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. SAPL TECHNIQUE
    Question (ahmed, ):
    • DEAR Dr.Hakan I am interested in lymphedema surgery. If you allow me to ask you about SAPL technique : 1_Which cannula type you prefer for liposuction ? 2_What is your solution for humping of forefoot (long lasting CDT or liposuction)? 3_what is the max. amount of liposuction per limb? 4_in st.II lymphedema,when you decide to liposuc? Thanks in advance A.Sawaby

    Answer:
    • Sep 2018

      Dear Dr A Sawaby,

      1. 3 and 4 mm


      2. Dorsum of hand and foot does not contain any adipose tissue, only fluid/lymph and sometimes fibrosis, thus liposuction is not performed here. The reason for the problem with swelling on hand/foot is dur to inefficacy of compression since the hand/foot is oval in shape and thus most of the compression is exerted on the sides of the hand/foot and not where you want it, that is on the dorsum. After liposuction many patients swelling on these locations decrease.


      3. See articles and info here: http://www.plasticsurg.nu (English)

       

      4. Non-pitting lymphedema. Our research had shown that adipose tissue deposition starts parallell to the accumulation of lymph. Thus a pitting edema needs to be treated conservatively to transform it to a non-pitting state. The remaining excess volume comprises of adipose tissue, which can be removed with suction assisted lipectomy to get a complete reduction.

       

       

  2. Liposuction of lipoedema
    Question (ahmed, ):
    • Dear sir Treatment of lipoedema is by liposuction followed by garment.For how long does the patient need to wear garment post operative to avoid edema? Thank you A.Sawaby Lecturer of vascular surgery

    Answer:
    • Aug 2018

      Dear Professor A. Swaby,

      This is very individual depending on the extent of surgery. Normally between 3-6 months, sometimes longer.

      Bet regards,

      Håkan Brorson, MD, PhD

  3. How to calculate BMI When having lymphedema?
    Question (Regina, ):
    • Dear Dr. Brorson, Questions about BMI: - should the extra weight of the lymphedematous limb be subtracted before calculating BMI? - if yes, is 1 liter volume approximately 1 kilogram weight? Thank you, Regina

    Answer:
    • Jul 2018

      Dear Regina,

      Yes, you can subtract the extra weight before you calculate BMI.

      Yes, 1 liter volume is approximately 1 kilogram.

      Volume programs can be downloaded here:

      http://www.plasticsurg.nu

      Best regards,

      Håkan Brorson, MD, PhD

  4. What sort of compression does Dr Brorson advise?
    Question (Janet, ):
    • I cannot find by reading Dr Brorson (or others) papers on lymphatico-venous bypass as well as liposuction in lipoedema (lymphoedema?), the sort of compression hosiery that he or others have found to be most effective. I mean could this be round knit or is fitted obligatory? As compression is a medical device, I think this should be more clearly recommended or specified in scientific publications. What is your opinion? Thank you,

    Answer:
    • Feb 2018

      Thank you for your important question!

      Please follow the link: http://www.plasticsurg.nu

      You will find several scientific papers and book chapters regarding compression.

      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
      __________________________________________________________

       

  5. «Pitting» Primary lymphedema
    Question (Kristian, ):
    • Hi. I have left foot primary lymphedemia with pitting. I have had it for 6-7 years. Is surgery an option? Regards Kris

    Answer:
    • Jan 2018

      Dear Kris,

      Lymphedema leads to deposition of adipose tissue. Deposition begins parallell to the start of lymphedema or soon thereafter.

      Since I perform liposuction for lymphedema I answer your question with based on indications for liposuction.

      Liposuction is only performed in a non or minimally pitting lymphedema. This means that the fluid component of the swelling has been removed by conservative treatment such as CDT or CCT and that there is still a significant volume excess.

      Since adipose tissue deposition does not occur in the hand or foot liposuction is not performed in there areas.

      I therefore recommend you to have conservative treatment for your foot swelling. Conservative treatment is always the initial treatment of any lymphedema.

      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
      —————————————————————————————————————————————-
      Homepage: http://www.plasticsurg.nu
      _________________________________________________________

  6. 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
      _________________________________________________________

       

       

       

  7. 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).

