Exploring the Surgical Treatment of Lipedema with Lymphatic Sparing Techniques

February 25, 2019

In today's society, we understand more than ever about the human body and especially how diet and disease are related and affect us. Advancements in fields such as exercise physiology have taught us the proper way to customize workouts uniquely for ourselves based on age, goals, nutrition and medical conditions. Despite these advancements, Lipedema is an under-diagnosed disorder and more education is needed on the surgical treatment of Lipedema.

Hope, Support & Surgical Treatment of Lipedema "Painful Fat"

There is a large subset of the population, mainly women, who cannot seem to lose weight. This is especially true in certain parts of their bodies no matter how much they exercise, diet or even go toward more advanced surgical treatments such as gastric bypass.

These women (and some men) seem to have a disproportionate amount of lipodystrophy in the lower body as compared to the upper body. These areas can also become painful to the touch, bruise easily, feel nodular and also have peculiar patterns such as skin “cuffing” at the ankles and wrists and “column-like legs”.

If you know someone like this, chances are they have seen many doctors who have told them they are just overweight and need more diet and exercise. Many of them just accept that this is their body type and rationalize that they have inherited it from a close or distant relative.

Of course, this thought process usually continues until the situation gets even worse. Fatigue worsens, swelling in the legs does not dissipate even with elevation and pain at rest can occur. It is at this point that many women begin to look for reasons as to why they suffer this way and alternatives to the diet and exercise theory that has not made them any progress.

Some finally stumble upon the word “Lipedema” which usually occurs online. As they read about “Painful Fat” and check off all of the boxes of where they are and what they have gone through, along with 11% of the female population, they also realize there is hope, support, and treatment.

The Exact Cause of Lipedema is Unknown

However, due to extensive research, we understand more about the different pathogenic processes that occur. It appears to have a commonality and possibly even related to connective tissue disorders which is why some will notice hyper-mobile joints.

The community as a whole will focus on the lymphatic vessels whose primary role is to remove cellular debris and fluid that have accumulated in the tissues. From what we do know about Lipedema, it appears that early on the lymphatics function normally. As the edema (fluid build up) increases it can 1) overpower the amount the lymphatics can transport and 2) the lymphatics in the skin get stretched out resulting in microaneurysms (a localized abnormal weak spot in a vessel), that can cause these vessels that should be collecting fluid and removing it, to leak.

When looking at the cellular pathology, it appears the smaller blood vessels are very affected. Our vascular system is composed of arteries that carry oxygenated blood to the tissues from the heart. These branch into arterioles which then lead to capillaries.

Capillaries are thin-walled vessels that allow for fluid and nutrient exchange. This is mainly accomplished by varying pressures in the capillaries and tissues. Hydrostatic pressure pushes fluid and proteins away while Oncotic (also known as Colloid Osmotic) pressure pulls toward itself. The proteins and fluid that are brought back into the capillaries then connect to venules which coalesce into veins that go back to the heart and lungs to get oxygenated again.

In patients with Lipedema, there is dilation of the subdermal capillaries, fibrosis (scarring) of the arterioles, fibrosis, and dilation of the venules as well as hypertrophy (cell enlargement) and hyperplasia (increased number of cells) of the adipocytes (fat cells). The damaged vessels in the skin are commonly seen as very easy bruising in patients with Lipedema.

The damaged blood vessels are leaking their contents such as proteins and growth factors into the surrounding fat which causes it to enlarge and grow into “abnormal” fat. This further leads to an increased amount of fluid and proteins in the tissues which pulls even more fluid out of the vessels. As the fluid builds up and the metabolic demands of the fat cells increase, the area becomes hypoxic (lower oxygen saturation). Hypoxia cause cells to send out “distress” signals that recruits more inflammatory cells which lead to more inflammation. This causes even more swelling and even leakier capillaries as part of a vicious cycle.

Surgical Treatment of Lipedema - Lymphatic Sparing Techniques

Since the underlying cause of Lipedema is unknown, the primary treatments are mainly aimed at decreasing the symptoms. A standard treatment for Lipedema is Complete Decongestive Therapy (CDT) which includes a combination of decongestive massage known as Manual Lymph Drainage (MLD), bandaging, compression garments, exercise, and self-care. Beyond that, there is also the option of surgical treatment.

