Swelling of the limbs in patients with longstanding lymphoedema is not always due to increased fluid build-up. Long-standing lymphatic fluid stasis in the tissues can result in the deposition of fat. There are many postulated theories for why this occurs.

In these patients, surgical techniques which address the re-routing of lymphatic fluid, are not appropriate. This fact must be appreciated. These patients need to be treated appropriately with an aggressive form of liposuction to address the lymphoedema.

Clinically, this may be suspected in patients who have failed to progress with conservative techniques such as complete decongestion therapy and controlled compression therapy and who have non-pitting swelling of the limbs.

Radiologically investigating using Magnetic Resonance Scanning (MRI) is essential to verify this. Also, in these patients a lymphoscintigraphy would be useful as a baseline investigation in mapping the lymphatic draining and studying the lymphatic function.

This operation was pioneered by Professor Hakan Brorson in Sweden. It is carried out under general anaesthetic with an in-patient hospital stay of 4-5 days. The operation lasts for 3-4 hours depending on the excess volume of the limb.

Preoperatively, the patients are seen by the lymphoedema physiotherapist and assessed again and measured for a post-operative compression garment. The procedure is done with a limb tourniquet and is carried out with a power-assisted liposuction machine through multiple tiny stabs wounds on the skin.The procedure is carried out in a controlled manner on segments of the limb from distally to proximally. Frequent measurements are taken during the operation to ensure a satisfactory result. Once the liposuction is completed to a satisfactory result, the compression garment is fitted on the patient by the lymphoedema physiotherapist whilst still under the anaesthetic.

The garment is removed on day 2 post-op and a new one fitted. The patient is discharged after day 4 post-op.

All the measurements pre- and post-op are done in a strict and standardised manner and recorded for audit purposes.

This technique is the most successful in treating lymphoedema with the potential to result in near-complete reduction of the excess volume. However, patients who have had this procedure would need to wear the compression garments for life.