Liposuction for Head and Neck Lymphedema – Does it Work? For Which Patients?

A tantalizing new study by a Canadian group recently caught my eye. The authors’ conclusion: “Submental liposuction is an effective and safe procedure to improve the quality of life for head and neck cancer patients suffering from post-treatment lymphedema.” So should we be recommending liposuction for head and neck lymphedema?

Background

Head and neck lymphedema is a chronic and progressive swelling condition caused by damage to lymph nodes and vessels in the head and neck, a very common side effect of head and neck cancer treatment. Head and neck lymphedema is predominantly managed using combined decongestive therapy (CDT), the recommended conservative treatment for lymphedema. This treatment combines massage techniques, compression, and education to reduce swelling and prevent the additional build-up of fluid. Despite the safety and effectiveness of CDT, it suffers from a few key drawbacks: it doesn’t cure the underlying lymphatic damage, it has limited effectiveness on very advanced cases of lymphedema, and patients typically need to learn and adhere to life-long self-management practices. Consequently, there is much interest in devising new methods of treatment, including surgical options.

Broadly speaking, microsurgical treatments for lymphedema such as lymph node transplantation or lymphovenous bypass (connecting lymph vessels to veins), have enjoyed marginal success. At best, these approaches have been shown to reduce (but not eliminate) symptoms for some patients. They are also inherently difficult to perform, and not widely available. Arguably the most dramatic surgical results have been achieved by a small number of teams who have successfully used liposuction to treat cases of advanced lymphedema of the arms and legs. You can read our detailed discussion of this procedure here: “Patient Guide to Liposuction for Lymphedema”. This appears to be a very promising approach to reduce some of the symptoms of advanced lymphedema in some patients, but once again, it is not a cure.

Considering the success of liposuction for arm and leg lymphedema, you might be tempted to take this latest study’s conclusion at face value. But beneath the surface there are problems with this new study, and the authors’ conclusions.

This new study unfortunately tells us little about the effectiveness of liposuction for head and neck lymphedema

In total I have found three clinical papers examining liposuction for head and neck lymphedema, and all by the same group. In this most recent study the authors compared the satisfaction of 10 head and neck cancer patients who underwent submental liposuction (see Figure 1 for an example of where the liposuction was performed) to 10 who did not. They conclude their study by stating, without caveat, that they “recommend this procedure for head and neck patients suffering emotionally or physically from post-treatment neck lymphedema”. Despite such a strong endorsement, their study is unfortunately unable to answer the question of whether or not liposuction can – or should – be broadly applied as a treatment for head and neck lymphedema patients.

Figure 1: Authors’ example of surgical markings outlining where submental liposuction for head and neck lymphedema was performed. Figure reproduced from reference 1.

But first, a caveat: although I will spend much of the remainder of this article questioning the authors’ approach and conclusions, I commended them for their work on this special population, and I hope it spurs additional clinical interest and research. It’s important to also keep in mind that despite best intentions, setting up and executing a ‘perfect’ clinical study is in most cases not possible. Clinical studies are expensive, time consuming and difficult, and so researchers need to make compromises. That said, when clinical study results are used to recommend real-world clinical interventions, we have a responsibility to be skeptical and fastidious in our analysis.

With that out of the way, here’s why you should be skeptical of this study’s conclusions:

