Limited-Incision Surgical Debulking of Lymphatic Malformations Using Ultrasound-Assisted Liposuction

Abstract

Sir:FigureLymphatic malformations located on the extremities can cause severe functional impairment and disfigurement. Large lymphatic malformations that fail conservative management have traditionally been treated with surgical debulking through large incisions that are prone to complicated wound-healing and extensive scarring. We report our experience with a limited-incision surgical option using ultrasound-assisted liposuction with pull-through technique. This study was approved by the Committee on Clinical Investigations at Children's Hospital Los Angeles on September 20, 2010, as study CCI-10-00161. Ultrasound-assisted liposuction has been effective in debulking involuted hemangiomas by liquefying low-density tissues such as fat while sparing neurovascular structures and connective tissue.1 Ultrasound-assisted liposuction demonstrates decreased blood loss and fluid shift, improved contour, and decreased surgeon fatigue compared with standard liposuction.2,3 Ultrasound-assisted liposuction also provides advantage in areas of significant fibrous tissue such as the male breast and back.3 Eight patients with large microcystic lymphatic malformations of the lower extremity underwent ultrasound-assisted liposuction with pull-through technique. Under general anesthesia, tumescent solution was injected into the lymphatic malformation and surrounding subcutaneous tissues. Liposuction ports were triangulated around the lymphatic malformation. Using a LySonix 3000 (Byron Medical, Inc., Tucson, Ariz.), the ultrasound-assisted liposuction probe was introduced subcutaneously through each port and passed through multiple planes. Standard liposuction was performed using 3.7- to 10-mm cannulae until desired debulking was achieved. To create a smoother contour, the ultrasound-assisted liposuction probe was reintroduced for feathering the transition zone between lymphatic malformation and normal tissue. Remaining fibrous septa and connective tissue were stripped and extracted through the ports using an alligator clamp (Fig. 1). The incisions were closed loosely with a single deep dermal suture to promote drainage. Postoperatively, the limb was placed in a pressure dressing for 4 weeks.Fig. 1: Six-year-old patient with a microcystic lymphatic malformation of the right lower extremity shown preoperatively (left) and 18 months postoperatively (right) following limited-incision debulking using ultrasound-assisted liposuction with pull-through technique.All eight patients demonstrated stable improvement in limb girth and contour, with postoperative follow-up ranging from 3 months to 2 years (Fig. 2). There were no postoperative infections, seromas, or other complications. Mild residual contour irregularities were noted in all patients, with one patient experiencing undercorrection requiring traditional debulking.Fig. 2: Four-year-old boy with recurrent symptomatic microcystic lymphatic malformation of the right leg and foot shown following excisional debulking with subsequent recurrence (left) and 12 months postoperatively after undergoing limited-incision debulking of the leg using ultrasound-assisted liposuction with the pull-through technique (right).Both medical and surgical approaches to treatment of lymphatic malformations have been successful in achieving symptomatic relief. Choice of treatment is guided by size, anatomical location, the nature of lymphatic malformation (i.e., microcystic versus macrocystic), and surgeon experience. Lasers, irradiation, and interferon/octreotide medical therapy can be useful; however, each is associated with considerable side effects.4,5 In addition, sclerotherapy is useful for macrocystic variants of lymphatic malformations. Likewise, surgical debulking is helpful for the treatment of large lymphatic malformations but is often associated with extensive scarring and other complications including perioperative infection and poor or delayed wound healing. We demonstrate successful treatment of lower extremity lymphatic malformations using ultrasound-assisted liposuction with pull-through technique resulting in smaller scars, reduced complications, and improved contour. Our technique is inherently limited as to the extent of debulking compared with an open excisional approach; however, in our experience, the retained tissue was stable over time, resulting in minor contour irregularities. Furthermore, conversion to an open surgical approach can always be undertaken at a later date should limited-incision debulking prove inadequate or if the lymphatic malformation recurs. Further studies will examine use of this technique in the upper extremity and trunk. Cameron S. Francis, M.D. Division of Plastic and Reconstructive Surgery, University of Southern California, Keck School of Medicine Elizabeth A. Rommer, B.S. Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles Justin T. Kane, M.D. Division of Plastic and Reconstructive Surgery, University of Southern California, Keck School of Medicine, Los Angeles, Calif. Kathryn Iwata, B.S. New York University School of Medicine, New York, N.Y. Andre Panossian, M.D. Division of Plastic and Maxillofacial Surgery, Children's Hospital Los Angeles, Los Angeles, Calif. DISCLOSURE The authors have no financial interest in any of the products or devices mentioned in this communication.