Ask Dr. Håkan Brorson

Areas of expertise:
  • Lymphedema leads to adipose tissue increase
  • Liposuction of lymphedema

Håkan Brorson, MD, PhD is senior consultant plastic surgeon at the Department of Plastic and Reconstructive Surgery, Skåne University Hospital, Lund University, Malmö, Sweden.

In 1998 he defended his thesis: Liposuction and Controlled Compression Therapy in the Treatment of Arm Lymphedema following Breast Cancer with Professor Charles Witte as opponent. He was appointed Associate Professor at Lund University, Sweden and Professor at Esculera de Graduados, Asociación Médica Argentina (EGAMA), Buenos Aires, Argentina in 2010.

His research is focused on the formation of adipose tissue in lymphedema using CT, MR Imaging/Spectroscopy and Dual Energy X-ray Absorptiometry for gross anatomy, and micro-array and RT-PCR for genetic studies. He has also published papers focusing on Laser Doppler Imaging, lymphoscintigraphy and Quality of Life. He is editor of the Swedish National Lymphedema Treatment Program and member of the International Lymphoedema Framework (ILF).

He has trained several teams around the world to treat lymphedema with liposuction. He was President of the 29th Congress of the European Group of Lymphology in 2003, and President of the 23rd International Congress of Lymphology in 2011; both held in Malmö, Sweden. He is President Elect of the International Society of Lymphology 2011-2013 and will become President of the same Society 2013-2015.


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  1. C. Smith
    Question (Corrina, ):
    • Hi Dr. Brorson, I have lymphedema in my right leg and will be having lymphedema liposuction combined with the lymph node transplant procedure. Research shows that you must wear compression garments immediately after the surgery. My question is: are these off the shelf garments or custom made. I trying to figure out how custom garments could me made in a short period of time. Or is a patient measured for garments immediately after surgery? I have always used custom garments. Also, Do you think a patient can have the liposuction more that one time , if the leg swelled back up after liposuction, mainly due to lack of compression after the procedure ? Thanks

    Answer:
    • Sep 2017

      Dear C Smith,


      The reason for microsurgery if to reconstruct the lymphatics. So if lymph node transfer works you do not need to wear any compression.

      Reading available literature and my experience of patients that have had microsurgery is that in chronic non-pitting lymphedema microsurgery does not work.

      Lymphedema leads to adipose tissue hypertrophy and adipose tissue can only be removed with liposuction.

      Liposuction is not covered by insurance in USA, but microsurgery is. So now surgeons perform liposuction (not paid for) combined with microsurgery (paid for).

      If surgeons were reimbursed for liposuction and not for microsurgery, would then the surgeon still combine liposuction with microsurgery?

      I have trained 2 teams from USA in Sweden and they know all about preoperative assessment, surgery and postoperative treatment.

      So if your have had full information from your physician you would already have had your questions answered.

      Garments to be used is custom made and flat knitted. Measurements are taked 2 weeks before surgery based on measurements of the healthy extremity. Garments arrive after 7 days. One of the compression garments is put on right after surgery.

      I have operated on more than 300 patients with complete reduction with a follow-up of at most 23 years without recurrence. Liposuction is only done once.

      Wearing of compression garments after liposuction is mandatory. If not, the lymphedema will recur. Initially the swelling is accumulated lymph. Thus liposuction should not be performed since lymph can be removed with conservative treatment.

      For details read this paper: Brorson H. Liposuction in lymphedema treatment. J Reconstr Microsurg 2016; 32: 56-65.


      Best regards,

      Håkan Brorson

      _________________________________________________________
      Håkan Brorson, MD, PhD
      Associate Professor (Lund University)
      Professor (Faculty of Medicine, EGAMA, Buenos Aires)
      Senior Consultant Plastic Surgeon
      Director, Lymphedema Center
      Department of Clinical Sciences, Lund University
      Plastic and Reconstructive Surgery, Jan Waldenströms gata 18, 2nd floor
      Skåne University Hospital, SE-205 02 Malmö, SWEDEN
      —————————————————————————————————————————
      Past President International Society of Lymphology
      —————————————————————————————————————————
      Email: .(JavaScript must be enabled to view this email address) – Homepage: http://www.plasticsurg.nu
      Secretary: +46-40-33 67 29 – Phone (work) : +46-40-33 34 37
      Cellular: +46-706 46 38 38 – Fax (work): +46-40-33 62 71
      _________________________________________________________

       

       

       

  2. Type of adipose deposited due to long term lymphedema
    Question (Darcy, ):
    • I understand that adipose tissue is created and deposited due to long term lymphedema. What type of fat is it? Is it the lipoedema type or the type that could be lost by diet and exercise? I have stage 3+ primary lymphedema and lipoedema. Thank you.

    Answer:
    • Apr 2017

      As per Dr. Brorson


      Answer: Our research has shown that the deposition of fats starts when lymph fluid accumulate. The chronic local inflammation leads to larger fat cells and at the same time fat cell precursor transforms into fat cells. So far nobody had done the same investigations in lipedema. If you lose weight, the fat will decrease all over the body. Weight loss is a balance between energy intake (diet) and energy loss (normal metabolism + exercise).

  3. Liposuction for Non pitting chronic lymphedema
    Question (kaumudi, ):
    • Hi Dr. H. Brorson. I have left leg lymphedema since 1999 after my cancer surgery and post surgery radiation. Till date I have tried MLD, compression garment, compression machine, Acupressure and few more like Yoga, Pranayam etc. All the above helped me a little. But last 10 years there has been no difference in my leg. I have the compression machine at home that I use every night but it shows no improvement. I read you work and your articles on liposuction for chronic lymphedema. I want to know if I can get it done. What all information do you need from me to be able to help me. I am sure you can help me with my condition. regards Kaumudi

    Answer:
  4. type of liposuction canula
    Question (ahmed, ):
    • There are many types of canula used for liposuction e.g.vaser ,simple suction Do you prefer certain type ?

