Lipedema Tummy Tuck, or Panniculectomy
Lipedema is known as a painful fat syndrome. Recent studies demonstrate that in addition to painful fat many patients also experience abnormal structure of their connective tissues, which affects skin, subcutaneous tissues, lymphatic vessels, blood vessels, and skin.
It is estimated that lipedema may affect between one and 11% of women worldwide.
There is no universal agreement on what causes this condition, however we know that there is a significant hereditary component and if left untreated, it becomes progressively worse over the years.
Traditionally, most common features of lipedema is excessive fatty tissue deposition in the lower extremities, buttocks, hips, legs, even abdomen. Because of abnormal connective tissue strength and large amount of fatty tissue accumulation, abdominal or stomach skin is extra prone to stretching, loosening and pain.
Dr. Boris Volshteyn is a Board Certified Plastic Surgeon and lipedema expert in New York and New Jersey. He commonly performs abdominoplasty procedures not only for cosmetic patients but also for lipedema patients in his practice.
Lipedema tummy tuck or Lipedema abdominoplasty may help lipedema patients with removal of painful fat, reduction of skin and improvement of pain and shape of the abdomen.
Lipedema Tummy tuck or Lipedema abdominoplasty is performed differently than traditional cosmetic tummy tuck.
What is Lipedema Tummy Tuck or Panniculectomy
Once is the patient is diagnosed With lipedema, qualified surgeon needs to be familiar with differences between traditional cosmetic tummy tuck and tummy tuck or abdominoplasty performed for Lipedema.
Lipedema tummy tuck usually combines five separate components –
1. Excision of excess skin,
2. Removal of painful fat with liposuction,
3. Manual removal of painful knots from subcutaneous tissues and from muscle,
4. Specialized anesthesia protocol,
5. 24 hour observation and follow up.
Excision of the abdominal skin in Lipedema patients is similar to traditional abdominoplasty or tummy tuck procedure. Depending on the amount of excess of skin, incision can go across the lower portion of the abdomen from one hip to another, or possibly extend through the sides and to the back.
The main difference between cosmetic tummy tuck and Lipedema tummy tuck surgery is that the plane of elevation of the skin has to be different. In cosmetic patients the skin is usually elevated at the level of the muscle fascia. Because Lipedema patients have inherent problem with lymphatic vessels, skin must be elevated slightly above that level leaving lymphatics intact, otherwise patient has significantly higher chance of complications, fluid accumulation, or seromas.
Many lipedema patients come to our office after having previous C-section or other gynecologic procedures. Therefore, it is very important to incorporate previous C-section scar into tummy tuck scar and avoid double scar line formation.
It is also very important to remove excessive scar tissue in the lower half of the abdomen from previous surgeries because leaving those scar tissues in tact can promote fluid accumulation also.
Most of the time we have to put drains in the abdomen to promote healing of the abdominal skin. Based on our experience, lipedema patient have to have drains in place for a longer period of time.
The second component of successful Lipedema tummy tuck or abdominoplasty surgery is careful removal of painful subcutaneous and deep fat using gentle lymph sparing liposuction technique using either water assisted liposuction, power assisted liposuction, ultrasonic assistive liposuction or combination of various techniques.
There’s usually significant difference in the amount of fat in the mid portion of the abdomen, upper portion of the abdomen, lower portion of the abdomen and the pubic area. It is very important to make sure that at the end of the procedure the thickness of the abdominal skin is the same from the top to bottom, especially on both sides of the abdominal incision. Otherwise the patient will have a muffin top appearance. It is our goal to make sure that at the end of the procedure many patients are able to wear a two-piece swimsuit if possible.
The third component of successful Lipedema tummy tuck or abdominoplasty surgery is removal of painful knots or nodules. It is well documented that some Lipedema patients have symptoms consistent with Dercum's disease.
Dercums disease is a condition of having painful small lipomas under the skin. The difference between Lipedema and Dercums disease is that in Lipedema patients pain is diffuse throughout the abdomen with palpable small rice sized or pea sized Lesions. They can be located immediately underneath the skin or underneath the facia.
