Overview

Article

Number of patients/ follow-up

Direction of conclusions

Reasons for non-inclusion in summary of key evidence section

Agko M, Ciudad P, and Chen HC. (2018) Staged surgical treatment of extremity lymphedema with dual gastroepiploic vascularized lymph node transfers followed by suction-assisted lipectomy-A prospective study. Journal of Surgical Oncology 117(6):1148-56

n=12

FU=23.5 months

Vascularised lymph node transfer followed by suction-assisted lipectomy can allow people with late Stage 2 lymphoedema achieve near normal limb size and eradication of infectious episodes. At follow-up, these desirable outcomes were maintained well after discontinuation of compression therapy. Complications included blood transfusion and transient numbness.

Studies with more people and longer follow-up included. Combination of surgical techniques used.

No new safety outcomes reported.

Alamoudi U, Taylor B, MacKay C et al. (2018) Submental liposuction for the management of lymphedema following head and neck cancer treatment: a randomized controlled trial. Journal of otolaryngology - head & neck surgery 47(1):22

n=10

FU=6 months

There was a statistically significant improvement in people' self-perception of appearance and statistically significant subjective scoring of appearance following submental liposuction.

Studies with more people and longer follow-up included. Included in the Tang, 2021 systematic review.

Al-Farhan AH, Allawi BSA, Wais MM et al. (2020) Liposuction assisted brachioplasty, evaluation of its efficacy and safety. Archivos Venezolanos de Farmacologia y Terapeutica 39(7):884-9

n=15

FU=1 year

Liposuction assisted brachioplasty has a lower complication rate than the standard procedure (without liposuction) and has better aesthetic and functional satisfaction.

Studies with more people and longer follow-up included.

No new safety outcomes reported.

Bolletta A, Di Taranto G, Chen SH et al. (2020) Surgical treatment of Milroy disease. Journal of Surgical Oncology 121(1):175-81

n=4

FU=20.2 months

Vascularised lymph node transfer together with therapeutic lipectomy proved to be a reliable technique in moderate cases of Milroy disease, providing an alternative path for lymph drainage, and reducing the lymph load and the excess of subcutaneous adipose tissues, thus improving patients' quality of life.

Studies with more people and longer follow-up included. Combination of surgical techniques used.

No new safety outcomes reported.

Boyages J, Kastanias K, Koelmeyer LA et al. (2015) Liposuction for advanced lymphedema: a multidisciplinary approach for complete reduction of arm and leg swelling. Annals of surgical oncology 22: 1263-1270.

n=21

FU=1 year

All people had improved symptoms and function. Bioimpedance spectroscopy showed reduced but ongoing extracellular fluid, consistent with the underlying lymphatic pathology.

Liposuction is a safe and effective option for carefully selected people with advanced lymphoedema. Assessment, treatment, and follow-up by a multidisciplinary team is essential.

Studies with more people and longer follow-up included.

Brake MK, Jain L, Hart RD et al. (2014) Liposuction for submental lymphedema improves appearance and self-perception in the head and neck cancer patient. Otolaryngology - Head and Neck Surgery (United States) 151: 221-225.

n=9

FU=12 months

Submental liposuction improves the appearance and quality of life for head and neck cancer patients suffering from posttreatment lymphoedema by way of improving their self-perception and self-confidence.

Studies with more people and longer follow-up included. Included in the Tang, 2021 systematic review.

Brazio PS and Nguyen DH. (2021) Combined Liposuction and Physiologic Treatment Achieves Durable Limb Volume Normalization in Class II-III Lymphedema: A Treatment Algorithm to Optimize Outcomes. Annals of plastic surgery 86(5):s384-s389

n=21

FU=mean 250 to 301 days, dependent on type of therapy received.

People with predominantly nonpitting presentation benefit from liposuction to maximize removal of fibroadipose tissue and optimize after surgery compression, followed by lymphovenous anastomosis or Vascularised lymph node transfer to improve lymphatic drainage.

Studies with more people and longer follow-up included. No new safety outcomes reported.

Brorson H (2012) Pitting and non-pitting lymphedema: The presence of adipose tissue in lymphedema. European Journal of Lymphology and Related Problems 23: 27-28.

