Lymph-Sparing Liposuction – Marketing Ploy or Medically Accurate Phrase?
Our medical carrier reimbursement project for liposuction for lipedema is marketing something: that liposuction for lipedema is reconstructive and medically necessary. Toward that goal we want the very best verbiage that helps us win the most cases. I believe we need to differentiate reconstructive liposuction from cosmetic liposuction.
It appears that Body Jet™, the WAL people have done a good job of making their product synonymous with “lymph-sparing” and liposuction for lipedema. So, it terms of marketing, BodyJet has clearly marketed WAL and lymph-sparing as the only way to go.
On the www.lipoforlipedemareimbursement.com website I have elected to use the phrase Lymph-Sparing, Tumescent Liposuction, abbreviated to LS-TL. However I am not differentiating techniques (WAL, PAL, laser, Ultrasound). It has come to our attention that some liposuction experts consider lymph-sparing to be “marketing” and that there is no difference in technique for lipedema–it’s the same whether it’s for lipedema or cosmetic.
In terms of just getting paid, the exact phrasing is not relevant–as long as it gets the desired results. All I am doing is trying to get into the head of an insurance carrier review board, which is made up mostly of doctors, and make the best case why we should be reimbursed. If we have 100 carriers, my guess is that maybe 25% will appreciate how we address safety and the reconstructive aspect with the phrase “lymph-sparing”–and approve it; and there may be 5% that might assert that LS-TL requires a separate CPT code, and we would need to use an unlisted code; it’s just harder to get paid but can be done.
The more data we gather, it becomes more apparent that we will always be working a fine line between differentiating cosmetic liposuction from reconstructive liposuction and the issue that reconstructive liposuction for lipedema should be a new or unlisted CPT code. For the majority of healthcare carriers, just calling it liposuction may well be enough.
As a much longer-term strategy, the surgical associations and doctors should think about whether a new reconstructive code is something you wish to pursue. I don’t think the comparable procedures for cleft palate and breast reconstruction have their own codes but liposuction is different. Most patients, Providers, and insurance companies consider liposuction to be a cosmetic procedure. For that reason I want to emphasize it’s unique usage in terms of lipedema.
Ultimately the way the patient will submit the claim documentation package and appeal package will be based on how the doctor documents the liposuction from the beginning.
If your surgeons does not use the phrase lymph-sparing anywhere in the surgical Operative Report or office notes I don’t recommend adding it.
You may ask before you begin the entire process if the doctor has been trained in the lymph-sparing technique (he/she may not consider it any different than generic liposuction) and plans to document it as such.
My guess is if the doctor uses WAL then they will, by habit, include the phrase “lymph-sparing” in their notes. If it’s PAL or another technique, and they were not trained by someone who emphasized lymph-sparing, then probably not.
This is a detailed and nuanced document. I’ve been working with doctors and helping them document for administrative compliance and reimbursement for over 20 years. In many ways, it’s different than how they think clinically. We are preparing to battle with the healthcare insurance companies. Let’s be prepared. Bottom line: paid claims.
Research
I found four (4) research articles using the term, “lymph-sparing.” Two are related to lipedema, one is for another condition and the Dr. Stutz article appears to be an internal journal from Body-Jet™.
MON-116 Liposuction for Lipedema (Persistent Fat) in the US Improves Quality of Life (Cobos L et al, 2019) Lymph-sparing liposuction confirmed
Reduction of lipedema fat is achieved effectively only by removal of fat by lymph-sparing liposuction. Women with lipedema noticed improved ambulation after liposuction, likely due to removal of excess adipose tissue from the legs. Fat growth after liposuction was reported consistent with published data. Improvement in quality of life after liposuction agrees with European data, and greater perceived benefit in earlier stages emphasizes the importance of early detection of lipedema and earlier intervention with liposuction. Prospective studies are needed to assess quality of life, fat growth, weight loss and ambulation after liposuction in women with lipedema in the US.
