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My personal opinion: If pregnancy is planned within the next 1–3years, I would
rather not recommend liposuction in advance. If the time is unknown or in the distant future, we recommend lipedema treatment in advance. Finally, it is also a question of cost coverage and nancial means.
Conclusion on Surgical Liposuction Treatment for Lipedema Neither conservative nor surgical treatment can cure lipedema. We do not share the classic recommendation that conservative therapy should be exhausted and now consider surgical
therapy to be the treatment of choice for the treatment of lipedema, but only with the
inclusion of possible obesity in the sense of complex surgical treatment with an
individual therapy plan. Likewise, the complex surgical treatment also includes a
forward-looking assessment of the impending change in body shape and requires
mandatory consideration of possible tightening operations.
Z. Jandali et al.
3.8 Treatment Example
In the following, we would like to tell you a very classic lipedema patient story: The
36-year-old patient presented for the rst time in our outpatient consultation. She
reported suffering from a disproportion in favor of the legs and arms since puberty—
initially very discreet and only noticeable to herself, but then increasingly. The rst
attempts at dieting failed, and there was a slow weight gain, almost always after
dieting. In addition to the disproportion described, the affected person reported that
she experienced pain under stress and later also at rest. At the slightest bump, she
suffered a bruise. The disproportion became more pronounced over time. Likewise,
the pain worsened. All further attempts to maintain and control the body weight
failed. On the contrary, there was a creeping weight gain. The pregnancy of the rst
and the second child led to a signicant aggravation. Especially the pain would have
been almost unbearable by now. Many visits to the doctor followed, all of which
were disappointing and unsuccessful. Finally, she presented to a vascular surgeon
colleague in private practice. The diagnosis was made: lipedema.
Further examination of the vascular system revealed no evidence of disease. A
colleague from the vascular surgery department referred the patient to our consultation. When the patient presented to our clinic, she was in sheer despair. Compression
treatment and consistent lymphatic drainage were unable to achieve any signicant
improvement.
On the day of the examination, body weight was 98kg with a height of 1.67m.
The examination showed clinically a very pronounced lipedema of type IV stage 2.
We talked to the patient about the possible options and showed her the advantages and disadvantages and risks of surgical and conservative treatment. First, we
led an application for cost coverage, which was rejected by several instances. The
patient did not want to take legal action because of the poor prospects of success.
Our surgical treatment plan included liposuction of the front of the lower extremity (hips, thighs, knee region, and lower legs) and liposuction of the back of the
lower extremity. In another session, liposuction of the arms (upper arms and
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forearms) was also planned. If there was tissue sagging in the inner thigh area, a
thigh lift could be considered (this was unlikely at the time). In addition, the patient
wanted liposuction of the abdomen and ank region (we combined this with liposuction of the arms).
Finally, the planned procedures were performed (with the exception of the thigh
lift). During the three liposuction procedures, nearly 28L of fat were removed using
our own technique. After each of the procedures, the patient stayed with us in the
clinic for 3days. Dizziness and nausea were not reported, there was only a slight
decrease in the Hb value (hemoglobin). On each of the following days, the patient
was able to move freely on the ward level. Of course, there were bruises and indurated areas. Lymphatic drainage was started early, and in time the initial swelling
and bruising subsided.
The further course was unspectacular. The soft tissues recovered well. The pain
was already virtually gone after the rst liposuction in the surgical regions—as it
was at the end of the treatments. The pain was completely gone. The patient gave
up compression only slowly after 6months. The aesthetic result was very good
(for the patient and also from our point of view). The patient thanked us with a
basket of chocolates at the end of the treatment. Another control will follow
in 1year.
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3.9 Cost Absorption
Reimbursement for treatment, whether outpatient or inpatient, requires that the condition and treatment be recognized by the health insurance system.
Lipedema is a recognized disease and is listed as a medical diagnosis in the
International Statistical Classication of Diseases and Related Health
Problems (ICD).
In the German version of the current ICD-10, lipedema is coded E88.2x.
Classication according to ICD-10-GM.
E88.20 Lipedema stage I (Fig.3.43 left)
E88.21 Lipedema stage II (Fig.3.43 center)
E88.22 Lipedema stage III (Fig.3.43 right)
E88.28 Other or unspecied lipedema
Thus, one part of the requirement for cost coverage is met. The other part, namely
the treatment, is somewhat more problematic in this case. Conservative treatment in
the sense of compression treatment and lymphatic drainage are usually covered by
health insurance for life. Unfortunately, when it comes to liposuction, the situation
is different. Liposuction (liposuction) is not recognized as a measure for the treatment of diseases and thus also of lipedema.
