Liposuction with lipedema: Q & A with dr. Amron

We’ve covered liposuction in the past. There are still many questions, but we're no doctors and can only speak from experience. Therefore we’re proud to announce that we found dr. Amron willing to answer our questions. The ladies at Lipese Challenge, our chatgroup on Facebook, were given the opportunity to send in their questions. Below you find dr. Amron’s expert view on the issues raised. At the bottom of the Q&A you can read more about dr. Amron and his background.

1. Does medical insurance cover liposuction?

Insurance companies in the United States are very difficult to work with, and for the most part, they’re not covering liposuction surgery for lipedema. Several patients around the country have been successful getting their surgeries covered, however, most of this comes from the patient’s persistence after surgery to seek reimbursement.

When patients are successful, it’s typically through gathering a lot of support and recommendations from numerous physicians they’ve seen – these doctors explain liposuction was medically necessary in their cases. So, it would be helpful to seek medical specialists in this regard, as well as have complete reports from the physician who performs the surgery.

Right now, the majority of the general public has never heard of this disease, and even a lot of physicians and surgeons haven’t either. That being said, insurance companies aren’t recognizing it as a unique condition that needs to be covered. Hopefully things will change once there’s greater recognition of lipedema.

I’m working to increase public awareness of lipedema in various ways, with hopes it will soon translate into insurance companies recognizing it as a disease that needs to be covered, so no one is forced to suffer due to financial constraints.

2. Describe the procedure you use for liposuction on patients with lipedema.

Curing lipedema is extremely rare, and various medical treatments have been met with limited success. The only real possible cures, which I perform in my practice, are water-assisted liposuction (WAL) and tumescent lymphatic-sparing liposuction, which many surgeons are reluctant to perform.

There are several advantages to performing tumescent lymphatic-sparing liposuction to treat lipedema patients. First, it’s much safer as an approach, and as mentioned, it’s lymphatic sparing. Second, it helps prepare the tissue by reducing the bleeding during the surgery and getting a much more pure removal of the fat. Lastly, it’s very important in terms of patient positioning, which is vital to lipo-sculpture, especially with lipedema patients.

The reasoning for many surgeons’ reluctance to treat lipedema with liposuction is likely because these are very complicated areas we’re dealing with. The calves, ankles and anterior thighs are areas most liposuction surgeons who do liposuction tend to avoid, even in non-lipedema patients, as these areas are very prone to irregularities and are technically very difficult to treat.

3. You offer a procedure that is touted as lymph sparing. What makes it lymph sparing?

One of the most crucial elements of liposuction for lipedema patients is that the surgeon approaches it in a lymphatic-sparing way, with respect and care for the patient’s deeper lymphatics.

I strongly believe doing the surgery under purely tumescent local anesthesia is the best approach for not only lipedema patients, but for all liposuction patients.

When a surgery is performed under local anesthesia, the surgeon is forced to stay only within the subcutaneous layer of fat between the skin and muscle where there are no major lymphatics.          

Damage to the lymphatic system usually occurs when the patient is under general anesthesia and the surgeon has gone into areas that are deeper than the anesthesia allows.

However, under local anesthesia, that situation is almost impossible. If the surgeon were to go outside of the field of anesthesia, which is the fat layer, the patient will absolutely be able to feel the surgeon. So, by doing it under local anesthesia, it really is lymphatic-sparing because the surgeon is forced to stay within the appropriate layers of the body, ensuring there’s no damage to a person’s lymphatics. 

4. Can liposuction be performed on patients with stage three or four lipedema, or even when they have lipo-lymphedema?

Yes, patients with stage three lipedema, stage four lipedema and even patients with lipo-lymphedema can have liposuction. However, these patients need more specific care both preoperatively and postoperatively.

It’s important to wait longer between surgeries for stage three and stage four lipedema patients, as well as for lipo-lymphedema patients. In stage one or stage two patients, I’ll perform sequential surgeries fairly close together.  But, for patients who have more advanced cases, I’ll wait about four weeks between surgeries, and sometimes possibly a bit longer. It will always vary depending on the case and the patient.

Also, with patients who have more advanced lipedema, it’s really crucial to properly bandage them with compression therapy after the surgery. Furthermore, I strongly encourage and recommend my patients have proper care for manual lymphatic drainage (MLD) by Vodder trained lymphatic specialists.

