Guidelines and Standards
of Liposuction for Lipedema

Liposuction in the proper setting and with the proper multidisciplinary team can be an effective treatment for lipedema. The evidence of this will discussed further below. First, all the medical experts who are dedicated to the care of lipedema patient around the world recommend these steps to occur before liposuction for lipedema minimize risks and to ensure the best clinical outcomes.

A Proper Diagnosis of Lipedema

Lipedema has three stages and five types. It is essential that your physician can diagnose lipedema and also determine your type of lipedema, or all of the areas where your body has it and the stage of lipedema you have in each of the areas. Very early on, lipedema fat or tissue causes a secondary swelling or lymphedema. The swelling or secondary lymphedema in the arms and legs can be seen quickly, or it can develop more slowly and only seen in stage 2 or 3. Patients are much more likely to appreciate the swelling and heaviness in their arms and legs, but even doctors who may recognize lipedema and even seem interested in treating lipedema may not correctly recognize or diagnose the secondary lymphedema. To accurately diagnose lipedema a thorough physical exam should be performed; specific clinical signs should be checked. A proper diagnosis of lipedema cannot be made on Skype. You should be very cautious with any doctor who claims they diagnose lipedema without an appropriate exam. Exactly how lipedema impairs lymphatic circulation is not entirely known, but all experts who study and treat this disease agree the lymphedema should be diagnosed and treated before considering surgery.

Complete a Trial of Conservative Therapy

The treatment of lipedema is multidisciplinary. Lymphedema therapy performed by certified lymphedema therapists is an important and ongoing part of the management of lipedema. Lymphedema therapy, including manual lymph drainage and compression garment use, should start prior to any surgical intervention. Early and continued lymphedema treatment primes and optimizes the health of the skin and subcutaneous tissue and the immune function which helps healing and management of the swelling that will occur post liposuction surgery. Since there is no cure for lipedema, diet modification is an integral part of the successful management of lipedema. Early instruction on a low carbohydrate, anti-inflammatory diet is not just helpful to manage symptoms; it also can reduce the risk of progression or worsen the disease. Resistance exercise and water exercise improves strength and muscle tone which helps prevent complications of lipedema and aids in the speedy recovery post surgery.

The Health Care Team Needs to Follow and Document 

It is important that your doctors and lymphedema therapist follow and adjust your non-surgical treatments. There is often a lot of work and adjustments to be done to get well fitting compression garments. Effective manual lymph drainage takes time and practice to learn. Dietary modifications need to followed up on and calibrated to meet individual needs. All of this needs to be documented if you have any thoughts about asking an insurance company to pay for any part of your treatment.

Choose Your Liposuction Surgeon Carefully

Lipedema is a disease that impairs lymphatic function. Most women with lipedema by the time they have been they are aware of their disease and are diagnosed have impaired lymphatic circulation. Liposuction can further injure the lymphatics. Extra care should be taken to avoid injury to lymphatic flow and function during liposuction. Detailed knowledge of lymphatic anatomy and a careful surgical technique that is developed to minimize the risk of injury to the lymphatic structures is required. These liposuction surgeries are often called lymph sparing liposuction. The skills and goals of liposuction for lipedema are very different from the skills used in general liposuction and currently are only employed by a few surgeons who are dedicated to the comprehensive treatment of lipedema. However, there are many surgeons who claim to be experts on liposuction lipedema yet do not follow the standards of care adopted by researchers and physicians who have an in-depth knowledge of the lipedema disease.

How can you know if the surgeon you are considering for your liposuction for lipedema really has the expertise to give you optimal improvement with your lipedema and lowest chance of complication? How long has your prospective surgeon been performing liposuction for patients with lipedema? What criteria does the surgeon use to diagnose lipedema? Does he or she offer to diagnose lipedema via Skype without a physical exam? Does the surgeon follow the standard of care for a multidisciplinary approach to the treatment of lipedema? What surgical techniques does your prospective surgeon use to avoid injury to the lymphatics? Does the surgeon you are considering participate in research or registries to track outcomes and prove the benefits of the liposuction surgery they perform?

Reliable Lipedema Surgical Outcomes

How does the surgeon determine the outcomes of his or her surgery? How does your prospective surgeon follow his or her lipedema patients? If the surgeon does not follow the lipedema patients after the liposuction, they cannot know for sure if the lipedema patients had any complications. Far too often surgeons do not follow their patients and look for improvements or complications such as clinical changes such as decreased or increased swelling. Often the very same surgeons who do not check claim they have no complications, thus proving the point if you don’t look you don’t find.

