Dr. Domanski’s surgical skills are complemented by his compassionate bedside manner. He got me through a scary situation, and really listened to what I had to say. A winning combination of art and science and an excellent medical practitioner..
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.
Lipedema is classified by stage (severity) and types (body sites affected).
Class 1: Buttock
Class 2: Thigh
Class 3: Thigh and lower leg
Class 4: Arm
Class 5: Lower leg with spearing of the thigh
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.
CANDIDATES
We will evaluate patients for lipedema surgery who:
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.
Call today and make an appointment with award-winning plastic surgery near Fairfax, VA: (703)-596-1660.
Before and after results of surgical lipedema treatment
BE PREPARED TO DISCUSS:
Important: In respect of your time, before scheduling your appointment, please make sure to fill out and email us the Pre-Appointment Screening Form for the Surgical Treatment of Lipedema.
Please complete the following forms (Lipedema Intake Form, Bluemont Intake Form) 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!
There are some questions frequently asked by lipedema patients at appointments. We have compiled them here, answered by Dr. Domanski, to help provide clarity and guidance.
1. How many lipedema surgeries have you done and how often do you do them?
Dr. Domanski has been performing liposuction since 2015. Dr. Domanski’s goals for lipedema treatment are safety and efficacy. To achieve these goals, Dr. Domanski recommends a full preoperative workup, including two preoperative visits with him.
During surgery, Dr. Domanski communicates with the anesthesiologist to ensure safe fluid management. After surgery, Dr. Domanski makes himself available to ensure that patients are progressing in their recovery.
Dr. Domanski finds that these aspects of pre-operative, intraoperative, and postoperative planning are more important than any specific surgical technique.
2. How many liters do you usually remove? How much would you be able to safely remove from me?
The more liters of lipedema removed, the more the risk. Therefor most lipedema surgeries are staged to break up the lipedema removal into safe volumes. However, multiple surgeries carry a risk as well.
Dr. Domanski has found that 11-12 liters is a reasonable target for each surgery. Some patients who have “more years of life experience” may be better served by removing less volume. Patients who have more aerobic ability may be able to tolerate more. Patients with varicose veins may do better with lower volumes removed.
There is a lot of information online. However, information does not equal knowledge. Assessment and interpretation of information creates knowledge. Knowledge combined with experience produces judgement. If you don’t trust your surgeon’s judgement, they should not be your surgeon.
We aim to remove as much lipedema fat as possible, in a safe and effective manner.
3. Does having both Lipedema and Lymphedema make this surgery particularly challenging?
Lipedema is the deposition of abnormal and often painful fat between the skin and the underlying fascia. Lymphedema is the accumulation of interstitial fluid in the soft tissues. Lipedema = fat. Lymphedema = liquid.
Interestingly, both lipedema and lymphedema can be treated with liposuction. Thus, the surgery is not more challenging. However, the results of patients with lymphedema and lipedema may not be as dramatic as patients with lipedema alone.
4. Can the Lymphatic system and lymph nodes be damaged/ harmed? If so – how would you protect my Lymphatic system?
Injury to the lymphatic system or lymph nodes is a risk of any lipedema surgery. To minimize this risk, Dr. Domanski orients the liposuction cannula parallel to the lymphatic vessels as much as possible. Dr. Domanski is cognizant of the location of the lymphatic vessels – along the inner thigh, knee, and leg. During skin resection procedures such as a brachioplasty and thigh lift, Dr. Domanski uses a lymph-sparing shear technique to remove excess skin while preserving lymphatics. This decreases the need for drains and helps minimize the risk of seromas.
5. Which techniques do you use? WAL or PAL?
Almost all surgeons used some form of WAL (water assisted liposuction) during liposuction. First tumescent fluid (numbing medication, normal saline, and epinephrine) are injected into the area to be treated. Then liposuction is used to remove the fat thought a cannula. A cannula is a blunt needle with the hole on the side. This is less traumatic to the tissues.
Power assisted liposuction is the use of a vibrating cannula for liposuction. Rather than the surgeon doing all the work to move the cannula back and forth, the vibrating cannula helps break up the fat. This increases efficiency during the surgery, meaning shorter operative times and potentially faster recovery.
6. Tell me what liposuction technique/method you would recommend for my surgeries?
Dr. Domanski prefers a super-wet, tumescent, water assisted, power assisted liposuction technique. For skin excision, Dr. Domanski prefers the lymphatic spearing shear technique.
