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Lipedema

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WHAT IS LIPEDEMA?

Lipedema is a chronic disorder presenting in women during puberty or other times of hormonal change such as childbirth or menopause, characterized by symmetric enlargement of nodular, painful abnormal disposition of subcutaneous adipose tissue.

Lipedema is often unrecognized or misdiagnosed; its causes are still unknown.  Lipedema often runs in families with multiple female relatives being affected to various degrees.  Some studies have proposed an autosomal dominant incomplete penetrance inheritance pattern.  Others have proposed a link to the AKR1C1 gene.  This gene is responsible for the protein aldo-keto reductase which helps reduce progesterone to its inactive form 20-α-hydroxyprogesterone.  This may explain why lipedema is typically seen in females and seems to be triggered by puberty, pregnancy, or menopause.

Lipedema often starts in the lower extremities leading to circumferential bilateral lower extremity enlargement that is typically seen extending from the hips to the ankles and resulting in edema, pain, and bruising. Secondary lymphedema can occur, resulting in increased edema and fibrosis.  Abnormal tissues in the trunk and arms can also be found.

 

Lipedema is distinct from obesity.  Some patients with lipedema can also be obese but these are separate clinical entities.  Early-stage lipedema classically has increased accumulation of fatty tissue in the extremities (while sparing the hands and feet) compared with the abdomen and trunk.  This contrasts with obesity, in which fatty accumulation is global, affecting the hands and feet as well.

Lipedema is also distinct from lymphedema.  Lymphedema is caused by the accumulation of protein-rich fluid, called lymph, in the soft tissues.  Lymph is normally drained through the lymphatic system.  Lymphedema patients may have a positive Stemmer’s sign while lymphedema patients will not.   If an examiner cannot pinch the skin on the top of a patient’s foot or hand, this is called a “positive Stemmer’s sign.”  A positive Stemmer’s sign suggests fluid (lymph) accumulation in the soft tissues. 

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HOW IS LIPEDEMA CLASSIFIED?

Lipedema is classified by stage (severity) and types (body sites affected).

Lipedema Stages

  • Stage 1:  Thickened skin with soft, small palpable nodules.  The skin surface is smooth
  • Stage 2:  Some larger nodules of fat, skin surface is uneven.
  • Stage 3:  Hardened large fat nodules prominent, with disfiguring fat distribution
Stages of lipedema

Lipedema TYpes

Class 1:  Buttock

Class 2:  Thigh

Class 3:  Thigh and lower leg

Class 4:  Arm

Class 5:  Lower leg with spearing of the thigh

There is five (5) types of lipedema.
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Lipedema Treatment

WHY UNDERGO LIPEDEMA TREATMENT?

Women with lipedema find it difficult to lose weight caused by fat in the extremities.  A significant number of women have failed bariatric surgery or semaglutide.

NON-OPERATIVE TREATMENT OF LIPEDEMA

We recommend that patients have tried non-operative management of lipedema first.  This also is consistent with insurance requirements.  It makes sense to attempt non-operative management of a condition before proceeding with surgery.

Some patients have found benefit with compression, manual lymphatic massage, vibration plate, or a pump.  For patients with lipedema for whom these non-invasive modalities do not resolve their symptoms, surgery may be an option.

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Surgery For Lipedema

Dr. Domanski, Fairfax, Northern VA plastic surgeon, talking to a patient during in-office plastic surgery consult.

CANDIDATES

We will evaluate patients for lipedema surgery who:

  • been diagnosis for lipedema
  • failed conservative treatment
  • undergone a physical therapy functional evaluation
  • have their “insurance packet” ready to submit to for an authorization
  • for assistance with compiling their insurance packet, we recommend seeking advice from a professional patient advocate 

WHO IS NOT A SURGICAL CANDIDATE

As a board-certified plastic surgeon, Dr. Domanski has a commitment to patient safety.  Some patients with lipedema but also have other health conditions that make them poor candidates for surgery.  Complications from surgery can have profound impacts on the lives of patients and their family members.  While we are empathetic to the challenges that lipedema places on patients, we will appropriately decline proceeding with surgery if we feel that it is not in a patient’s best interest.

