose tissue. By infiltrting dilute drenline nd lignocine into sucutneous ft, oth the excessive loss of lood nd the need for generl nesthesi with its ssocited risks re reduced (Wojnikow et l, 2007). Figure 24: Liposuction of rm lymphoedem. The procedure tkes out two hours. From preopertive to postopertive stte (left to right). Note the tourniquet, which hs een removed t the right, nd the concomitnt rective hyperemi Figure 25: Preopertive picture showing ptient with lrge lymphoedem (2.900 ml) nd decresed moility of the right rm. Figure 25: The cnnul lifts the loose skin of the treted forerm. Figure 25c: The distl hlf of the forerm hs een treted. Note the shrp order etween treted (distl forerm) nd untreted (proximl rm) re c According to other uthors, more thn 3000ml of ft cn e removed during liposuction under locl nesthesi without sedtion (Klein, 1987; Klein, 1993). Smdl et l (1995) reported the mount of whole lood contined in the spirte is roughly 2% (volume/ volume) when superwet or tumescent techniques re used, wheres in the dry technique it is 25% (Goodpsture nd Bunkis, 1986), nd in the wet technique 15% (Clyton et l, 1989). When the uthors tem strted to tret rm lymphoedem following rest cncer tretment, they used the dry technique. Lter, to minimise lood loss, tourniquet ws used in comintion with tumescence. Liposuction ws performed up to the distl edge of the tourniquet. A sterile compression grment ws put on nd the tourniquet relesed. The re covered y the tournique ws infiltrted with dilute drenline efore liposuction ws completed (tumescence) (Figure 23; Wojnikow et l, 2007). This technique keeps lood loss to minimum, thus removing the need for trnsfusions. How to perform liposuction for lymphoedem surgicl technique Liposuction for oth leg nd rm lymphoedem is similr, removing excess hypertrophied dipose tissue under loodless conditions (Figure 24). Generl 16 Brorson C, finl 3.indd 16 6/4/09 20:03:44

7 Liposuction s tretment for lymphoedem nesthesi is used in most cses ut some ptients with rm lymphoedem prefer nerve lockde with plexus nd sclenus lock. Neither locl nesthetic nor epinephrine is injected distl to the tourniquet; hence, the dry technique is used. Through round 15 20, 3mm long incisions, the shoulder nd rm re treted (Figures 24 nd 25). Figure 26: Cnnuls: The upper cnnul is used for esthetic procedures, wheres the lower is used for liposuction for lymphoedem. Note the lrger openings t the tip Cnnuls re connected to vcuum pump giving negtive tmospheric pressure of 0.9. The cnnuls re 15 cm long with n outer dimeter of 3 nd 4 mm, with three openings t the tip (Figure 26). The finer cnnul is used minly for the distl prt of the forerm, nd lso when irregulrities re remedied. The openings differ from norml liposuction cnnuls in tht they tke up lmost hlf of the circumference to fcilitte the liposuction, especilly in lymphoedems with excess firosis. Liposuction of n rm cn e done mnully using ordinry cnnuls (Figure 26) or y power ssisted liposuction, which uses virting cnnul to fcilitte nd speed up surgery. This is especilly importnt in the leg. Mde-to-mesure compression grments (two sleeves nd two gloves) re ordered two weeks efore surgery. The size of the grments is mesured ccording to the size of the helthy rm nd hnd. Liposuction is executed circumferentilly, step-y-step, from hnd to shoulder, nd the hypertrophied ft is removed s completely s possile (Figure 24). Figure 27: After liposuction on the proximl prt of the upper rm the grment is pulled up nd secured with the nds of the grments tht re fstened with velcro Figure 28: Glove with fingertips cut off When the rm distl to the tourniquet hs een treted, sterilised mde-to-mesure compression sleeve is pplied (Jost Elvrex BSN medicl, compression clss 2) on the rm to stem leeding nd postopertive oedem (Figure 27). An Elsto-Gel (Southwest Technologies, USA), 10 x 10 cm, is put on the ventrl spect of the elow joint (for the first two weeks), nd etween the thum nd index finger to ese off the pressure from the new grment nd glove. A sterilised Esy-Slide (Credenhill, Englnd) fcilittes putting on the grment nd is lter lwys used for this procedure. A sterilised, stndrd interim glove (Cictrex interim, Thusne, Frnce), where the tips of the fingers hve een cut to fcilitte gripping, is put on the hnd (Figure 28). The tourniquet is removed nd the most proximl prt of the upper rm is treted using the tumescent technique. Finlly, the proximl prt of the compression sleeve is pulled up to compress the proximl prt of the upper rm. The incisions re left open to drin through the sleeve. The rm is lightly wrpped with lrge sorent compress covering the 17 Brorson C, finl 3.indd 17 6/4/09 20:03:46

