LIPEDEMA SURGERY

In medical terminology, "edema" means swelling. For people who have lipedema (aka lipoedema), that swelling is caused by an overgrowth of fat cells, which can grow abnormally in size and number. The condition occurs almost exclusively in women and most often involves the buttocks, thighs, and calves, though the upper arms and torso can also be affected. 

The cause of lipedema is unclear, but the condition tends to run in families. A gene associated with lipedema, AKR1C1, was recently discovered. 

This medical condition often develops during times of hormone fluctuations, such as puberty, pregnancy, or menopause, so a hormonal connection is suspected. As we mentioned, inflammation also plays a role, as “a chronic inflammatory process leads to pain and disability, particularly in the extremities," says Dr. Schwartz. 

There are four stages of lipedema, according to the Cleveland Clinic. Symptoms range from normal-looking skin with a pebbly texture accompanied by possible pain and bruising to rectangular-shaped legs with protruding fat pads that make walking difficult.

The classic presentation is a woman with a small upper body and a disproportionately fatty lower body—in fact, it's not unusual for someone with this condition to be a size 4 top and size 14 bottom. Swelling can occur from the hips down to the ankles, and the legs often look column-like. 

Frequently, people with lipedema are misdiagnosed with obesity and told to go on a diet and exercise. "Awareness of lipedema is poor," says Dr. Wright. "Studies have shown that most physicians fail to recognize the disease in patients who present to them with symptoms. Many women are misdiagnosed as obese or having lymphedema."

Dr. Wright also cautions that "Some women are diagnosed with lipedema, even though they actually have another fat disorder. Finding a clinician who can recognize and expertly diagnose lipedema can be challenging. Specialists in venous, lymphatic, or physical medicine who focus on lymphedema can be very helpful in ensuring the proper diagnosis and treatment is started."

Lipedema fat doesn't readily respond to weight loss, Dr. Wright explains. "Lipedema fat is different biologically from non-lipedema fat. It is relatively resistant to weight loss and can proliferate with even a small calorie excess." 

That's because these rogue cells have extra fluid, which distorts the skin and changes its size, shape, color, texture, and sensitivity. Even lipedema patients who undergo bariatric surgery lose fat primarily from the waist up, while the legs keep the fatty tissue. 

This fat can be very tender and easily bruised if you apply pressure. The fat deposits can hurt for no apparent reason, and the skin can become thicker and less elastic. "The fluid buildup can cause chronic pressure and pain, especially if it's near a nerve," says Dr. Schwartz. 

Lipedema also often has an unusual texture within the fat that can feel like rice, peas, or walnuts beneath the surface of the skin. Referred to as “lipedema pearls,” these nodules are intertwined in other connective tissues and firmly attached to the skin.

• Average Cost:
• $16,208

• Range:
• $6,200 - $30,000

The price you pay will depend on:

• your surgeon's credentials and level of expertise
• the complexity of your procedure
• whether you need more than one procedure, to achieve your desired results
• the qualifications of your anesthesia provider
• whether you have your procedure performed at a hospital or surgery center

During your consultation, as for a personalized, all-in cost quote that includes any pre-op tests, the surgeon's fee, facility fee, anesthesia fees, the cost of surgical supplies, and follow-up care.

Also ask if you'll need to budget for prescription pain medication, compression garments, and other recovery supplies.

The lipedema surgery photos in our gallery have been shared by the surgeon who performed the procedure, with the patient's consent.

Until recently, insurance companies considered all liposuction—including surgical treatment of lipedema—elective cosmetic surgery and didn't approve coverage. 

Now, many insurance companies do consider it medically necessary when all criteria for a diagnosis of lipedema are met. 

There are many stipulations around this coverage, Dr. Wright explains. "The insurer may cover lipedema surgery in some but not all of the areas of the body where lipedema tissue can occur," he says. "Medical insurers only cover lipedema that is significantly impairing mobility and the ability to perform daily activities. Some insurers will not cover lipedema if you have a BMI over a certain number, unless you have had bariatric surgery."

According to Dr. Wright, all insurers also require a trial of three to six months of conservative treatment to manage symptoms. These conservative trials include diet changes, daily medical-grade compression stocking use, compression therapy, and/or manual lymphatic drainage. 

Even when you meet all the criteria of your insurer, they may only cover part of the cost of lipedema liposuction.

Talk with your insurer about their requirements for coverage. Your health care providers will then be able to assist you in providing documentation of your treatment and, if conservative measures don't work, why surgery is medically necessary for you.