Liposuction can be performed in people who do not respond to conservative management or microsurgical reconstruction because the hypertrophy of the subcutaneous adipose tissue cannot be removed or reduced by these techniques. The long-term results of liposuction for chronic large postmastectomy arm lymphoedema (17 years) and primary and secondary leg lymphoedema (8 years) leading to complete reduction, without recurrence, will be described.

Studies with more people and longer follow-up included.

Brorson H, Ohlin K, Olsson G, et al. (2008) Controlled compression and liposuction treatment for lower extremity lymphedema. Lymphology 41: 52-63.

n=1

This paper explains the authors philosophical approach: a pitting lymphoedema first should be treated conservatively to remove excess fluid, then liposuction can be performed to remove remaining excess volume bothersome to the person.

No new safety or efficacy outcomes.

Studies with more patients included.

Brorson H, and Svensson H (1998) Liposuction combined with controlled compression therapy reduces arm lymphedema more effectively than controlled compression therapy alone. Plastic and reconstructive surgery 102, 1058-67, discussion 1068

n=28

FU=1 year

Liposuction combined with controlled compression therapy reduces arm lymphoedema more efficiently than the therapy alone. Continued use of compression garments is, however, important to maintain the primary surgical outcome.

Studies with more people and longer follow-up included.

Brorson H (2000) Liposuction gives complete reduction of chronic large arm lymphedema after breast cancer. Acta oncologica (Stockholm, and Sweden) 39, 407-20

n=20

FU=1 year

The use of a compression garment after liposuction is necessary in order to maintain the normalised arm volume. Liposuction and combined compression therapy did not affect the already impaired lymph transport; it merely increased skin microcirculation. A reduced incidence of cellulitis was noted.

Studies with more people and longer follow-up included.

Campisi CC et al. (2016) Fibro-lipo-lymph-aspiration with a lymph vessel sparing procedure to treat advanced lymphedema after multiple lymphatic-venous anastomoses: the complete treatment protocol. Annals of Plastic Surgery 00: 1-7.

n=146

FU=1 year

Liposuction is efficient. An entire leg can be completed within 90 minutes. Recovery time is short, and cosmetic results are immediate. More importantly, the removal of excess tissue is completed without further damage to lymphatic vessels.

Study is included in the Chang, 2021 systematic review.

Carl HM, Walia G, Bello R et al. (2017) Systematic Review of the Surgical Treatment of Extremity Lymphedema. J Reconstr Microsurgery.

n=105 people, 4 studies

FU=12 to 38 months

This systematic review and meta-analysis evaluated literature on surgical treatment of extremity lymphoedema. Four studies were identified that used liposuction. The weighted excess volume reduction was 96.6% (95% CI: 86.2 to 107%, I²: 0.0%). Three studies reported better patient QoL outcomes after surgery. There were no complications reported.

More recent systematic review and meta-analysis included.

Cook KH, Park MC, Lee IJ et al. (2016) Vascularized Free Lymph Node Flap Transfer in Advanced Lymphedema Patient after Axillary Lymph Node Dissection. Journal of Breast Cancer 19, 92-5

n=1

FU=1 year

In this study, a two-stage operation in a person with advanced lymphoedema was done. First, a debulking procedure was performed using liposuction. A vascularised free lymph node flap transfer was then conducted 10 weeks after the first operation. In this case, good results were obtained, with reduced circumferences in various parts of the upper extremity noted immediately post operation.

Larger case series already included. No new safety outcomes reported.

Damstra RJ, Voesten HGJM, Brorston H et al. (2009) Circumferential suction-assisted lipectomy for lymphoedema after surgery for breast cancer. BMJ 96: 859-864.

n=35

FU=12 months

Circumferential lipectomy combined with lifelong compression hose is an effective technique in end-stage lymphoedema after treatment for breast cancer.

Overlap with paper 3 table 2.

Only outcome reported is limb size reduction.

Di Taranto G, Bolletta A, Chen SC et al. (2021) A prospective study on combined lymphedema surgery: Gastroepiploic vascularized lymph nodes transfer and lymphaticovenous anastomosis followed by suction lipectomy. Microsurgery 41(1):34-43

n=37

FU=2 years

Lymphaticovenous anastomosis, vascularised lymph node transfer, and suction lipectomy can be integrated together in a combined approach, in synergy to enhance the outcomes

Studies with more people and longer follow-up included. Combination of surgical techniques used. No new safety outcomes reported.