8 1st Jost Scientific Symposium, 2008 whole rm (60 x 60cm, Cover-Dri, The rm is kept t hert level on lrge pillow. The compress is chnged when needed. The following dy, stndrd guntlet ( glove without fingers with thum), where the thum hs een cut off (Jost Elvrex BSN medicl, compression clss 2) is put over the interim glove (Figure 29). If the guntlet is put on stright fter surgery, it cn exert too much pressure on the hnd when the ptient is still unle to move the fingers fter the nesthesi. Operting time is, on verge, two hours. An isoxzolyl penicillin or cephlosporin is given intrvenously for the first 24 hours, nd then in tlet form until incisions hve heled, out dys fter surgery. Figure 29: Stndrd guntlet without thum (Jost Elvrex BSN medicl, compression clss 2), is comined with stndrd interim glove (Cictrex interim, Thusne(R), Frnce) Postopertive cre The rm is held rised y the ptient herself during hospitl sty. Grments re removed two dys postopertively so tht the ptient cn tke shower nd mesurements re compred with the norml rm (Figure 30). There is no ruising ecuse the compression is put on efore relesing the tourniquet. The tumescence solution nd ny lood lek out through the smll incisions. Wter-solule ointment tht does not destroy the grment is pplied. Then new Elsto-Gel (Southwest Technologies, USA) is put on the elow. The other set of grments is put on nd the used set is wshed nd dried. This is repeted y the ptient herself fter nother two dys efore dischrge. The stndrd glove nd guntlet is usully chnged to the mde-to-mesure glove t the end of the sty. Figure 30: Mesurements eing tken t postopertive follow-up. Arm is still swollen t this stge. Firm mesurements re tken to overcome the norml postopertive oedem. Note the indenttion y the tpe mesure 18 The ptient lterntes etween the two sets of grments (two sleeves nd two gloves) during the first two postopertive weeks, chnging them dily or every other dy so tht clen set is lwys put on fter showering nd luricting the rm. After the two-week control, the grments re chnged every dy fter eing wshed. Wshing ctivtes the grment y incresing the compression due to shrinkge (Figure 31). It lso removes perspirted slt tht cn cuse dry nd irritted skin. During the susequent course, this rigorous compression regime, referred to s controlled compression therpy (CCT), is mintined exctly s descried elow. Controlled compression therpy (CCT) A prerequisite to mintining the effect of liposuction, nd, for tht mtter, conservtive tretment, is the continuous use of compression grment (Brorson nd Svensson, 1998). Compression therpy is crucil, nd its ppliction is therefore thoroughly descried nd discussed t the first clinicl evlution. If the ptient hs ny douts out continued CCT, she is not ccepted for tretment. After inititing compression therpy, the custommde grment is tken in t ech visit using sewing mchine, to compenste for reduced elsticity nd reduced rm volume. This is importnt during the first three months when the most notle chnges in volume occur. At the one- nd three-month visits the rm is mesured for new custom-mde grments. Figure 32 shows n online order form for the different grments. This form is useful s it hs ll the vlues, enling you to see wht you re iming for nd wht you hve ordered efore. Mesurements re pulled tightly since it is the postopertive oedem tht you wnt to reduce (Figure 30). This procedure is repeted t six, (nine) nd 12 months. If complete reduction hs een chieved t six months, the nine-month control my e omitted. If this is the cse, rememer to prescrie Brorson C, finl 3.indd 18 6/4/09 20:03:47

