What are lipedema and lymphedema?
Lipedema and Lymphedema 2 often coexisting conditions that are very prevalent in patients that are otherwise known as the “fat leg syndromes”, because they all result in swollen, “column like” legs that result in patients being heavier from the waist down, despite being lean from the waist up.
What are the symptoms of lipedema and lymphedema and how are they diagnosed?
The typical external appearance, as well as easy bruising, pain and tenderness of the legs, as well as the inability to stop soft tissue swelling and growth even with calorie restriction is critical to the diagnosis of these problems. Not every patient with legs that appear this way are diagnosed with every condition, and very often several diagnostic tests must be performed to diagnose them correctly. Patients may undergo dieting, heavy exercise, and other caloric restriction, and often experience continued growth, particularly of fatty tissue, and especially in the hip and leg area. These diseases often coexist, and the approach to treatment must evaluate for the root cause, as well as other secondary problems the patient may have as a result of the primary disease process.
Lipedema is a disease, which is largely hereditary, but inherited in various levels of expression, which causes in most cases disproportionate fatty tissue deposits, in a symmetric fashion from the hip to the ankle. Most often, the feet are normal, and the rest of the body is not affected to such a significant degree. In the early stages, patients mostly just notice that maybe their ankles are not quite as thin as they would like them to be, or their legs have a “column-like” appearance, but very often this is the only manifestation. Typically, they bruise very easily, and spider veins as well as varicose veins will form in the fragile tissue of the legs.
In the later stages of disease, the legs become more and more swollen, andoften the excess fatty tissue in the lower legs causes compression of veins, as well as lymphatic vessels, making patients more prone to skin breakdown, infections, and immobility. Many patients never progress to this more severe stage, but for those that do, at times the damage is quite noticeable.
Lymphedema is the blockage of lymphatic vessels (the vessels that return tissue fluid back to the heart from the legs and arms) causing swelling in the arms or legs. The lymphatic system works together with the venous circulation to return fluid to the heart. Unlike pure lipedema, in lymphedema, swelling persists past the ankle and most often into the foot as well. Lymphedema can be due to previous surgery, infectious causes, scar tissue, or vein problems. The key differentiation to lipedema and lymphedema is lymphedema always involves the foot when it comes to the legs.
Do you always have to have only one of these conditions?
Absolutely not. Very often, they exist together. Why? Simple. Lipedema is the overgrowth of fatty tissue in a bodily compartment, most often the legs. In these compartments, there are several different components. Typically, this is made up of muscle, blood vessels, nerves, and lymphatic vessels. When the compartment is overstuffed by the tissue that accumulates in lipedema, the other components get compressed, often resulting in injury. The most sensitive components to compression injury include veins and lymphatic vessels, which is why very often in patients with more severe lipedema, abundant varicose veins and swelling begin to manifest in later stages.
How can I be checked?
Screening for these diseases is quite simple, non-invasive, and painless. Typically, a thorough physical exam is performed, by a physician who is very familiar with these conditions. A duplex ultrasound is often performed as well, which is a non-invasive test that uses high resolution, dynamic ultrasound imaging to visualize the blood vessels in the leg and document their function. From this test, we can often assess how much of the disease is due to vascular, lymphatic, or fatty tissue, as well as determine the adequacy of your circulation to heal wounds if surgery is planned.
What options are there for treatment?
As with most medical problems, there are two main options – surgical and non-surgical. Non-surgical management in most cases consists of various forms of physical therapy, most commonly “MLD” or “manual lymphatic drainage”. While MLD often makes the legs transiently better, you must realize that the core problem with this disease, is excess soft tissue and fluid which does not improve significantly without surgery. In general, we decide how aggressive to be based on the patient’s symptoms and desires. In patients who are not significantly affected, most often we take a conservative, non-surgical approach. In patients that are suffering severe symptoms, we are typically more aggressive. Some patients may not have severe symptoms, but be very traumatized by the aesthetic disturbance to their legs, and opt to pursue surgical treatment sooner.
What are the surgical options?
In general, surgery for lipedema is quite minimally invasive, but like any other surgical endeavor, the level of intensity is largely based on the severity of the problem at hand. There are two main arms to treatment, microcannula liposuction (of various types) and surgical contouring. The two main types of liposuction we use at NYC Surgical are water jet assisted liposuction and VASER liposuction. Both of these use very small, gentle micro cannulas, not the traditional larger sized cannulas, and scarring and trauma is in general much less.