7. I’ve heard that hormones can be released from the lipedemic fat during and post-surgery. What is the best way to deal with the influx of hormones and the emotional fallout from that?
While we are aware of patients mentioning such issues online, we have not noted this complication in our patients.
We know that emotional changes that occur with any surgery happen. Our strategy here is prevention. We believe that mental health is a key aspect to surgical preparedness. Just like a blood sugar level that is out of control may require postponing surgery, we would not hesitate to postpone surgery if a patient is not in the proper mental state or does not have the right support to undergo the procedure.
8. Would liposuction help with long-term pain relief?
Pain is almost impossible to measure objectively. So, we must respect what people tell us about their experiences.
While we cannot promise that lipedema surgery will improve pain, we have heard that it does so many times from patients that we believe it.
One theory is that lipedema fat puts the sensory nerves on stretch. By removing lipedema fat, we may reduce the stretch on sensory nerves – providing pain relief.
9. Would liposuction increase my mobility?
Heavy painful legs make it hard to be mobile. Consider the difference between a basic versus a top of the line running shoe. The top of the line running shoe will have better support and be lighter – because weight in the wrong places on our extremities makes a big difference.
Lipedema weight in the wrong places reduces mobility.
10. What else can help with long-term Lipedema pain relief and increase my mobility?
Patients have found that non-invasive modalities such as compression, vibration plate, and leg pumps can provide pain relief. Manuel lymphatic massage may also be of benefit. It is always important to consider non-invasive modalities before surgery.
11. I understand I could develop fibrotic tissue from liposuction.
Surgeons think of scars not as two but as three-dimensional structures. Fibrotic tissue (fibrosis) after liposuction can be internal scar.
The traumatic the liposuction, the higher the risk of fibrosis. Dr. Domanski uses the super-wet tumescent technique to safely remove large volumes of lipedema while minimizing the risk of internal scarring or fibrosis.
12. What type of compression do you recommend patients with secondary lymphedema wear pre-surgery and post-surgery?
There are almost as many different types of compression as there are body types. Compression should decrease swelling, pain, while being comfortable.
Immediately after surgery, Dr. Domanski uses a combination of ABD pads, kirlex or webroll, and extra wide ACE bandages to hold compression. Hospital staff are familiar with these bandages, and they are readily available. Thus, they can also be changed easily as needed.
Postoperatively, patients may use their preoperative compression as soon as putting them on and removing them does not cause undue discomfort.
While some providers place a lot of emphasis on specific types of compression, there is no consensus among surgeons or in the scientific literature about compression. Therefore, our practice has adopted an approach based on common sense. Compression should be comfortable and make patients feel better. Since each patient’s body is somewhat different, there is no one type of compression for all patients.
13. How long do you recommend patients wear compression garments?
Compression garments can reduce swelling after surgery. As swelling can be uncomfortable, compression garments can improve patient satisfaction. As swelling is most pronounced in the first 48 hours after surgery, this is the most critical period of potential benefit. The benefit of compression should decrease day by day. We find that at two months, patient’s swelling has remarkedly reduced. While some patients find that they no longer need compression after lipedema surgery, others will continue to find benefit – because everybody’s body is different.
14. Do you provide any compression garments?
We apply ABDS, kirlex or webroll, and ACE bandages during surgery. We then transition patients to their own compression garments. We do not provide specific compression garments for patients.
15. Note that my height will make it difficult for me to wear store bought compression garments.
There are many online specialty compression brands that may be able to for your with custom compression garments based on your body habitus.
16. What are the risks of lipedema surgery?
As risks cannot be avoided, our strategy is to minimize risk.
We minimize the risk of infection using peri-operative antibiotics. Antibiotics are administered as a patient is going asleep, before surgical start time.
We minimize the risk of bleeding by using tranexamic acid, a medication that inhibits the breakdown of clot.
We minimize bleeding by using a Mercedes tip liposuction cannula, which we find to be less traumatic than a basket tip. We also use a super-wet tumescent liposuction technique that decreases bleeding while improving fat removal.
We minimize the risk of seromas using compression bandages.
We minimize the risk of deep vein thrombosis by early ambulation, and by a pharmacological prevention strategy.
17. Am I a candidate for surgery?
Patients should obtain a diagnosis from a non-surgical healthcare provider, be of otherwise reasonable health. The ideal candidate should have a body mass index of less than 45 and be able to walk a quarter of a mile (around a high school track). Ultimately, candidacy for surgery can only be determined with an in-person interview.