Liposuction is an Effective Treatment for Lipedema 

Studies have shown Liposuction to be an effective treatment for lipedema when done as part of comprehensive treatment for the disease. A consensus of experts around the world and in the USA agree that liposuction in which extra care is taken not to injure lymphatic ducts can improve swelling, symptoms such as heavingness, pain and tenderness and improve mobility. The following are direct quotes from the most up to date standards of care guidelines.

Spanish Standard of Care Guidelines:

According to the Spanish Standard of Care Guidelines:

The surgical treatment of lipedema has become, in the last decade, the only definitive treatment option for these patients, present in clinical guidelines and protocols. Its main objective is the reduction of the fatty compartment by reducing the circumference and volume of the extremities.

Prior to surgical treatment, associated aggravating factors such as edema, obesity, unhealthy lifestyle or lack of physical activity should be corrected.

In liposuction, small incisions are made in the skin for the introduction of the cannula. These incisions are 2-4 mm and are performed in the most appropriate locations for the removal of fat.

The liposuction technique in lipedema is different from conventional techniques. Thinner and blunt cannulas are used, and liposuction must follow an axial or longitudinal pattern, and not transverse as usual in traditional liposuction. The objective is to minimize the potential lesions of the superficial lymphatic system (Mladick R, 1990).

The perfect anatomical knowledge and the correct execution of the technique are essential to reduce the possibility of complications, in specific areas such as ankles and knees. (Frick A, 1999).

It is a sequential treatment, because to achieve satisfactory results and maintain safety criteria, it is necessary to perform an average of 2 or 3 interventions, with a variable range between 1 and 6.

Consensus en Espanol TRANSLATED 2.7.19

Dutch Standard of Care Guidelines:

According to the Dutch Standard of Care Guidelines published on Phlebology: The Journal of Venous Disease and the US National Library of Medicine:

This technique has been proven to be a highly effective treatment for lipedema with positive morphological and functional long-term results, including the reduction of complaints, such as pain and bruising, and enhanced overall quality of life.1,2,3,4 Consistent criteria to determine the ideal time or patient characteristics for liposuction are not available. Some studies report better outcomes in early stages compared with advanced cases, but recent data demonstrate a more distinct change of complaints in more advanced cases.

Ideally, TLA is performed at a relatively early stage to prevent progression.2,4 The guideline task force recommends tumescent liposuction as part of the therapeutic armamentarium in the management of lipedema. However, tumescent liposuction is only the treatment of choice for patients with a suitable health profile and/or inadequate response to conservative and supportive measures.

publicatie-r-damstra-april-2017-2

German Standard of Care Guidelines:

According to the German Standard of Care Guidelines published on the Wiley Online Library and on the Association of the Scientific Medical Societies in Germany:

Liposuction is used for the permanent reduction of abnormal subcutaneous fat on the arms and legs. It is especially indicated when despite consistently carried out conservative therapy, symptoms still remain or there is a progression of findings (subcutaneous fat volume) and/or symptoms (pain, edema) (Cornely 2000, Schmeller 2014). 

Due to its many advantages, liposuction should be carried out using tumescence local anaesthesia (TLA), i.e. a “wet technique” with blunt micro-probes (Klein 2000, Sattler 1997 & 2002, Rapprich 2002 & 2011, Cornely 2003 & 2006, Schmeller 2007). Supporting techniques such as vibration or water jets can also be used (Stutz 2009). This procedure can be carried out as an outpatient or inpatient (Schmeller 2012, Rapprich 2011, Cornely 2014).

Furthermore, due to the reduction of fatty tissue deposits on the inner sides of the upper leg and knee, mechanical and occlusive related skin damage is reduced or eliminated. Correction of leg deformity leads to improvement of movement and gait (Stutz 2011), as well as risk reduction for further orthopedic complications as a consequence of lipedema-associated pathological gait.

German_Lipodem_Guidelines_2015-de_de-en_us-C

British/ UK Standard of Care Guidelines:

According to the UK Standard of Care Guidelines published on Lipoedema UK:

Liposuction should be carried out by a surgeon who is appropriately qualified to treatment someone with lipoedema and who works as part of a multidisciplinary team.

Patients should research clinics carefully to ensure an adequate standard of care and to establish that the procedures on offer are appropriate for their individual needs. They need to be aware that liposuction procedures are not without risk in the immediate post-operative period and may cause long-term complications (Stutz & Krahl, 2009; Rapprich et al, 2015).