To test the effectiveness, the Federal Joint Committee (G-BA) has commissioned
a clinical trial in which liposuction (surgical liposuction) has been compared with
the standard nonsurgical treatment of lipedema since the beginning of 2020. During
the trial study, the costs of liposuction will be borne by the statutory health insurance funds.
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Z. Jandali et al.
Fig. 3.43 Stages of lipedema
Women with lipedema in all stages (I–III) in the leg region can participate in the
study. The basic prerequisite for participation is that there has not been sufcient
relief of symptoms under conservative measures. There are a number of inclusion
and exclusion criteria that we do not wish to discuss further here, as the inclusion
deadline is Dec. 31, 2019. The aim of the trial study is to assess the potential of the
method in the indication to include the method in the benets catalog of the statutory health insurance (SHI) if the result is positive—a ray of hope for all patients
who cannot participate in the trial study. We ourselves are participating as a study
center, but we strongly criticize the study design. Through the study, we all hope to
gain more insight into the extent to which liposuction has a positive effect on the
symptoms of lipedema.
However, there are two other options through which liposuction is possible as a
health insurance benet.
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– Since 2020, liposuction in severe cases has become a statutory health insurance
benet. By “in severe cases” it means the presence of stage III.We have already
discussed in detail that this criterion makes no sense, because stage III says noth-
ing about the pain, nor about the suffering pressure, nor any other form of impair-
ment. The fact that stage III liposuction has been included in SHI-accredited care
was decided by the Federal Joint Committee (G-BA). The service has been
included for a limited period until December 31, 2024. By then, the ndings
from the above-mentioned trial study, which is to assess the effect of liposuction
in all stages of lipedema, should be available.
– Cost absorption by the health insurance fund is also possible via a so-called indi-
vidual case decision. The individual case decision is an administrative act based
on separate circumstances. An individual case decision is requested from the
health insurance fund. An application includes a medical report and an initially
informal request formulated by you. As with all measures for which the health
insurance fund is to cover the costs, there must be a medical indication.
Surely you have already read the term “medical indication” and if this is not the
case, you will certainly encounter it in the course of the application process.
Indication in itself means “indication of cure.” It simply means which measure, for
example, an operation or a drug, is the right one for the therapy of disease. The word
“medical” means that the treatment is for an actual illness.
In the case of lipedema, pain or restriction of movement would be the reason for
treatment. The treatment of facial wrinkles with Botox® (botulinum toxin A) or by
a facelift would be a cosmetic (=aesthetic) indication, since there is no physical or
health impairment here. Consequently, it is a treatment of a condition which, by
denition, is not a disease. These treatments are also referred to as IGeL services
(individual health services).
A medical indication exists in the case of a disease or disgurement within the
meaning of the Fifth Social Code (SGB V). This means that the health insurance
fund will bear the costs of treatment for those affected. This means that in the case
of a medical indication, the health insurance fund must bear the treatment costs.
Actually, the health insurance company would have to cover the costs of treatment per se, provided that the doctor sees a pathological change. Before an eye,
intestinal, or foot operation, the health insurance company is not asked either, since
no one gets the idea that these could be “desired operations.” This is different for
lipedema or tightening operations. Here, the view of the health insurance companies
often differs from that of the plastic surgeons who provide a medical indication. The
health insurance companies very often refuse to reimburse the treatment costs after
the treatment has taken place. The health insurance company argues that there was
no pathological condition and that the operations were scheduled, not acute.
Therefore, the health insurer should have been asked in advance whether, in its
opinion, there was a medical indication and the operation could be charged to the
health insurer.
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Against this background, the individual case application for cost coverage must
be made in advance. Since many employees at health insurance companies are pure
clerks and do not have the competence to assess medical facts, the health insurance
company often helps itself with the medical service of the health insurance company (MDK).
The Medical Service of the Health Insurance Fund (MDK) is an institution
that advises health insurance funds on medical issues, among other things.
Doctors from various specialities are permanently employed by the Medical
Service and, to put it simply, work as “experts.” In the rarest of cases, the
MDK can call on the services of a plastic surgeon. Therefore, doctors from
other elds often deal with plastic surgery issues, which unfortunately often
leads to incomprehensible decisions. But here, too, the MDK and the physicians work continuously to achieve comprehensible decisions.
Thus, health insurance usually decides only after obtaining an expert opinion
from the MDK.The MDK either decides on the basis of les, which is very difcult
in the case of these operations, or it conducts an expert opinion.