18. When can you do the surgery?
We are generally able to schedule patients for surgery within two months of their approval.
19. What order of body parts would you operate on first and why?
While everybody is different, the order of surgeries typically is front of the legs, arms with skin excisions, back of the legs, and thigh lift if needed.
20. How many surgeries do you think I’ll need?
This depends on severity of disease and goals. Most severe legs can be treated with two surgeries. A skin excision would be another procedure. Arms can generally be treated with one procedure. A panniculectomy (removal of stomach skin with fat) is generally a separate procedure.
21. Would you need to see me in person first?
We love our prospective patients and want to meet them!
We would not want to operate on a patient without meeting them first. We generally meet patients three times before surgery!
We recommend that you meet your surgeon in person before any surgery.
The first appointment has several goals. We must determine if the patient is a medical candidate for surgery. We must reach a “meeting of the minds.” We determine can be accomplished, and what cannot.
We generally have a second appointment about a month prior to surgery. At this preoperative appointment, we confirm our surgical plan and go over pre and postoperative instructions. The surgical plan can be tweaked as needed.
The morning of surgery, Dr. Domanski will meet you a third time, mark the areas of the body to be treated with a pen. At this time, patients may highlight an area of the body that they want Dr. Domanski to focus extra on.
22. What is the time-period between surgeries?
We typically let patients recover three months between surgeries. This is helpful in minimizing DVT (deep vein thrombosis, or blood clot risk).
If we are planning a subsequent surgery on the legs want all the swelling to be gone and a patient to have completely recovered from their surgery. For that reason, if a patient is treating both their arms and legs, we may do the front of the legs on one surgery, the arms three months later, and the back of the legs three months after that.
23. What hospital would the surgery take place in? (so I can find out from the hospital if they are in network)
We perform Lipedema surgeries at Inova Alexandria or Reston Hospital Center.
24. Are prior authorization or functional assessment required for the surgery?
Prior authorization from insurance is required. Functional assessment may be required for insurance purposes.
While we understand that lipedema impairs walking, patients should be able to walk around a high school track (1/4 of a mile) as patients who are unable to do this are at significantly higher risk of postoperative complications.
25. What type of anesthesia is used for this surgery?
General anesthesia is used. Patients are asleep, and do not feel or remember anything.
26. Do I need a pre-op check w/ my PCP or will that be done at the hospital where you operate?
Patients should be evaluated by their primary care physician about 30 days prior to surgery to be cleared and or medically optimized for surgery. For example, a patient may benefit from a change in their blood pressure medication.
We desire patients to have basic labs, including a complete blood count (CBC) and basic metabolic panel (BMP). Patients over age 50 should have an EKG. This information should be faxed to our office AND the hospital at least 2 weeks prior to surgery.
27. How do you ensure that patients have aesthetically pleasing results? Note that I’m more interested in getting rid of all the diseased fat so I lower my chances of regrowth.
Lipedema is different from aesthetic liposuction in that the goals of treatment are different. However, aesthetic results are important even in medical lipedema cases.
We minimize the risk of irregularities and contour deformities by using a delicate technique. For this reason, we prefer the Mercedes tip liposuction cannulas rather than the basket tip. We also use multiple access points to remove lipedema fat in an even manner. Furthermore, we focus on the parts of the body that bother patients the most, ensuring that we have a meeting of the minds in terms of reconstructive priorities and what we are willing to accept in terms of aesthetics.
28. How do you deal with excess loose skin?
Excess skin that can be pinched off between two fingers can generally be removed. Like a tailor removes extra fabric, a crease or incision line is required.
29. Do you do skin removal surgery after all the swelling goes down or at the same time as liposuction?
Our preference is to perform skin removal on the legs after swelling has resolved. Skin removal on the arms is performed at the same time as liposuction.
30. Without skin removal at the same time as Liposuction- would I have a greater chance of regrowth due to more “empty” space where Lipedema could grow?
The premise of this question does not address the pathophysiology of lipedema. Once lipedema fat cells are removed, the body does not produce more fat cells. However, whatever remaining fat cells present can swell, giving the appearance of adiposity. The space that is left after liposuction is not empty space like a vacuum but rather filled with fluid (swelling) that resorbs. Once the swelling is gone (fluid is resorbed), contraction of the skin is the result.
