Boyages, J., Kastanias, K., Koelmeyer, L.A., Winch, C.J., Lam, T.C., Sherman, K.A., . . . Mackie, H. (2015). Liposuction for advanced lymphedema: A multidisciplinary approach for complete reduction of arm and leg swelling. Annals of Surgical Oncology, 22, 1263–1270. 

DOI Link

Study Purpose

To evaluate a liposuction surgery and multidisciplinary rehabilitation approach for advanced lymphedema of the upper and lower extremities

Intervention Characteristics/Basic Study Process

Liposuction was performed under general anesthesia following limb exsanguination and tourniquet application. Using specialized Helixed Tri-Port III cannulas (22 and 30 cm long, 4–5 mm wide) connected to a vacuum pump, subcutaneous tissue was removed through multiple small incisions along the limb. Presurgical limb volume determined how much tissue was removed to equalize volume relative to the unaffected limb. Compression garments were applied to the affected limb immediately postsurgery prior to tourniquet release (custom-made 30 mmHg JOBST® Elvarex for arms, or Ready Wraps® [Solaris] for legs). From one week postsurgery, all leg patients wore JOBST Elvarex custom-made compression garments 50–80 mmHg. Initial postsurgical garments were measured using the circumference of the unaffected limb. Subsequent measurements were obtained from the operated limb by a trained garment fitter. Every order consisted of two garments, allowing one to be worn while the other was washed. Throughout follow-up, compression garments alone were used in areas where liposuction was performed. However, decongestive lymphatic therapy was used when indicated in areas where liposuction was not performed (hands or feet) or areas that could not be adequately compressed (shoulder or hip).

Sample Characteristics

  • N = 21 (15 arm and six leg)
  • MEAN AGE = 57.8 years (range = 25–69 years) in arm group; 50.7 years (range = 18–66 years)
  • FEMALES: 100%
  • KEY DISEASE CHARACTERISTICS: Cancer-related secondary lymphedema
  • OTHER KEY SAMPLE CHARACTERISTICS: Cancer-related secondary lymphedema was a more common reason for liposuction (85.7%) than primary (congenital) lymphedema (14.3%) with breast cancer treatment being the most common underlying cause (66.7%). The mean time of longstanding lymphedema was 9.1 years (range = 2–29 years) in the arm group versus 15.5 years (range = 3–42 years) in the leg group. 

Setting

  • SITE: Single site    
  • SETTING TYPE: Multiple settings
  • LOCATION: Australia

Phase of Care and Clinical Applications

  • PHASE OF CARE: Late effects and survivorship
  • APPLICATIONS: Elder care

Study Design

Prospective clinical study, one arm, pre and post measures

Measurement Instruments/Methods

  • Limb volume by tape was calculated using 4 cm truncated cone circumferential measurements
  • Lymph fluid measured by bioimpedance spectroscopy (L-Dex®) measurement
  • Functional and emotional impairment was assessed using the Patient-Specific Functional Scale (PSFS). PSFS is reliable and valid across contexts and sensitive to change in breast cancer survivors, but it was not previously validated for lymphedema.

Results

A significant postliposuction reduction in limb volume was achieved for all patients. The mean preoperative limb difference was 45.1% (range = 23–83), decreasing between two and six weeks postsurgery to 13.2% (range = -2–24), a significant 68.2% reduction (range = 35–104; t[20] = 9.66; p < 0.001). Limb volume difference reduced to 3.8% by six months postsurgery, an 89.6% (range = 38–149) reduction of presurgical volume (t[18] = 9.17; p < 0.001). This near-complete reduction was maintained to 12 months (n = 8), a 97.7% reduction (range = 73–123; t[8] = 5.73; p < 0.001). Mean presurgical limb volume difference was 45.1% (arm 44.2%; leg 47.3%). L-Dex increased four weeks postsurgery to 55 (range = 32–73), reflecting the extracellular fluid associated with postsurgical swelling (t[18] = -2.51; p = 0.02). Functionally, all patients reported improvements on the PSFS index of personally important activities by six months postsurgery (p < 0.01). 

Conclusions

Liposuction was safe and may be an effective option for carefully selected patients with advanced lymphedema. Assessment, treatment, and follow-up by a multidisciplinary team is essential.

Limitations

  • Small sample (< 30)
  • Baseline sample/group differences of import 
  • Risk of bias (no control group)
  • Risk of bias (no blinding)
  • Risk of bias (no random assignment) 
  • Risk of bias (no appropriate attentional control condition)  
  • isk of bias (sample characteristics)
 

Nursing Implications

Liposuction is a surgical approach to lymphedema. It should be noted that even with continuous compression therapy, postliposuction, patients’ lymph fluid level was elevated beyond normal. Nurses should continue observing the impact of liposuction on patients’ physiological, functional, and emotional aspects. Nurses should also advise patients according to current evidence.