Lipoedema Liposuction

This is an informed consent document that has been prepared to help inform you concerning Lipoedema Liposuction surgery(s), its risks, and alternative treatment(s).

It is important that you read this information carefully and completely. Please initial each page, indicating that you have read the page and sign the consent for surgery as proposed by your Consultant and agreed upon by you.

We advise you take enough time to carefully read and understand the information in this document.

General Information

Lipoedema is a metabolic condition, characterised by abnormal and excess fat deposition on the lower limbs. It is very different from normal weight gain in that patients report pain associated with the fat deposition, and the fat is diet and exercise resistant. Other features include a tendency to bruise easily, soft tissue pressure hypersensitivity, joint laxity, orthostatic oedema (ankle swelling with prolonged standing), varicose veins and knee osteoarthritis.

Lipoedema almost exclusively affects females with an estimated prevalence of one in twelve. There appears to be a genetic component with patients often reporting a positive family history. However, it can skip generations. The disease appears to worsen at times of hormonal imbalance such as puberty, pregnancy and menopause.

The tissue changes in lipoedema include:

• Excess fat deposition on the lower and upper limbs
• Subcutaneous fat adopting a nodular consistency / lipomas (fat lobules)
• Soft tissue pain
• Folds of excess skin
• Varicose veins
• Skin hypothermia

The most common areas of the woman's body affected by lipoedema are the lower limbs. However, lipoedema may affect other areas as well, including:

• Upper limb (circumferentially from shoulder to wrist)
• Lower back
• Buttocks
• Lower abdomen

What is Lipoedema Liposuction?

Lipoedema liposuction refers to a specialised technique of liposuction to remove the excess fat of lipoedema. The Consultant uses two different liposuction techniques when performing lipoedema liposuction, namely tumescent liposuction and water assisted liposuction (also known as WAL or Bodyjet).

Both techniques have a proven track record in lipoedema liposuction but are completely different in how they remove fat. Each technique has pros and cons and during your consultation, your Consultant will advise you on which technique is best for you. The objectives of lipoedema liposuction are:

• Alleviate / lessen soft tissue pain.
• Halt progression of the disease
• Reduce weight of the lower limbs and improve knee joint mobility.
• Improve appearance of the lower limbs and restore body proportions.

1. The change in appearance to your limbs after lipoedema liposuction may not be the same as in other patients. Each lipoedema patient is unique and the change that occurs is specific to their lipoedema, extent of surgery, quality of the skin, healing and their perception of their limbs. Lipoedema liposuction may not be possible if you:

• Have needle phobia (for both sedation or general anaesthesia you will need to have blood tests and intravenous access).
• Have multiple allergies to or are unable to take painkillers and/or antibiotics.
• Have unrealistic expectations of the outcome.
• Have not allocated enough time for recovery (you will need a minimum of four to six weeks).
• Are not psychologically prepared for complications such as delayed healing, prolonged swelling etc.
• Have allergy to local anaesthetics or sensitivity to adrenaline.
• Have medical issues that prevent you from having major surgery.
• Are unwilling to follow postoperative instructions e.g. continuous wear of compression garments.
• Are overly anxious.

2. Lipoedema liposuction is primarily performed to halt the progression of lipoedema, relieve pain, reduce weight on the lower limbs and improve knee range of motion.

3. The primary aim of the surgery is not to improve the appearance of your limbs, although many patients are satisfied with the improvement in appearance. There is no guarantee that lipoedema liposuction will eliminate or lessen the soft tissue, knee or hip pain associated with lipoedema.

4. Although your Consultant takes photographs of your limbs throughout your treatment pathway, these are not routinely provided. These photographs are for your medical notes and surgical planning. You are advised to take as many photographs as possible of your limbs before surgery.

5. Immediately following lipoedema liposuction, you may not see much difference in the appearance of your limbs. No one can predict the degree by which your limbs will change in size/shape, and this is dependent on many factors e.g. how much fat was removed, how well your skin shrinks, which areas were treated, how large your limbs were prior to surgery etc.

6. If you are planning to undergo lipoedema liposuction to primarily improve the appearance of your limbs, then you must have realistic expectations of the result and clearly communicate this to your Consultant prior to surgery so he can correctly manage your expectations.

7. Having firm, healthy, and elastic skin will result in a better final contour following lipoedema liposuction. Skin that has diminished tone due to stretch marks, weight loss, natural ageing, smoking or other medical conditions may not reshape itself to the desired new contours and may require additional surgical techniques to remove and tighten excess skin.

8. The amount of fat removed differs from patient to patient and depends on many factors. You may have more or less fat removed compared to a patient with the same Type and Stage of lipoedema as yourself. In some instances, your Consultant may remove less than 5L of fat and this does not mean you have received suboptimal treatment.