Pros

• Lipedema surgery involving liposuction is the most effective treatment to alleviate the painful symptoms caused by lipedema.
• Quality of life usually improves greatly after surgery. "Lipedema surgery truly is a life-changing treatment," says Dr. Schwartz. "Most patients report a virtual vanishing of their pain immediately following surgery." It can also provide a huge boost in confidence and help patients lead a more active lifestyle.
• While there is some postsurgical discomfort (often described as a sore feeling), many patients consider it mild compared to the pain of lipedema.
• This treatment is widely considered safe when performed by an experienced provider.

Cons

• Depending on the type and severity of your condition, you may need two or more treatment sessions (as soon as a few days apart).
• Depending on your skin's elasticity and the amount of fat extracted, you may be left with loose, sagging skin. This can be surgically removed via a thigh lift, butt lift, arm lift, or body lift, but if insurance doesn’t deem skin removal medically necessary, such surgical options could add significantly to your cost.
• Though surgery often relieves the symptoms of lipedema, it's not a cure. Ongoing therapies, such as exercise, compression garments, and manual lymphatic drainage may still be necessary to prevent and/or manage swelling and reduce pain.
• This surgery requires more specialized techniques than standard liposuction, and it can be difficult in some areas of the country to find a physician who is skilled at performing this procedure.

If you’ve been diagnosed with lipedema and are healthy enough to undergo surgery, you’ll likely be a good candidate.

Because of the higher pressure in affected areas, vein disease and problems with lymphatic vessels often occur simultaneously. Prior to surgery, your circulation should be assessed to ensure your blood supply is healthy enough to allow appropriate healing, as well as to minimize any risk from the procedure from abnormal blood vessels that often are present in the affected areas.

If you have any pre-existing conditions apart from lipedema, discuss them with your surgeon. 

If you’re a smoker, you’ll also need to stop smoking before and after your procedure.

Liposuction for lipedema treatment is an outpatient procedure that usually takes from three to five hours. “To adequately debulk, lipedema reduction surgery uses a small blunt cannula to remove larger volumes over larger areas in a procedure that’s significantly longer than cosmetic liposuction,” explains Dr. Wright.

Related: I Got Surgery for Lipedema, and Here’s How It’s Different Than Regular Liposuction

Most patients require more than one procedure, so providers recommend first treating the body areas with the highest level of severity (the most painful). This takes some of the pressure off of your lymphatic and vascular system.

Prior to your procedure, tumescent fluid containing local anesthesia is injected into the fatty tissue, to minimize pain and shrink the blood vessels in the treatment area, reducing bleeding. If your provider is only using local anesthetic, you'll feel a pinching sensation as the tumescent solution is injected. After that, you will feel pressure but it shouldn’t be painful.

For larger volume fat removal procedures, some providers prefer a combination of either local and IV sedation or general anesthesia, so you'll be completely unaware of the surgery while it's being performed. (Either of these options will increase your cost.)

The goal of this liposuction procedure is to take out as much fat and fibrous tissue as possible, without further damaging the lymphatic system. To minimize risk of injury to the lymphatic channels, extra care is taken. This includes: 

• Mapping venous and lymphatic vessels
• Using ultrasound during liposuction to help "visualize" the lymphatics
• Employing surgical techniques that orient the cannula lengthwise

There are several different lymphatic-sparing liposuction techniques used to treat lipedema. 

• Water-jet assisted liposuction (WAL), which uses a fan-shaped jet of saline (saltwater) to simultaneously dislodge the fat from the connective tissue and remove it, is a popular lymph-sparing technique. According to one study, WAL causes less tissue trauma than traditional tumescent liposuction, which leads to less swelling and bruising and a faster recovery. 
• Power-assisted liposuction (PAL) uses a cannula with a vibrating tip that breaks up fat cells, reducing trauma to the surrounding tissue.
• VASER liposuction uses ultrasound waves to break up the fat. It’s thought to be particularly effective in areas with very dense fat. 

Once a portion of the fat is removed, some surgeons also perform a manual lipedema extraction that's akin to a deep massage, removing the more fibrotic nodules via small incisions.

"After liposuction, the nodules become even more apparent. But because they're so thick and hard, they can't be removed by suction," says Dr. Schwartz. "If they're not removed, the fibrosis doesn't go away, the pain doesn't go away, and the inflammation doesn't go away. Removing these nodules is what truly allows us to treat lipedema." It also leaves behind a smoother, softer skin texture.

Most patients can return to work in two weeks and fully get back to normal activities, including workouts, within six weeks. How long your recovery takes will depend on how many areas were treated and how much fat was removed.

