The Addition of Hyaluronidase to Tumescent Local Anesthesia Supports Lymphological Liposculpture of Secondary Lymphedema

Proteoglycans (PG) are essential for regulating water flow in the interstitium. From stage 1 of lymphostasis, there is an accumulation of interstitial PG, which regulate the increasing fluids. As the disease progresses, more PG are formed than degraded, resulting in proliferation, and increases in circumference and volume of solid tissue. The removal of this subcutaneous tissue, which is very rigid due to cross-linked PG, is a particular challenge in lymphedema surgery. Hyaluronidase has a lytic effect on these PG structures and, after subcutaneous infiltration, reduces the viscosity of the extracellular matrix, promoting diffusion and penetration of solutions into the surrounding tissue. By using hyaluronidase in our vascular-sparing surgical protocol (lymphological liposculpture), we have not observed any lymphedema recurrences even after 15 years.