Doren EL, Smith PD, Sun W al. (2012) Feasibility of liposuction for treatment of arm lymphedema from breast cancer. Cancer Research 72

n=6

FU=15 months (mean)

Liposuction can safely reduce volume of arm lymphoedema and improve functionality/quality of life. Larger studies (longer follow-up) are needed to validate the durability of these early results

Studies with more people and longer follow-up included.

Eryilmaz T, Kaya B, Ozmen S, and Kandal S (2009) Suction-assisted lipectomy for treatment of lower-extremity lymphedema. Aesthetic Plastic Surgery 33: 671-673.

n=1

FU= not reported

A case of lymphoedema reduction with suction-assisted lipectomy in a person with bilateral lower-extremity lymphoedema.

Studies with more people and longer follow-up included.

Espinosa-de-Los-Monteros A, Hinojosa CA, Abarca L et al. (2009) Compression therapy and liposuction of lower legs for bilateral hereditary primary lymphedema praecox. Journal of Vascular Surgery 49: 222-224.

n=1

FU= 14 months

No complications were seen and compression therapy was continued. Fourteen month follow-up reveals no increase in leg volume over time, absence of pain, and no further episodes of cellulitis with complete ability to ambulate and return to normal activities. Even when it does not eliminate the underlying cause of primary lymphoedema, combined therapy consisting of compression and liposuction is safe and is able to achieve control, at least on a short term, of clinically disabling conditions associated with advanced stages.

Studies with more people and longer follow-up included.

Forte AJ, Huayllani MT, Boczar D et al. (2019) Cureus 11(10)

n=191 people, 8 studies

FU=14 to 96 months

This systematic review evaluated literature on liposuction for lower limb lymphoedema. articles. A volume reduction greater than 50% was found in all people. Complete volume reduction was found after four to five years of follow-up. A greater volume reduction was found for secondary lymphoedema when compared to primary lymphoedema.

More recent systematic reviews included.

Granoff MD, Pardo, J, and Singhal D. (2021) Power-assisted liposuction: An important tool in the surgical management of lymphedema patients. Lymphatic Research and Biology 19(1):20-2

n=39

FU=1 year

Debulking with power-assisted liposuction is an effective treatment for chronic lymphoedema, supported by improvement in both objective and subjective metrics.

Likely identical patient population to Granoff, 2020, but presents fewer results.

Hoffner M, Bagheri S, Hansson E et al. (2017) SF-36 Shows Increased Quality of Life Following Complete Reduction of Postmastectomy Lymphedema with Liposuction. Lymphatic Research and Biology 15, 87-98.

n=60

FU=1 year

Liposuction of arm lymphoedema in combination with controlled compression therapy improves patients QoL as measured with SF-36. The treatment seems to target and improve both the physical and mental health domains.

Included in both the Chang, 2021, and Tang, 2021 systematic reviews.

Hoffner M, Peterson P, Mansson S et al. (2018) Lymphedema Leads to Fat Deposition in Muscle and Decreased Muscle/Water Volume After Liposuction: A Magnetic Resonance Imaging Study. Lymphatic research and biology 16(2):174-81

n=13

FU=1 year

Using water-fat MRI-based fat quantification, the fat and water contents may be quantified and localized in the various compartments in lymphoedema.

Studies with more people and longer follow-up included. No new safety outcomes.

Kandamany N and Munnoch A (2014) Liposuction for lower limb lipodystrophy in congenital analbuminaemia: A case report. Journal of Plastic, and Reconstructive and Aesthetic Surgery 67: e54-e57.

n=1

FU= 12 months

We have demonstrated that liposuction along with controlled compression therapy is a safe and effective treatment for managing lipodystrophy secondary to congenital analbuminaemia. Although rare, clinicians need to be aware that liposuction is a successful treatment modality, which should be made available to this select group of people.

Studies with more people and longer follow-up included.