1. It’s not clear that the patients in this study had lymphedema, or if they did, what stage of lymphedema it was. The primary criteria for a patient to be entered into this study was that they had been treated for head and neck cancer and complained about swelling in the neck region below their chin. No diagnosis of lymphedema or determination of the stage of the disease was performed. The authors did mention in passing that it appeared that all patients had Stage 3 lymphedema, but it’s not clear by what criteria they determined this (Firmness? Pitting? Reversibility of swelling? Skin surface changes? You can find staging criteria here). It certainly isn’t clear from the few patient photos shown in their paper that this was the case. And since staging wasn’t part of the criteria used to select patients to be included in the study, should we believe that, by chance, everyone who wished to participate in the study had advanced stage 3 lymphedema? I think we can conclude that it’s at least feasible that some of the participants might not have had advanced stage 3 lymphedema, or perhaps further still, that some may not have had lymphedema at all. Why is staging relevant? Because in the early stages of head and neck lymphedema the swelling is composed of lymph fluid, which can be effectively treated without liposuction (see #2 below). I’m sure if we asked the authors they would assure us that they removed lots of fat and not just fluid. But how do we know that the fat wasn’t present before the surgery (neck fat is hardly rare), and how do we know that it wasn’t simply lymph fluid build-up that was responsible for patient dissatisfaction with their appearance?
2. It’s not clear that the patients couldn’t have simply been treated conservatively. Liposuction has been used successfully to remove fat deposits that appear in advanced cases of arm and leg lymphedema, but it is unnecessary and unwarranted in less advanced cases that are comprised of fluid alone. It appears from this paper that none of the patients had previously received conservative therapy (combined decongestive therapy or CDT), and the authors remarked that there was no local lymphedema therapist available with experience treating head and neck lymphedema. So perhaps CDT could have been equally effective. Why would I argue that it is unwarranted to use liposuction to treat lymphedema that might otherwise be treated conservatively with CDT? Patient safety for one (see #4 below), and higher risk of lymphedema recurrence (see #3).
3. It’s not clear that liposuction for head and neck lymphedema will have any lasting effect – and it wouldn’t be expected to, without ongoing conservative management practices in place for the patient. The follow-up period for this study was only 6 months (although the authors planned to continue following the patients longer), which is not long enough to conclude that the liposuction permanently resolved the ‘lymphedema’. More importantly, there is no reason to believe that liposuction could permanently resolve lymphedema; there is no mechanism by which liposuction could repair the underlying lymphatic damage caused by lymph node removal or irradiation. Therefore, if the patients did in fact have lymphedema, we should expect the swelling to return without ongoing conservative lymphedema management. This is why ongoing conservative management is a core component of the more established liposuction treatment protocols for advanced arm and leg lymphedema. Reading this study, it is clear that conservative management was not recommended before or after treatment (except, perhaps for a facelift dressing worn for one week post surgery that would provide some compression). So why do the authors believe that liposuction will cure these patients’ lymphedema? Curiously, the authors didn’t attempt to address this elephant in their paper. Perhaps the authors are imagining something novel? Perhaps they are hypothesizing that swelling and fibrosis caused by cancer treatment was just enough in these patients to temporarily overwhelm their lymphatic systems, creating a ‘precursor lymphedema’ that if caught early enough, could be ‘cured’ with liposuction removal of local fat, fluid and fibrosis, thereby restoring sufficient lymphatic flow permanently? There may be some precedence for this. For example, in lymphedema induced by morbid obesity it is possible that patients who lose weight fast enough (by any means) may be able to permanently reverse their lymphedema symptoms preventing permanent damage (see our article). Similarly, could liposuction be alleviating a ‘precursor’ lymphedematous state in head and neck patients? Perhaps. But then again, if this is indeed the case, combined decongestive therapy might be equally effective at breaking up the scar tissue, removing the fluid, and preventing lifelong lymphedema from becoming established.
4. It’s not clear that the benefits of liposuction for head and neck lymphedema outweigh the risks for all patients. Surgery, needles, and injury should generally be avoided in lymphedematous areas of the body, because these areas are prone to infection and inflammation, which will worsen symptoms. Importantly, such trauma might also initiate the onset of lymphedema in individuals who are predisposed to developing it (such as head and neck cancer patients). In addition to potentially triggering or worsening lymphedema, the authors themselves note that complications from liposuction of the neck can include: “hematoma, scarring, cellulitis, necrotizing fasciitis, skin redundancy, platysmal banding and possible marginal mandibular nerve injury”. In fact, compression and manual lymphatic drainage massage is often also used after cosmetic liposuction as part of the recovery process – to help reduce the swelling and fibrosis liposuction causes. Therefore, I think it’s fairly easy to conclude that liposuction for head and neck lymphedema should only be recommended for advanced cases that are refractory to conservative treatment (among other criteria listed below) – as is the case for liposuction of the arm and leg. Let me be clear that I’m not suggesting that the authors of this study jeopardized the safety of their patients in any way. These researchers followed their professional ethics, and had their study approved by an independent ethics board. In support of this, they report in the study that conservative treatment was not available to their patients. Incidentally, they may also be fantastic surgeons whose patients seldom experience any complications. Where I find issue is only with their conclusions. They recommend this treatment as safe and effective without stating the vital caveat that it should only be recommended if conservative treatment is ineffective.

Questions, questions, questions.

