Liposuction - Dr. Stutz (#1 of 6)

Lipedema is a hereditary symmetrical fatty tissue disease, affecting mostly the thighs, lower legs, and arms, as well as the buttocks at times. Traditionally, the upper body is very slim, and disproportionate to the legs. The waist to hip ratio is usually lower than 0.7. In fact, the primary indicators of lipedema are a small waist, large buttocks, and trunk like legs. For unknown reasons, this disease only affects women, with one known exception. For this reason, it is suspected that the disease is linked to estrogen. 85% of patient’s symptoms started during puberty, and 7% started with pregnancies. There is a mixture of other onsets, most starting at menopause, without any prior symptoms. There are also patients whose lipedema began after tragic loss or emotional trauma, without any symptoms prior. There is no explanation for this. These points aside, more specific details and clear facts on the disease are yet unavailable. The symptoms of lipedema are clear. The legs tend to swell during the day, especially in heat, and bruise easily. Often, patients will wake up with bruises without knowing where they came from. The affected areas, such as the legs, are painful, especially when squeezed, touched, or poked. There are also usually cold sensations in the affected areas. It is also not a modern disease. Historically, there are numerous depictions of figures with the physical symptoms of lipedema-small waist, large buttocks, and trunk like legs- in Egyptian art, South african paintings, etc. Lipedema is most commonly confused with obesity, or adiposity. Unlike lipedema, obesity does not inherently cause pain. Lipedema also does not respond to diet or exercise. Another common misdiagnosis is lymphedema, because of the leg swelling. This is a rather rare condition compared to lipedema. Lymphedema is not symmetrical, and affects the hands and feet, unlike lipedema. Unfortunately, it is difficult to get a decent diagnosis in the United States. Germany has a better track record, and even there it can takes up to ten years. Despite the fact that it is often misdiagnosed, lipedema is actually quite simple to identify. A proper examination, wherein the patient is examined without clothing, and a conversation with the patient are all one really needs for a decent diagnosis. Ask them if there are similar symptoms in family members; undress them, and look at the fat distribution, the skin texture, the waist to hip distribution, and the way they move. A pinch test is helpful, squeezing the tissue and asking where it hurts more. The affected areas, such as the legs or arms, will be more painful than the belly, for example. Many patients are also starving themselves, and their metabolic rate is down. Even though they think they eat normally, they are starving, hoping to lose the weight. For this reason, one of the biggest threats after liposuction is to get people back to normal eating habits.


Liposuction - Dr Stutz (#2 of 6)

In cases of lipedema, as previously stated, the upper body is traditionally slim, with enlargement around the buttocks. The distinct difference between the tissue in the affected area and the tissue in the rest of the body is important to note. Affected tissue is uneven. Traditionally, the upper body has smooth, soft tissue, and going down to the legs, the tissue becomes lumpy. Even though many women who suffer from lipedema later become obese, there is always a distinction between the consistency of the fatty tissue in the affected areas and in the rest of the body.
Everybody with lipedema should have an ultrasound done. It helps to reach a diagnosis, and to prepare for liposuction, as it allows one to measure the skin, which is likely thickened due to lack of lymph fluid. You can measure the diameter of the lipid tissue, and squeeze the tissue with a probe to get an impression of how much fat can be removed through liposuction. An examination of the legs and leg joints is also important, as there is likely a misalignment. This can affect the way in which a patient moves and walks. Using a probe on the leg may be helpful, as one can see the enlargement of the lymph vessels and the stenosis around them. Dr. Stutz gives the example of a patient who weighed 240kg (400lbs). She was bedridden for three years, unable to walk or care for herself. Entirely dependent on her family, she was told by experts that she was obese, and only after painstaking research did she come to the conclusion that she had lipedema. At her weight, she did qualify as obese, but under closer examination, it became clear that the root issue was lipedema. Her upper body was rather slim, but her arms were very large, for example. She was under the strongest available pain medication, and was never pain free. She clearly had lipedema. The convincing factor, according to Dr. Stutz, was her bra. It did not cut into the tissue, as is normally the case with obesity, and was much smaller than the width of her hips. She starved herself, yet kept gaining weight. Many patients get bariatric surgery in an attempt to remedy the problem. This is not recommended, because it is not necessarily helpful. Usually, after liposuction, when the legs are normalized to an extent and the patient is pain free, it is quite easy to lose weight. According to Dr. Stutz, losing weight prior to liposuction is essentially ineffectual. The tragedy is that, if left undiagnosed or treated, lipedema may become lipolymphedema. Lymphedema is non-symmetrical, and in late stages, can cause skin folds. It will test positive via the Kaposi-Stemmer Sign. Though it was previously lipedema, such damage is done to the lymph function which the disease has progressed into lipolymphedema.