Karafa M, Karafova A, and Szuba A. (2020) A compression device versus compression stockings in long-term therapy of lower limb primary lymphoedema after liposuction. Journal of wound care 29(1):28-35

n=1

FU=3 months

This case study shows that in primary oedema one class of compression garment is not always sufficient, nor is the combination of two garments with varying degrees of compression. In some cases, the situation requires the use of non-elastic leg binders to help improve clinical outcomes after liposuction.

Studies with more people and longer follow-up included.

No new safety outcomes.

Karlsson T, Karlsson M, Ohlin K et al. (2021) Liposuction of Breast Cancer-Related Arm Lymphedema Reduces Fat and Muscle Hypertrophy. Lymphatic research and biology.

n=18

FU=1 year

Liposuction and combined compression therapy effectively remove the excess fat in people with nonpitting breast cancer-related lymphoedema, and a total reduction of excess arm volume is achievable. An after surgery decrease in excess muscle volume was also seen, probably due to the reduced weight of the arm after surgery.

Studies with more people and longer follow-up included. No new safety outcomes.

Klernas P, Johnsson A, Boyages J et al. (2018) Test of Responsiveness and Sensitivity of the Questionnaire "Lymphedema Quality of Life Inventory". Lymphatic research and biology 16(3):300-8

n=50

FU=1 month

The Lymphoedema Quality of life Inventory responsiveness and sensitivity indicated that the tool can be used to evaluate people undergoing conservative or surgical lymphoedema treatments.

Studies with more people and longer follow-up included. No new safety outcomes. Included in the Tang, 2021 systematic review.

Klernas P, Johansson A, Boyages J et al. (2020) Quality of Life Improvements in Patients with Lymphedema after Surgical or Nonsurgical Interventions with 1-Year Follow-Up. Lymphatic Research and Biology 18(4):340-50

n=57

FU=12 months

People were assigned to a rehabilitation programme or liposuction. Treatment with either the conservative rehabilitation programme in moderate lymphoedema or with liposuction combined with controlled compression therapy in severe lymphoedema improves health-related QoL.

QoL outcomes covered extensively in the Tang, 2021 systematic review. No safety outcomes.

Lamprou DAA, Voesten HG, Damstra RJ et al. (2017) Circumferential suction-assisted lipectomy in the treatment of primary and secondary end-stage lymphoedema of the leg. The British journal of surgery 104, 84-89.

n=88

FU=2 years

Circumferential suction-assisted liposuction is an effective method for treating both primary and secondary lymphoedema of the leg.

Included in the Tang, 2021 systematic review.

Lee M, Perry L, and Granzow J. (2016) Suction Assisted Protein Lipectomy (SAPL) Even for the Treatment of Chronic Fibrotic and Scarified Lower Extremity Lymphedema. Lymphology 49(1):36-41

n=1

FU=15 months

Following liposuction, a stable excess volume reduction of 86% was achieved along with a significant improvement in range of motion of the knee. Furthermore, the person had no further episodes of recurrent cellulitis. We have found SAPL to be effective even in people with complex, chronic lymphoedema presentations with, extensive pre-existing scarring from prior surgery.

Studies with more people and longer follow-up included.

No new safety outcomes.

Leppapuska IM, Suominen E, Viitanen T et al. (2019) Combined Surgical Treatment for Chronic Upper Extremity Lymphedema Patients: Simultaneous Lymph Node Transfer and Liposuction. Annals of plastic surgery 83(3):308-17

n=21

FU=48.9 months

Liposuction can safely be performed with lymph node transfer in 1 operation to achieve optimal results in people with chronic lymphoedema. The combined technique provides immediate volume reduction and further regenerative effects on the lymphatic circulation.

Studies with more people included. Combination of surgical techniques used. No new safety outcomes.

Maclellan RA, Chaudry G, Greene AK (2016) Combined Lymphedema and Capillary Malformation of the Lower Extremity. Plastic and Reconstructive Surgery - Global Open 4, e618

n=8

Lymphoedema and capillary malformation can occur together in the same extremity. Both conditions independently cause limb overgrowth primarily because of subcutaneous adipose deposition. Compression garments and suction-assisted lipectomy can improve the condition. Lymphoedema-capillary malformation should not be confused with other vascular malformation overgrowth diseases that have different morbidities and treatments.

Studies with more people included.

