From the Division of Plastic and Reconstructive Surgery, Stanford University, Palo Alto, CA.
Ann Plast Surg. 2021 May 1;86(5S Suppl 3):S384-S389. doi: 10.1097/SAP.0000000000002695.
Outcomes of surgical lymphedema treatment are currently suboptimal. Physiologic procedures including lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) reestablish lymphatic flow but cannot correct fibroadipose deposition, whereas liposuction alone cannot prevent disease progression. We propose a treatment algorithm combining liposuction with LVA or VLNT that can achieve normal limb volumes and prevent disease progression in stage II-III lymphedema.
We performed a retrospective chart review of patients undergoing liposuction and physiologic lymphedema operations at our institution between January 2016 and June 2019. Patients were assigned to treatment groups according to their clinical presentation: physiologic first, followed by no further treatment (physiologic only) or liposuction (physiologic then liposuction); liposuction then physiologic; or simultaneous. Preoperative patient characteristics and sequence of operations were recorded. Compression garment usage was self-reported. Limb volumes were approximated as a truncated cone.
Twenty-one patients met the inclusion criteria. The liposuction then physiologic group had significantly higher stage and excess limb volume at baseline, whereas the physiologic first groups had lower excess volume. While the physiologic only group had predominantly stage I disease, the patients who later required liposuction (physiologic then liposuction group) all had stage II disease. All groups achieved 82% to 106% mean excess volume reduction, and volume reduction was maintained for up to 2.4 years. Compression garment class was not reduced, but mean postoperative compression duration decreased from 12.5 to 7.5 h/d (P = 0.003). Ten of 11 patients with history of cellulitis had no further recurrence.
Lymphedema represents a continuum of fluid and fibroadipose disease. Accurate staging and timely treatment with physiologic procedures and liposuction can normalize limb volume. We propose a treatment algorithm to optimize outcomes. Patients with predominantly nonpitting presentation benefit from liposuction to maximize removal of fibroadipose tissue and optimize postoperative compression, followed by LVA or VLNT to improve lymphatic drainage. Patients with primarily pitting edema are best treated with physiologic procedures initially, reserving selective liposuction as a second stage. Patients with mixed presentation are best served by single-stage combination procedures.
目前，外科淋巴水肿治疗的效果并不理想。生理程序，包括淋巴静脉吻合术（LVA）和带血管淋巴结转移术（VLNT），可以重建淋巴液流动，但不能纠正纤维脂肪沉积，而单纯抽脂则不能阻止疾病进展。我们提出了一种结合抽脂术和 LVA 或 VLNT 的治疗方案，可以实现 II-III 期淋巴水肿肢体的正常体积并预防疾病进展。
我们对 2016 年 1 月至 2019 年 6 月在我院行抽脂术和生理淋巴水肿手术的患者进行了回顾性图表审查。根据患者的临床表现将其分配到治疗组：生理程序先行，然后不再进行治疗（仅生理程序）或抽脂术（生理程序后行抽脂术）；先抽脂术，然后行生理程序；或同时进行。记录术前患者特征和手术顺序。压缩服装的使用情况为自我报告。肢体体积近似为截头圆锥体。
21 例患者符合纳入标准。抽脂术先行组的基线期分期和过量肢体体积明显更高，而生理程序先行组的过量体积较低。生理程序仅先行组主要为 I 期疾病，而后来需要行抽脂术的患者（生理程序后行抽脂术组）均为 II 期疾病。所有组的平均过量体积减少了 82%至 106%，并且体积减少持续了长达 2.4 年。压缩服装的类别没有降低，但术后平均压缩时间从 12.5 小时/天减少到 7.5 小时/天（P = 0.003）。11 例有蜂窝织炎病史的患者中，有 10 例无进一步复发。
淋巴水肿是一种液体和纤维脂肪疾病的连续体。准确分期和及时采用生理程序和抽脂术治疗可以使肢体体积正常化。我们提出了一种治疗方案，以优化治疗效果。主要表现为非凹陷性的患者受益于抽脂术，以最大限度地去除纤维脂肪组织，并优化术后压缩，然后行 LVA 或 VLNT 以改善淋巴引流。主要表现为凹陷性水肿的患者最好首先采用生理程序治疗，保留选择性抽脂术作为第二阶段。混合表现的患者最好采用单阶段联合手术治疗。