9 Liposuction s tretment for lymphoedem Figure 31: Two identicl compression grments on top of ech other, showing the effect of wshing on the grment. Note tht the circumference hs decresed 4 cm fter wshing Figures 32 nd : Online ordering forms for compression grments grments for six months, which normlly mens doule the mount tht would e needed for three months. It is importnt, however, to tke in the grment repetedly to compenste for wer nd ter. This my require dditionl visits in some instnces, lthough the ptient cn often mke such djustments herself. When the excess volume hs decresed s much s possile, i.e. no pitting is seen, nd stedy stte hs een chieved, new grments cn e prescried using the ltest mesurements. In this wy, the grments re renewed three or four times during the first yer. A checkup should e done t one nd hlf yers for complince nd volume mesurements. If everything is stle t two yers, once-yerly visit is enough Two sets of sleeve nd glove grments re lwys t the ptient s disposl; one eing worn while the other is wshed. Thus, grment is worn permnently, nd tretment is interrupted only riefly when showering nd, possily, for forml socil occsions. The ptient is informed out the importnce of hygiene nd skin cre, s ll ptients with lymphoedem re susceptile to infections nd keeping the skin clen nd soft is prophylctic mesure (Brorson nd Svensson 1997, 1998). The life spn of two grments worn lterntely is usully four to six months. After complete reduction hs een chieved, the ptient is seen once yer when new grments re prescried for the coming yer, usully four grments nd four gloves (or four guntlets). In ctive ptients, six to eight grments nd the sme mount of guntlets/gloves yer re needed. Ptients without preopertive swelling of the hnd cn usully stop using the glove/guntlet fter 6 12 months postopertively. For legs, the uthors tem often uses up to two to three compression grments on top of ech other, depending on wht is needed to keep pitting wy. A typicl exmple is Jost Bellvr compression clss 2, Elvrex compression clss 3, Forte nd Elvrex compression clss 2 (BSN medicl). The ltter cn e leg-length or elow-the-knee grment. Thus, such ptient needs two sets of 2 3 grments. One set is worn while the other is wshed. Depending on the ge nd ctivity of the ptient, two sets cn lst for 2 4 months. Thus, ptients should e prescried grments 3 6 times during the first yer. After complete reduction hs een chieved, the ptient is seen once yer when ll new grments re prescried for the coming yer. Controlled compression therpy cn lso e used to effectively tret pitting oedem s n lterntive to complete decongestive therpy (CDT), which, in 19 Brorson C, finl 3.indd 19 6/4/09 20:03:49

10 1st Jost Scientific Symposium, 2008 Excess volume (ml) Grment off Grment on Grment on Grment off Preop. 2w 4w 3m 6m 1y 1y + 1y + 1.5y 2y 2y + 2y + 1w 2w 1w 2w Time Figure 33: Removing the compression grment leds to ccumultion of lymph. Putting it on gin, reverses the sitution (Brorson nd Svensson, 1998) contrst to CCT, comprises dily interventions (Brorson nd Svensson, 1998). Controlled compression therpy is simple, economic nd efficient. Every chin hs its wekest link nd the wekest link in oedem tretment is the compression grment. If oedem increses fter the opertion, it is due to the compression grment eing ineffective or decresed ptient complince. Compression is crucil to mintin the effect of liposuction. Incresing compression Compression cn e incresed when pitting is still present. Incresed compression cn e chieved y: decresing the circumferentil mesurements when ordering compression grments incresing the compression clss using severl compression grments (multilyer) incresing the mount of grments prescried t the sme time, or tking in existing grments. Figure 34: Ineffective nd poorly-fitting compression grment Figure 35: Effective, tilor-mde compression grment tht fits perfectly Pitting Prolem: lymph Conservtive tretment (CDT, CCT) Pitting test Still lrge rm No pitting Prolem: dipose tissue Liposuction Figure 36: The pitting test decides if conservtive therpy or liposuction is indicted to reduce excess volume Clss 2 is often used, ut some ptients need clss 3. With legs, clss 3 or 4 cn e used. Alterntively, severl lyers cn e plced on top of ech other. Removl of compression grments Figure 33 shows the pre- nd postopertive excess volumes in six ptients. To see wht would hppen if compression grments were not worn, the uthors removed them from six ptients nd fter one week the excess volume hd incresed in ll the ptients. The grments