Here’s what you can expect during recovery:

• You’ll be encouraged to be up and walking around by the day after lipedema surgery. Light walking can help reduce pain, prevent blood clot formation, and boost blow flow, which can help with healing.
• Pain is usually minimal in the first few weeks, and most patients don’t need anything more than nonprescription medication like Tylenol. However, some discomfort and bruising for at least 2-3 weeks is expected.
• You'll likely have surgical drains, to prevent fluid buildup. You’ll need to empty these drains a few times a day and record the fluid levels.
• The small surgical incisions are typically left open to encourage further drainage, which can seem excessive. Don't be alarmed, though: leakage from incision sites is completely normal. Disposable "puppy" pads can help absorb this fluid.
• Expect significant swelling in the treated areas for the first few weeks after surgery.

RealSelf reviewers tend to describe their recovery experience in similar ways. "It wasn’t a walk in the park. While I never had true pain, I had my share of discomfort, and for a couple of days I felt like someone had taken a baseball bat to my legs. I managed the pain with occasional acetaminophen, though, and within a week the bruising was fading," says Lipedema Lady, who had similar recoveries after two lipedema surgeries.

Less than three months post-op, one RealSelf member, JustformeKYFL, reported that she occasionally still had swelling, "but my legs are a million times better even on my worst days."

During your recovery (and ideally beyond), you'll be wearing compression garments, to help reduce swelling and encourage your skin to heal smoothly over your new contours. 

They're typically worn 24/7 for the first 2–3 weeks, and then after that for up to 12 hours a day, even after your lipedema surgery recovery period.

Compression therapy is not a requirement, but it helps prevent fluids from obstructing the susceptible lymphatic pathways. "Getting used to continually wearing compression garments would be in the best interest of your health," Dr. Schwartz says.

You'll still see a large difference in your body mass immediately after surgery, but it takes time for the swelling to resolve enough that you can see your true results. 

At the three-month mark, most people see about 50–60% of their final improvement. It can take up to a year for all the swelling to resolve, so you can see your final results. 

Though your treated areas will feel significantly better almost immediately after surgery, it’s important to have realistic expectations about how much cosmetic improvement you can expect with lipedema surgery. 

Unlike traditional liposuction, which creates a smoother contour, lipedema surgery doesn't always produce an aesthetically perfect result. The goal is often to help patients fit better into clothing. 

Such was the experience with RealSelf member Lipedema Lady, who reports that "the difference in my legs is striking, both in appearance and functionality. While they're not pretty, I never expected a bikini body, and I’m happy to look a lot better in clothes. And my legs feel lighter and oddly, my balance is better."

As for the longevity of the improvement, authors of a 2021 study that surveyed 60 lipedema patients a dozen years after their surgery found that "the positive effects of liposuction lasted 12 years without relevant worsening." The upshot: "liposuction for lipedema leads to a permanent reduction of symptom severity and need for conservative therapy."

When performed by an experienced, board-certified plastic surgeon or dermatological surgeon who specializes in lipedema surgery, the procedure rarely has complications. 

A 2019 study on 111 patients with advanced lipedema treated with liposuction over a 10-year period found that serious adverse events occurred in 1.2% of procedures, the infection rate was 0%, and the bleeding rate was 0.3%.

Other possible risks are similar to those with all types of liposuction: 

• Hematoma, a pooling of blood under the skin
• Seroma, a pocket of fluid under the skin (a risk that can be reduced with a good compression garment)
• Thrombophlebitis, when blood clots form in the deep veins
• Changes in skin color or sensation
• Fat embolism, which occurs when a piece of fat separates and becomes trapped in a blood vessel

Your surgeon should explain all of those risks to you during your consultation, so you can make a fully informed decision.

Though the names sound the same, these medical conditions are very different. 

• Lipedema is a chronic disorder of fat metabolism and distribution that usually manifests as a symmetrical amount of excess fat, usually on the lower body.
• Lymphedema is an excess buildup of fluid that usually affects only one side of the body. It occurs most often in the arms and lower legs, including the hands and the feet, and often arises from damage to the lymphatic system (which is responsible for the removal of fluid from the tissues), often as a result of cancer treatment—for instance, after mastectomy, or radiation therapy. 

A telltale difference between the two conditions: Lymphedema can affect any body area, including the hands and feet, while lipedema will stop (or cuff) at the wrist or ankle. 

Unmanaged, lipedema can lead to what's called secondary lymphedema (or lipo-lymphedema): As the fat cells get larger, they can compress the surrounding lymphatic channels. This can cause fluid to accumulate, causing "real" edema and potentially leading to blood infections and fibrosis, the thickening and scarring of connective tissue. 

As the fat cells continue to enlarge, they may also affect the blood vessels, causing circulatory system problems. And as the condition worsens, people with lipedema become less mobile.