Therefore, the key to prevent recurrence is a healthy diet and appropriate compression.
31. Do you do skin removal at the same time as liposuction or do you do that as another surgery?
Our preference is to perform skin removal on the legs after swelling has resolved. Thus, liposuction of the legs and skin removal (thigh lift) are performed on separate days, generally 3-4 months apart. Skin removal on the arms is performed at the same time as liposuction.
32. How to best setup myself up for post-surgery success? I live alone.
As there can be medical contraindications to surgery (like a heart problem), there can be social contraindications to surgery (like a lack of social support). This is not a statement on the value of each patient as a person, but rather an affirmation that without proper planning, we can expect problems – and we don’t like problems.
We require a patient to have a responsible adult (not an Uber driver) to take them home after surgery. This responsible adult should be with the patient for at least 24 hours after they go home. The patient should also have access to a responsible adult who can help with any issues such as dressing changes for the first two weeks.
It may be a good strategy to prepare dressings supplies, food and groceries a head of time.
33. What are your aftercare and follow-up protocols? How much pain should I expect and for how long?
We frequently have our patients on an antibiotic to minimize the risk of infection, a blood thinner to minimize DVT (blood clot) risk, and compression to minimize the risk of seromas.
We minimize pain by using a numbing medication in the tumescent as part of the lipedema removal surgery. In the days after surgery, pain is typically managed by prescription medication for the first couple of days. Most patients transition to Tylenol and or ibuprofen and use a prescription medication only at night for a couple of more days. We have seen some patients be off all prescription medications and driving at one week, while others have required 2-3 weeks before they can drive.
Our goal is for pain to be manageable with minimal side effects.
34. How to manage sensory anxiety issues and recovery (itchiness, tingling sensations)
Itching can be a side effect of prescription pain medication which cause a histamine release. Thus, we recommend over the counter anti-histamines as a first line therapy.
Tingling sensations are normal. This is often a sign of nerves “waking up” after surgery. If tingling sensations are severe, they can be decreased using muscle relaxants and anti-neuropathic pain medications.
35. What does the recovery process look like?
Our goal is for patients to be walking and getting back to their life at two weeks after surgery. As recovery is a gradual process, we anticipate patients getting back to their exercise routines, travel, and other responsibilities at 6-8 weeks.
36. How long do I spend in the hospital?
For patients undergoing over 5 liters of lipoaspirate, we routinely have them spend the night in the hospital. Treatment includes intravenous hydration, labs, and monitoring.
37. Lymphedema management: MLD? How soon after surgery and how often?
There are many types of manual lymphatic drainage as there is no standard approach. Some are more aggressive than others. If we are familiar with the physical therapist or certified lymphedema therapist, we are okay with starting therapy 2-4 weeks after surgery.
Pumps can be started as soon as the patient gets home and can be placed on top of the surgical compression. Vibration plate therapy can be started after a week.
38. Recommendations for a CLT (certified lymphedema therapist)?
Your certified lymphedema therapist should be near where you live, and you should be comfortable with their treatment approach.
39. When post-op should I start using my pump system?
Pumps can be started as soon as the patient gets home and can be placed on top of the surgical compression.
40. When post-op should I start MLD by a CLT?
If we are familiar with the physical therapist or certified lymphedema therapist, we are okay with starting therapy 2-4 weeks after surgery.
41. How often should I see a CLT post-op?
It may be appropriate to visit a CLT (certified lymphedema therapist) one to twice a week after surgery.
42. One of the plastic surgeons I have researched wants their patients to wait 30 days to start MLD so everything firms up and creates natural self-compression.
Every surgeon has their own reasons for their recommendations. As a surgeon, I would defer to the judgement of your surgeon.
43. What measures do you take to make sure someone is comfortable enough post-surgery?
Lidocaine in the tumescent, pain medication, and compression.
44. I sleep on my sides and don’t think I can sleep on my back.
If you must sleep on your sides, then let your surgeon know, and we can adjust the treatment plan to enable you to sleep on your side.
45. How do you help patients with really bad anxiety?
By listening, being kind, and respect a patient’s autonomy.
If anxiety is so severe that a meaningful level of trust cannot be obtained, we defer surgery until the anxiety is better controlled by the patient’s primary care or mental health practitioner.
We view mental health issues just like any other medical condition. As we would not operate on a patient with an unstable heart condition, we cannot operate on someone with an unstable mental health condition. Thankfully, both heart and mental health conditions are treatable.