9. In some lipoedema patients, albeit rarely, untreated areas of excess fat deposition can become painful after lipoedema liposuction. One cannot predict if this will occur in you, which areas will be affected, and the interval between surgery and development of pain. If this does occur, this is not considered a failure of treatment and you may require further lipoedema liposuction to address the painful areas, at additional cost.

10. Lipoedema liposuction is not a cosmetic procedure and therefore the hospital guidelines regarding revision surgery for a suboptimal aesthetic outcome do not apply.

11. Some lipoedema patients, particularly those with Stage Two or Three disease have swellings around their ankles, below the cuff of fat (circled area in the photo below). These swellings are not removed by lipoedema liposuction. They are sometimes composed of thickened connective tissue (synovium) and not excess fat.

The ankle joint comprises of strong connective tissue surrounding the joint known as the joint capsule. The joint capsule is lined with specialised tissue known as the synovium (or synovial membrane) which is responsible for secreting lubricating fluid (synovial fluid) into the ankle joint, therefore reducing friction during ankle movements.

Example of a lipoedema patient who has soft tissue swelling around the ankle.

12. Lipoedema liposuction is not performed as a weight loss measure. Weight can fluctuate and increase as a result of fluid retention. There are no guarantees your weight will decrease after lipoedema liposuction.

13. Lipoedema liposuction is not performed to help you achieve a certain dress size, allow you to wear specific clothing, boots or footwear.

14. On the day of surgery, you will be seen by your Consultant, and he will mark out all the areas to be liposuctioned. Only the areas marked out will be liposuctioned. If during the surgery there was more fat than anticipated, then your Consultant may not liposuction all the marked areas, as there may be a risk to your safety.

15. Discomfort should be expected after lipoedema liposuction. Tolerance to pain varies between patients and some patients require more or less painkillers than others. You will be offered Paracetamol and Codeine regularly after surgery (providing you are not allergic to either medication). If you still remain uncomfortable despite these medications, then it is your responsibility to request stronger painkillers (such as Tramadol or Morphine) from the hospital nursing staff. Stronger painkillers will only be offered after you have tried Paracetamol and Codeine first.

16. After lipoedema liposuction you will be required to wear compression garments and it is your responsibility to obtain your garments before surgery. You will be provided with all the necessary information regarding the type required and where to obtain them from. If the garments are not available at the time of surgery, the surgery will be cancelled and rescheduled. You are therefore advised to obtain your garments well in advance of surgery. Cancellation and rescheduling of surgery will require payment of a new non-refundable booking deposit. Please see the Terms & Conditions with regard to cancellation costs.

17. Prior to surgery, the location of your surgery will be agreed. Any issues relating to Kinvara Private Hospital such as your room, food, visiting hours, overnight stay of relatives etc. must be communicated with the hospital directly on 01709 464200.

18. Your Consultant is under no obligation to complete your lipoedema surgery pathway and may decline further surgery if he considers surgery is not in your best interests, there are clinical contraindications, you have suffered complications that place you at greater risk with your next operation or if he feels you are no longer suitable for surgery because of physical or psychological issues.

19. Many lipoedema patients require two or more operations of lipoedema liposuction to treat their entire lower / upper limbs. The minimum interval between sessions is twelve weeks but no guarantee can be made by the Consultant or Kinvara Private Hospital that surgeries can be scheduled twelve weeks apart.

20. If you experience significant weight loss after a lipoedema liposuction and are due to have further lipoedema liposuction, you must inform your Consultant, as further surgery may not be in your best interests. You may be required to return to the clinic to be reviewed by your Consultant.

Surgical Plan

In lipoedema liposuction, the volume of fat removed is not the primary target or outcome measure. Instead the target for each surgery is primarily an area, whilst at the same time ensuring that the volume of fat aspirated is within safe limits for that patient.

Ultimately, the number of operations and areas to be treated will depend on your lipoedema Type and Stage and your goals. Your Consultant can make no guarantees on the total number of surgeries required.

Liposuction of the buttocks can be performed but one should expect the buttocks to appear deflated, flat and sagging postoperatively. There is also a risk the buttock skin will become dimpled, resembling cellulite.

Alternative treatments for lipoedema include:

• Do nothing and see how you get on over the next few years.
• Non-surgical treatments such as Manual Lymphatic Drainage (MLD), compression garments or deep oscillation therapy.

These treatments improve symptoms but will not significantly reduce the size of your limbs.

Every surgical procedure involves a certain amount of risk, and it is important that you understand the risks involved with lipoedema liposuction.