Masià J, Pons G, and Rodríguez-Bauzà E. (2016) Barcelona Lymphedema Algorithm for Surgical Treatment in Breast Cancer-Related Lymphedema. Journal of reconstructive microsurgery 32(5)

n=52

FU=16 months

Considerable improvements in results of limb circumferences and subjective symptoms were obtained after incorporating several modifications into the surgical strategy for lymphoedema treatment. A detailed before surgery assessment should be performed to determine whether reconstructive surgery or palliative surgery is indicated.

Outcome data are combined for different techniques.

McGee P and Munnoch DA. (2018) Treatment of gynaecological cancer related lower limb lymphoedema with liposuction. Gynecologic oncology 151(3):460-5

n=21

FU=Up to 5 years

Liposuction combined with compression garments demonstrated significant and sustainable reduction in limb volume in people with lower limb lymphoedema secondary to gynaecological malignancy.

Studies with more people and longer follow-up included.

Micha JP, Goldstein BH, and Nguyen DH. (2018) Successful management of persistent lower extremity lymphedema with suction-assisted lipectomy. Gynecologic Oncology Reports 23:13-5

n=1

FU=23 months

A cervical carcinoma person who developed persistent, lower extremity lymphoedema following surgery and adjuvant therapy. Despite numerous attempts at using conventional therapy (e.g., manual lymph drainage, physical therapy), the condition remained intractable. Eventually, the person had suction-assisted lipectomy to address her symptoms and has currently exhibited a beneficial, clinical outcome with 23 months of follow-up.

Studies with more people and longer follow-up included.

No new safety outcomes.

Nicoli F, Constantinides J, Ciudad P et al. (2015) Free lymph node flap transfer and laser-assisted liposuction: a combined technique for the treatment of moderate upper limb lymphedema. Lasers in medical science 30: 1377-1385.

n=10

FU=1 year

Skin tonicity was improved in all people. After surgery lymphoscintigraphy revealed reduced lymph stasis. No person suffered from donor site morbidity. Our results suggest that combining laser liposuction with lymph node flap transfer is a safe and reliable procedure, achieving a reduction of upper limb volume in treated people suffering from moderate upper extremity lymphoedema.

Studies with more people and longer follow-up included.

O'Brien BM, Khazanchi RK, Kumar PAV et al. (1989) Liposuction in the treatment of lymphoedema: A preliminary report. British Journal of Plastic Surgery 42: 530-533.

n=19

FU=10 months

The average reduction in this group was 20.5%. The average follow-up time was 9.5 months. From this preliminary report it can be concluded that liposuction, either as a primary procedure or as an adjunct, can be a useful procedure in the treatment of both primary and secondary lymphoedema.

Studies with more people and longer follow-up included.

Qi F, Gu J, Shi Y et al. (2009) Treatment of upper limb lymphedema with combination of liposuction, myocutaneous flap transfer, and lymph-fascia grafting: a preliminary study. Microsurgery 29: 29-34.

n=15

FU=6 months

Combining laser liposuction with lymph node flap transfer is a safe and reliable procedure, achieving a reduction of upper limb volume in treated people suffering from moderate upper extremity lymphoedema

Studies with more people and longer follow-up included.

Sando WC and Nahai F. (1989) Suction lipectomy in the management of limb lymphedema. Clinics in plastic surgery 16(2)

n=15

FU=3 to 30 months

The authors recommend suction lipectomy for mild temporary cases, specifically involving the upper extremity, and liposuction plus excisional debulking for more severe cases and for the lower extremity.

Studies with more people and longer follow-up included. No new safety outcomes.

Schaverien MV, Munro KJ, Baker PA et al. (2012) Liposuction for chronic lymphoedema of the upper limb: 5 years of experience. Journal of Plastic, and Reconstructive & Aesthetic Surgery: JPRAS 65: 935-942.

n=11

FU=26 months

After surgery measurements in an average of 26 months follow up showed that significant decrease of circumferences of the arms on all levels at surgery side were achieved. The onsets of erysipelas were also reduced. There was no chronic lymphoedema found in the donor leg after harvest of the lymph-fascia graft. The results suggest the strategy of liposuction, latissimus myocutaneous flap transfer, and lymph-fascia grafting may provide a useful method for treatment of the chronic upper extremity lymphoedema with severe axillary scar contracture.

