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    Overview

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    Safety summary

    Blood transfusion

    The before-and-after study of 105 people reported that 20 people needed after surgery blood transfusions (Hoffner, 2018). The need for blood transfusions differed based on the technique used. The technique used depended on when the people were operated on – the first people (from 1993 to 1997) had the 'dry' technique without tourniquet, the authors then progressed to using the dry technique with a tourniquet, and then finally to the tumescent technique with a tourniquet.

    • The first 27 people had the 'dry' liposuction technique without a tourniquet. Using this technique, there were 15 people that needed blood transfusions (56%).

    • The next 35 people had the 'dry' liposuction technique with a tourniquet. Using this technique, there were 5 people that needed blood transfusions (14%).

    • The final 43 people had the tumescent liposuction technique with a tourniquet. Using this technique, there were 0 people that needed blood transfusions.

    The before-and-after study of 69 people reported that 2 people needed after surgery blood transfusions (2.9%) (Stewart, 2018).

    The before-and-after study of 39 people reported that 1 person needed a blood transfusion (Granoff, 2020).

    The before-and-after study of 15 people reported that 2 people needed blood transfusions (13.3%). People had localised skin loss that healed secondarily (Greene, 2016).

    Infections

    The following infections are reported in addition to those described in the Cellulitis/erysipelas reduction section of the Efficacy summary.

    The systematic review and meta-analysis noted that 1 case series of 8 people reported 1 case of cellulitis (Chang, 2021).

    The before-and-after study of 130 people that, of 54 people who were not diagnosed with erysipelas before surgery, 6 had erysipelas in the follow-up period (11.1%) (Lee, 2016).

    The before-and-after study of 15 people reported that 1 person had an infection that needed operative debridement (Greene, 2016).

    Skin necrosis

    The before-and-after study of 69 people reported 3 cases of skin necrosis (4.3%), 1 of which needed excision and direct closure (Stewart, 2018).

    Other adverse events

    Ulcers

    The systematic review and meta-analysis noted that 1 case series of 41 people reported 1 case of decubitus ulcer (Chang, 2021).

    The before-and-after study of 39 people reported 3 skin ulcers secondary to garment use (7.7%). All resolved with modification of their garments (Granoff, 2020).

    Hyperpigmentation

    The systematic review and meta-analysis noted that 1 case series of 8 people reported 2 cases of hyperpigmentation (Chang, 2021).

    Peroneal nerve palsies

    The before-and-after study of 69 people reported 2 cases of temporary peroneal nerve palsies due to tight compression garments (2.9%). Both resolved at 6 months after surgery (Stewart, 2018).

    Anecdotal and theoretical adverse events

    In addition to safety outcomes reported in the literature, professional experts are asked about anecdotal adverse events (events which they have heard about) and about theoretical adverse events (events which they think might possibly occur, even if they have never happened). For this procedure, professional experts listed the following anecdotal adverse events: thromboembolism, recurrent falls (from overcompensating for their no-longer bulky limb), foot drop.

    Coroner-Regulation 28 letter findings summary

    Number of procedures required

    Summary: 1 before-and-after study reported that for people with bilateral lower leg oedema, liposuction was done on each leg separately, with a minimum of 3 months between operations (Stewart, 2018). All other studies that reported details of the technique reported a single procedure only.

    Volume of fluid infiltrated during the procedure

    Note: the typical procedure of liposuction for lymphoedema involves application of a tourniquet on the proximal limb, followed by liposuction of the limb distal to the tourniquet. The tourniquet is then removed, and the proximal limb, unable to be controlled by tourniquet, is infused with tumescent solution, and then aspirated. Calculating fluid balance from the figures below may be inaccurate because only some of the limb is infiltrated with fluid, but fluid from all of the limb is aspirated.

    Summary: 4 before-and-after studies reported details about the volume of fluid infiltrated. Three studies reported infiltrating approximately 1,000 ml; 1 study reported infiltrating 1,000 ml into the arm, and 2,000 ml into the leg.

