MQ Health - Macquarie University

Lymphoedema Clinic

Surgical options: Liposuction

At ALERT we use liposuction to treat both advanced lymphoedema and lipedema. There are some differences in the pre- and post-surgical treatment for these two conditions, so please refer to the relevant section below.

Liposuction for Advanced Lymphoedema

Background

Liposuction for the treatment of lymphoedema was pioneered in Sweden by plastic and reconstructive surgeon Professor Håkan Brorson and was introduced into Australia in 2012 by Dr Helen Mackie and the team at MQ Health Lymphoedema.

Liposuction is not a cure for lymphoedema and ongoing rehabilitation and compression therapy is a necessary component of the long-term management. However, it can have a positive outcome in terms of reducing the swelling in the arm and leg, increasing patient comfort and benefiting patients emotionally and socially.

Read the paper documenting the results of our surgery.

Surgery

The technique involves removing fat via some 15–20 small incisions (around 4-5 mm each) along the limb. The liposuction treatment is effective, because it removes the excess fatty tissue. There is complete reduction of swelling, which decreases pain and heaviness and increases limb mobility. This reduction comes not only from the initial surgery, but also from the pre- and post-operative care that your limb will require. For patients with lymphoedema of the leg, the swelling can take up to 12 months for the limb to match the volume of the other side. For arm patients, the arm can match the other side usually within 6 months.

An absolute requirement for post-operative success is vigilant use of a custom-made compression garment. This garment must be used at all times or lymphoedema inevitably recurs. The operation will be performed at Macquarie University Hospital and a minimum 12 months of post-operative care will be conducted at MQ Health Lymphoedema Surgical Assessment Clinic.

As part of post-operative care, we will measure limb volumes, adjust or replace garments, check skin condition and discuss other matters of concern. Patients are also encouraged to contact the team whenever any unexpected problems arise.

The use of a multidisciplinary team during the whole process is a pre-requisite for thorough pre-operative consideration, for fully informing patients about the treatment and for successful maintenance of immediate post-operative improvements.

Assessment

To be considered for liposuction, a patient must have tried complex lymphoedema therapy (CLT), including manual lymph drainage (MLD) and compression therapy performed by a skilled therapist. CLT includes massage, bandaging during two to four weeks and, thereafter, using compression garments, which must be worn all the time.

Conservative therapy is performed until all pitting has disappeared or until there is minimal pitting (max 3–4mm). (The ‘pitting test’ involves pressing as hard as possible with the thumb for 60 seconds on the forearm to determine whether the arm shows pits on pressure). If swelling is still present (more than 800–1000ml) after vigorous conservative therapy and no or minimal pitting occurs, liposuction can be performed to remove the excess adipose tissue (only).

An assessment by Dr Mackie and lymphoedema therapist will be undertaken for selection into the program, following the international best practice guidelines established by Professor Broson. (See criteria for selection below).

Measuring the volume of the limbs

Part of patient assessment includes measuring the volume of each limb. Limb volumes can be measured by water displacement pletysmography (volumeter) or by circumference measurements and bio-impedence spectroscopy (L-Dex).

When a water volumeter is used, the arm is put into a water tank and the displaced water is measured. As both limbs are measured, the difference in limb volume equals the amount of swelling.

Circumferential measurements can also be used for the calculation of limb volume. For arm measurements, the wrist to the arm pit, the circumference is measured every 4cm on both arms. Using a computer program, the volume can then easily be calculated.

Liposuction surgery does not cure the lymphoedema, but re-shapes the limb to normal size, which is maintained by the use of compression garments.