were put ck on nd, fter nother week, the excess volume hd gin lessened. A yer lter the experiment ws repeted ecuse the uthors thought tht possile postopertive scr formtion within the tissue might stilise the sitution. Agin, the excess volume returned on removl of the grments nd disppered when the grments were put ck on (Brorson nd Svensson, 1998). Thus, the wy to control oedem is compression, compression, compression. Correct compression must lso e worn. Figure 34 (right) shows grment tht is too lrge nd hs slithered down, strngulting the wrist. Figure 34 (left) shows compression grment tht is thought to e for the lower leg, ut the ptient hs een using it herself on the rm y cutting off the foot. This will hve no effect whtsoever. Figure 35 is n exmple of how compression grment should fit: custom-mde nd fitting perfectly. 20 Brorson C, finl 3.indd 20 6/4/09 20:03:50

11 Liposuction s tretment for lymphoedem c Figure 37: Lymphoscintigrpy. Typicl derml ckflow in the right leg, while the left leg shows norml lymph trnsport Figure 38: A mn with congenitl lymphoedem tht worsened fter surgicl removl of seminom nd postopertive rdiotherpy. Preopertive excess volume ws ml. Figure 38: After six months, 10 litres of fluid hd een removed. Figure 38c: Eight yers fter CCT nd liposuction no recurrence cn e seen Liposuction is not the first choice of tretment nd should not e performed without trining. It is lifetime commitment oth for the surgeon, who should e well trined, nd for the ptient. Liposuction per se is not the solution it is the strt nd should then e continued with compression grments for life, just like fter CDT. The key to success is the informtion provided to the ptients. A mentl contrct with them fcilittes complince. Eqully, if ptient cnnot e supplied with sufficient numer of grments, liposuction should not e performed. As sid, the pitting test cts s simple mens of clssifiction (Figure 36). Where there is pitting, there is still oedem; if there is no pitting, lymphoedem hs turned into dipose tissue (Box 1). If there is still pitting, the ptient should e treted with conservtive therpy until no, or miniml pitting is seen. Then the decision cn e mde s to whether it is sufficient for the ptient. If the ptient wnts further reduction, liposuction is n option. Mny lymph therpists regrd it s norml for ptients to come ck regulrly for mintennce therpy. Ptients re plesed with their initil tretment, ut then return to the therpist ecuse their rm hs swollen gin, out six months lter. The whole process with CDT is repeted. After nother six months the rm is swollen gin, new tretment with CDT, nd so on... This egs the Box 1: Inclusion criteri for liposuction No pitting Continuous compression with grments Arm swelling round 1000 ml, cn e s low s 500 ml ut lso the ptient s BMI should e considered No ctive rest cncer No effect of conservtive therpy No wounds question s to why the therpist did not nlyse why nd when the rm hd ecome swollen gin. If therpist hd seen the ptient every two months during the first yer fter tretment, mesuring oth rms nd seeing when the swelling strted to come ck, new grments could hve een ordered. Thus, fter one yer you would know exctly how mny grments the ptient needed, nd the correct numer could e ordered for the following yer. A check-up should e done t one nd hlf yers for complince nd volume mesurements. If everything is stle t two yers, once-yerly visit is enough. In the long run this will sve time, money nd unnecessry visits. 21 Brorson C, finl 3.indd 21 6/4/09 20:03:51

12 1st Jost Scientific Symposium, 2008 Before liposuction After liposuction Figure 39: MRI ) Shows the swollen left leg efore tretment. ) Result fter CCT nd liposuction Figure 40: Typicl exmple of primry lymphoedem. Left-hnd figure shows preopertive lim with n excess volume of ml; right-hnd figure two yers postopertively Figure 42: 73-yer-old womn who hs hd primry lymphoedem since she ws 50 yers old. Preopertive excess volume ws ml (left-hnd figure), nd six months fter surgery where there is slight overcorrection (right-hnd figure) Figure 41: Typicl exmple of secondry lymphoedem. Left-hnd figure shows preopertive lim with n excess volume of ml; right-hnd figure one yer postopertively Figure 43. Preopertive excess volume 6630 ml (left-hnd figure). Postopertive result fter two yers where excess volume is 30 ml (right-hnd figure) 22 Brorson C, finl 3.indd 22 6/4/09 20:03:55