    Answer:
    • Apr 2015

      The use of ultrasound (Vaser), radiofrequency and laser is contraindicated in patients with lymphedema since there is a risk for skin necrosis due to heat production. I use power assisted liposuction. For further information read the papers here: https://lu.box.com/s/9abvigfbx2rw7afgk9kz
      Håkan Brorson, MD, PhD

  5. 24/7 compression garment
    Question (Ellen, ):
    • I am a person with lower bilateral le. In one leg it is worse. Calf region and ankle do not respond to (very intensive) conservative treatment after 4 years. I heard that liposuction is only for very severe cases... But I want to know how I can get rid of the hard tissue that is keeping me from doing my job and so paying my le treatment. Is it so that extra tissue in lymphedema limb can go away with liposuction? Does that mean that after surgery a person with le need to wear his stocking 24/7? Is it only for severe cases (and if yes; what to do with very local hard tissue, not severe (yet) but very limiting? ). Thank you very much for your reply

    Answer:
    • Apr 2015

      I cannot tell what the hard tissue represents without seeing you. Lymphedema typically leads to adipose tissue deposition that can be removed with liposuction. See previous answer regarding adipose tissue from another patient. Just like after conservative treatment (CDT) constant use of compression garments is mandatory. Further information can be downloaded here: https://lu.box.com/s/9abvigfbx2rw7afgk9kz

       

  6. Adipose tissue in Lymphedema
    Question (Kate, ):
    • Dr Brorson I have read extensively about how you discovered adipose tissue present in lymphedema limbs and then pioneered liposuction for the removal of this. What I would like to understand is whether in your opinion exercise can remove this adipose tissue and if not how it differs from "fat" in a healthy limb? Kind Regards K

    Answer:
    • Apr 2015

      Dear K,

      When you exercise you consume energy and this can be taken from fat cells. So when you exercise you will lose adipose tissue all over the body, not only in the arm. Therefore there will still be excess fat in the arm even if you lose a lot of adipose tissue. Patients who diet lose weight and the volumes of both arms/legs decrease, but there is still a volume excess of the affected arm/leg. Naturally it would be great if you could direct the reduction of adipose tissue to the arm/leg only, but that is not possible, even if you just exercise the arm/leg.

      The deposition of adipose tissue starts already when the lymphedema starts and there is no correlation between the duration of the lymphedema and amount of excess adipose tissue. Also if you have a heavy arm lymphedema for many years the muscle volume increases as well because your arm works every day against a force which leads to muscle hypertrophy. Therefore this muscle excess also contributes to the volume excess of the arm. After removing the excess adipose tissue with liposuction the muscle volume also decreases because the excess volume/weight of he arm has been removed (data to be published).

      When we started liposuction more than 20 years ago we noticed that patients who had had optimal conservative therapy to remove the fluid/lymph did not show pits on pressure (”pitting test”) and that the arm became smaller, but the excess volume was not completely reduced. So we thought that there must be some component that prevented a normalization. MRI showed excess fat so it was natural to remove this by the use of liposuction. We have 21 years’ follow-up on patients with arm lymphedema and 11 years on leg lymphedema. We are very happy that we have not had any recurrence.

      The fat cells in patients with lymphedema are larger as compared to the unaffected arm or leg. There is also an increase in the number of fat cells. In animal experiments it has been shown that chronic inflammation leads to an increase of the adipose tissue.

      For more detailed information see references below.

      Best regards,

      Håkan Brorson, MD, PhD


      References:
      Brorson H, Ohlin K, Olsson G, Nilsson M. Adipose tissue dominates chronic arm lymphedema following breast cancer: An analysis using volume rendered CT images. Lymphat Res Biol 2006; 4: 199-210.

      Harvey NL. The link between lymphatic function and adipose biology. Ann N Y Acad Sci 2008; 1131: 82-88.

      Brorson H, Ohlin K, Olsson G, Karlsson MK. Breast cancer-related chronic arm lymphedema is associated with excess adipose and muscle tissue. Lymphat Res Biol 2009; 7: 3-10.

      Zampell JC, Aschen S, Weitman ES, et al. Regulation of adipogenesis by lymphatic fluid stasis: part I. Adipogenesis, fibrosis, and inflammation. Plast Reconstr Surg 2012; 129: 825-834

      Aschen S, Zampell JC, Elhadad S,Weitman E, De Brot M, Mehrara BJ. Regulation of adipogenesis by lymphatic fluid stasis: part II. Expression of adipose differentiation genes. Plast Reconstr Surg 2012; 129: 838-847

      Levi B, Glotzbach JP, Sorkin M, Hyun J, Januszyk M, Wan DC, Li S, Nelson ER, Longaker MT, Gurtner GC. Molecular analysis and differentiation capacity of adipose-derived stem cells from lymphedema tissue. Plast Reconstr Surg. 2013; 132: 580-589.”

  7. Garments After Liposuction
    Question (Anon, ):
    • Have any of your patients been able to stop using compression garments after liposuction?

    Answer:
    • Aug 2014

      Yes, but these few patients are exceptions.

  8. Microsurgical Reconstruction
    Question (J, ):
    • Liposuction removes adipose tissue. Do you think that microsurgical reconstruction can remove the accumulated adipose tissue caused by chronic inflammation?

    Answer:
    • Aug 2014

      No.