Liposuction for chronic lymphoedema

Evidence-based recommendations on liposuction for chronic lymphoedema in adults. This involves using suction to remove fluid and fat through punctures in the skin.

# Recommendations
Evidence on the efficacy and safety of liposuction for chronic lymphoedema is adequate. The evidence on safety shows that the potential risks include venous thromboembolism, fat embolism, and fluid overload. This procedure can be used provided that standard arrangements are in place for clinical governance, consent and audit. Find out what standard arrangements mean on the NICE interventional procedures guidance page.
For auditing the outcomes of this procedure, the main efficacy and safety outcomes identified in this guidance can be entered into NICE's interventional procedure outcomes audit tool (for use at local discretion).
Patient selection must be done by a multidisciplinary team with expertise in managing lymphoedema.
The procedure should only be done in specialist centres by clinicians with training and expertise in liposuction for lymphoedema following agreed perioperative protocols.# The condition, current treatments and procedure

# The condition
Lymphoedema is the abnormal accumulation of subcutaneous fluid and sometimes fat in body tissues. It leads to chronic swelling that can cause disability, pain, and cosmetic issues. Any part of the body can be affected, but the condition is most common in the arms and legs. Lymphoedema can be complicated by recurrent infection (cellulitis), which further damages the lymphatic vessels and aggravates the condition. Primary lymphoedema results from a range of conditions that affect how the lymphatic system develops and functions. Secondary lymphoedema results from damage to the lymphatic system or removal of lymph nodes by surgery, radiation, infection, or injury. Liposuction may be particularly appropriate for select people with primary lymphoedema and for people with cancer-related lymphoedema.

# Current treatments
The current conservative treatment for lymphoedema is decongestive lymphatic therapy. This involves compression bandaging, skin care and exercise. For some people, manual lymphatic drainage massage that stimulates lymph to move away from the affected limb may also be helpful. Once decongestive lymphatic therapy sessions are stopped, the person is fitted with a custom-made compression garment, which is worn every day for life. These techniques aim to reduce the pain and discomfort associated with lymphoedema. In severe and chronic cases, in people with lymphoedema that does not respond to conservative treatment, liposuction can be used. Procedures to restore lymphatic flow from the limb, such as lymphovenous anastomosis or lymph node transfer, are less commonly used and are usually reserved for earlier-stage lymphoedema.

# The procedure
Liposuction for chronic lymphoedema is usually done under general anaesthesia, but using regional nerve blockade is also possible. A tourniquet is applied to the proximal limb. A few small incisions are made in the limb. Cannulas, connected to a vacuum pump, are inserted into the incisions and oedematous adipose tissue is removed by vacuum aspiration. Liposuction is done around and all the way along the limb up to the distal border of the tourniquet. The tourniquet is then removed; the proximal limb, which is unable to be controlled by tourniquet, is infused with tumescent solution; and the fat and fluid from this area are aspirated. Immediately after liposuction, a compression bandage is applied to the limb to control any bleeding and to prevent post-surgical oedema. Antibiotics and prophylaxis against venous thromboembolism are typically prescribed before and after the operation. After the procedure, a custom-made compression garment must be worn for life to maintain the volume reduction. This garment needs to be revised multiple times until the oedema volume has been reduced as much as possible and a steady state has been reached, but must be worn for life.