Liposuction - Dr. Stutz (#3 of 6)

Lipedema causes a myriad of complications. Patients are often down to 800 calories a day, regularly starving themselves. Some people can’t exercise anymore because of the pain lipedema causes them, and they gain weight. Or they become frustrated by their lack of progress from diet and exercise. Obesity is one of the many larger issues related to lipedema, and the latter is often mistaken for the former. BMI is unreliable, because it will test positive for obesity, when under closer examination; the physical symptoms of lipedema are present. Lipedema causes lymphedema, which results in CD4 inflammation and increases fatty tissue. When the tissue increases, it deteriorates the lymph vessel even more. The lymph system cannot function in this tissue anymore. Very late, untreated cases can be tragic. Lymph fluid may ooze from the skin. It’s very difficult to treat lymphedema, though it is easily detected by ultrasound. When the lymphatic system is already impaired, the patient is prone to other infections. This can destroy a lot of lymph vessels, and huge skin lapses may develop, causing even more problems. Usually liposuction focuses on the painful areas. Misalignment of the leg axis is another problem. The foot is out of place because of the tissue in the middle of the back; the legs then rub against each other and form a v shaped appearance. Lipedema takes a toll on the knee and ankle, but it never affects the hip joint. An important focus of liposuction is to get all of those areas, allowing the patient to walk normally again. If it’s not taken care of, it can lead to severe back problems. There is no correlation between the thickness of the fatty tissue, and the amount of pain the patient experiences. You can’t tell their pain level by looking at them. Severe lipedema means agonizing pain. The tragedy is that, more often than not, patients have to pay for liposuction out of pocket because the insurance company refuses to cover it. So what can you offer the patient? Dr. Stutz recommends dieting only for patients who are not already on a diet and who exhibit symptomatic obesity - higher blood pressure, diabetes, and so on. Then he asks them to regulate their diet before they take further steps. Bandaging and compression treatment have also proven helpful.


Liposuction - Dr. Stutz (#4 of 6)

There has only ever been one case of a man with lipedema. He was tested in every way, there was no family history, and no indication of a link to estrogen. The medical community has no idea how he got it. Almost 30% of patients experience severe pain on a regular basis, and almost 10% report unbearable pain. In addition, psychological and emotional pain are equally important to address. Many women end up struggling with eating disorders. There are a very small percentage of lipedema patients, in fact, who do not have some sort of food disorder. Many have unspecified eating disorders, starving themselves then binge eating, never going to the doctor for it. 60% of patients suffer from anorexia nervosa, despite the fact that it does not help them lose weight in their legs at all. Some are bulimia patients, others are binge eaters. This is an important issue. They also experience mental torment in their daily lives, due to the judgments of the public eye, or their inability to take care of themselves. Many suffer from depression, and 8 out of 100 patients have attempted suicide. The amount of emotional and mental stress on these women is unbelievable. Many patients are athletes, whose careers are affected by the disease. One woman was an aerobic athlete, thin and fit, but the muscle definition of her upper body was not reflected in her lower body. She could not get her legs defined, and this only got worse after pregnancy. She was in severe pain, but after treatment, she was able to lead a normal life and get back to competitive athletics. Treatment is extremely important. Long-term complications arise from not treating lipedema, such as the development of lipolymphedema and misalignment of the leg axis. Often, women are blamed and in turn blame themselves for the ways in which this disease affects their bodies. There are several available options for treatment. Conventional liposuction is one. There is also power-assisted liposuction, ultrasound assisted liposuction, etc. All of these methods use TLA, or tumescent local anesthesia. These options have been around, but it’s important to develop new, better methods. TLA contains a drug, which is dangerous for the heart, so it can only be used in certain amounts. This means coming back for more surgery. The Wasserstrahl-assistierte Liposuktion (WAL) system does not involve these extra steps. It just gets in, removes the fat, and gets out. There isn’t a huge amount of fluid involved since the legs don’t need to be pumped. The WAL method doesn’t remove as much fat as the TLA, though, but it’s an effective option. The TAL method removes more fat because it is done in multiple segments. The most important thing is to get treatment: to stop pain, stop the progression of the disease, and get the body back to normal mobility.