When are you entitled to have costs covered? Section 7 sentence 1 of the German
Social Code Book V states: “Insured persons are entitled to health treatment if it is
necessary in order to recognize or cure an illness, to prevent its aggravation or to
alleviate symptoms of illness.”
Specialist lawyer T. Werner has written the very interesting Chap. 6
c
with all the necessary information on medical indications and questions
of cost coverage. I can only warmly recommend this to you.
In the case of psychological problems, according to case law, treatment with
psychotherapy, or psychiatry is indicated as a priority. Therefore, you should never
apply for cost coverage on the basis of psychological stress; a rejection would be
inevitable.
In reality, medical indications are far less tangible than the legal text would sug-
gest. The assessments by the MDK are so varied that we can no longer even make a
prognosis as to whether costs will be covered. This most often has to do with the
existing or lacking qualication of the physicians of the medical service in this particular eld. How well trained is a trauma surgeon, internist, or gynecologist to
decide if liposuction is the right treatment? We have read very questionable and
astonishing decisions by the MDK in our daily clinical practice. In addition, the
health insurance company does not always follow the recommendation of the MDK,
which it does not have to per se.
Costs for operations for which there is no medical justication are not covered
by health insurance. These are essentially aesthetic operations. The person concerned must pay for these. In contrast to medically justied operations, where the
entire treatment, including treatment of complications, is fully covered by the health
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insurance, the affected person will share in the costs of complications after aesthetic
operations, depending on their income. To exclude this risk of co-payment, a socalled follow-up cost insurance can be concluded. In addition, operations that are
not medically indicated are charged with VAT.
Medically justified interventions are operations whose costs are charged
c
to the health insurance companies. Aesthetic procedures (operations
without medical indication) are charged to the patient. The costs of
follow-up operations or complications must then be borne by the
patient. To avoid this risk, a special follow-up insurance policy can be
taken out for this purpose before the operation.
After the refusal of cost coverage or if there is no medical indication, liposuction
can also be performed as a self-pay service. The costs of liposuction depend on the
number of regions to be treated during the operation as well as the difculty of the
operation, form of anesthesia, duration of anesthesia, length of stay, visits, and follow- up checks. It also plays a role whether the treatment is outpatient or inpatient in
the hospital. Liposuction starts at about 1000 euros plus VAT with local anesthesia
and a small circumscribed area. A hip–thigh liposuction on an outpatient basis
under twilight sleep anesthesia costs about 4500–6500 Euro plus VAT.For extensive
liposuction of the hip, thigh, and lower leg region, costs between 5500 and 7500
Euro plus VAT have to be calculated.
Other costs that are added to a self-pay service are follow-up insurance. If a
complication occurs during a self-pay service, your health insurance company may
charge you a share of the costs or refuse to cover the costs altogether. With follow up cost insurance, you can protect yourself against this nancial risk.
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3.10 Autologous Fat Grafting
Angel Pecorelli Capozzi, Zaher Jandali
You may think that this chapter is rather unusual for a lipedema book. However,
we performautologous fat grafting in about every tenth lipedema treatment. This
corresponds to about 10% of cases and is not entirely insignicant.
Liposuctioned fat can be used very well for autologous fat grafting. Autologous
fat grafting is also called “lipolling.”
Autologous fat grafting is also called lipofilling.
c
In this process, the extracted fat is washed, processed, and transplanted. The self-
transplanted fat grows on site to about 70% and remains in place forever. About
30% of the fat cells die after transplantation.
In autologous fat grafting, the extracted fat is washed, processed, and
c
transplanted.
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Z. Jandali et al.
For several years, autologous fat grafting (autologous fat transfer, lipolling) has
enjoyed increasing popularity. Most often, autologous fat transplantation is used for
volume augmentation and tissue rejuvenation. Volume augmentation is often performed for breast augmentation in cases of congenital or acquired volume deciency. When we talk about an acquired volume decit in the breast area, we are
talking about changes in the breast that occur due to the natural aging process, or
weight loss. However, volume loss also occurs in the face during the aging process,
as well as aging and sagging of the skin. The loss of volume in the face occurs due
to a reduction of fatty tissue and bone, as well as sagging of the soft tissues due to
gravity.