5. What are your aftercare procedures for lipedema patients who’ve had liposuction?

I’m still continuing to refine my patient-aftercare technique specifically for those with lipedema, but it all depends on the stage of condition. For stage one patients, most do completely fine with the typical compression garments for liposuction. Certainly MLD can hasten the resolution of some of the swelling, but it’s not as vital as it is for patients with more advanced stages of lipedema.

Stage two patients are usually bandaged and wrapped right after surgery, and follow up with a trained MLD therapist for compression therapy thereafter. Postoperative care is essential regarding patients recovering from the third stage of lipedema, or lipo-lymphedema, and I work very closely with Vodder trained MLD specialists.

As you move into the third stage of lipedema or lipo-lymphedema, it’s important to wait approximately four weeks between surgeries. Postoperative care at this point in the disease is extremely important, and I work very closely with Vodder trained MLD specialists.

6. Does the fat grow back after liposuction? Is there something we can do to prevent regaining fat on the legs?

With my aesthetic liposuction patients, my answer is normally a flat-out “no”, the fat will not return to the areas where liposuction is done properly. However, in lipedema patients, I do think there’s potential for the fat to return. In my experience treating lipedema with liposuction, I’ve never seen it happen to any patients of my practice. However, I’ve heard stories from other patients about fat growing back. It’s possible that the procedure was not done as completely as it should have been, and that left fat in the body to duplicate.

Ultimately, this question cannot be answered with complete certainty, but there is a possibility that lipedema patients could theoretically see fat regrow in areas if liposuction surgery is not done properly.

7. What is the long-term effect of surgery? Are there reports of lipedema patients 5-10 years after liposuction surgery?

If liposuction surgery is done properly, patients will not have any more of the diseased fat in their body, and they will continue on with normal lifestyles.

In lipedema patients there’s an aspect of hypertrophy, which means growth of new fat tissue. That said, in theory the fat could come back years later, but since I’ve known of lipedema, I’ve never seen the fat return.

Certainly, if there’s a component of lymphedema along with the swelling that comes along with lipedema, I do expect the fat component to return. For your average lipedema patient, however, the fat should not return in the long run.

I’m fairly certain there are no studies in the United States addressing the long-term benefit of liposuction for lipedema, and this is research that certainly needs to be done.

8. Should liposuction leave women with sagging skin, what are our options to fix that?

Whether it’s for lipedema or not, liposuction should always cause tightening of the skin. However, when someone has a lot of redundant loose skin, the surgeon has to be careful of how much retraction of the skin he or she is going for.

After liposuction surgery, if someone already has a lot of loose skin to begin with, there may be a need for a subsequent body lifting procedure, such as a thigh lift. It’s very important to consult with a surgeon who has vast experience in body lifting procedures, and has an understanding of the specific limitations of a lipedema and/or lipo-lymphedema patient.

9. How young can liposuction be performed for lipedema patients?

In most patients, the disproportionate storage of fat is already set in place in the middle of their teenage years typically, after they’ve started their menstrual cycles. That’s generally the youngest age I will perform liposuction on a patient, and I would apply that age range to lipedema patients, too. If lipedema has been already been diagnosed and there’s disproportion in place, quite honestly, the earlier it’s targeted, the better. This will prevent it from advancing to its later stages.

About Dr. David Amron

Dr. David Amron, M.D., is a board-certified dermatologic and cosmetic surgeon with two decades of experience and specialization in all aspects of liposuction surgery. He is medical director of the Roxbury Institute in Beverly Hills, CA.  Amron has an international reputation for excellence in complicated liposuction cases and revision liposuction surgery. His unique approach to difficult-to-treat areas, as well as lipedema, has been extensively featured in the media. His years of surgical experience, specifically with liposuction, along with his skilled artistry and refined judgment, are an essential part of the care he brings to the treatment of every lipedema patient.

Passionate about education, Amron regularly publishes articles and videos, and has contributed content to various medical textbooks and media outlets including the Wall Street Journal, Los Angeles Times and Cosmopolitan. Entertainment Tonight calls Dr. Amron “Guru of Liposuction,” and he’s been featured on programs such as Discovery Channel, the Today Show, Good Morning America, CNN, BBC, 60 minutes Australia, Extra, Inside Edition, VH1, ABC News and more.