I think it’s elucidating that in the introduction of this paper the authors comment that: “The decision to undertake such a trial was based on feedback from other surgeons who felt that the disease process may simply improve with time despite our belief that this is not the case.” It makes me wonder if these unnamed surgeons were unconvinced that the swelling experienced by these patients was due primarily to fat (since fat wouldn’t go away on its own), and perhaps instead suspected that it was due to fluid accumulation. If so, swelling could go away on its own if it wasn’t due to lymphedema, or with combined decongestive therapy if it was. But I’m just speculating.

There is a significant body of clinical research that supports the use of liposuction for advanced cases of arm or leg lymphedema, but it doesn’t appear to have informed the clinical approach used in this study. This larger body of work presents a convincing argument that liposuction is not a cure for lymphedema (how could it be?), and not surprisingly, that the swelling will return without appropriate post-treatment conservative lymphedema management practices. Consequently, since the patients in this study are apparently not following conservative lymphedema management practices post-liposuction, the swelling will return if it was lymphedema, and won’t return if it wasn’t.

Of course, we can’t know with certainty what’s going on in this study. Perhaps these head and neck cancer patients had a temporary lymphatic insufficiency resulting from lymphatic damage and scar tissue, that this promoted the accumulation of lymph and a relatively quick conversion to fat tissue, and that through liposuction this fat and scar tissue was removed, thus improving lymphatic drainage and curing what could have otherwise have progressed to become permanent lymphatic insufficiency (aka lymphedema). But then again, perhaps combined decongestive therapy could have been equally effective at resolving the swelling and preventing its progression to lymphedema. Or even more likely, that identifying swelling early on and removing it with combined decongestive therapy would have prevented the whole scar tissue, lymph and fat build up in the first place.

So where does this research leave us?

Contrary to the authors’ conclusions, the data presented by this group does not in my mind support the general use of liposuction for head and neck lymphedema, and the larger body of liposuction research in arm and leg lymphedema would support my position. However, liposuction studies of arm and leg lymphedema DO offer hope for some patients with head and neck lymphedema:

Liposuction for head and neck lymphedema might still be beneficial and warranted for SOME patients

The objective for lymphedema liposuction is to reduce excessive fat (not lymph) that accumulates in advanced cases of lymphedema, and which is impervious to conservative therapy. Liposuction can be profoundly beneficial for arm and leg lymphedema patients, and it’s reasonable to assume that this may be the case for head and neck lymphedema patients as well.

When might liposuction for head and neck lymphedema be warranted?

1. When the swelling is due to lymphedema,
2. AND it causes a considerable functional or aesthetic problem for the patient,
3. AND combined decongestive therapy is unable to reduce the swelling despite maximal effort,
4. AND the swelling is known to be composed primarily of fat and fibrosis (not lymph fluid),
5. AND an experienced surgical team performs the appropriate liposuction procedure,
6. AND compression garments and best management practices are employed consistently post-surgery to prevent recurrence,
7. AND the patient has no general surgical contraindications.

When might liposuction for head and neck lymphedema not be warranted?

1. As a general treatment for head and neck lymphedema.
2. When the patient lacks a diagnosis for their swelling.
3. When the patient’s swelling isn’t primarily composed of fat caused by advanced (Stage 3) lymphedema.
4. When the patient’s swelling can be removed by conservative treatment.
5. When the patient doesn’t commit to ongoing lymphedema self-management practices post-surgery, or doesn’t have access to the necessary support.

Summary

Does the small body of research on liposuction for head and neck cancer patients suggest that cosmetic improvements to neck swelling are possible? Certainly. And I commend the authors and encourage them to do more pioneering work in this field. But should we broadly recommend liposuction for head and neck lymphedema patients, as the authors suggest? Not according to our current understanding of the disease, and not according to the larger body of lymphedema liposuction research on arm and leg patients. At the same time, this larger body of evidence does suggest that liposuction could be very beneficial for some patients with advanced head and neck lymphedema, and as with advanced cases of arm and leg lymphedema, liposuction might profoundly change some lives for the better.

References

1. Alamoudi U, Taylor B, MacKay C, Rigby MH, Hart R, Trites JRB, and Taylor SM. Submental liposuction for the management of lymphedema following head and neck cancer treatment: a randomized controlled trial. J Otolaryngol Head Neck Surg. 2018 Mar 26;47(1):22.