  8. test
    Question (Jim, ):
    • Jim woodman test

    Answer:
    • Jul 2018

      Jim woodman test

  9. Test question for Dr. Brorson
    Question (Jim, ):
    • test

    Answer:
    • Jul 2018

      Test ok

  10. 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:
  11. TEST QUESTION
    Question (Phyllis, ):
    • This is a test question for Dr. Brorson.

    Answer:
  12. Test Question
    Question (Phyllis, ):
    • This is a test question

    Answer:
    • Jul 2018

      N/A

  13. Test question
    Question (Phyllis, ):
    • This is a test question. Let me know if you receive this. Thanks, Phyllis

    Answer:
    • Jul 2018

      Yes.

  14. Liposuction As An Aid For Lymphodema
    Question (Mike, ):
    • Being as 'Liposuction and Debulking Operations for Lymphedema' is a part of your expertise, can you elaborate on facts as they pertain to lessening or eliminating altogether the effects of Lymphedema? When I think of liposuction I think of fat removal of the stomach area (at least for men). In doing so, can the removal of fat either through liposuction or natural means control Lymphedema? In other words, is Lymphodema more prevalent in overweight/obese people? I'm referring to those that have had no removal of lymph nodes for whatever reason. I notice that during summer's humidity my legs and feet (in one leg more than the other) swells to the point of not being able to bend my foot. Does humidity in fact play a role in the disease and would it be more beneficial to live in a dry heat climate like the southwest vs Florida where it is humid? What effects do salt and sugar have on Lymphodema? Is it advisable to take a daily water pill/diaretic as an aid? I have been using for the last month a supplement called 'Butcher's Broom' that is to be used for circulation. While there is no scientific or FDA research to support this claim I personally have noticed a lessening in the puffy severity I was experiencing previously. That being said, I can't say for certain that it wasn't do in part to being less humid now than it was before I started taking the supplement. I realize when the claim for 'Butcher's Broom' aiding in circulation that they may be referring to blood and not water / fluid which I have learned from you is a different kind of circulation than with blood. All things considered, in your opinion is there any credence to the circulation claim? Are there any other supplements (natural) that could play a part in Lymphodema? Lastly, what causes 'flare-ups'? I notice that some days my legs might not only be more inflamed than others but at the same time there are (what I term) EXTREME pimples with large white heads on them. They will just pop-up out of nowhere. They are larger and more redened pimples than the typical teenage acne and the white-heads are sore to the touch. After 2-3 days the white heads turn to dark with the red ring around them. I try to think back to what might have caused the flare-ups in terms of what I ate the day. On a side note, I would like to buy stock in companies that are furthering research for Lyphedema as well as the stem cell programs you eluded to previously. Where can I come by a listing of these companies? Thank you for your time, knowledge and good works. Respectfully, Mike Laurie

    Answer:
    • Jul 2018

      Dear Mike Laurie,

      How do you know you have a lymphedema?

      Liposuction does not cure lymphedema, but it “turns the clock back” to when lymphedema started and by the use of 24/7 compression lymph fluid cannot stimulate fet deposition.

      Obesity is a risk factor for developing lymphedema. People with BMI around 50 will all get lymphedema in spite of a normal lymph system because it cannot drain all the excess fat. Also morbid obesity leads to problem with walking and activating the muscle pump.

      There are no papers written regarding humidity and lymphedema. This goes for sugar and salt. Al lot of sugar increase weight and thus risk for lymphedema.

      Diuretics are not recommended in lymphedema. If FDA has not recommended a medication it has no effect.

      Pimples with white heads can be milia, that is blocked sweat channels or blocked sebaceous channels.

      I have no idea regarding what stocks you should buy.

      Best regards,

      Håkan Brorson, MD, PhD

  15. 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

  16. 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

       

  17. 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:
    • Jul 2018

      Dear K,

      Weight loss leads to decreased weight, mainly reduction of adipose tissue. If you have a non-pitting edema it means that the excess volume contains deposited adipose tissue. Only liposuction can remove this.

      If you reduce you weight with exercise by burning more calories both the edematous and healthy extremity will loose volume/weight, but there will still be a difference (excess volume).

      Fat cells in the edematous limb are larger than in the healthy one.

  18. 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:
    • Jul 2018

      See 16-

  19. 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.”

  20. 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.

  21. 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.