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Combined Surgical Treatment for Chronic Upper Extremity Lymphedema Patients

Simultaneous Lymph Node Transfer and Liposuction

Leppäpuska, Ida-Maria MB*; Suominen, Erkki MD, PhD*; Viitanen, Tiina MD, PhD*; Rannikko, Eeva MD*; Visuri, Mikko MD*; Mäki, Maija MD, PhD; Saarikko, Anne MD, PhD; Hartiala, Pauliina MD, PhD

doi: 10.1097/SAP.0000000000001828
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Background Upper limb lymphedema is a common problem after axillary lymph node dissection. Lymphatic drainage can be improved by microvascular lymph node transfer, whereas liposuction can be used to reduce arm volume and excess of adipose tissue. We present the results of chronic lymphedema patients who have undergone lymph node transfer and liposuction simultaneously in 1 operation and compare the results with patients who have undergone lymph node transfer without liposuction.

Methods During May 2007 to February 2015, 20 postmastectomy patients and 1 Hodgkin's lymphoma patient presenting with chronic nonpitting lymphedema (age between 37 and 74 years, average 56.7 years) were operated using the combined technique and 27 postmastectomy patients presenting with early-stage lymphedema (age between 31 and 68 years, average age 50.2 years) were operated using only the lymph node transfer. Compression therapy was started immediately after the operation and the patients used compression 24 h/d at least 6 months postoperatively. Changes in clinical parameters (number of erysipelas infections, pain), arm volume, transport indexes calculated form lymphoscintigraphy images, and daily usage of compression garments were compared preoperatively and postoperatively and between groups (combined technique vs lymph node transfer). The study was a retrospective observational study.

Results In the combined technique group, the average arm volume excess decreased postoperatively 87.7%, and in 7 of 10 patients, the edema volume did not increase even without compression. Seventeen of 21 patients were able to reduce the use of compression garment. Lymphoscintigraphy results were improved in 12 of 15 patients and the improvement was significantly greater in the combined technique group than in the lymph node transfer group (P = 0.01). The number of erysipelas infections was decreased in 7 of 10 patients and the decrease was significantly greater in the combined technique group than in the lymph node transfer group (P = 0.02). In the lymph node transfer group, the average excess volume decreased postoperatively 27.5%. Fourteen of 27 patients were able to reduce the use of compression garments. Lymphoscintigraphy results were improved in 8 of 19 patients, and the number of erysipelas infections was decreased in 1 of 3 patients.

Conclusions Liposuction can safely be performed with lymph node transfer in 1 operation to achieve optimal results in patients with chronic lymphedema. The combined technique provides immediate volume reduction and further regenerative effects on the lymphatic circulation. The significantly greater reduction in lymphoscintigraphy values and erysipelas infections suggests that the combined technique might be better for late-stage lymphedema patients than lymph node transfer alone.

From the *Departments of Plastic and General Surgery and

Clinical Physiology and Nuclear Medicine, Turku University Hospital, Turku;

Department of Plastic Surgery, Helsinki University Central Hospital, Helsinki; and

§Institute of Biomedicine, University of Turku, Turku, Finland.

Received October 3, 2018, and accepted for publication, after revision December 16, 2018.

Conflicts of interest and sources of funding: This study was supported by The Finnish Medical Foundation, the Special Governmental Funding (EVO) allocated to Turku University Hospital and the Varsinais-Suomi Regional Fund of the Finnish Cultural Foundation. T.V., E.S., A.S., and P.H. are research scientists involved in a clinical trial (Herantis Pharma). The authors declare no conflict of interest.

Reprints: Pauliina Hartiala, MD, PhD, Department of Plastic and General Surgery, Turku University Hospital, P.O. Box 52 Kiinamyllynkatu 4-8 FI 20521, Turku, Finland. E-mail: pauliina.hartiala@tyks.fi.

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