# Circumferential Negative Pressure Lymphedema Therapy: A Novel Rapid Perioperative Decongestion Strategy for Advanced Stage III-IV Lymphedema

## TL;DR

A new therapy using negative pressure rapidly reduces severe lymphedema, making surgery possible and safer in advanced cases.

## Contribution

Introduces circumferential negative pressure lymphedema therapy (CNPLT) as a novel preoperative decongestion strategy for advanced lymphedema.

## Key findings

- CNPLT significantly reduced limb circumference at multiple sites within a week.
- Body weight and improved urine output were observed, indicating systemic fluid mobilization.
- Skin laxity improved markedly, enabling safe reductive surgery with minimal complications.

## Abstract

Introduction: Advanced Stage III-IV lymphedema, particularly in filariasis-endemic regions, presents with severe fibrosis, massive limb enlargement, and a poor response to conventional conservative therapy, complicating reductive surgical interventions in resource-limited settings. This study evaluated circumferential negative pressure lymphedema therapy (CNPLT), a novel rapid preoperative decongestion technique, for transforming inoperable limbs into suitable surgical candidates.

Methods: This prospective clinical study enrolled 14 patients (16 limbs) with Stage III-IV lower extremity lymphedema at a high-volume public tertiary hospital in India (September 2022-March 2024). Patients underwent intensive CNPLT (continuous subatmospheric pressure 200-250 mmHg via circumferential polyurethane foam dressings) for seven to eight days preoperatively. Limb circumference was measured daily at four standardized levels (mid-foot, lateral malleolus, 10 cm, and 20 cm above the malleolus). Body weight, 24-hour urine output, and skin suppleness were monitored. Following clinical readiness, patients underwent lympho-liposuction or excisional reductive surgery. Statistical analysis was performed using paired t-tests, repeated-measures analysis of variance, post hoc analysis with the Bonferroni test, and McNemar’s test (p < 0.05).

Results: CNPLT produced highly significant limb circumference reductions at all sites: mid-foot (5.7 ± 1.2 cm), lateral malleolus (17.5 ± 2.8 cm), 10 cm above (17.4 ± 3.1 cm), and 20 cm above (14.0 ± 2.8 cm) (all p = 0.001). Mean body weight decreased from 91.5 ± 12.6 to 72.9 ± 15.8 kg presurgery (p = 0.001), with urine output rising from 1,200 ± 250 to 1,850 ± 300 mL/day (p = 0.001). Skin laxity improved markedly, with complete resolution increasing from 14.3% preoperatively to 85.7% preoperatively (p = 0.001). Reductive surgery was performed safely; minor wound dehiscence occurred in six cases and resolved conservatively. No major complications (necrosis, infection, or seroma requiring intervention) were observed. Post hoc analyses with Bonferroni correction revealed significant reductions in both weight and urine output from the pre‑CNPLT stage to the presurgery and postsurgery stages (all p < 0.001). The mean hospital stay was 12-13 days.

Conclusion: CNPLT offers a safe, rapid, and effective preoperative decongestive strategy for advanced lymphedema, achieving substantial volume reduction, systemic fluid mobilization, and tissue softening within one week. This technique facilitates safer surgery, shortens hospitalization, and has strong potential in high-burden endemic settings.