    The before-and-after study of 105 people (all had arm lymphoedema) reported that, in the proximal limb unable to be controlled by tourniquet, 1,000 ml of saline mixed with 1 mg adrenaline and 40 ml lidocaine 2% was infiltrated (Hoffner, 2018)

    The before-and-after study of 69 people (all had leg lymphoedema) reported that, in the proximal limb unable to be controlled by tourniquet, 20 ml of 0.5% levobupivicaine (5 mg/ml) and 1 mg of 1:1000 adrenaline in 1,000 ml of Hartmann's solution was infiltrated (Stewart, 2018).

    The before-and-after study of 39 people reported that, in the proximal limb unable to be controlled by tourniquet, was tumesced with 1,000 ml (arm) or 2,000 ml (leg) of tumescent solution (Granoff, 2020).

    The before-and-after study of 15 people reported that 1,000 ml of tumescent solution (1 mg 1:1000 epinephrine, 50 ml 1% lidocaine in 1 ml of normal saline) was infused into the subcutaneous space, not to exceed 35 mg/kg of lidocaine (Greene, 2016).

    Volume of fluid aspirated during the procedure

    Note: the typical procedure of liposuction for lymphoedema involves application of a tourniquet on the proximal limb, followed by liposuction of the limb distal to the tourniquet. The tourniquet is then removed, and the proximal limb, unable to be controlled by tourniquet, is infused with tumescent solution, and then aspirated. Calculating fluid balance from the figures below may be inaccurate because only some of the limb is infiltrated with fluid, but fluid from all of the limb is aspirated.

    Summary: 4 before-and-after studies reported details about the volume of aspirate during liposuction. For people with arm lymphoedema, the mean volume of aspirate ranged from 855 ml to 1,831 ml in 3 studies. For people with leg lymphoedema, the mean volume of aspirate ranged from 2,550 ml to 4,550 ml. Of studies reporting ranges, the lowest volume of aspirate removed was 575 ml and the highest volume was 12,150 ml.

    The before-and-after study of 105 people (all had arm lymphoedema) reported that the total aspirate mean volume was 1,831 ml (SD 599 ml; range 650 to 3,780 ml) for all people (Hoffner, 2018).

    The before-and-after study of 69 people (all had leg lymphoedema) reported that the mean volume of aspirate was 4,550 ml (range 575 to 12,150 ml) (Stewart, 2018).

    The before-and-after study of 39 people reported that for liposuction of the arm, the mean volume of aspirate removed was 855 ml (SD 398 ml). For liposuction of the leg, the mean volume of aspirate removed was 2,550 ml (SD 907 ml). (Granoff, 2020).

    The before-and-after study of 15 people reported that the mean lipoaspirate volume was 1,612 ml (range, 1,200 to 2,800 ml) for the arm and 2,902 ml (range, 2,000 to 4,800 ml) for the leg (Greene, 2016).

    Post-procedure patient recovery plan

    Summary: 5 before-and-after studies reported details of the post-procedure patient recovery plan. This typically involve antibiotic prophylaxis 7 to 11 days. Thrombosis prophylaxis was also given by 1 study. Compression garments were prescribed by 4 studies.

    In addition, 2 of the guidelines/consensus statements described in Existing assessments of this procedure discuss the importance of long-term, continuous compression to maintain reductions in limb excess volume (McLaughlin, 2017; Executive Committee of the International Society of Lymphology, 2020).

    The before-and-after study of 105 people reported that antibiotics were given intravenously for 24 hours and then orally for approximately 10 days after surgery. Compression garments were worn 24 hours per day after surgery (Hoffner, 2018).

    The before-and-after study of 130 people reported that people had isoxazole penicillin (clindamycin if allergic to penicillin) before and after surgery over 7 days (Lee, 2016).

    The before-and-after study of 69 people reported that people were on bed rest and had intravenous antibiotics for the first 48 hours, then oral antibiotics for 7 days. Thrombosis prophylaxis was given daily. People wore compression garments after surgery and were remeasured after 2 weeks (Stewart, 2018).

    The before-and-after study of 39 people reported that people were admitted to the hospital for after surgery monitoring. During this time, people worked closely with physical therapy regarding garment and skin care. People with arm lymphoedema were educated on the management of hand swelling. Compression garments were worn immediately after liposuction (Granoff, 2020).

    The before-and-after study of 15 people reported that operative dressings were worn for 2 to 3 days after surgery. Compression bandages were changed daily for 6 weeks when a new bandage was fitted (Greene, 2016).