In these cases, we advise patients what medical comorbidities are currently preventing proceeding with a surgery.  We make referrals to internal medicine providers that may be of help optimizing a patient’s condition so we can revisit the option for surgery in the future.

RESULTS YOU CAN SEE

Before and after results of surgical lipedema treatment

Before Image After Image
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First Visit

BE PREPARED TO DISCUSS:

  • Your expectations and desired outcome
  • Non-invasive Lipedema treatments you’ve tried before
  • Medical conditions, drug allergies and previous medical treatments
  • Use of current medications, vitamins, herbal supplements, alcohol, tobacco and drugs
  • Previous surgeries
  • Any history of bleeding problems
  • Family medical history 
  • Previous results of any mammograms or biopsies
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Forms

Please complete the following forms before your visit. This will help maximize the value of your time. You should bring your ID and insurance cards for medical/reconstructive appointments. This will save time and allow us to help you process any claims. (You do not need to bring your insurance card for aesthetic appointments since insurance doesn’t covers cosmetic procedures.)

In order to be respectful of the time of other patients, we do charge a late fee and a no-show fee. We do understand that things happen, so if you can’t make your appointment or are running late, call and let us know!

FAQs

Lipedema requires a clinical diagnosis based on a medical history and physical exam.   There is currently no medical test such as an x-ray or blood work that can diagnose lipedema.  Lipedema must be differentiated from obesity and lymphedema.

We recommend that you reach out to your primary care physician or a weight loss medical physician to be evaluated to see if you have lipedema.  The associated diagnostic paperwork is important for future insurance submissions and you should have this in your files.

Time to return to work depends on the surgery performed, type of work, and patient.

For liposuction, we find patients who work from home able to return to work within a week.  For patients that need to return to the office, two weeks may be reasonable.  For patient’s whose work requires prolonged standing such as nurses or teachers, 3 weeks may be appropriate.  We would always prefer a patient to have more than enough time off than not enough.

For skin excision procedures, we would add a week to each amount of time off above.

Yes.  We can remove lipedema on the sides of the knees.  A common concern is a fat pad on the inside of the knee.  While this fat can be removed, this medial knee also contains lymphatics that help decrease swelling in the calves and feet.  For this reason, we need to be appropriate in our technique for the medial knee by using less aggressive liposuction cannulas.  Furthermore, there is a zone of skin adherence that causes the medial knee skin to sag or even appear full after liposuction.  Patients sometimes choose to have this area then addressed by skin excision techniques.

Many patients have managed to get lipedema surgery covered by their insurance.  While patients are still responsible for their deductibles and coinsurance, we do our best to minimize patient out of pocket costs for their procedures.

Some patients have chosen to pay out of pocket for lipedema treatment.  It is impossible to give a quote online because this depends on the severity of the disease.  There are also factors such as facility fee and anesthesia costs which will vary from surgery center to hospital.  We find that we are best able to provide and explain a quote once we have evaluated you in person.

Liposuction will remove fat between the layers of the skin and the deeper muscles.  These fat cells will NOT come back.

No.  Removing fat in one area does NOT cause growth of fat in another part of the body.  The only caveat is that if afterwards a patient undergoes weight gain or loss, the fat will be gained or lost proportionally to the current fat cell distribution throughout the body.

For example, if a patient gains 10 lbs after surgery, that weight gain will be noted in parts of the body that were not treated by liposuction.  

The most significant swelling is in the first 2 weeks after surgery.  Some swelling persists for several months.  For this reason, we will typically stage surgery 3-4 months apart.

Areas of the body recover at different rates.  Some areas may undergo something called fat necrosis which results in inflamed hand nodules.  While some providers have tried to soften these areas with needles, our experience is that these hard nodules often go away after about a year.  We recommend manual lymphatic massage during that time.

If hard nodules persist after a year and have failed manual lymphatic massage, this may be due to internal fibrosis or related to lines of skin adherence that are a natural body phenomenon.  A clinical evaluation at that time would be required to recommend a specific treatment.

The American Society of Plastic Surgeons Liposuction Safety Guidelines define high volume liposuction as more than 5000 cubic centimeters (milliliters) or lipoaspirate (volume removed).

With high volume liposuction, there is a significant body surface area under the skin that can ooze and cause inflammation.  Patients may undergo fluid shifts resulting in anemia or dehydration.  This can be safely monitored and treated in a hospital setting.

