by Ali R. Abtahi, DO (@AbtahiPlastics)
Second-year Independent Resident
Division of Plastic and Reconstructive Surgery
University of Iowa Hospitals and Clinics
Treatment of lymphedema and its sequala is a hot topic in Plastic Surgery. The University of Iowa has been a pioneer in the field and recently published an article by Dr Wei F. Chen in the November 2019 issue of PRS Global Open.
The article describes his technique for the treatment of advanced staged lymphedema, defined as a “solid state” disease whereby the underlying subcutaneous tissue has fibrosed. Classic pitting edema of the extremity is absent and resultant skin changes are present such as hyperpigmentation, thickening, or papillomatous growths. At this stage, the only effective treatments are surgical debulking, which a variety of techniques have been described to include serial excision, the Charles procedure, and liposuction without concomitant skin excision (pioneered by Brorson). Our institutional belief, however, was that concomitant skin-reduction after debulking would optimize outcomes, much for the same reasons that skin excision is necessary in body contouring procedures such as brachioplasty, thighplasty, and abdominoplasty after massive weight-loss.
The study describes 43 consecutive patients with solid-predominant extremity lymphedema (ISL stage II or III disease) who underwent either standard liposuction without skin excision (sLIPO) or the modified technique that included skin excision (mLIPO). All patients demonstrated “stardust” or “diffuse” patterns by ICG, irreversible limb bulkiness out of proportion to quantitative bioimpedance spectroscopy, and MRI evidence of abundant lipodystrophy. Patients with Lipedema (a separate disease process) were excluded.
Our mLIPO technique can be viewed here.
In brief, an epinephrine tumescent is instilled into the affected limb until a strong turgor is achieved. 10 minutes later, the limb is exsanguinated and a tourniquet inflated. Circumferential, power-assisted liposuction is performed via stab incisions with 4- and 5-mm cannulas until 0.5-1cm subcutaneous tissue thickness is achieved. Skin redundancy is assessed by means of a positive “Flying Squirrel Sign”, a term we coined for 4cm or more of excess integument. Skin is excised using a longitudinal “Double Ellipse” technique the entire length of the limb segment (i.e. below-elbow to axilla or medial malleolus to knee). No drains are placed, however, short stretch bandage compression is applied immediately postop.
Fifteen patients underwent sLIPO versus 26 mLIPO. Cohorts were similar in demographics, disease type, and liposuction reduction volumes. Skin excision in the mLIPO group increased OR time by approximately 48 minutes. After an average 20-month follow-up, outcomes were compared between groups. sLIPO patients developed seroma/hematoma in 33%, contour irregularities in 53%, and skin necrosis in 20%. Comparatively, mLIPO patients had no seroma/hematoma or wound infection complications, contour irregularities in 19%, and one wound dehiscence (3.8%).
These results showed unexpectedly that when a more invasive surgery was performed (liposuction + skin excision), the complication rate decreased. Postoperative satisfaction scores were also higher (7.1 for sLIPO vs 9.3 for mLIPO). Despite its limitations (non-randomized, small sample size, empiric threshold for the 4cm “Flying Squirrel Sign), the study describes a promising technique with superior aesthetic results, patient satisfaction, and surgical outcomes. The implications of these results may even extend beyond high-risk lymphedema patients, with circumferential limb liposuction plus immediate skin excision being a feasible option in healthy aesthetic patients undergoing body contouring. Furthermore, our mLIPO patients have gone on to receive hybrid reconstruction with either vascularized lymph vessel transfer or lymphovenous anastomosis, contingent on their degree of lymphatic regeneration seen on follow-up ICG lymphography.
1. Chen WF, Zeng W-F, Hawkes PJ, Man J, Bowen M. Lymphedema Liposuction with Immediate Limb Contouring: Plastic and Reconstructive Surgery – Global Open. 2019;7(11):e2513. doi:10.1097/GOX.0000000000002513