Liposuction - Dr. Stutz (#5 of 6)

Treatment does, of course, provide an improvement in aesthetic appearance, but it’s important to stress that this is not the main goal. The main goal is to reduce pain, stop the progression, and get the body to normal, healthy mobility. Many women wonder whether they should get liposuction before or after pregnancy. It’s recommended that it be done after pregnancy, because then there is no drastic change to the body following treatment. There are limits to what liposuction can do. Many severe cases can’t expect to look completely normal after treatment, or go back to normal size. Then again, there can be tremendous results. But treatment can only remove the fat, it can’t necessarily reshape the legs. There is a big difference between cosmetic and therapeutic liposuction. Dr. Pier-Francois Fournier, the grandfather of liposuction, stated that good liposuction is defined by what you leave behind, to form and shape the body. With lipedema, nothing is left behind. The aim is to get rid of the fatty tissue, and make sure it does not come back. Sometimes there is even a cosmetic disadvantage. For this reason, it is important to have realistic expectations. Speaking to one’s doctor or surgeon to get an idea of the expected results is important. The three goals of pain reduction, halting progression, and normal mobility are the most important to keep in mind. It can take a while for the body to change. A test was done, with a patient on a treadmill, measuring the distribution of pressure on the feet. The pressure was mostly on the inner sides of the feet, indicating a misalignment of the joints. One year after liposuction, without any additional treatment, the pressure distribution was normal, equally distributed on either side of the foot. The change that liposuction provides is far beyond any concept of appearance. This treatment gives people their lives back. Liposuction repairs misalignment, stops lifelong progression of lipedema, it stops swelling, pain, and certainly contributes to appearance.


Liposuction - Dr. Stutz (#6 of 6)

Q&A Portion:

Q: If a surgeon messed up liposuction and caused lymphedema, would you notice immediately?
A: You would not notice immediately. It can take up to ten years to notice something is wrong if the surgeon has messed up the lymph vessels.

Q: Do you consider liposuction a cure?
A: Yes.

Q: Is WAL liposuction effective for a patient who’s already had TLA liposuction that wasn’t effective? Was damage done by the TLA surgery?
A: Whatever treatment you use, whether TLA or WAL, there is a possibility of harming the lymph vessels. At the end of the day, the surgeon is either being careful or not. WAL is helpful because you can cut it down from 4 or 5 operations to 2. And it’s easier because it does not involve a lot of fluid, unlike TLA. It’s a gentler method, but can still be harmful to the body. In the end, it comes down to the surgeon. If you’ve had a TAL, you can use WAL. It’s much easier to get rid of the fat that hasn’t been removed in the first operation.

Q: Does the skin retract after WAL liposuction?
A: All liposuctions result in the skin retracting, WAL is no exception. The retraction process begins immediately after the procedure.

Q: Is liposuction possible for people with varicose veins and for people taking blood thinners?
A: Yes it is possible, though it depends on which blood thinners you are taking. It is recommended that the varicose veins is treated prior to liposuction, because it can cause bleeding. It doesn’t have to, but can. Also, it might be a part of the swelling, so just getting treated prior to liposuction is the best option.

Q: If you are considering liposuction for lipedema, but you also need a knee replacement, which surgery should you do first?
A: If you have not had liposuction and have not had some of that fat removed, your orthopedic surgeon will likely reject you for knee replacement surgery. The thick layer of fat around the knee makes the replacement difficult, and there is a danger of infection. It is recommended that the liposuction be taken care of first.

Q: Do you ever get too old for liposuction?
A: Essentially, no. Dr. Stutz has treated patients in their 70s, and would go so far as to treat an 80 year old patient.

Q: If you have lipolymphedema, do you ever do liposuction of the feet?
A: It’s not necessary. Sometimes it is done in the hands, when patients have severe lymphedema and can’t use their hands anymore, but never the feet. You get rid of that swelling with the MLD and you may still have to wear compression stockings anyway in cases of lipolymphedema.

Q: When you’re doing liposuction, how do you know that you’re taking out lipedema fat and not regular fat? And does that lipedema fat come back ever after liposuction?
A: Microscopically, there is no difference between lipedema fat and regular fat, there is no distinction, so they take out whatever they can get. It does not come back, though, with the exception of anorexics. People who have anorexia and continue to starve themselves are prone to get this disease again.

Q: Have you treated any patients with Dercum’s disease?
A: Yes, he's had a patient who had both Dercum’s disease, in a very limited area, and lipedema. These are two completely different fat disorders. With lipedema, the patient can be treated for good; with the other one, it must be explained to the patient that they will find a lot more bruising after the procedure when they have taken out the lumps. The pain is reduced, but it is not like lipedema. The condition itself has not been stopped, it is not cured. The patient will continue to get lumps and pain. Lipedema can be permanently stopped, Dercum’s can’t.


Liposuction - Dr. Amron (#1 of 2)

Dr. Amron begins by stating that liposuction should be about targeting disproportion and creating balance. With that, liposuction is about identifying where a person is out of proportion, typically from genetics, and creating harmony with the entire body. It is necessary for the surgeon to look at the entire body and create balance while defining a treatment plan. For a patient with Lipedema, he/she may need assistance with finding a balance during consultation. Moreover, Dr. Amron reviews the components of the area that may require liposuction: disproportion, skin laxity, muscle tone laxity, and cellulite. He explains that there should be move or less “a grading system” to focus on specific elements of flab. Liposuction should in the end cause the tissue to retract and become tighter, superficially. Dr. Amron’s approach consists of purely Tumescent anesthesia. This was developed by strictly derm surgeons in the 1980s. All surgeries are completed at fully accredited surgery centers with patients monitored through an I.V.


