Lymphatic Sparing Liposuction

Liposuction, also known as suction lipectomy, is the most common cosmetic procedure performed today. It can be executed in various ways, utilizing different cannula sizes and types, including laser liposuction, ultrasonic liposuction, dry versus wet liposuction, power-assisted, water-assisted techniques, and many other liposuction devices. Each of these techniques serves specific purposes and applications.

However, it’s crucial to understand that liposuction for lipedema, often referred to as lipedema liposuction, is not a cosmetic operation. This procedure is performed for therapeutic or functional reasons. The reduction in fat volume achieved through liposuction leads to the decongestion of lymphatic channels and vessels, ultimately decreasing pain. That said, the patient will see a significant cosmetic improvement after lipedema liposuction. Many, many liters of lipedema fat are removed with each liposuction session and the patient will see an immediate reduction in volume and diameter of the legs and/or arms. And while this reduction in volume provides a beautiful cosmetic result, the purpose of removing this much lipedema fat is to decrease the lymphatic congestion and improve the symptoms of lipedema.

To effectively perform liposuction for lipedema, specialized techniques must be employed. Most importantly, the infiltration of lipedema tissue with tumescent fluid aims to separate the edematous fat from the surrounding tissues while preserving lymphatic channels. This can be accomplished using a dual infiltration cannula or a water-assisted liposuction device. This is the primary difference between WAL or water-assisted liposuction and other tumescent techniques such as PAL. In my opinion, PAL offers distinct advantages over WAL. I prefer to infiltrate the tissue with tumescent fluid then allow the tumescent fluid to take it’s effect on the lipedema tissue. Giving the tumescent fluid 15-20 minutes allows for better separation of the fat from the surrounding tissues, improved numbing effects of the lidocaine solution, and enhanced vasoconstriction/hemostasis due to the epinephrine in the tumescent solution.

This lipedema liposuction is carried out in a specific linear fashion, following but never crossing the direction of lymphatic channels. This innovative technique was pioneered in Europe and is practiced by some of the top lipedema surgeons worldwide. Incisions for lipedema liposuction are strategically placed to avoid crossing lymphatic channels, with the primary goal of decongesting and reducing edema. When performed correctly with a small or thin traumatic liposuction cannula, significant volumes of lipedema fat can be removed in a single procedure. This results in an incredible reduction in volume, alleviation of edema, and improved lymphatic congestion for the patient

Step-by-Step Procedure for Lymphatic Sparing Lipedema Liposuction

Step 1: Preoperative Preparation

Greet the patient in the morning.
Answer any questions the patient or her family members may have.
Take standard preoperative photographs.
Mark the areas that will be treated.

Step 2: Procedure Room Setup

Take the patient to the procedure room.
Start an IV for anesthesia.
The procedure will be performed under either sedation or Total Intravenous Anesthesia (TIVA).
Once the patient is sedated, prep the legs in a sterile fashion using Betadine.
Lift both legs and place a sterile drape underneath.

Step 3: Infiltration of Tumescent Solution

Create small wheals of 1% lidocaine with epinephrine at the liposuction incision sites.
Using an 11-blade scalpel, make a small nick in the skin at each wheal.
Introduce an infiltration cannula into the subcutaneous tissue.
Infiltrate a tumescent solution containing:
1 liter of saline
20 cc of 1% lidocaine
1 amp of epinephrine, diluted in 1 liter of sterile saline.
For the first stage (lower legs and knees), begin infiltrating at the ankles with the tumescent solution circumferentially, extending upwards to the medial and lateral knee and posterior knee.
Allow time for the tumescent fluid to take effect, which will help separate fatty tissue from surrounding muscle and subcutaneous tissues, provide local anesthesia, and allow for hemostasis by constricting small blood vessels.

Step 4: Liposuction Procedure

Using a 3 or 4 mm cannula with a power-assisted liposuction device, perform linear lymphatic sparing liposuction.
The goal is to preserve lymphatic vessels, decongest lymphatic pathways, and remove significant volumes of lipedema fat.
Conduct the liposuction circumferentially, aiming to remove as much affected edema fat as possible, which may appear as lipomatous fat.
If large nodules are encountered, make small incisions over these nodules to remove them manually.
For diffuse and small nodules, proceed with caution, as they may not require individual removal.