Studies with more people and longer follow-up included.

Sen Y, Qian Y, Koelmeyer L et al. (2018) Breast Cancer-Related Lymphedema: Differentiating Fat from Fluid Using Magnetic Resonance Imaging Segmentation. Lymphatic research and biology 16(1):20-7

n=5

MRI imaging may be a useful tool to quantitatively measure fat tissue and fluid for people with advanced lymphoedema and may assist in the selection of eligible liposuction candidates at initial assessment and follow-up of people who proceed with surgery.

Studies with more people included.

Smile TD, Tendulkar R, Schwarz G et al. (2016) A Review of Treatment for Breast Cancer-Related Lymphedema: Paradigms for Clinical Practice. Am J Clinical Oncology

n=145 people, 7 studies

FU=6 months to 5 years

A small number of studies suggest that liposuction may be an efficacious and safe treatment for moderate to severe breast cancer-related lymphoedema. Further study is needed with respect to comparing BCRL treatment modalities.

No meta-analysis, no new safety data. More recent systematic reviews included.

Stephen C, Munnoch DA (2016) Lymphoedema of the upper limb: a rare complication of thyroid surgery? BMJ Case Reports 2016, 10.1136/bcr-2016-214376.

n=1

FU=1 year

A 40-year-old woman had an elective thyroidectomy for a non-toxic, multinodular goitre. In the early after surgery period, the person developed a significant unilateral swelling of the right upper limb, which was subsequently confirmed to be lymphoedema. This was eventually treated successfully using liposuction and compression garment therapies. This study reports a case due to its rarity and present a possible explanation for such an unexpected complication based on known anatomical variations of lymphatic drainage of the upper limb.

Studies with more people and longer follow-up included.

Taylor S and Brake M. (2012) Liposuction for the management of submental lymphedema in the head and neck cancer patient. Otolaryngology - Head & Neck Surgery 146:1028-30.

n=10

FU=1 year

No person had recurrence and there were no adverse events from the procedure at the end of 1-year follow-up.

Studies with more people and longer follow-up included. No new safety outcomes.

Trinh L, Peterson P, Brorson H et al. (2019) Assessment of Subfascial Muscle/Water and Fat Accumulation in Lymphedema Patients Using Magnetic Resonance Imaging. Lymphatic research and biology 17(3):340-6

n=13

FU=1 year

An excess fat volume was found in the intramuscular and intermuscular compartments in people with lymphoedema. The results suggest that the subfascial compartment needs to be studied separately as no correlation between intramuscular/intermuscular fat accumulation and other measured parameters was found.

Studies with more people and longer follow-up included. No new safety outcomes.

Tyker A, Franco J, Massa ST et al. (2019) Treatment for lymphedema following head and neck cancer therapy: A systematic review. American journal of otolaryngology 40(5):761-9

n=40

FU=6 months

This systematic review identified 3 studies that reported on use of liposuction for lymphoedema following therapy for head and neck cancer. Two of these studies reported significant self-perceived improvement in appearance and reduction of distress in people receiving liposuction in comparison to control. One study reported 100% patient satisfaction.

More recent systematic reviews included.

Wallmichrath J, Frick A, Weiss M et al. (2020) Microsurgical lymphatic vascular grafting and secondary liposuction: Results of combination treatment in secondary lymphedema. Lymphology 53(1):38-47

n=28

FU=37 months

The mean arm volumes were reduced significantly after the combination procedure. Microsurgical restoration of lymphatic outflow followed by SLS eliminates the need for additional treatment in more than two-thirds of people.

Combination of techniques used. No new safety outcomes.

Wojnikow S, Malm J, and Brorson H (2007) Use of a tourniquet with and without adrenaline reduces blood loss during liposuction for lymphoedema of the arm. Scandinavian Journal of Plastic & Reconstructive Surgery & Hand Surgery 41: 243-249

n=62

Using a tourniquet significantly reduced blood loss and the number of transfusions, which was further reduced by tumescence. In the historical reference group, the number of blood transfusions increased as the volume of aspirate increased, and further if no adrenaline was added.

Studies with longer follow-up included. No new safety outcomes.