Prevention of Progression of Lipedema With Liposuction Using Tumescent Local Anesthesia; Results of an International Consensus Conference (Sandhofer M et al, 2019) Confirmed lymph-sparing research long-term.
Results: Multiple studies from Germany have reported long-term benefits for as long as 8 years after liposuction for lipedema using tumescent local anesthesia.
Conclusion: Lymph-sparing liposuction using tumescent local anesthesia is currently the only effective treatment for lipedema. [This is essentially my phrase here – Jeff]
Zur Inzidenz lymphatischer Komplikationen nach varizenchirurgischen Eingriffen (Baier P et al 2018) This is not for lipedema; but it does reference the phrase: lymph-sparing confirmed
Conclusion Lymph-sparing surgical techniques and anatomical–topographical knowledge of the lymph supply are prerequisite for varicose vein surgery. In the cases of lymphatic complications, conservative measures should be exhausted before surgical revision is performed.
The procedure is not liposuction and varicose veins, not lipedema, but the fact that they use the phrase outside of the WAL influence indicates to me that lymph-sparing is a medically valid term – Jeff.
Lymph-Sparing Liposuction for Lipoedema – American-European Expert Meeting (Stutz J et al, 2014) References in the title lymph-sparing liposuction confirmed; this appears to be a Body-Jet™ publication.
Here’s a fifth research article related to lymphedema but not liposuction. The phrase “Lymph Vessel Sparing Procedure” is included.
Fibro-Lipo-Lymph-Aspiration With a Lymph Vessel Sparing Procedure to Treat Advanced Lymphedema After Multiple Lymphatic-Venous Anastomoses: The Complete Treatment Protocol
Scientific IRCCS Network Italian Ministry of Health
Corrado Cesare Campisi, Melissa Ryan, Francesco Boccardo, Corradino Campisi
Liposuction doctors who include the phrase “lymph-sparing” on their website:
- Thomas Wright, MD; he has a very involved description of lymph-sparing.
- Stefan Rapprich; Lymph-Sparing Lipedema University; Youtube Video
- Jamie S. Schwartz, description on website
- Marcia Byrd, MD, description on website
- Josef Stutz, MD (references it in his article)
- Dr. David Greuner, surgical director of Roxbury Associates
- Dr. David Amron, see reply below
It appears that the seven leading liposuction for lipedema surgeons above are “marketing” lymph-sparing. As far as I could tell, all of them use BodyJet™ or Water-Assisted Liposuction. So the influence by the vendor is real but the phrase appears to be medically valid as well. My impression is that the term addresses the uniqueness of liposuction for lipedema and a safety issue.
At the Fat Disorders Resource Society (FDRS) Annual Meeting, Dallas, TX, Dr. Wright gave a talk on Lymph-Sparing Liposuction Safety.
Dr. Jamie Schwartz writes:
Lymphatic-Sparing Liposuction: The mainstay treatment for Lipedema is Lymphatic-Sparing Liposuction. This specialized Liposuction is more selective at removing the “bad” lipedematous fat while sparing the more vital structures such as nerves, blood, and lymphatic vessels.
Lymphatic-Sparing Liposuction is performed by using larger, blunt cannulas and releasing the fat cells and fibrotic connective tissue prior to suctioning. Some physicians prefer Water Assisted Liposuction (WAL) since this was one of the first types of liposuction used in patients with Lipedema.
The only difference is that the tumescent (fluid placed prior to liposuction to decrease pain and bleeding) is gently sprayed by the WAL. The rest of the procedure is similar in that the larger cannulas should be directed as parallel to the major lymphatic vessels (along the axis of the limb) as possible. The newer technique is known as SAFE Lipo.
SAFE is an acronym that stands for: Separation Aspiration Fat Equalization
This technique employs all of the best methods for consistent, safe outcomes. My own method using this technique is to place the tumescent with a larger diameter, blunt vibrating handpiece of the Power Assisted Liposuction (PAL) machine. This separates or gently break up the fat cells and thick connective tissue which is known as Simultaneous Separation Tumescence (SST).