Step 5: Closing Incisions

Once the circumferential section is complete, close the small skin incisions with fine removable sutures.
Step 6: Postoperative Care
Wash the patient’s legs free of any Betadine prep solution and dry them carefully.
Wrap the legs from the bottom up to minimize postoperative swelling.
Transfer the patient to the recovery area for monitoring before discharge.### Advantages and Disadvantages of Anterior-

Two Approaches to Staging Lipedema Liposuction:

There are two basic approaches regarding how to stage lipedema liposuction. The reason for staging is that a great deal of fat is typically removed during each stage, and doing too many areas at once increases the complication rate. There are safety guidelines in place which limit the amount of lip-aspirate (the amount of fat removed) during a single session of liposuction. These safety guidelines were established because exceeding these amounts is associated with fluid shifts in the body and can cause a variety of issues, including a dilutional drop in hemoglobin and hematocrit. We typically break the procedures into 3-5 stages, depending on the amount of lipedema fat in each area. By doing the lipedema liposuction in stages spaced 6 weeks or more apart, the procedures are extremely safe and we avoid these fluid shifts.

Anterior-Posterior Approach

With this approach, the entire anterior (front) of both legs from the thighs down to the ankles are liposuctioned during one stage. After 4 weeks or more the patient returns to have liposuction of the entire posterior of the both legs.

One of the advantages of this approach is the potential for fewer stages but I feel very strongly that the risks of this approach outweigh the rewards. In lipedema stage 2, 3, or 4 patients, there is typically a great deal of lipedema fat in the lower legs and thighs. Performing liposuction of the entire anterior lower leg and thigh in these patients would often exceed the safety parameters for a single procedure.

Another major concern with this approach is the potential risk of lidocaine toxicity when performing extensive liposuction. The use of tumescent fluid, which contains lidocaine for local anesthesia and hydro dissection, necessitates careful dosage management.

Lidocaine has specific safe dosage limits (35 to 45 mg per kilogram). When treating a patient with stage two or higher lipedema, the amount of tumescent fluid needed can exceed safe limits, particularly if more than 5 liters are required for procedure completion. For these reasons I do not use the anterior-posterior approach when it comes to lipedema liposuction.

Segmental Approach

I believe that the segmental approach to lipedema liposuction is superior because it avoids complications such as the risk of lidocaine toxicity or excess fat removal in a single stage. With the segmental approach I divide the legs and arms into segments and approach each as it’s own stage. For example I may do lipedema liposuction of the lower legs (calves and ankles) and knees in a single stage. The patient will recover from this procedure and begin using compression garments and wraps before we move onto the next stage, which may be entire thighs, or we may divide the thighs into anterior and posterior depending on how much fat will be removed. By limiting the treatment to specific segments (like the lower legs and knees), the segmental approach significantly reduces the volume of tumescent fluid required—typically not exceeding 5-7 liters for a single stage. This minimizes the risk of lidocaine toxicity and allows for safer outpatient procedures. This method permits the safe removal of 5 to 7 liters of lipedema fat in one stage without concerns about fluid shifts or anemia, ensuring better patient safety.

Tailored Treatment

The segmental approach allows for a more individualized treatment plan, addressing areas based on the patient’s specific needs and the volume of fat present. This flexibility can lead to improved outcomes and satisfaction.

Disadvantages

The primary disadvantage of the segmental approach is that it requires multiple stages of liposuction. When it comes to lipedema treatment I actually see this staging as an advantage but I understand that patients would like to undergo as few procedures as possible.

Conclusion

Both the anterior-posterior and segmental approaches to lymphatic sparing liposuction for lipedema have their advantages and disadvantages. The anterior-posterior method offers a comprehensive treatment in one session but carries risks associated with lidocaine toxicity and excessive fat removal. Conversely, the segmental approach promotes safer, more manageable procedures with less risk of complications, although it may require multiple treatment stages.

Postoperative Care for Lipedema Liposuction

Compression Garment: It is essential to wear a compression garment 24/7, except during showering. This helps reduce swelling and supports the healing process.
Wraps: In addition to the compression garment, use elastic ACE wraps around the feet, extending all the way up to the knee joint. A wrap width of 3 to 4 inches is typically recommended, and you may need two wraps per leg.
Duration: Maintain the use of compression garments and wraps for at least eight weeks, though it may extend up to three months, depending on individual healing.
Manual Drainage Therapy: Schedule manual drainage therapy sessions twice a week starting one week prior to the procedure and continuing for four weeks afterward.
Spacing Between Procedures: It is advisable to have at least 4 to 6 weeks between consecutive procedures to ensure optimal recovery.

Following these guidelines will assist in achieving the best outcomes after lipedema liposuction.

Lymphatic Sparing Liposuction