Lymphedema is a chronic condition that 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 attention is paid to the complications, for instance, BCRL. In addition, the risk of erysipelas occurring on the lymphedema limb is especially higher than 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 progressive 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 nonsurgical and surgical treatments. The International Society of Lymphology reported four clinical stages of lymphedema. 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 (15). Those refractory to conservative treatments and are more severe will receive surgical treatments. At present, the most common surgical methods for limb lymphedema are debulking procedures (including excisional surgery and liposuction) and lymphatic reconstructions (including lymphovenous anastomosis (LVAs), vascularized lymph node transfer/transplantation (VLNT), and lymphatic grafting) (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 the lymphatic vessel is higher than in the 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 the Department of Lymphatic Surgery, Beijing Shijitan Hospital, and the outcome was quite satisfactory in this study.

This study was approved by the Medical Ethics Committee of Beijing Shijitan Hospital [sjtkyll-lx-2020(50)].

Patients with unilateral upper limb BCRL admitted to the Department of Lymphatic Surgery, Beijing Shijitan Hospital, from November 2015 to February 2018 were reviewed in this study. Patients’ demographics, breast cancer surgical approach, chemical and radiation therapy, operative notes, circumferences of arms, and episodes of erysipelas were prospectively recorded.

During the follow-ups, the patients’ conditions of both arms, including frequency of erysipelas episodes and dependence on compression garments, were recorded.

Our interest in solving lymphedema started 30 years ago. In the development of lymphedema, thickening and sclerosis of the skin and adipose tissue contains a large amount of fibrotic tissue, which makes the subcutaneous tissue denser than usual (21). The traditional liposuction with negative atmosphere could hardly remove the dense fibrotic tissue. Therefore, we used a PAPLM that can effectively destroy fibrotic and adipose tissue with cannula vibration and shorten the operation time. Additionally, we made the cannulas parallel to the longitudinal axis of the upper limbs during the procedure to reduce damage to lymphatic and blood vessels and prepare for the next LVAs according to Frick’s theory (22).

Lymphatic channels were anastomosed end-to-end or end-to-side to subdermal venules above deep fascia at multiple points traditionally, which was on the traditional anatomic basis that there are no wide connections between the superficial and deep lymphatic vessels, and hypertrophic and proliferative tissue changes in lymphedema occur mainly in the tissue above the deep fascia (23). However, recently, single or multiple deep collecting lymph vessels have been found along neurovascular bundles in the forearm and upper arm, and perforating lymph vessels have been found, which link the superficial and deep lymph vessels (24). All the 158 LVAs procedures were performed using deep lymphatics and brachial vein tributaries beneath deep fascia, which were proved to be effective in improving lymph flow. At the same time, LVAs using deeper lymphatic and blood vessels instead of superficial ones reduced the chance of anastomotic closure from infection or trauma, and LVA procedure beneath the deep fascia would also not be affected by liposuction performed months before. After LVA procedures, lymph fluid flow into veins and lymphatic stasis was ameliorated gradually. Then, the pressure of the lymphatic vessel declined little by little and finally blood reflux occurred at the anastomosis. As a result, thrombus formed and blocked the anastomosis (25, 26). Considering this problem, we improved the LVA procedure by selecting the vein with better valve function to avoid or reduce blood reflux, and reduce the venous pressure at the anastomosis. In terms of the lymphatic vessel, we chose those with a thinner wall with less fibrotic and more obvious contractive function to ensure the flow of lymph fluid. With all these efforts, long-term results after our combined treatments were gratifying.

Based on the above data, we concluded that all the 158 patients’ swelling limbs got relieved after the combined treatments and the condition of the treated arms remained stable from after the treatments to the follow-ups. Therefore, liposuction followed by LVAs for BCRL not only reduced the volume of affected arms and the amount of lymph fluid production but also rebuilt the lymph flow. In this way, the vicious cycle of lymph stasis, fat hyperplasia, and more lymph stasis is broke. After all these systematic surgical treatments and compression therapy, there were patients who already got rid of compression garments. How many of them would be independent of compression therapy at last and return to normal life completely remained to be investigated further.

Our combined treatments of liposuction followed by lymphovenous anastomosis for breast cancer-related lymphedema received satisfactory results without worrying complications. The volume of affected arms reduced significantly and kept reducing from 7 days after the surgery to at least 22 months later during the follow-ups. After the systematic treatments, some patients got rid of compression garments and returned to normal life again, and there were no recurrences during the follow-ups.