An individual's choice to undergo a surgical procedure is based on the comparison of the risk to potential benefit. Although the majority of patients do not experience these complications, you should discuss each of them with your Consultant to make sure you understand the risks, potential complications, and consequences of lipoedema liposuction.

1. Scarring – Although the incisions created for lipoedema liposuction are minimal and good wound healing after the procedure is expected, abnormal scars may occur within the skin and deeper tissues in rare cases. Scars can be red, raised, stretched, itchy and painful. Additional treatments, including surgery, may be necessary to treat abnormal scarring.

2. Infection – Infection following lipoedema liposuction is unusual but can occur. Infection can range from erythema to sepsis or necrotising fasciitis. Should an infection arise treatment including antibiotics or additional surgery may be necessary. Although extremely rare, life threatening infections such as sepsis or necrotising fasciitis could occur after surgery, regardless of the technology utilised.

3. Bleeding – While unusual, it is possible to have a bleeding episode during or after surgery. Should postoperative bleeding occur, it may require emergency treatment to drain accumulated blood or require a blood transfusion. Non-prescription herbs and dietary supplements can increase the risk of surgical bleeding. Do not take any aspirin or anti-inflammatory medications for two weeks before surgery, as this may increase the risk of bleeding. Please review our medication list for products and ingredients to be avoided.

4. Chronic Pain – Chronic pain and discomfort following lipoedema liposuction is rare but can occur.

5. Stiffness – The limbs may feel stiff after lipoedema liposuction and this stiffness may persist for several weeks.

6. Bruising and/or Swelling – Bruising and swelling can occur and, in rare situations, persist for several weeks.

7. Asymmetry – There is a risk that your limbs will appear asymmetric after lipoedema liposuction. Almost no one has perfectly symmetrical limbs and any preexisting asymmetry may persist after lipoedema liposuction. Please bear in mind that limb contour also depends on skin elasticity, muscle tone and bony prominences. None of these are affected by liposuction. A degree of asymmetry between the right and left halves of your body is entirely natural.

8. Over/Under Correction – When performing lipoedema liposuction, every effort is made to ensure the lipoedema fat is removed in a systematic and even manner. However, there is always the risk that too much or too little fat is removed from a particular area. As such, adjustment surgery may be necessary at additional cost.

9. Unsatisfactory Result – Although good results are expected, there is no guarantee on the ultimate outcome.

10. Prolonged Postoperative Swelling/Lymphoedema – Postoperative swelling is entirely expected but can last for several weeks. One cannot predict when the swelling will subside. Your postoperative swelling may be shorter or longer in duration than similar patients. There is always the risk of developing lymphoedema in a limb that has undergone liposuction. Lymphoedema may not become apparent until many years after the initial surgery. Furthermore, lipoedema is a progressive condition and lymphoedema can potentially develop as an unrelated issue after surgery.

11. Subcutaneous Irregularities/Nodularity – It is common for the liposuctioned area to feel lumpy, but this tends to settle over time. Permanent irregularities can occur and may be in the form of dents, dimples, grooves, wrinkles or folds.

12. Skin Laxity – In certain areas of the body, the skin is prone to laxity after liposuction. This may be due to poor skin elasticity, which is in turn related to patient age, ethnicity and genetics. Areas prone to laxity after liposuction include the abdomen, posterior arms, medial thighs, suprapatellar region and saddlebag region.

Patient Example with Stage III lipoedema had suprapatellar skin laxity after liposuction (circled area in the photo above).

13. Skin Contour Irregularities – Skin contour irregularities and depressions in the skin are possible. Visible and palpable wrinkling of skin can occur, particularly when large quantities of fat is removed and/or the skin is lacking good elasticity. Postoperative skin contour irregularities could necessitate additional treatments including surgery, at additional cost.

14. Skin Loss – Skin necrosis is a rare complication of liposuction surgery. Skin necrosis can occur if a patient has poor nutrition or is a smoker. Skin necrosis can normally be treated with dressings which will allow the skin edges to heal by secondary intention. In rare cases, the necrotic skin may have to be excised and re-stitched. Poor scarring as a result of skin necrosis can also be treated with either further adjustment surgery once the area has healed.

15. Change in Skin Sensation (Numbness or Hypersensitivity) – Numbness of the skin after liposuction is entirely expected and usually improves over several weeks. Reduced or increased skin sensation that does not completely resolve can occur.

16. Damage to Deeper Structures – Injury to deeper structures including nerves, blood vessels, and muscles is rare but could occur.

17. Seroma – While the incidence and severity of seromas associated with liposuction are not common, such fluid accumulation is possible and could require additional treatments or surgery to promote drainage.

