More than 25 years ago I performed liposuction in the hand and fingers. I found no adipose tissue here, which was also confirmed with MR. Swelling here is caused of accumulated lymph which is treated conservatively with compression.

Thank you for your question.

No, liposuction is not performed on the hand or fingers since there is no excess adipose tissue here. 30 years ago, I did it but since no adipose tissue came out, also verified with CT/MRI, I stopped doing it. The same goes for the foot.

Swelling of hand and foot is caused by lymph only. The problem with compression in the hand and foot is that they are oval in shape which leads to that the pressure of the garment is mostly exerted on the sides of the hand/foot and not where you want it, that is on the surface of the hand/foot.

There is no swelling on palm of the hand or the sole of the foot because there are very tight ligaments from the skin preventing fluid accumulation here.

Posted by Steve Palmer (LE&RN;) for Prof. Brorson. A PDF is linked because of the length of the response.

Prof. Brorson’s response to the question “Bandage after SAPL”

1. Yes, this is highly recommended. Liposuction does not cure lymphedema, but removes the excess adipose tissue created by chronic inflammation that the accumulate lymph has created. In order to prevent new lymph accumulation compression is needed. If you do not wear garments during night the arm/leg will become larger.

2. Yes, I have trained the team of Professor Andrzej Szuba including plastic surgeon Dr. Marek Paul. Also, I have operated on 10 patients from Poland here in Sweden after referral from Narodowy Fundusz Zdrowia (NFZ) with complete reduction of the lymphedema (arm 4,2 liters, leg 8.4 liters).

Further information can be downloaded here: http://www.plasticsurg.nu

This is the typical effect of our treatment.

Yes, if you lose weight the lymphedematous arm/leg will be smaller, but that also goes for the normal arm/leg, so there will always be a difference between the extremities. The fat cells are larger in lymphedema as compared to normal fat.

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.

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

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

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
__________________________________________________________

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
_________________________________________________________

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
_________________________________________________________

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).

Test ok

N/A

Yes.

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

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

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

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.

See 16-

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.”

Yes, but these few patients are exceptions.

No.