Selection criteria

Criteria for selection for liposuction

  1. Late stage lymphoedema with fatty change and minimal fluid in the limb
  2. Completed and complied with conservative treatment, massage, bandaging and wearing of firm compression garment
  3. An arm-volume difference of 750–1000 ml (or arm ratio above 1:1.3) and a leg-volume difference of greater than 3000ml
  4. The lymphoedema limb must be causing problems such as heaviness or difficulty in use such that a patient wants something done
  5. No recent cellulitis (infection)
  6. No skin lesions or ulcers in the limb
  7. No evidence of active cancer
  8. No surgical or anaesthetic contraindications for liposuction
  9. Patient must be prepared to attend follow-up appointments and wear compression garments as instructed, replacing them when needed
  10. Patient must be prepared to undergo a surgical procedure with anaesthetic and to stay at Macquarie University Hospital for up to 10 days, and be available for follow-up over a minimum 12-month period
  11. Patient must not be obese, and have weight (minus limb extra weight) in normal range for height (calculated BMI < 27)

Follow-up

After liposuction surgery, treatment is continued with compression therapy via garmenting. This is very important during the first three months when the most notable changes in volume occur. At the three-month visit, we will measure you for new custom-made garments. We repeat this procedure at 6, 9 and 12 months after your surgery. This means that your garments are renewed three or four times during the first year.

Measuring for garments after surgery is a complex process and it is extremely important that it is done by our therapists who have been specially trained to do so. The garment is measured differently from a regular lymphoedema garment and requires close collaboration between you and the therapist to get the best fit. Consequently, if you undertake to have liposuction surgery, you must commit to attending the clinic for at least 12 months after surgery to ensure the best possible outcome from the surgery. Although we teach therapists from all over the world about our therapy techniques, it is vitally important that one of our therapists develops your personalised post-operative garment regime. This requires that we examine and measure you to achieve the best possible result. Garments are expensive, so it is essential to get the correct fit.

After surgery, you may have two or more garments to make up your required set (for example, a sleeve and a mitten for arm lymphoedema). It is important that two sets of compression garments are always at your disposal so that one can be washed, every other day, while you wear the other. It is imperative that you wear your garments constantly, taking them off only to shower or change to your other set. Normally two sets of garments last for six months, but if you are very active, you may have to renew them every three to four months.

After complete limb volume reduction, you will normally need reviews every 6 months, when new garments are prescribed. Remember that these garments will be the same size as your unaffected limb. We will help you receive as much reimbursement from the health funds and Government schemes as possible.

Once your limb has achieved 100% reduction, you may choose to be discharged from MQ Health Lymphoedema Surgical Assessment Clinic and continue your therapy with your local therapist.  At this time, we will provide you with your ongoing garment prescription to take to your therapist to order your replacement garments. Of course, we would like to keep in touch with you to monitor our results to help inform our patients of the future.

Liposuction for Lipedema

Background

What is lipedema?

Lipedema is a painful familial disorder primarily affecting women that typically leads to a pattern of fat accumulation in the legs from the hips to the ankles and sometimes in the arms (approximately 30% of cases). It may be found in women of all shapes and sizes.

Symptoms of lipedema

  • The legs are symmetrically enlarged and the arms can also be affected
  • The waist is small in proportion to the thighs, buttocks and legs
  • Feet and hands are not affected, so a 'bracelet' or cuff effect can appear just above the ankles and wrists
  • Legs/arms can be heavy, aching and extremely painful, even to touch
  • Affected limbs bruise easily
  • The fat is soft and wobbly, while the skin can be cold to touch
  • Hot weather can make the symptoms worse
  • Diet and exercise can have minimal effect on limb size
  • Lipedema can worsen when significant hormonal changes occur
  • Skin can have a cellulite or ‘mattress-like’ appearance

Adapted from the Lipoedema Australia website. For more information about lipedema, visit their website

How does lipedema differ from lymphoedema?

CHARACTERISTICLIPEDEMALYMPHOEDEMAOBESITY
GenderAlmost exclusively femaleMale or femaleMale or female
Age at onsetUsually 10-30 yearsChildhood (mainly primary); adult (primary or secondary)Childhood onwards
Family historyCommonOnly for primary lymphoedemaVery common
Areas affectedBilateral
Usually symmetrical
Most frequently legs, hips, buttocks (sometimes arms)
Feet/hands spared
May be unilateral or bilateral depending on causeAll part of the body
Usually symmetrical
Effect of dieting on conditionWeight loss will be disproportionately less from lipedema sitesProportionate loss from trunk and affected limbsWeight reduction with uniform loss of subcutaneous fat
Effect of limb elevationAbsent or minimalInitially effective in reducing swelling; may become less effective as the disease progressesNone
Bruises easilyYesNot usuallyNo
Pain/discomfort in affected areasOften
Hypersensitivity to touch in affected areas
May be uncomfortable
No hypersensitivity to touch
No
Tenderness of affected areasOftenUnusualNo
Skin consistencyNormal or softer/looserThickened and firmerNormal
History of cellulitisUnusual (unless lipolymphoedema is present)OftenUnusual