Water jet is a more gentle type of liposuction that has a reputation for not damaging lymphatics as much as traditional liposuction, and we use it for specific areas. It causes minimal skin tightening, and is quite time consuming, but for the correct application, it works well.
VASER is an energy based liposuction that uses ultrasound energy to liquefy fat and break it up for absorption. VASER has undergone several generations of improvement, and the latest hardware which we possess at NYC Surgical, is quite effective. It is very useful at breaking up scarred, fibrotic fat (which is often present in lipedema) with minimal trauma to the surrounding tissues. It allows a very controlled removal of the tissue, and helps significantly with skin tightening, which is a very helpful feature in some patients with lipedema,
especially those with less elastic skin.
In general, we pick the technique that matches the goals and patient, and at times, we use both in the same patient.
In patients with more severe disease, and tremendous amounts of skin laxity, no degree of skin tightening will address their issue completely, and surgical contouring, or resection of excess skin with reconstruction is needed.
Does insurance cover this surgery?
In general, it depends on the severity of your disease, and what you have done in the past to treat it without success. There are several criteria needed before submitting a claim to your insurance provider. If you have obtained all of these, and can document it with medical records, coverage is typically obtainable.
1. Severe pain and disability
2. Over 3 months for MLD without significant symptom improvement
3. Another outside MD who verifies your condition
4. A patient involved in discussing this with their insurance company
We have the resources to help you obtain insurance coverage (if possible) if you meet the criteria listed at NYC Surgical Associates.
What are the risks of surgery?
All surgery has risks of scarring, damage to adjacent structures, and bleeding, however the risks of microcannula liposuction of all types is largely quite small. Patients with lipedema are often much higher risks than the rest of the population in general because of the circulation problems that accompany the disease. There is always a small risk of lymphatic vessel damage, which we have never seen despite hundreds of cases done at NYC Surgical Associates, even in very high risk patients. Always pick the most experienced, capable surgeon that you have access to for the treatment of your problem.
What should I expect post-surgery?
Typically there are two or three post-surgical benefits. First, the amount of mass will be reduced. This will result in less pressure on your hip, knee and ankle joints as well as a less column like appearance. Second, you will have more mobility allowing you to move around more freely and in less pain. Third, any venous issues that you may have will be resolved resulting in less swelling and reduced possibility of a DVT. Overall you will be healthier and have the opportunity to start being more active in your daily activities.
What are the risks of not treating my disease?
In general, not catastrophic. Some patients present to us with very advanced disease and the question on whether to operate or not is very simple as a result. Most often, however, the condition progresses slowly over the course of several years, and not dramatically. These are rarely life threatening diseases, and cause mostly morbidity and distress. That being the case, rushing into this decision probably isn’t the right move. The perceived benefit for any surgery, is usually very closely correlated to how much distress the condition caused the patient. What this means is, a patient with a worse problem would be more satisfied than the patient with a lesser problem by the surgery, even with a similar outcome. Pick surgery when the condition is causing you a significant amount of distress. I want treatment, and I would like to obtain insurance coverage. What do I do now? We can help you. The first step is always to gather all medical records, if you meet the criteria listed. If you do not, you must go through the process, and ensure that you have all documentation present to support your case, much like a legal battle. We have a good network of both therapists and MDs who can help support your case if needed, but treatment must be completed as described. At the completion of all of your documentation, we will submit a complete packet for you. In most cases, a 3rd party arbitration company must be used, similar to a lawyer for a court case, to ensure your case is heard by your insurance company. We can assist you with recommendations for this, although we do not do this specifically. After the arbitration company submits your case, the time needed is approximately 6 months to gain approval. It Is a bit of a process, but often very worth it, especially in more severe patients that need several procedures.
I was approved for surgery! Now what?
In general, we start with correcting the circulation first, for two reasons. First, when circulation is not optimal, healing is always compromised. This is usually rather simple. Once the circulatory issues are corrected, we move on to the soft tissue problems and liposuction or body contouring, depending on which is the more prominent problem. For both of these procedures, typically 1-2 weeks is needed off of work. In all but the simplest cases, more than one procedure is needed, typically spaced at least a month apart, to allow for healing. This is a very “tailor-made” approach to your specific condition, as every single patient is completely different. Speak to your provider specifically about this plan.
Before & After
Lipedema Before & After Photos