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The Principles of Lymph Sparing Liposuction

Lymph sparing liposuction should also be the gentle and low risk liposuction. Before any liposuction can be performed, complete decongestion of lipedema tissue needs to occur.  This is achieved with compression garments, manual lymph drainage, wraps, and intermittent compression pumps. Ensuring complete decongestion of the tissues with compression is important because it not only reduces swelling which inevitably gets worse temporarily after liposuction, the compression also reduces inflammation, tenderness, fatigue and heaviness.  It also ensures the patient can appreciate the significant benefits of compression and increase the likelihood of compliance through the post-operative period which ensure the best results.

Patients with Lipedema often have other medical comorbidities and are generally at higher risk for complications than patients undergoing liposuction for cosmetic reasons. Therefore, all efforts must be made to minimize the risk of complications.

Liposuction complications have been shown to be lower when performed under the following conditions

If the patient has significant varicose veins greater than 4.0mm in the area that liposuction is planned, and/or significant underlying venous reflux, this should be treated before undertaking liposuction because large varicose veins increase the risk of bleeding and/or fat embolization during the liposuction procedure. Since Lipedema patients frequently have varicose veins this is especially important for lipedema patients.

Liposuction with generous tumescent technique that avoids general anesthesia operative and peri-operative complications, which even with modern techniques is often as high as 0.3%, 3 in 10,000, in lipedema patients with comorbidities. So avoidance of general anesthesia and reliance on tumescent anesthesia alone makes liposuction safer for lipedema pateints.

Liposuction that limits the amount of fat removed in one liposuction procedure should be adhered to. While lipedema patients have more subcutaneous fat than most other liposuction candidates, and there is a temptation to remove very large amounts of fat, it is a liposuction surgery that does cause trauma to the skin.  Generally, 5.0 liters of fat removal is considered to be safe.  There is literature supporting that the risk of complications triples once more than 5.0 liters of total volume aspirate is removed in one procedure. Since lipedema patients have more subcutaneous fat per surface area treated, they often can have 5.0 liters of fat safely removed with a total aspirate of only slightly more than 5.0 liters while still performing liposuction on only 5 – 8% of total body surface area.  Although more liposuction at one time may be requested and performed, our current medical literature shows an increased risk, and in some states, there are medical mandates or policies against exceeding these volume limits (California and Florida).

Small liposuction cannulas should be used. Larger diameter liposuction cannulas are more traumatic and more likely to disrupt lymphatic vessels and small venules.

Finally, the surgical technique with which the suction cannulas are used in the tumesced subcutaneous tissue is also very important. Intimate knowledge of the locations and anatomic variations of the lymphatic drainage in the limb or body area that is going to be treated is crucial.  Great care should be taken to orient the suction cannulas in a longitudinal manner parallel to the lymphatic collecting ducts in the epi facial areas. Knowledge of location and orientation of pseudo-fascial lymphatic pathways and the afferent lymph vessels is also important to avoid transecting this pathway during the liposuction procedure.

References by topic:
Smaller Cannula Size Less Traumatic Liposuciton
Jayashree Venkataram   Tumescent Liposuction: A Review    J Cutan Aesthet Surg. 2008 Jul-Dec; 1(2): 49–57.    doi:  4103/0974-2077.44159 or Google Scholar Link

Skouge JW. The biochemistry and development of adipose tissue and pathophysiology of obesity as it relates to liposuction surgery. Dermatol Clin. 1990;8:385–93. [PubMed] or Google Scholar Link

Lawrence N, Coleman WP., 3rd Liposuction. Adv Dermatol. 1996;11:19–49. [PubMed]

Risk of General Anesthesia
People in excellent health , no  medical condition have .04 %[ .4  / 100,000  chance of death from general anesthesia ] however if you have medical  mild or moderate significant medical conditions the anesthesia related mortality increases to .27 % or 27 /100,000 Dtsch Arztebl Int. 2011 Jul; 108(27): 469–474. or Google Scholar Link

Published online 2011 Jul 8. doi:  3238/arztebl.2011.0469
PMCID: PMC3147285

Review Article
Is Anesthesia Dangerous?
André Gottschalk, PD Dr. med. MBA,*

Volume of  Fat Removal and Risks with Liposuction.
Is There a Limit? A Risk Assessment Model of Liposuction Volume on Complications in Lipoabdominoplasty.Chow I, Hanwright PJ, Gutowski KA, Kim JYSPlast. Reconstr. Surg. 2015-10-01 or Google Scholar Link

Large Volume Liposcution refers to removal of more that. Large volume liposuction clinically refers to the removal of more than 5 liters of total volume from the patient.

Large volume liposuction clinically refers to the removal of more than 5 liters of total volume from the patient. Gilliland et al,[17,18] or Google Scholar Link

Tumescent liposuction complicated by pulmonary edema.
Gilliland MD, Coates N
Plast Reconstr Surg. 1997 Jan; 99(1):215-9.
ReviewSafety issues in ultrasound-assisted large-volume lipoplasty.
Gilliland MD, Commons GW, Halperin B
Clin Plast Surg. 1999 Apr; 26(2):317-35; x.
[PubMed] [Ref list]

>Large cannula cause more trauma
“large cannulae instruments caused damage to neurovascular bundles and occasionally led to uneven contours and seromas or hematomas in patients. ”

Indian J Plast Surg. 2008 Oct; 41(Suppl): S27–S40.
PMCID: PMC2825130

Lakshyajit D. Dhami

Higher BMI Increased Risk of  DVT
Prevention of Venous Thromboembolism in Body Contouring Surgery . Ann Plast Surg. 2011 Mar; 66(3): 228–232.

A National Survey of 596 ASPS Surgeons
Julio A. Clavijo-Alvarez, MD, PhD,

Safety of Aesthetic Surgery in the Overweight Patient: Analysis of 127,961 Patients.
Gupta V1, Winocour J1, Rodriguez-Feo C1, Bamba R1, Shack RB1, Grotting JC1, Higdon KK1.

Author information
BMI greater than 30 is an independent risk factor for DVT [ Deep Vein Thrombosis} 2-3 times higher than those of normal weight.

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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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* Results May Vary From Person to Person