In patients with Dercums disease, the painful lipomas are usually more well defined, they may be located not only in the subcutaneous area but also on top or inside of muscles. However, sometimes difficult to differentiate between two conditions. It is also commonly difficult to identify those painful lipomas during liposuction surgery. That is why Dr. Volshteyn uses a proprietary technique of removal of those painful lipomas manually after liposuction. In our experience, if it’s much easier to feel those thickened and calcified isolated lipomas after Liposuction had been performed. Dr Volshteyn commonly uses ultrasound assisted liposuction technique in order to better identify Dercums disease type-lipomas because ultrasonic assisted liposuction usually does not remove them and helps to identify them easier during the surgery.
If the patient’s present with subcutaneous painful lesions similar to Dercums disease lipomas, we strongly encourage the patient to mark those painful areas at home prior to arrival to our surgical facility and identify most painful ones specifically to make sure that those very painful subcutaneous lesions are removed. If it is not done, it is very difficult to identify most painful ones during the surgery without the guidance from the patient.
The fourth component of successful Lipedema tummy tuck or abdominoplasty surgery has to do with safe administration of anesthetics, which is different compared to majority of cosmetic tummy tuck patients. Because large number of patients with Lipedema also have connective tissue disorder, plastic surgeon has to take into account and be familiar with risks of anesthesia specifically associated with these conditions.
According to national guidelines, it is recommended that the patients with connective tissue disorders undergoing general anesthesia, including most Lipedema patients, have to stay overnight for observation. The main reason is that Lipedema patients with connective tissue disorders can have abnormal reaction to anesthetic agents.
This is different from traditional cosmetic tummy tuck patients, who can go home the same day. That is why Dr. Volshteyn specifically developed the protocols for the patients to stay overnight either at the hospital or at a rehabilitation hospital facility under close observation.
Lipedema tummy tuck, or lipedema abdominoplasty surgery has to be performed either at the hospital or at the accredited outpatient surgical facility. Outpatient surgical facility has to be certified either by Medicare, AAAASF, AAAHC, or JCAHO. It is also very important to make sure that the facility has ability to keep patients overnight with proper monitoring equipment.
Lipedema tummy tuck or abdominoplasty surgery can take between one and a half hours and three hours or more depending on size of the abdomen, amount of excessive skin, amount of excessive fat to be removed and number of painful lipomas.
Usually the patients are placed in a compressive garment for at least six weeks. We have also developed protocols for patients to start using their mechanical decongestive therapy devices, such as Lymphapress and others early after the surgery.
What is the benefit of Lipedema tummy tuck procedure
If properly performed in a safe environment by a qualified plastic surgeon familiar with Lipedema, the patient can see significant reduction of pain, reduction of skin, reduction of excessive fatty tissue and significant improvement in the shape of the abdomen.
It is common to perform tightening of abdominal muscles during the Lipedema tummy tuck or Lipedema abdominoplasty surgery, Which can further improve the appearance of the abdomen. Patient may also observe improvement of the pubic area and significant improvement of the appearance of the groins, which is most visible in swimsuits or intimate attires.
What is the difference in final outcome between cosmetic abdominoplasty or tummy tuck surgery and Lipedema abdominoplasty or tummy tuck surgery
It is important to remember that the patients who have true lipedema also have increased skin laxity due to associated connective tissue disorder. That is why patient with Lipedema may not achieve the same degree of abdominal skin tightening as cosmetic patients overtime.
What is recovery from Lipedema tummy tuck or lipedema abdominoplasty surgery looks like.
The recovery from Lipedema tummy tuck or lipedema abdominoplasty surgery is similar to cosmetic procedure. However, patients with Lipedema have increased chance of complications prolonged swelling, Seroma or fluid accumulation under the skin, loosening of the skin because of connective tissue abnormalities and residual discomfort associated with painful lipomas that were not identified or removed during the original surgery.
However, in our experience, the degree of satisfaction with Lipedema patience is greater than the cosmetic ones. I believe that the reason for that is that patients experience significant reduction of pain, which is their primary goal for surgery, compared to the cosmetic patients were only the appearance is important.
Who is a good candidate for Lipedema tummy tuck or lipedema abdominoplasty surgery?
Patients with Lipedema, who have excessive amount of painful fat in the abdomen, excessive amount of skin, with or without painful subcutaneous lipomas may be a good candidate if they also satisfy requirements for cosmetic tummy tuck or cosmetic abdominoplasty procedure. They have to have stable weight, overall normal health, All their medical conditions have to be controlled, such as diabetes, hypertension, reflux disease, asthma, etc.
Also they cannot use any nicotine products or smoke for at least six weeks prior to surgery and six weeks after the surgery.