Over the years, various synthetic llers and implants have been used to treat
these volume decits. Each of the substances had its advantages and disadvantages,
and the practitioners always had to make compromises due to the often not insignicant disadvantages. In the past, liposuction procedures were traumatic, and fat cells
were destroyed during liposuction. This is no longer the case today. Nowadays,
liposuction procedures, whether WAL, PAL, or standard, are very gentle procedures
and the fat cells obtained as a result have good vitality. As a result, fatty tissue has
proven to be an ideal ller for the above-mentioned indications. But not only that:
fatty tissue offers much more. As we have read in the introductory chapters, we also
nd stem cells and growth factors in adipose tissue. We can extract these stem cells
and growth factors and deliver them to the skin to support collagen synthesis,
improve blood circulation and improve skin quality. Here we are already in the
middle of the topic of regenerative medicine. However, we most often use lipolling
for breast augmentation and wrinkle treatment.
Possible applications are own fat breast augmentation, facial wrinkle
c
treatment, lip modeling, and many more.
Autologous fat grafting is divided into two parts. First, liposuction is performed,
followed by fat grafting. In all techniques, the suctioned fat must be collected in a
special canister or system for fat grafting (Fig.3.44).
After repeated cleaning and, if necessary, processing of the fatty tissue, it is
drawn up into syringes and can be injected into the recipient area, for example, the
breast (Fig.3.45).
Roughly speaking, we distinguish between three types of fat that are suitable for
transplantation: In addition to macro fat, which is the simple fat that we harvest
with our suction cannulas, there is also micro fat and nano fat. The macro fat, as
shown in Fig.3.46, we use, for example, for breast or buttock augmentation, but
also the correction of dents or irregularities. In macro fat, the fat particles are larger
than 1.5mm, on average about 2–3 or 4mm. The fat tissue is obtained with ne
cannulas.
Roughly speaking, we distinguish three types of fat for autologous fat
c
grafting: macro fat, micro fat, and nano fat.
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Fig. 3.44 The collected
grease is drawn up from
the collection container via
syringes
Fig. 3.45 Drawn-up fat
syringes for transplantation
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Fig. 3.46 Macro fat when
inserted into the breast for
breast augmentation
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Fig. 3.47 After
autologous fat grafting to
the breast with previously
severe asymmetry and
bilateral hypovolemia
Z. Jandali et al.
If the fat conglomerates are broken up, then we obtain micro fat (Fig.3.47). The
micro fat particles have a diameter of about 1mm and are aspirated through special
micro fat cannulas with a hole diameter of 1mm. The micro fat is particularly suitable for facial wrinkle treatment.
When we talk about nano fat, we are basically no longer talking about adipose
tissue per se, but only about the stem cells found in adipose tissue. Nano fat is all
about regenerative medicine. Nano fat is produced via a process in which we rst
break up the fat conglomerates into tiny particles and nally further process the
entire fat emulsion through a lter. In the end, we have an aqueous-yellowish emulsion that no longer contains intact fat cells, but instead contains a great many stem
cells with regenerative potential. We use nano fat most frequently for sustainable
improvement of the skin’s appearance (Fig.3.48).
The exact mechanism of fat cell survival after transplantation is not yet fully
understood. We would like to briey present one of the common theories: After the
fat cells are removed from the donor region and transplanted into the recipient
region, a race against time begins for each individual fat cell- death versus survival.
For the survival of the transplanted fat cell, the supply of oxygen and nutrients is
indispensable. Since the fat cells do not have their own blood vessels, they must be
supplied via diffusion until the fat cells have reconnected to the local vascular network and can be nourished via it. This diffusion provides an initially sufcient supply for most of the cells.
It should be noted that the higher the oxygen content of the recipient tissue, the
better the growth rate of the fat cells. Negative inuencing factors such as smoking
and excessive pressure on the cells should therefore be strictly avoided. Clinically,
an average survival rate of transplanted fat cells of about 60–70% is observed.
Autologous fat grafting in smokers more often shows a poor fat cell
c
attachment rate. Poorer tissue perfusion and a lower oxygen supply in
the recipient tissue are responsible for this.
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Fig. 3.48 Micro and nano
grease
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In addition, it is important to avoid too much pressure on the transplanted area.
Pressure from the outside causes reduced blood ow, which in turn causes the cells
to die. This means, for example, that you should not wear a compression bra or tight
bandage at rst after a breast augmentation. You can wear a light sports bra that does
not exert much pressure from the second week. Likewise, you should not lie on your
stomach after a breast augmentation with your own fat. Too much internal pressure
due to “overlling” with fat cells can also lead to fat cell death. Warmth, on the other
hand, has a positive effect on fat cell survival. The warmer the recipient area, the
better the blood circulation in this area.
The most important factor for the growth of as many fat cells as possible is the
technique of transplantation. If fat transplantation is performed with an excessive
amount of fat tissue, too much internal pressure is exerted on the transplanted cells.
On the one hand, this impairs the blood supply to the resident cells, and on the other
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