Post SAPL recovery plan

[NievesAzules]

Hello,

I’ve had SAPL on my right leg a few weeks ago. I have primary in my right leg that showed up 9 years ago. While the surgery went well, I realized that the post surgery recovery plan is not as defined as it should be.

I had custom compression made pre surgery based off the measurements of my good leg. But my operated thigh is smaller than the good one now so the legging is loose on the thigh. Also, the compression in the ankle is so tight that a vein in my ankle inflamed. Because of this I’ve had to wear off the shelf compression that fits better. Two weeks later my leg looks almost healed but the pain in my foot has worsened. I definitely was not expecting the intense foot pain (and I never had swelling in my foot pre surgery).

I’ve heard other people get bandaging after SAPL. I’m wondering if this would have helped.

What have others post op plans looked like?

[PenelopeUK]

It could be that your foot is painful and has swelled because the compression on your ankle is too tight. Who was your surgeon and where are you based? Could you go back to the clinic where you had it done for advice aftercare? The right compression very important for long term good results

[j9sinclair in reply to PenelopeUK]

I had SAPL on my left leg in 2018. I did not wear a stocking and had to bandage my leg for a few weeks after. This protocol was followed due to the multiple incisions throughout my leg that required dressing changes. I was fitted with a custom flat knit thigh high after healing. Also, it would have been extremely painful to put on and take off a compression garment during this time. I did have pain in my foot and all around my ankle, especially the front of my ankle and top of my foot. This seemed to be due to an incision at the front of my ankle that took a little longer to heal. The foot pain was attributed to the 23/7 compression inflaming nerves. This eventually went away. I also wear a toe cap to minimize any swelling in my toes.

[NievesAzules in reply to PenelopeUK]

Thank you for your response. Like you said, it is likely a compression issue. Unfortunately, the replacement custom-made compression took a couple of weeks - it arrived a day ago but the toe caps didn’t arrive with it. Apparently, the toe caps are an essential piece as the pressure will continue to build up in my foot without it. So, I have to keep waiting.

The closest incision to my ankle was 4 inches away and that one healed very quickly. The rest of my leg looks great but the foot pain is almost unbearable.

I go to see my therapist in 2 days and am hoping for an interim solution.

[Snaomi]

Hello, I was measured right after surgery for custom garments and wrapped until they came in. I wore a class 3 with a class 2 everyday for a year taking class 2 off at night for sleep. After a year went to just a class 3. It sound to me as though you should be remeasured. If garments are to tight they can cause swelling. To loose and they don't help. Also important to be remeasured every 4 months for new pair. Good luck.

[NievesAzules in reply to Snaomi]

I did get remeasured about 2 weeks after surgery. The first pre-surgery garment was taken from measurements of my left unaffected leg. But after surgery my affected thigh was almost 2 inches smaller than my left so the garment was sliding down on the thigh while squeezing my ankle. I had to change back to my off-the-shelf 20-30 garment while I waited for the replacement. Unfortunately, the vein is so inflamed even this put too much pressure on my foot. My surgeon told me that if nothing else I may need to take off the compression for a day and elevate most of the day to let the vein recover.

[Annale]

When my son had this surgery, he was actually told not to wear compression on his leg for a month, but to wrap lightly with an ace bandage. My son is just stage 2 and is lot large, but I was surprised that his surgeon didn’t want him to wear compression for a month. Now I understand why.

[Microsurgeon]

This is a really interesting problem and there is no perfect plan after surgery. Each patient needs a bespoke plan for them based on some underlying principles. Firstly - why do you need compression?. After SAPL the fat under the skin is removed leaving a potential space to fill with fluid. This fluid is not wanted as it volume (and the whole point is volume reduction), impairs healing and increases risk of infection. Good compression reduces the formation of this fluid and helps to push it out of the liposuction scars whilst the initial healing takes place. The more fat is removed the more important compression is but more tricky it is to get right. The early post op compression helps to set the scene for later and longer term compression. Secondly - what is practical to apply compression? There are many types of compression from circular knit, flat knit, wraps and bandages etc. You essentially need a graded compression that is effective over the area of liposuction and from the very end of the limb. We often start with wraps post op as the have infinite adjustment and just seem more practical. Whilst we aim for a comparable volume with the other leg, I cannot guarantee the exact shape and volume of the leg post op and so having a garment made pre op sometimes doesn't work well. The first few weeks after the surgery requires a lot of therapy input to get the garments optimised as the limb continues to change in volume. As the limb continues to reduce in volume then a flat knit garment can also be remodelled by sewing in a pleat to reduce the garment circumference over time (rather than a whole new garment). Eventually after 6-12 months a final volume is achieved and stable garments can be used. SAPL is a major operation with a long recovery period before you get the final result where the therapist (person in charge of the compression) is as important at the surgeon. Generally you need a good surgeon + good therapist + engaged patient = good result. However a few ups and downs in the early post operative period are normal and after an initial bumpy ride then things should settle down and be more stable. You might like to consider wraps for a period whilst your vein / foot settle down as you might benefit from being able to adjust your compression. Good luck and I hope you recovery goes well.

[NievesAzules in reply to Microsurgeon]

Thank you for your concise but very informative response. I would definitely say to another patient considering SAPL and who can choose surgeons to find out the post-op care strategy. I believe my surgeon is skilled and the medical institution is prestigious but the aftercare is scant. I’ve had to coordinate the fitter and the therapist on my own (I don’t see my surgeon for another three months). I can do this work but, of course, it would be better if it was directed from my surgeon’s office. Additionally, had I known this would be an issue I would have set things up long in advance - not as a result of injury.

A week ago I had a venous duplex ultrasound which did show evidence of superficial thrombophlebitis. The theory is that it is a result of too tight compression but also possibly the lack of toe caps (they had not been specified in the prescription as needed & I had not worn them previously).

So, not only is a skilled surgeon and an engaged patient needed but also a clearly and well coordinated post-op plan.

[Microsurgeon in reply to NievesAzules]

Totally agree. The therapist guiding post op compression is a critical member of the team and you will need a positive and long term relationship with them. Interesting Brorson, the surgeon from Malmo who pioneered with work, has two brilliant therapists who have been with him for 20 years. Post op he sees the patient for a couple of minute but the therapists will spend 45 minutes with the patient attending to all their ongoing compression issues, doing measurements etc. They are the ones in charge of the post op care! In Oxford, we didn't start this operation until we were totally onboard with an experienced therapist who we trusted to guide the patient in the post operative rehabilitation. We felt the operation was the relatively easy part and the therapy / post op plans were much more demanding and difficult to get spot on. We provide the therapist and over see the post op plan but it is delivered 90% by the therapist. Pre op 50% surgeon, 50% therapy input. Operatively 90% surgeon, 10% therapist. Post op 20% surgeon, 80% therapist. Those seem to be the amount of time put in be each member of the team at the different stages of the plan.

Good luck. Stick with it and things will come right over time.