Best-Practice-for-Lipoedema UK

Effects of Liposuction in Lipoedema

Overall, liposuction in patients with lipoedema reduces tissue bulk, pain and bruising, and improves mobility, functioning and quality of life (ReichSchupke et al, 2012; Peled & Kappos, 2016). A study of tumescent liposuction in 85 patients with lipoedema found that six months after surgery patients’ scores for a wide range of symptoms, including pain, bruising, swelling and impaired mobility, were all significantly reduced in comparison with pre-operative scores (p<0.001 for change in each item score) (Rapprich et al, 2015). Patients received a mean of 2.61 (range 1 to 6) sessions of liposuction. There is also evidence of longer-term benefits of liposuction. A study sent a questionnaire to 112 patients who had undergone tumescent liposuction between 5 and 11 years previously and who had also been evaluated by questionnaire four years before (Schmeller et al, 2012; Baumgartner et al, 2016). Responses were received from 76% of patients. Changes over time in seven parameters (including pain, bruising, oedema, mobility and quality of life) that contributed to an overall impairment score were examined. The significant reductions in pre-operative and post-operative scores for each item and for overall score (all p<0.001) noted at 4 years were also present after 8 years (Schmeller et al, 2012; Baumgartner et al, 2016). However, studies are awaited that present data for the longer-term outcomes that are relevant for this patient group.

Advising Patients with Lipoedema

Patients with lipoedema considering liposuction should be advised and encouraged to undertake non-surgical treatment for at least 6-12 months as a first step. Pre-operative counselling is very important to ensure that the patient has realistic expectations of what can be achieved, understands the procedure and the importance of post-operative care (including compression therapy), and comprehends that there is no evidence that liposuction is curative.

Summary and Conclusions

The disease lipedema presents some unique issues with regard to its management. In the USA Lipedema, the recognition, understanding, and treatment of lipedema are inconsistent by the majority of physicians and surgeons. Patients with lipedema need to do their research to find surgeons who perform lymph sparing liposuction and who are dedicated to following the standards of care and comprehensively treat lipedema patients. In the proper multidisciplinary teams hands liposuction can significantly improve the symptoms, quality of life and mobility of patients with lipedema.

References: 

1. Forner Cordero I, Szolnoky G, Forner Cordero A, et al. Lipedema: an overview of its clinical manifestations, diagnosis and treatment of the disproportional fatty deposition syndrome – systematic review. Clin Obes 2012; 2: 86–95 https://www.ncbi.nlm.nih.gov/pubmed/25586162

2. Langendoen SI, Habbema L, Nijsten TEC, et al. Lipoedema: from clinical presentation to therapy. A review of the literature. Br J Dermatol 2009; 161: 980–986. https://www.ncbi.nlm.nih.gov/pubmed/19785610

3. SchmellerW, Hueppe M and Meier-Vollrath I. Tumescent liposuction in lipoedema yields good long term results. Br J Dermatol 2012; 166: 161–168. https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2133.2011.10566.x and https://www.ncbi.nlm.nih.gov/pubmed/21824127

4. RapprichS, Dingler A and Podda M. Liposuction is an effective treatment for lipedema – results of a study with 25 patients. JDDG 2011; 9: 33–40. https://www.ncbi.nlm.nih.gov/pubmed/21166777 and https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1610-0387.2010.07504.x

5. Peled AW, Slavin SA and Brorson H. Long-term outcome after surgical treatment of lipedema. Ann Plast Surg 2012; 68: 303–307.

https://www.ncbi.nlm.nih.gov/pubmed/21629090 and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4986968/

6. Meier-Vollrath, Iand Schmeller W. Lipoedema – current status, new perspectives. JDDG 2004; 2: 181–186. https://onlinelibrary.wiley.com/doi/abs/10.1046/j.1439-0353.2004.04051.x and https://www.lymfoedeem.nl/files/publicatie-r-damstra-april-2017-2.pdf

7. Buck DW, Herbst KL. Lipedema: a relatively common disease with extremely common misconceptions. Plast Reconstr Surg Glob Open. 2016;4(9): e1043. https://www.ncbi.nlm.nih.gov/pubmed/27757353. and https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5055019/

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Dr. Wright

Meet Dr. Thomas Wright, medical director of Laser Lipo and Vein Center. Dr. Wright is a board certified Phlebologist and cosmetic surgery specialist, with over 15 years of practicing experience. A graduate of the University of Missouri Columbia medical program, Dr. Wright was one of the first two hundred surgeons to become a diplomate in Phlebology.

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