Adapted from Best Practice Guidelines: The management of lipoedema, Wounds UK, 2017

The role of liposuction

Liposuction for the treatment of lymphoedema was pioneered in Sweden by plastic and reconstructive surgeon Professor Håkan Brorson and was introduced into Australia in 2012 by Dr Helen Mackie and the team at MQ Health Lymphoedema.

Liposuction is also an effective procedure for fat reduction for lipedema. It is not a cure for lipedema and ongoing compression therapy is a necessary component of the long-term management.  By removing much of the excess fatty tissue, liposuction can have a positive outcome in terms of improved movement and function in the affected areas, increasing patient comfort and improving emotional and social outcomes.

Surgery

Liposuction for lipedema is generally performed separately on each leg in two surgeries. The operations will be performed at Macquarie University Hospital and a minimum 12 months of post-operative care will be conducted at MQ Health Lymphoedema Surgical Assessment Clinic.

The surgical technique involves removing fat via some 15–20 small incisions (around 4-5 mm each) along the limb. The liposuction treatment is effective, because it removes the excess fatty tissue. There is complete reduction of limb volume, which decreases pain and heaviness and increases limb mobility. This reduction comes not only from the initial surgery, but also from the pre- and post-operative care that your limb will require. For patients with lipedema in the legs, it may take up to 12 months to achieve a normal leg size.

An absolute requirement for post-operative success is vigilant use of recommended compression garments. These garments must be worn consistently, or lipedema may recur.

As part of post-operative care, we will measure limb volumes, adjust or replace garments, check skin condition and discuss other matters of concern. Patients are also encouraged to contact the team whenever any unexpected problems arise.

The use of a multidisciplinary team during the whole process is a pre-requisite for a thorough pre-operative assessment, as well as to keep patients fully informed about treatment and successfully maintain immediate post-operative improvements.

Assessment

To be considered for liposuction, you need to attend the MQ Health Lymphoedema Surgical Assessment Clinic to confirm the diagnosis of lipedema according to the symptoms described above. You must be a non-smoker, have good general and skin health and have a BMI below 32. It is also helpful if you have tried conservative therapies such as compression therapy prescribed by a skilled therapist. If you are otherwise overweight, we would encourage you to lose as much excess weight as possible before having surgery.

Cost

Lipedema is not currently recognised by Medicare as a rebatable medical condition, so surgery attracts no Medicare or private health insurance support and is very expensive. For information about the cost of this procedure, contact our clinic on 02 9812 2950.

Follow-up

After liposuction surgery, treatment is continued with compression therapy via garmenting. This is very important during the first three months after each surgery when the most notable changes in volume occur. At the three-month visit, we will re-measure you and may recommend for new garments. We repeat this procedure at 6, 9 and 12 months after your surgery.

Measuring for garments before and after surgery can be a complex process and it is extremely important that it is done by our therapists who have been specially trained to do so. Lipedema patients do not usually require custom-made garments and can manage their condition with off-the-shelf garments.  However, monitoring of your garments requires close collaboration between you and the therapist to get the best outcome. Consequently, if you undertake to have liposuction surgery through MQ Health, you must commit to attending the clinic for at least 12 months after surgery. Garments are expensive, so it is essential to get the correct fit.

Once your limb volume reduction has stabilised, you can be discharged from MQ Health Lymphoedema Surgical Assessment Clinic and continue to monitor your garment needs with your local therapist.  In most cases, you can buy ready-to-wear garments.