Lymphatic-Sparing Liposuction:  The mainstay treatment for Lipedema is Lymphatic-Sparing Liposuction. This specialized Liposuction is more selective at removing the “bad” lipedematous fat while sparing the more vital structures such as nerves, blood, and lymphatic vessels.

Research has shown good long-term results in reducing Lipedema pain and even stopping the progression of Lipedema. Due to these results, the need for adjunctive therapies such as massage therapy and compression is reduced and in some women, not needed at all.

Lymphatic-Sparing Liposuction is performed by using larger, blunt cannulas and releasing the fat cells and fibrotic connective tissue prior to suctioning. Some physicians prefer Water Assisted Liposuction (WAL) since this was one of the first types of liposuction used in patients with Lipedema.

The only difference is that the tumescent (fluid placed prior to liposuction to decrease pain and bleeding) is gently sprayed by the WAL. The rest of the procedure is similar in that the larger cannulas should be directed as parallel to the major lymphatic vessels (along the axis of the limb) as possible. The newer technique is known as SAFE Lipo.

SAFE is an acronym that stands for:

• Separation
• Aspiration
• Fat
• Equalization

This technique employs all of the best methods for consistent, safe outcomes. My own method using this technique is to place the tumescent with a larger diameter, blunt vibrating handpiece of the Power Assisted Liposuction (PAL) machine. This Separates or gently break up the fat cells and thick connective tissue which is known as Simultaneous Separation Tumescence (SST).

Research shows this method allows for less bleeding and trauma to the fat cells since it places the tumescent fluid close to the cells. The next step is to Aspirate the fat. I use only large, blunt cannulas and stay parallel to the long axis of the limbs. This technique is also used for the buttocks “gluteal shelf”, hips and abdomen which are commonly affected in Lipedema patients. Once the fat is thoroughly removed, a blunt cannula without suction is again introduced to “smooth out” the area known as Fat Equalization.

Most Lipedema patients need more than one procedure to remove the lipedematous areas. The amount of fat that needs to be removed needs to tempered by the amount of fat that can safely be removed at each surgery. This is also why it is very important to see a doctor that specializes in treating women with Lipedema.

Lymphatic Sparing Body Contouring:  I also believe that Lymphatic Sparing Body Contouring is known as Body LipoLift® also plays an important role in the treatment of Lipedema. By only performing liposuction there is an excess of skin left behind. There is a two-fold problem with this. 1) The excess skin doesn’t allow for proper fitting of compression garments. 2) The loose skin also allows for more fluid leakage since the pressure in the tissues is decreased as compared to the pressures inside the vessels. This leads to higher pressure pushing more fluid into the lower pressure space. Removing and tightening the skin increases the pressure in the tissues which will keep more fluid from leaking out which could decrease the vicious cycle of Lipedema.

Part of the Body LipoLift® procedure is to perform the skin excision body contouring while sparing the subdermal, superficial and deep lymphatic branches, giving women who suffer from this the best chance at healing and treatment.

Many patients look to treatment options of Dry Brushing, Manual Lymphatic Drainage (MLD), and medications and supplements.

The Take-Away: It Isn't Your Fault!

Although Lipedema is very common, it is under and misdiagnosed in the medical community. This unfortunate circumstance not only leads to improper symptomatic care but leaves women without answers as to what’s happening to their bodies. Even more crucial is that they may be led down a path of severe dieting or even unnecessary treatments.

The best way to get to understand the complexity of your case and the best outcomes to expect is to schedule an in-depth consultation with a plastic surgeon that has expertise in this area. From our experience in treating patients that have Lipedema, make sure to select a plastic surgeon that will spend a significant amount of time to understand your medical history, your goals, your previous surgeries and then craft a realistic plan forward for you.

ABOUT THE AUTHOR Jaime S. Schwartz MD, FACS, is a highly regarded expert & leader in the field of plastic surgery. Dr. Schwartz is known for his compassion & commitment to safety and advancing the field of plastic surgery through new techniques and procedures. From Dr. Schwartz’ values and relentless “patient-first” commitment, his practice is dedicated to both education and safety. Connect with Dr. Schwartz on Instagram. Read more articles from Dr. Schwartz!

---