Research shows this method allows for less bleeding and trauma to the fat cells since it places the tumescent fluid close to the cells.
Marcia Byrd writes:
Research shows lymph sparing liposuction yields good long term results in reduction of Lipedema pain and in stopping the progression of Lipedema. (Cornely et al., 2006; Schmeller et al., 2006; Warren et al., 2007; Stutz & Krahl, 2008; Rapprich et al., 2011, 2012).
I checked the listed research references above and none of them had the phrase “lymph-sparing” in the abstract portion. In other words, liposuction yields good results but not, per the research, specifically lymph-sparing. Most do not mention WAL either.
Dr. David Gruener writes:
Surgical treatment of lipedema. In Germany, the UK and elsewhere mostly in Europe, lymph sparing liposuction to remove liopedemic fat has been used for several years with excellent results, this extremely specialized technology has not been used in the USA, with the exception of at NYC Surgical where our lymphovascular team specializes in the full range of lymphatic and vascular issues, particularly pertaining to the lower extremities and other areas.
The LipedemaProject Website lists:
Lymph-sparing Liposuction [This is on their website
If surgical intervention is deemed necessary, patients can undergo lymph sparing liposuction. The liposuction removes lipedema fat, and has been shown to be effective at slowing or stopping the progression of lipedema and at reducing lipedema pain. Patients may undergo multiple sessions of liposuction treatment, which is typically an outpatient procedure with local anesthesia.
Managers of this website include Catherine Seo and Dr. Földi.
Dr. Amron reply to a patient Question [RealSelf.com April 17 2015]
Question: I know WAL, VASER, PAL are considered lymph sparing but what I really need to know is if tumescent liposuction with traditional syringe/cannula Lipo is considered lymph sparing also? Does using tumescent in itself make it as lymph sparing?
Answer: (Dr. Amron): Tumescent liposuction is not by itself lymphatic sparing. To me, what lymphatic sparing signifies the surgeon’s skill to only stay in the certain subcutaneous layer and not damage deeper branches. General anesthesia I feel would be more difficult to do this surgery, a surgeon can potentially poke into deeper tissues and damage the lymphatics. Please be sure to seek a board-certified surgeon for your medical needs and proper treatment.
Other answers to the question:
Answer: All tumescent liposuction techniques are lymph sparing; it also spares the blood vessels and the nerves. Dr. David Finkle [This contradicts what Dr. Amron said above – Jeff]
Answer: Pure tumescent liposuction (developed by Dr. Jeff Klein) is the procedure that spares lymphatic tissues the most. M Sapijaszko May 2015
Answer: Of all of the techniques, the least damage is caused to the lymphatics by the tumescent liposuction procedure. Gary Lawton, MD, Apr 2015
Answer: traditional tumescent liposuction can be lymph sparing, N Castillo MD apr 2015
https://www.realself.com/question/sydney-au-tumescent-liposuction-lymph-sparing
Note: None of the surgeons above asserted that there is no such thing as “lymph-sparing” and it is only a marketing ploy. – Jeff
Dr. Victoria Falcone writes: Water-Jet Assisted Liposuction (WAL) also known as Aquashape™ or Body-Jet™ liposuction, is a gentle lymph sparing liposuction technique used to remove lipedema fat, under local anesthesia.
The more of these I see, the more I realize that the phrase “lymph-sparing” is part of WAL marketing. At this point I’m not sure it even matters if they coined the term and it was adopted or it was in the medical literature and they liked it and used it to promote liposuction for lipedema.
I would not encourage any patient to use the phrase “lymph-sparing” if the surgeon never uses the phrase in their surgical operative report or doctor notes. It all goes back to the surgeon. And concerning the actual procedure, there does seem to me unique attention to the lymph system that is related to the lipedema fat that is different from traditional contouring liposuction. Our purpose is to educate patients what the phrase implies and its significance concerning both treatment and reimbursement.
If you have any comments on the phrase, lymph-sparing, tumescent Liposuction, or any details on this website please send me an e-mail.