13 Liposuction s tretment for lymphoedem Leg lymphoedem Most ptients with lymphoedem show positive Stemmer s sign, ut negtive Stemmer s sign does not exclude lymphoedem. Figure 37 shows typicl lymphoscintigrphy of lower leg lymphoedem. The injection cn e seen on the feet nd the uptke in the liver. After four hours there ws derml ckflow in the right leg nd no uptke in the lymph glnds in the groin. The left leg shows norml lymphtics nd lymph nodl uptke in the groin. Figure 38 shows mn with congenitl lymphoedem tht worsened fter surgicl removl of seminom nd postopertive rdiotherpy. Preopertive excess volume ws ml. A grment ws pplied to this ptient, which ws tken in fter the size reduced s result of CCT. In six months, 10 litres of fluid hd een removed (Figure 38). Eight yers fter CCT nd liposuction, no recurrence could e seen (Figure 38c). Where there is no pitting ut still excess volume, it is dipose tissue. The MRI scn in Figure 39 shows the thickness of sucutneous spce efore nd fter liposuction nd CCT in this ptient (Brorson et l, 2008). Figures show exmples of primry nd secondry lymphoedems efore nd fter surgery. Figure 44 shows mle ptient with clss III leg-long flt-knit compression, nd nother round-knit clss II compression grment nd elow-the-knee clss II flt-knit compression grment on the right leg. He lter developed lymphoedem in the left leg, where he wore clss III leg-long flt-knit compression nd nother leg-long round-knit clss 2. For one yer the uthors ordered six grments of ech t the sme time. The ptient numered the grments from one to six, so tht, for exmple, he wore those with numer three for 24 hours. These were then removed when he took shower nd luricted the skin with wter solule ointment. He would then put on the next set of grments mrked with numer four, nd so on. The used set ws wshed. By doing this, he lwys knew which set of grments should e put on. In totl he needed 30 grments yer, demonstrting the importnce of eing le to fford grments so tht the lymphoedem does not recur. Figures 45 nd 46 show how ptient found tht she could use ndges for hernis to tret loclised oedem in the genitl region. The ndge ws modified with piece of n elstic roll tht ws secured in the front with velcro. Conclusion Liposuction is n effective tretment on chronic lrge lymphoedem not responding to conservtive regimens. Figure 44: This ptient needs the following compression: Right leg: Elvrex 3 Forte (leg-long), Bellevr 2 (leg-long), Elvrex 2 (elow-the-knee). Left leg: Elvrex 3 Forte (leg-long), Bellevr 2 (elow-the-knee). For one yer he needs six of ech. All grments for one yer re ordered t the sme time, in totl 30 grments 23 Brorson C, finl 3.indd 23 6/4/09 20:03:56

14 1st Jost Scientific Symposium, 2008 Figure 45: This ptient hs otined excellent compression y the use of herni grment supplemented with piece of elstic roll (Duer) tht hs een sewn together t the ck nd fstened y velcro in the front Figure 46: Herni grment Providing tht the compression grments re used ll the time, even fter 14 yers there is no recurrence. Excess dipose tissue cn e removed y liposuction, ut not y CDT, compression pumping or microsurgery. In Sweden the costs for treting lymphoedem re: 8,300 euros for n rm; 11,000 euros for leg grments cost 120 euros pir guntlets cost 180 euros pir ptient pys 30 euros for ech outptient visit. The ptient pys nothing for hospitlistion (4 7 dys), surgery or compression grments, s it is done within the Swedish helth cre system. Since 1998 the uthors clinic hs een pproved s clinic for the tretment of postmstectomy nd lymphoedem with liposuction y the Swedish Ntionl Bord of Helth nd Welfre. To conclude, it is importnt to e open-minded with regrd to liposuction. In the uthors opinion, if they hd red ll the dos nd donts efore strting this novel tretment, they would never hve otined the results tht they hve chieved. All figures re reproduced y kind permission of Håkn Brorson References Bgheri S, Ohlin K, Olsson G, Brorson H (2005) Tissue tonometry efore nd fter liposuction of rm lymphedem following rest cncer. Lympht Res Biol 3: Borley NR, Mortensen NJ, Jewell DP, Wrren BF (2000) The reltionship etween inflmmtory nd serosl connective tissue chnges in ilel Crohn s disese: evidence for possile custive link. J Pthol 190(2): Brorson H, Svensson H (1997) Complete reduction of lymphoedem of the rm y liposuction fter rest cncer. Scnd J Plst Reconstr Surg Hnd Surg 31(2): Brorson H, Svensson H (1997) Skin lood flow of the lymphedemtous rm efore nd fter liposuction. Lymphology 30: Brorson H (1998) Liposuction nd Controlled Compression Therpy of Arm Lymphedem Following Brest Cncer. Thesis. Studentlittertur, Lund, Sweden 24 Brorson C, finl 3.indd 24 6/4/09 20:03:57