The risks of high-volume liposuction are well recognized.  In fact, the State of Florida only allows 4000 cubic centimeters to be removed in the outpatient.

While we are not in Florida, the laws of nature apply everywhere.  For this reason, we routinely treat lipedema patients in a hospital setting with overnight admission as appropriate.  Dr. Domanski has experience with high volume liposuction and has developed a protocol used by other surgeons. 

Debulking surgery is a lay term that means removal of diseased or damaged tissue.  Debulking surgery can be performed by liposuction.  If the clinical problem is extra skin, skin excision such as a brachioplasty, thigh lift, abdominoplasty or panniculectomy can be recommended.

We recommend a high protein, low glycemic index dietAvoid ultra-processed foods.  We believe that preparing one’s own food at home from scrap (meal prep) helps reduce consumption of sugary, low nutrient foods.  Bodybuilders say that meal prep is harder than lifting weights.

Avoiding sugary and sugar free drinks may be useful.  There is no clinical evidence that switching from sugary sodas to sugar-free soda helps with weight loss.  Furthermore, artificial sweeteners may alter the brain response to food in unnatural ways.  Recently, there is an increase in foods advertising themselves to be “low sugar” and “naturally sweetened.”  These foods may use “natural sweeteners” such as stevia or monk fruit extract that do alter our gut bacteria in unnatural ways.

We believe that abstaining or minimizing alcohol intake helps reduce empty calories and improve sleep.

The next time you are at the grocery store line, look around.  Notice the people who look healthy and energetic.  Then look in their grocery cart to see what they are buying.

Most patients will choose to have between 2-4 procedures.  This depends on severity, how much extra skin there is after liposuction, and patient preference.  We involve patients in their treatment choices.

We typically treat the body part that bothers patients the most.  This is frequently the legs.  The front of the legs is generally treated first.  We may perform treatment on the back of the legs 3-4 months later.  We may perform a skin reduction 3-4 months afterwards.

For patients with arm and leg concerns, we will typically do the anterior legs, arms, posterior legs, and then skin excision on the posterior legs.   Alternating body parts can help each body part recover between stages.

Cellulite is a natural condition of skin irregularity where the cutaneous tendons cause small contour irregularities.  There are multiple treatments for cellulite but historically, results have been underwhelming.

Lipedema is a condition caused by abnormal accumulation of fat in the arms and legs, with sparing of the hands and feet.

Lymphedema is caused by the abnormal accumulation of lymphatic fluid in the extracellular space. Lymphedema is more responsive to compression.  Lymphedema will have a positive Stemmer’s sign, where an examiner can not pinch the skin of the top of the foot or hand because the skin is swollen from lymphatic fluid.

Pain in lipedema believed to be due to exaggerated nerve signaling possibly linked to estrogens.  While the exact cause of pain in lipedema is unknown, reduction of lipedema has been correlated with pain reduction.

Dr. Domanski was trained in liposuction from 2011 though 2015 at the University of Mississippi.  He started Bluemont Plastic Surgery in 2015 and has been performing liposuction and skin excision procedures ever since.  Dr. Domanski started treating lipedema in 2022 after he learned about the lipedema at the annual meeting of the American Society of Plastic Surgeons.

Our practice has no financial relationship with any patient advocacy network.  However, our patients have found working with a professional advocate helpful to obtain insurance authorization for their procedures.

Advocates have been helpful with dealing with short-date restrictions, network exceptions, and appeal for coverage.  Some advocates have even counseled patients to change insurance carriers to obtain coverage for lipedema treatment.

As you can understand, these are complicated issues beyond what our office can do.  Therefore, we have seen that patients who work with an advocate have an easier time obtaining coverage.

We recommend compression for 2 months after surgery.  After 2 months, some patients may continue compression due to the comfort it provides.  Other patients may use compression intermittently as needed.

What mmHg (millimeters of mercury) grade compression do I need to wear?