Amron attended both UCLA and UC San Diego, where he received his bachelor’s degree. After earning a medical degree from Albert Einstein College of Medicine in New York, Amron returned to Southern California, where he continued his residency at UC San Diego and research fellowship at UCLA.

Stay in touch with Dr. Amron by following him on Twitter, Facebook and Google +

Be sure to stay educated and informed – check out Dr. Amron’s RealSelf profile, YouTube and issuu for lipedema and liposuction blogs.

What to consider when searching for a surgeon to perform liposuction

This blog could never cover everything relevant, but it's a start, coming from personal experience and what else I learned along the way. I do not recommend liposuction. This blog does not provide tools to assess whether you should have liposuction. However, I receive many questions on where to start when considering liposuction and in that context I offer this information as food for thought. Preferrably, in an ideal world, you would be going over these issues with your informed doctor, or better yet with a specialist in a multidisciplinary institute, where they could answer all your questions and offer the treatment when considered a good candidate.

Learn what exactly you are looking for.
Liposuction, liposculpture, WAL, PAL, tumescent: are you still with me? It's ALL liposuction. All of it. And it's all tumescent. I love this quote of dr. P. Aldea:

"Tumescent liposuction is nothing but the universally performed pre-liposuction infiltration of the fat to be suctioned with a dilute solution of a local anesthetic (lidocain, marcain etc.) and adrenaline (epinephrine) which increases the accuracy of fat removal, largely reduced blood losses AND increases patient comfort."

Source: http://www.realself.com/question/tumesecent-liposuction-general-local-anesthesia

As dr. Aldea puts it: the anesthesia is supplemented. Meaning: tumescent infiltration of the area to be suctioned is a given, but the type of anesthesia is a matter of choice. But mostly not the patient's choice. I'll get back on that.

PAL, WAL, UAL, LA etc.
Along with tumescent, there often are additional specifications regarding the technique a surgeon applies. They can use a specific suction device like Power Assisted (PAL) or apply a thin water beam to help losen the fat from the tissue: Water Assisted Liposuction (WAL). There are more flavors out there. I highlighted PAL and WAL, because lately these are frequently mentioned on patient forums. However, as you can read through the link, these are not the only options.

As you can read they all are presumed to have their merits and do something specific to spare the lymph, do minimal damage, minimize risk etc. Ask a surgeon which is best and you'll get an answer. Ask another surgeon and you'll get another answer.

As a layman I noticed the difference of opinion between professionals and let it be. A certain surgeon prefers a certain technique. Well, apparently that technique suits him/her best. My personal choice was to get over the various terms which I could only ever understand superficially and looked at the surgeon's track record instead: knowledge of lipedema and years of experience. After all: the tool doesn't define the result; it's the surgeon's skill in using the tool.

Note: there's more research out there now compared to the time I had my procedures. If you want to know more about a particular technique and how it works compared to an other or the "plain" technique, there's far more information to be found. Go straight for the "boring" stuff: formal publications, in order to avoid information designed as a scientific-looking piece of marketing. The quickest way to cut to the chase is to search through Google Scholar. It only contains scientific publications.

Plastic surgeon or cosmetic surgeon
A plastic surgeon is trained in hospitals by professionals and has completed related residencies. Cosmetic surgery is not taught through residency programs. Doctors seeking to learn cosmetic surgery typically get their training after their residencies. This pretty much means a doctor would need to organize his/her own training and has a certain freedom the raise the bar to his/her liking. Cosmetic surgery is practised by doctors from a variety of medical fields. Read more about the differences here.

However, deciding between a plastic surgeon or a cosmetic surgeon based on the title only is a trick question. Plastic surgery does NOT equal (knowledge of) liposuction. There are numerous specialties within plastic surgery. Plastic surgery is first and foremost focused on reconstruction of defects due to disorders you are born with, trauma, burns and disease. Lipedema qualifies as a 'disease'. Care to guess how many hospitals acknowledge the condition and offer liposuction as a treatment option? Few. Very few. As a consequence there are few well-trained and informed plastic surgeons out there. For reference: tumescent, which is raved about as a major improvement to liposuction surgery, is invented by an American dermatologist, dr. Klein.