Why is smoking or nicotine use important in Lipedema tummy tuck or lipedema abdominoplasty surgery?
Here I am going to scare you a little bit.
It is done on purpose to emphasize the importance of not smoking and not using nicotine in any shape or form, including vaping devices, Chewing tobacco or nicotine gum.
Nicotine is a very addictive drug. The main effect of nicotine is shrinking the size of the blood vessels throughout the body. The effect of nicotine can last up to two weeks. When the blood vessels decrease in size, the amount of blood, nutrients, proteins and all other healing factors that is delivered to the area is decreased dramatically. And this is just based on the size of the blood vessels.
Smoking also introduces carbon monoxide into the bloodstream. Carbon monoxide molecules attach to hemoglobin in red blood cells. When carbon monoxide attaches to the red blood cell, the red blood cell is unable to carry oxygen to the healing tissues.
Usually red blood cells look like a flat disc, which is very pliable and can easily navigate through the blood vessels. When carbon monoxide molecule attaches to the red blood cells, it turns it in a ball. Those red balls cannot get through small vessels and plug them up, further decreasing the the blood supply.
That is why patients who smoke are not good candidates for tummy tuck or arm lift or thigh lift surgery.
Their risk of infection Is approximately 12 times higher as well as risk of other complications, including increased amount of scar tissue formation. Red blood cells cannot recover from exposure to carbon monoxide. They cannot become back to normal. However, the lifecycle of red blood cell is only 120 days.
That is why if the patient does not smoke for at least six weeks prior to surgery, majority of the red blood cells will not be exposed to carbon monoxide and healing can be returned to normal.
Will I have a lot of pain after Lipedema can we talk or lipedema abdominoplasty surgery?
Majority of patients with Lipedema experience improvement of pain associated with Lipedema after properly performed Lipedema tummy tuck or lipedema abdominoplasty surgery.
Patient do experience discomfort from surgery if abdominal muscles are tightened. In order to reduce the discomfort associated with tightening of abdominal muscles, we use long lasting local anesthetic medication, such as exparel and Marcaine and place it strategically during the surgery into the areas where we can block the local nerves.
Wearing a compressive garment also reduces swelling and improves discomfort after the surgery.
How long does it take to see the results after Lipedema tummy tuck or lipedema abdominoplasty surgery?
Depending on the size of the abdomen, amount of skin and fat removed, overall health, sensitivity to pain, compliance with postoperative protocol, patient will see significant improvement immediately. Patient commonly report significant reduction of pain from Lipedema during their first postoperative visit. The symptoms continue to improve over the next 3 to 6 months.
Is lipedema tummy tuck or lipedema abdominoplasty covered by health insurance?
Traditional answer would be no.
However, in view of recent development and more acceptance of Lipedema as a medical condition, we have been able to get approvals from several major insurance carriers for liposuction, tummy tucks, and other Lipedema related surgical procedures.
The process does take time and requires additional testing and supportive documentation, photographs, etc.
Can I avoid having Lipedema tummy tuck or lipedema abdominoplasty surgery by losing weight or undergoing bariatric surgery?
Unfortunately, it is unlikely. Patients with true lipedema who undergo weight loss surgery rarely lose significant amount of weight from their lower extremities and lower abdomen. Interestingly enough, many patients are able to lose weight in their upper torso and upper portion of the abdomen.
Even if they do, they continue to have significant pain in the lower abdomen and extremities from Lipedema. If you are morbidly obese in addition to having Lipedema and you qualify for Bariatric or weight loss surgery, we suggest you having that surgery before.
Lose the weight first. Have stable weight for at least six months or a year. Make sure that you follow recommendations of your Bariatric Surgeon on proper nutrition, protein supplementation and vitamins.
Once your weight is stable, you may consider lipedema tummy tuck or lipedema abdominoplasty surgery.
Are there any non-surgical ways to reduce amount of skin on the abdomen in Lipedema patients?
There are a lot of medical devices claiming great degree of success in reducing amount of skin using radio frequency, heat, cold, laser or other methods.
Unfortunately, skin of the patients with Lipedema does not respond to those methods as well as a normal skin. As it is, all the above mentioned techniques have very limited improvement limited to skin of younger patients.
Many patients with Lipedema have abnormal looseness of the joints and excessive looseness of the skin and in our experience the money and efforts to reduce excessive may not justify the degree of the improvement.
There are no studies demonstrating any significant and measurable effect on the skin of lipedema patients with any of these techniques.