Compression is graded based on the amount of pressure it applies:

  • Class 1: 10-15 mmHg (Very light compression)
  • Class 2: 15-20 mmHg (Light compression)
  • Class 3: 20-36 mmHg (Moderate compression)
  • Class 4: 36+ mmHg (Strong compression)

Medical grade compression is class 3 compression and upwards.  Many patients find 20 mmHg an optimal amount.  If the compression hurts, something is wrong.  We have also seen some patients develop creases where compression has been too tight or folded over itself.  For this reason, more important that the amount of compression is the fit and comfort.  

We require patients to have a diagnosis of lipedema, have undergone conservative measures, and had a physiological assessment prior to being evaluated for a surgical plan.

Our office aims to provide a written surgical plan within two weeks of the visit.  We may submit for an authorization, but our office is not a patient advocate.  Patient advocates may be better suited to helping patients appealing short-date issues, network exceptions, or other insurance issues.

Not only will the scar location be explained, the day of the surgery, the location will be marked with a pen.  This is done in the preoperative holding area.  The patient is involved in the process.  Patients have pointed to their body part, and asked for the scar to be higher or lower, and we have made appropriate modifications in the past.

We find that 10-12 liters of lipoaspirate is an amount that patients tolerate well with overnight hospital observation.  If there are concerns about bleeding or a patient’s stability, the amount will be decreased.  In such a case, it should be possible to go back on a subsequent date and remove more lipedema.

Such surgical judgment takes years to develop.  Dr. Domanski’s medical education was 12 years long, not counting another 4 years of college.  You are in good hands.

Dr. Domanski performs power assisted (PAL) liposuction using a tumescent technique.  During the procedure, he first instills tumescent fluid through a cannula.  This decreases pain, bleeding, and helps break the fat up for easier removal.  Power assisted liposuction involves a vibrating tip of the liposuction cannula.  This vibration breaks the fat up easier, helping preserve normal tissue such as lymphatics.  Dr. Domanski generally does not do laser assisted liposuction because he feels that the risk of burns to the lymphatics and perforating vessels are not worth the risk.  Furthermore, there has not been any conclusive evidence that laser liposuction provides better skin contraction than liposuction alone.

You will meet Dr. Domanski and our lipedema coordinator.  Dr. Domanski will review your medical history and perform a physical exam to confirm the diagnosis.  A chaperone is always used during the exam.

As we would not operate on a bone without an x-ray, we will not operate on the skin or its contents without a photograph.  Photographs help us track and understand results.  Photographs are also critical for the insurance authorization process.

Photographs are taken to demonstrate the impact of lipedema on the body parts.  The head and face are not visible in the photographs.  Patients are photographed from the front, back, and sides.  These are not glamor shots.  We are documenting a medical condition. 

You may wear a solid color bra and underwear to not distract from the body parts being photographed.  Some patients have asked about shaving:  we would defer to you as you may do whatever is most comfortable for you.  However, we do ask that you do not shave for 5 days prior to surgery as this may decrease infection rates. 

High volume liposuction cases are performed at Inova Alexandria Hospital.

Surgery will last between 4-6 hours.  There is evidence that patients with plastic surgeries that last over 6 hours have harder recoveries.  During surgery, we use a normothermia protocol.  Keeping a patient warm during long surgeries has been shown to decrease infection rates.

We define traveling as driving more than 4 hours.  In such cases, we recommend a patient stay in the area for 1-2 weeks after a lipedema case.  We also recommend having a plan for postop follow-up.

We recommend patients have an overnight bag for the hospital.  The overnight bag should also contain the prescription medications the patient will use once they go home.  We recommend a plastic sheet such as a shower curtain to protect the car in case of any oozing from a bandage.  We recommend a mattress protector for the bed at home for the same reason.

Patients should have dressing supplies such as kerlix gauze and 4x4s.  Dressing supplies can be purchased “clean” instead of “sterile.”  Sterile dressings are specially packaged and are more expensive without providing a benefit at home.

If any oozing gets on something of value, hydrogen peroxide can help get stains out.

For hydration, we recommend Gnarly Sports Nutrition such as Gnarly Hydrate.  People say, “If the pee is clear – nothing to fear, dark yellow or brown – you are going down!”

To prevent constipation, which is a side effect of any narcotic pain medication, we recommend prune juice.  How much?  If you think you have had enough, have one more glass of prune juice.

For compression, many patients have had good experiences with Marena garments.

“Be Yourself,
Everyone Else Is Taken.”

– Oscar Wilde

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