15 Liposuction s tretment for lymphoedem Brorson H, Svensson H (1998) Liposuction comined with controlled compression therpy reduces rm lymphedem more effectively thn controlled compression therpy lone. Plst Reconstr Surg 102: Brorson H, Svensson H, Norrgren K, Thorsson O (1998) Liposuction reduces rm lymphedem without significntly ltering the lredy impired lymph trnsport. Lymphology 31(4): Brorson H, Åerg M, Svensson H (2004) Chronic lymphedem nd dipocyte prolifertion: Clinicl therpeutic implictions. Lymphology 37(Suppl): Brorson H, Ohlin K, Olsson G, Långström G, Wiklund I, Svensson H (2006) Qulity of life fter liposuction nd conservtive tretment of rm lymphedem. Lymphology 39: 8 25 Brorson H, Ohlin K, Olsson G, Nilsson M (2006) Adipose tissue domintes chronic rm lymphedem following rest cncer: n nlysis using volume rendered CT imges. Lympht Res Biol 4(4): Brorson H, Ohlin H, Svensson B, Svensson H (2008) Controlled compression therpy nd liposuction tretment for lower extremity lymphedem. Lymphology 41: Brorson H, Ohlin, K, Olsson G, Krlsson MK (2009) Brest cncer-relted chronic rm lymphedem is ssocited with excess dipose nd muscle tissue. Lympht Res Biol 7: 3 10 Clyton DN, Clyton JN, Lindley TS, Clyton JL (1989) Lrge volume lipoplsty. Clin Plst Surg 16(2): Courtiss EH, Choucir RJ, Doneln MB (1992) Lrge-volume suction lipectomy: n nlysis of 108 ptients. Plst Reconstr Surg 89(6): ; discussion Goodpsture JC, Bunkis J (1986) Quntittive nlysis of lood nd ft in suction lipectomy spirtes. Plst Reconstr Surg 78(6): Hrvey NL, Srinivsn RS, Dillrd ME, Johnson NC, Witte MH, Boyd K, Sleemn MW, Oliver G (2005) Lymphtic vsculr defects promoted y Prox1 hploinsufficiency cuse dult-onset oesity. Nt Genet 37(10): Illouz YG (1983) Body contouring y lipolysis: 5-yer experience with over 3000 cses. Plst Reconstr Surg 72(5): Jones B, Fishmn EK, Hmilton SR, Ruesin SE, Byless TM, Cmeron JC, et l (1986) Sumucosl ccumultion of ft in inflmmtory owel disese: CT/pthologic correltion. Int J Comput Assist Tomogr 10: Klein JA (1993) Tumescent technique for locl nesthesi improves sfety in lrge-volume liposuction. Plst Reconstr Surg 92(6): Klein JA (1987) The tumescent technique for lipo-suction surgery. Am J Cosmetic Surg 4(4): Lntz M, Vondrichov T, Prikh H, Frennder C, Ridderstrle M, Asmn P, et l (2005) Overexpression of immedite erly genes in ctive Grves ophthlmopthy. J Clin Endocrinol Met 90(8): Rohrich RJ, Mthes SJ (1990) Suction lipectomy. In: MJ Jurkiewicz, TJ Krizek, SJ Mthes nd S Ariyn, eds. Plstic Surgery: Principles nd Prctice. Mosy, St. Louis: 1553 Smdl F, Amlnd PF, Bugge JF (1995) Blood loss during suction-ssisted lipectomy with lrge volumes of dilute drenline. Scnd J Plst Reconstr Surg Hnd Surg 29(2): Schneider M, Conwy, EM, Crmeliet P (2005) Lymph mkes you ft. Nt Genet 37(10): Sheehn AL, Wrren BF, Ger MW, Shepherd NA (1992) Ft-wrpping in Crohn s disese: pthologicl sis nd relevnce to surgicl prctice. Br J Surg 79(9): Wojnikow S, Mlm J, Brorson H (2007) Use of tourniquet with nd without drenline reduces lood loss during liposuction for lymphoedem of the rm. Scnd J Plst Reconstr Surg Hnd Surg 41: Further reding Brorson H (2003) Liposuction in rm lymphedem tretment. Scnd J Surg 92: Brorson H (2004) Liposuction nd the consensus document: response to Professor M Foldi s remrks t the 19th Interntionl Congress of Lymphology. Lymphology 37(4): 174 Brorson H (2004) Adipose tissue in lymphedem: the ignornce of dipose tissue in lymphedem. Lymphology 37(4): Brorson H, Ohlin H, Svensson B (2008) The fcts out liposuction s tretment for lymphoedem. J Lymphoedem 3(1): Wrren AG, Brorson H, Borud LJ, Slvin SA (2007) Lymphedem: comprehensive review. Ann Plst Surg 59: Brorson C, finl 3.indd 25 6/4/09 20:03:57