I have put together a resource for my fellow CLT featuring postoperative instructions from surgeons around the world who perform liposuction on patients with lipedema.

I have learned a few things as a result of collecting this information:

• There are many different types, styles and goals for liposuction surgery for lipedema
• Different procedures necessitate different postoperative protocols
• Different countries have different insurance requirements for qualifying for surgery
• Uneven access to imaging technology also contributes to protocol differences
• Surgeons may not know how useful a CLT can be for making the surgery preparation and recovery process easier for the patient

Comparing answers between surgeons gives the CLT an idea of what different surgeons value. For the issue of patient selection criteria, for instance, the conversation with our client who is considering lipedema liposuction may include:  

• Do they have a diagnosis of lipedema?
• Do they have mobility issues?
• Are they seeing a plateau and no real continued improvement despite regular clinical treatment?
• Have they finished at least 6 months of conservative treatment including at least 6 weeks of CDT, are they wearing flatknit class II compression garments on affected areas and receiving manual lymphatic drainage regularly? 
• Have other medical issues including body dysmorphic disorder, pitting in the lower legs and varicosities been treated?
• If they have a high BMI, would smaller liposuction procedures (reducing fat pad around knee, for example) be of value to improve mobility? 

One surgeon who asked not to be named stated that "if the patient has experienced severe trauma in the past and will not tolerate being touched now, that is useful information. If the patient has built up a tolerance to anti-anxiety meds or pain meds, that is useful information."

I also asked surgeons for their goals for preoperative visits with a CLT. There is a great opportunity for CLT to communicate to surgeons that preoperative visits can be much more than just giving them MLD. Fellow CLT Karen Ashforth stated “the patients that I've had who've had second liposuction procedures felt they were much better prepared because they had all the tools vs. scrambling to acquire them immediately after surgery.” 

How can we stop the scrambling? 

The Standard of Care for Lipedema in the United States document states “people with lipedema should be assessed for lipedema, lymphedema, posture, balance, muscle strength, gait and joint hypermobility by a therapist with certified lymphedema therapist (CLT) training.” and “in the weeks before surgery, a certified lymphedema therapist can perform a pre-surgical screening to guide “prehab” exercise, perform manual therapies and recommend compression garments for the patient” (Herbst et al., 2021). 

Preoperative visits can also be a time to: 

• Score a patient's pain, function and strength
• Take circumference measurements and order garments
• Perform gait analysis and formulate a treatment plan
• Communicate the importance of exercise, nutrition, skin care, compression usage and care and self-care
• Educate client on pre and post surgical care, clarify expectations of the rehab process
• Show patients how to perform activities of daily living while recovering from surgery
• Improve patient’s cardiovascular and musculoskeletal physical condition prior to surgery
• Perform MLD and review Self MLD and breathing exercises

One surgeon who asked not to be named states that their "patients need to be able to walk for at least 10 minute intervals and must be able to balance on one leg. They also need to be able to roll from side to side unassisted. Touch therapy is extremely helpful for lipedema patients, pre-operatively. Many experience pain to touch. However, it is our experience that massage and other touch therapies can decrease the patient's sensitivity to touch and also make ... surgery ... tolerable."

I am hoping this document can be a valuable resource for CLT and inspire closer collaboration between surgeons and CLT in the future. If you refer patients to a surgeon (or if surgeons refer patients to a CLT) consider inviting them to your office (or OR) to see what you do!