46. What tools do you suggest they get for immediate post-op recovery?
Social support, having one’s prescriptions and supplies ready, and the right mindset.
Will I need a home health aid to help me out? Can you recommend a home health aid and how often would I need him/ her?
You will need someone to drive you from the hospital, be with you for the first 24 hours, help with daily dressing changes, and possibly some errands for the first two weeks.
47. Can you tell me about how I might experience my nerves regrowing? I’ve heard horrible stories about people feeling like they’re getting continuously shocked or that there’s water constantly running though their muscles.
Shooting pains is a normal part of recovery. If severe, they can be treated with neuropathic medication that is specific for this type of pain.
48. How would post-surgical complications be dealt with?
First and foremost, by prevention.
However, as it is not possible to drive without having a fender bender, flat tire, or issue with a car, it is not possible to operate without ever having a complication. Thus, preparation and planning are the key.
Board certified plastic surgeons are required to have hospital admitting privileges to care for their patients in case of re-admission.
Plastic surgeons undergo years of intense training requiring knowledge of aesthetics, but also reconstructive surgery. Plastic surgeons have experience treating patients after motorcycle accidents, burns, and gunshots. Therefore, plastic surgeons are experienced professionals that have the skill to take care of post-surgical complications arising from lipedema treatment.
Treatments for lipedema complications may include drainage of seromas (in the office), antibiotics, wound care, or hydration.
49. Is there somebody who I can call with questions about anything post-surgery?
The office is available to answer questions during business hours. A surgeon is available after hours for emergencies.
In the case of a life-threatening emergency, going to the emergency room or calling 911 is recommended.
50. How quickly does that person answer the phone or video or emails with photos?
We try to pick up our phone by the third ring. The doctor should be able to review critical findings the same day.
51. What measures do patients need to take post-surgery for best results?
We often suggest patients take an iron supplement after surgery to help blood counts recover faster.
Compression is important but should not be too tight as we have seen patients develop marks from over aggressive compression.
52. Compression: Do you provide post-surgery compression garments that will fit my specific measurements? (I’m super short- 4′ 9″)
We use ACE bandages as they are readily available in the hospital and the nursing staff is familiar with them. ACE bandages allow compression of various body types. ACE bandages allow the nurses to perform a first dressing change the morning after surgery.
We have the patient transition to their own compression garments on the second or third day after surgery, when patients are at home.
We recommend patients purchase their compression garments before surgery directly from suppliers.
53. How long post op do I have to wear compression garments. Keeping in mind that I live with lymphedema.
Compression garments are some of the most effective treatments for lymphedema. While liposuction can help with lymphedema, patients may still need compression garments lifelong.
As for lipedema patients, we recommend patients use compression as long as they feel they are helpful. As different bodies respond differently, we can’t give a blanket recommendation for every patient with every body type.
Thank you for reviewing this questionnaire. As a service to the lipedema community, I am committed to providing my honest, clear, professional opinion. I look forward to being a part of your future care.
Sincerely,
Mark Domanski
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 diet. Avoid 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:
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. Read more about Insurance Coverage For Lipedema Surgery.
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. You will be given a detailed Lipedema Pre- and Post-Op instructions.
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.
You can read our Lipedema Pre- and Post Op Instructions.
Dr. Domanski’s surgical skills are complemented by his compassionate bedside manner. He got me through a scary situation, and really listened to what I had to say. A winning combination of art and science and an excellent medical practitioner..
I am so happy with my results from Dr. Mark Domanski. I look so natural, all my friends are amazed. Would highly recommend
Had a great experience getting filler with Dr. Domanski. He took time explaining the processes and listened to exactly what I wanted. Loving the result!
I’m super picky about who I go to for beauty work. I’m just that person that does months and even years of research before choosing a doctor. Let me be the one to tell you that Dr. Mark Domanski is AMAZING! He is simply the best I’ve ever met. (…)
Dr. Domanski is such a skilled Professional. He makes you feel and look amazing, and always remembers me, and my friends who I have sent to him. He is extremely personable, which is rare these days. Go see him and you’ll definitely want to make it part of your routine:) Thanks Dr. D!
Dr. Domanski worked his magic and I am thrilled with the results. I highly recommend him for all your cosmetic needs!
“Be Yourself,
Everyone Else Is Taken.”
– Oscar Wilde