Liposuction - Dr. Amron (#2 of 2)

Dr. Amron continues with the advantages of tumescent anesthesia. Tumescent anesthesia is safer and has a faster recovery time. Only about 10% of patients experience bruising and discomfort after tumescent anesthesia due to the fact that the patient is conscious. With a conscious patient, the surgeon is avoiding muscle area and jabbing in the wrong area. Liposuction is about approaching the correct angle and staying in that specific layer of fat. Positioning of the patient is extremely important. The average tumescent anesthesia being used is below 55mg/kg of body weight. Dr. Amron discusses that if a surgeon goes about that amount, the danger of Lidocaine toxicity is present. Diluting the Lidocaine levels allows the surgeon to extend the area being worked on without the fear of Lidocaine toxicity. For outpatient surgery, the maximum amount of fat that can be removed in 5 liters at a time. The video discusses that liposculpture is more than sucking out fat. It is less about the tools being used and more about the technique, skill, and judgment the surgeon may have. A crisscross approach is used, as well as the concept of “debulk” from the bottom up. Incision points are imperative, as the surgeon must get around curved areas of the anterior thighs and ankle area; the incision point must be left open. Not only is the liposuction itself important, but also the counter retraction from the tech. It is necessary to move together throughout the areas of the body to complete the surgery well. Antibiotics, compression garments, supplements and proper exercise/nutrition are hugely important post-operative.


Liposuction - Dr. Emer (#1 of 1)

Dr. Emer begins by explaining some of the treatments used in the office that help to remove fat and cellulite and also tighten skin. This was done through thermal energy pre and post treatment, with most often enhances the results. In Lipedema patients, thermal energy was used to decrease swelling and asymmetries, as well as see a decrease in size much quicker than typical Liposuction alone. Although there are many products on the  shelves, most do not work for a long term period of time; however, heating and cooling of the tissue has been working. A combination of different treatments most often is effective. For example, Velashape III combines infrared energy, radiofrequency, and massage. Velashape works by targeting connective tissue and renewing collagen, treating cellulite and skin laxity, and lastly through lymphatic drainage. These treatments are typically done cosmetically, but if they were done on Lipedema patients, even better results could be displayed. Furthermore, a device being worked on now, Ultrashape, is a multi-focus ultrasound used to destroy fat. This device could be used to target localized areas of fat on patients who would prefer to avoid surgery. This painless treatment is non-invasive and may help circulation, lymphatics, and metabolic activity of tissues.


Assessing Lipedema Post Liposuction

The purpose of performing a physical exam on an individual post liposuction with lipedema is to palpate for excess tissue and nodules. Begin at the top of the head moving to the back, you should feel bone. Continue to palpate as you move your hands from back to front on the neck using a rolling technique of the fingers. Now focus on the supraclavicular area by having the patient shrug, you want the extra fat to depress, indicating lymph is moving through the area. Next, have the patient make a fist with a hole through the center bringing it to the mouth and breathing in while you observe the supraclavicular area for excess fat. Continuing with the trunk palpate the chest, less fat here on women may be a sign of lipedema. Finish the trunk by checking the weight of the breasts by gently lifting. Move to the hands and begin by bending the fingers back looking for fat at the MCP joints and base of the thumb. Flex the wrist observing for formation of skin folds then continue with the rolling technique of the fingers up the arm paying close attention to the area over the bracioradialis and under the armpit. In stage I/II nodules are often present over the bracioradialis muscle. Next, move to the abdomen, stand behind the patient and palpate under the ribs rolling the fingers laterally over the abdomen and moving centrally. The superpubic area is a common area for nodules, be sure to palpate well. Take note that fibrotic tissue often presents in the groin and top of the hips. Continue with larger sweeping palpations over the buttock by running fingers sideways, up, and down. Finish by feeling the weight of the buttock by gently lifting at the base. Finally, begin at the top of the legs and roll the fingers over the thigh towards the knee, fibrotic tissue is often found medially. Both sides of the knees, just inferior, and the popliteal space are common areas for pockets of fat and nodules. Perform the stemmer sign by pinching the skin on the top of the feet; a positive stemmer occurs when the skin cannot be pinched. On the inside of the foot observe for piezogenic papules, fat herniating to the skin. In stage I, there is often an absence of fat around the achilles and malleoli, in higher stages fat will be present here. Common spots for lipedema in women include: posterior arm, hips, buttocks, thighs and into ankles.