When considering a surgeon you best look at expertise and experience. While you're at it, also look at client/patient reviews. In that context, beware of posers, pretending to be content patients. In the past some clinics have used this despicable method to lure clients. It may still occur...

To improve cosmetically or to improve mobility and reduce pain
This is not about starting a debate. Your body, your choice. It's just very important to find out where your priority is and whether that priority matches with the surgeon you're considering for the job. It's not either/or per se. It can be a little of both. But trust me: there are surgeons out there with a 100% focus on mobility and they will NOT be open to a post-op debate over looks. Even when the result is very uneven and/or irregular. There's also the patient who, in her heart, wants killer legs (back). Again, not judging. Just make sure you set out for a realistic goal with a surgeon who is able and willing to help you strive for that goal. Strive, yes. We're quite the canvas to work with. It's no exact science.

You want a good or even super cosmetic result?
Ask. Ask for pre-op and post-op pictures of women much like you: size, build, with lipedema. Don't let the surgeon just show you his/her best work ever on young ladies with little excess fat and lovely elastic skin. There's skin elasticity and the condition of your connective tissue to consider. Ask about your personal possibilities and impossibilities and, if needed, try to adjust your expectations. It's better to know before than after when there's no going back.

Look for a surgeon with knowledge of lipedema
Typically, those seeking liposuction for purely cosmetic reasons need to have little fat removed. It's not designed as weight loss surgery. Many surgeons even refuse to operate when the BMI is on the high end. Many of these surgeons commonly remove 1 liter, maybe 2 per surgery. A drop in the bucket for most of us. We need someone who can and will remove more.

He/she would have to be aware of the fact that we need to be especially careful with our sluggish and sometimes already compromised lymphatic system. As well as: possible poor skin elasticity, weak connective tissue and possibly slower healing.

General anesthesia or local
General anesthesia in itself poses a (small) risk, on top of the risks inherent to liposuction. You can draw the line there or you can reason that didn't stop you in the past to, say, have your appendix removed.

General anesthesia burdens your body. When I insisted on general anesthesia myself in an entirely different procedure, my surgeon warned me it would take me more time to recuperate afterwards compared to undergoing the same procedure with an epidural. It simply adds to what your body needs to process when healing. Local anesthesia is also favored by some to have the patient able to move and, if need be, stand to assess the evenness of the result. On the other hand, the prospect of enduring the procedure wide awake can be stressfull. Maybe too stressfull for some.

If you are to opt for general anesthesia, you may need to look a little harder for a suitable surgeon. Many clinics can't or won't offer general anesthesia. It requires additional facilities, knowledge and assistance during the procedure. If not that, some surgeons truly want you awake to monitor your wellbeing themselves and have you participating by moving during the procedure.

Pre-op and post-op care
What is being checked and looked into to dertermine you are a suitable candidate? Is it thorough? Do you have a good feeling about this? Do you know the basics and were provided with information on how to prepare for the procedure, what to expect and how to arrange care post-op? How can you reach the clinic when you (feel) you need to? What if post-op complications arise? Who covers these expenses? Where can you turn to? This is particularly relevant if your surgeon is far from your home and you travel back soon after the procedure. At the same time: don't wait to be asked about specifics. Share your medical history and use of medication in detail.

Do inform your primary, even if he/she doesn't support the idea. Make sure they understand what you embark on so they can help in case of problems.
Obvious stuff? Sadly no. I still read about questions like: "Is it normal to still have swelling after a week" and "Is it normal the cuts ooze". That's basic stuff. You should be told about this sort of thing in advance.

Insurance
In rare cases the procedure is covered. Ask around on forum if someone from your country managed to get it covered and what they did. Even if the odds are slim, consider trying. Health Insurance companies need to become aware of lipedema and liposuction as a serious treatment option.

Also, think how far you want to take this. Going ahead with the surgery while still butting heads with your health insurance may ruin your chances of coverage. It may also lead to a road where you can't have the procedure done by your surgeon of your choice. Ask around. Patient forums on for instance Facebook are a wonderful source of practical information.