Lymphedema is a chronic condition which is usually not life-threatening, but can cause quite a deleterious impact on the quality of life. The swelling limb also reduces functionality and increases the risk of comorbidities, anxiety, and depression [1, 2]. Insufficiency or obstruction of lymph backflow caused by lymphatic vascular malformations or secondary factors such as trauma, infection or mostly oncologic therapy leads to fluid accumulation of extremities. The condition of excess infiltration of interstitial fluid rich of protein then causes fibrosis and sclerosis of skin and adipose tissues, which finally ends up with the increase of fluid and tissue volume of limbs [3–6]. Breast cancer-related lymphedema (BCRL) is currently the leading cause of secondary lymphedema in the upper limbs. Lymphedema in BCRL usually happens at the ipsilateral upper limb. It is reported that the incidence of BCRL in breast cancer patients is 3%-65% depending on the factors such as surgical options, wound healing of the surgical area, radiation therapy, invasive manipulation of the ipsilateral limb, body mass index (BMI), delayed recovery of the affected limb function and repeated infection of the affected limb [7–12]. The survival rate of breast cancer has been continuously improved with the development of the diagnosis and treatment. As a consequence, more and more attentions are paid to the complications, for instance, BCRL. Besides, the risk of erysipelas occured on the lymphedema limb is especially higher than the normal occasions, which makes BCRL one of the complications that impairs the long-term life quality most seriously.
Lymphatic obstruction leads to the increase of lymphatic hydrostatic pressure, which causes progressively damage of lymphatic structures manifesting as dilated lymphatic vessel, impaired valve function, and distal lymph stasis. Long-term stasis of lymph rich of nutrient leads to tissue deposition of fat, fibrosis, repeated erysipelas, and thickening of extremities eventually. It is a vicious cycle that the increase of cutaneous and subcutaneous lesions produces more lymph which in turn increases lymph pressure [13, 14].
The treatment of BCRL includes non-surgical and surgical treatments. The International Society of Lymphology reported four clinical stages of lymphdema. The latent or subclinical stage, defined as stage 0, refers to the impaired lymph transport without extremity lymphedema. Stage I represents an early fluid accumulation presented as pitting edema that subsides with limb elevation. Stage II signifies pitting and fibrosis, which manifests that limb elevation alone rarely reduces tissue swelling. Stage III encompasses lymphostatic elephantiasis where pitting is absent and trophic skin changes, such as acanthosis, fat deposits, and warty overgrowths. The severity within each stage is based on the volume differences between two upper limbs: minimal (< 20% increase), moderate (20–40% increase), and severe (> 40% increase). Patients with BCRL at the early-stage of lymphedema mostly get relieved with conservative therapies . Those refractory to conservative treatments and more severe will receive surgical treatments. At present, the most common surgical methods for limb lymphedema are debulking procedures (including excisional surgery and liposuction, etc.) and lymphatic reconstructions (including lymphovenous Anastomosis (LVAs), vascularized lymph node transfer/transplantation (VLNT), lymphatic grafting, etc.) [16, 17]. When the excess volume is dominated by dermato-lipo-fibrosclerosis tissue instead of accumulated lymph, conservative treatment is limited. Liposuction enables the removal of the adipose tissue besides accumulated lymph, which microsurgical reconstructions cannot achieve. Compared with the traditional excisional surgery, liposuction is safer and lesser invasive, and can be perform twice [18, 19]. While liposuction can effectively reduce limb volume and is aimed at the process from hyperplasia to lymph stasis in the pathophysiological cycle of lymphedema, the lymph flow is still obstructed without effective lymphatic flow pathways. As a result, lymphedema recurs and aggravates gradually with the accumulation of lymph fluid. When the pressure in lymphatic vessel is higher than in vein, lymph fluid smoothly flows from lymphatic vessels to the vein. In this aspect, lymphatic reconstructions can effectively improve the lymphatic flow and reduce the lymphatic stasis of the affected limb.
For the first time, the combination of liposuction and LVAs in the treatment of BCRL was carried out widely in department of lymphatic surgery, Beijing Shijitan Hospital, and the outcome was quite satisfactory in this study.