18. Wound Healing Issues – Occasionally wounds can be slow to heal as a result of infection, poor nutrition or poor blood supply. It is important that you tell your Consultant if you smoke or have any history of poor wound healing or scarring.

19. Unresolved Knee Pain – Many lipoedema patients suffer knee pain. This may be related to soft tissue pain or may be due to knee osteoarthritis. There is no guarantee preexisting knee pain will improve after lipoedema liposuction.

20. Fibromyalgia/Chronic Pain Syndromes – There is a risk that lipoedema liposuction can worsen the symptoms of fibromyalgia or other chronic pain syndromes.

21. Risks of Anaesthesia – All forms of anaesthesia or sedation, whether administered locally or generally, carry risks including the possibility of complication, injury, and even death. Risks of general anaesthesia include Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE), drug allergies, cardiorespiratory issues, injury to teeth, pressure sores, ocular injuries and cardiac / respiratory arrest.

22. Pressure Sores (Resulting from Poorly Fitting Compression Garments) – There is a risk that your compression garments may cause pressure sores. This is particularly so around the ankle, where folds in the compression tights can develop. If your compression garments feel too tight or uncomfortable, it is your responsibility to liaise with the provider of your garment to obtain a more comfortable / correctly fitting version. Neither Kinvara Private Hospital, its employees, or your Consultant accepts any responsibility for compression garments that are incorrectly sized, poorly fitting or uncomfortable.

23. Allergic Reactions – Allergies to tape, dressings or suture material, used in lipoedema liposuction can occur. More serious systemic reactions due to drugs administered during surgery and prescription medicines can also arise and may require additional treatment.

24. Long Term Effects – Subsequent alterations in body contour may occur as a result of ageing, weight loss or gain, pregnancy, or other circumstances not related to lipoedema liposuction.

25. Sleep Apnoea/CPAP – Individuals who have breathing disorders such as "Obstructive Sleep Apnoea" and who may rely upon Continuous Positive Airway Pressure (CPAP) devices or utilise nighttime oxygen are advised that they are at a substantive risk for respiratory arrest and death when they take narcotic pain medications following surgery. This is an important consideration when evaluating the safety of surgical procedures in terms of very serious complications, including death, which relate to preexisting medical conditions. Surgery may be considered only with monitoring afterwards in a hospital setting in order to reduce risk of potential respiratory complications and to safely manage pain following surgery.

Please consider the following symptoms of sleep apnoea:

• I am frequently tired upon waking and throughout the day.
• I have trouble staying asleep at night.
• I have been told that I snore or stop breathing during sleep.
• I wake up throughout the night or constantly turn from side to side.
• I have been told that my legs or arms jerk while I'm sleeping.
• I make abrupt snorting noises during sleep.
• I feel tired or fall asleep during the day.

It is important for you to inform and discuss any of the above symptoms that you have experienced with your Consultant.

26. Patient Selection – Individuals with poor skin tone, medical problems, or unrealistic expectations may not be candidates for lipoedema liposuction.

27. Pulmonary Complications – In extremely rare cases, fat droplets could become trapped in the lungs to create a possibly fatal complication called fat embolism syndrome. Pulmonary complications may occur secondarily to blood clots (pulmonary emboli) or partial collapse of the lungs after general anaesthesia. Should either of these complications occur, you may require hospitalisation and additional treatment. In some circumstances, pulmonary emboli can be life threatening or fatal.

28. Skin Pigment Changes – Skin hyperpigmentation at the incision sites can occur and in rare cases, be permanent.

29. Surgical Shock – Liposuction could conceivably cause severe trauma, particularly when multiple or extensive areas are treated in a single session. Although serious complications are rare, infections or excessive fluid loss could lead to severe illness and even death. Should surgical shock occur following your liposuction, hospitalisation and additional treatment may be necessary. Individuals undergoing liposuction to remove large volumes of fat are at greater risk of complications.

30. Lidocaine Toxicity – There is the possibility that large volumes of fluid containing dilute local anaesthetic drugs and adrenaline that is injected into fatty deposits during surgery may contribute to fluid overload or systemic reaction to these medications. Additional treatment including hospitalisation may be necessary.

31. Disappointment with Results – While we have attempted to assist you in building realistic expectations for your lipoedema liposuction, you may be disappointed with your surgical results. However infrequent, it may be necessary in your case to perform additional surgery to improve results, at additional cost.

32. Limited Understanding of Lipoedema – Our understanding of lipoedema is very limited and there is no guarantee that your mobility or soft tissue pain associated with lipoedema will improve after surgery. The effect of lipoedema liposuction on preexisting medical conditions is not known and there is a risk that symptoms may be worsened. You should not have lipoedema liposuction if you cannot accept this risk.