Surgical Treatments for Lymphedema and Lipedema - CAM 253
Lymphatic fluid is a clear fluid that travels throughout the body. Its job is to remove wastes and bacteria from tissue. Lymphedema is swelling when too much lymphatic fluid accumulates in any part of the body. Lymphedema can be a result of certain surgeries or other procedures that remove or affect lymph node drainage. Lymphedema occurs because there are fewer natural channels for the fluid to move through. Typical treatment calls for raising the affected arm, massaging the area, or using pumps that apply light pressure. Certain surgeries are now being studied. These surgeries call for rerouting the flow of lymphatic fluid by connecting lymph vessels to veins, lymph nodes and veins, or lymph vessels to other lymph vessels. Other surgeries try to reduce swelling by moving other tissue into the surgical area or using suction to remove excess fat and proteins. Many of these surgeries are investigational (unproven). More studies are needed to see how well they work over the long term.
Physiologic microsurgery for lymphedema is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration.
Lipectomy or liposuction for the treatment of lymphedema or lipedema may be considered MEDICALLY NECESSARY when the following criteria are met:
- There is documentation of significant physical functional impairment (e.g., difficulty ambulating or performing activities of daily living); and
- The individual has not responded to at least 3 consecutive months of optimal medical management (such as conservative treatment with compression garments and manual lymph drainage); and
- The plan of care postoperatively is to continue to wear compression garments as instructed to maintain the benefits of treatment; and
- For the diagnosis of lipedema, the individual has all of the following clinical exam findings: (see Table 1)
- Bilateral symmetric adiposity in the extremities,
- Non-pitting edema;
- Tissue in affected areas is soft to palpation;
- Tissue in affected areas is tender to palpation
- Submission of photographs documents the affected extremities requested for treatment and are consistent with the diagnosis of lipedema or lymphedema
The following surgical treatments to treat lymphedema (e.g., upper or lower extremities or genitalia) are investigational/unproven and therefore considered NOT MEDICALLY NECESSARY:
- Lymphatic physiologic microsurgery
- Lymphatico-lymphatic bypass
- Lymphovenous bypass o Lymphaticovenous anastomosis
- Autologous lymph node transplantation
- Vascularized lymph node transfer
- Tissue transfer (e.g., omental or mesenteric flap)
- Reductive/ablative techniques
- Direct excision
Lymphatic physiologic microsurgery performed during nodal dissection or breast reconstruction to prevent lymphedema (including, but not limited to, the Lymphatic Microsurgical Preventing Healing Approach) in individuals who are being treated for breast cancer is investigational/unproven and therefore considered NOT MEDICALLY NECESSARY.
Reverse lymphatic mapping used during lymphatic surgical or liposuction procedures is investigational/unproven and therefore considered NOT MEDICALLY NECESSARY.
The patient’s medical records submitted for review for all conditions should document that MEDICALLY NECESSARY criteria are met. The record should include the following:
- Office visit notes that contain the relevant history and physical (with the specific surgical procedure requested, any physical functional impairment noted, medical management tried, post-op plan of care for use of compression garments)
- If request is for the treatment of lipedema, all of the following clinical exam findings are documented: bilateral symmetric adiposity in the extremities, non-pitting edema, tissue in affected areas is soft to palpation, and tissue in affected areas is tender to palpation
- Photographs document the affected extremities requested for treatment and are consistent with the diagnosis of lipedema or lymphedema
Surgery and radiotherapy for breast cancer can lead to lymphedema and are some of the most common causes of secondary lymphedema. There is no cure for lymphedema. However, physiologic microsurgical techniques such as lymphaticovenular anastomosis or vascularized lymph node transfer have been developed that may improve lymphatic circulation, thereby decreasing symptoms and risk of infection.
Lymphedema is an accumulation of fluid due to disruption of lymphatic drainage. Lymphedema can be caused by congenital or inherited abnormalities in the lymphatic system (primary lymphedema) but is most often caused by acquired damage to the lymphatic system (secondary lymphedema).
Diagnosis and Staging
A diagnosis of secondary lymphedema is based on history (e.g., cancer treatment, trauma) and physical examination (localized, progressive edema and asymmetric limb measurements) when other causes of edema can be excluded. Imaging, such as magnetic resonance imaging, computed tomography, ultrasound, or lymphoscintigraphy, may be used to differentiate lymphedema from other causes of edema in diagnostically challenging cases.
Table 2 lists International Society of Lymphology guidance for staging lymphedema based on "softness" or "firmness" of the limb and the changes with an elevation of the limb.1
Table 2. Recommendations for Staging Lymphedema
|Stage 0 (subclinical)||Swelling is not evident and most patients are asymptomatic despite impaired lymphatic transport|
|Stage I (mild)||Accumulation of fluid that subsides (usually within 24 hours) with limb elevation; soft edema that may pit, without evidence of dermal fibrosis|
|Stage II (moderate)||Does not resolve with limb elevation alone; limb may no longer pit on examination|
|Stage III (severe)||Lymphostatic elephantiasis; pitting can be absent; skin has trophic changes|
Breast Cancer−Related Lymphedema
Breast cancer treatment is one of the most common causes of secondary lymphedema. Both the surgical removal of lymph nodes and radiotherapy are associated with development of lymphedema in patients with breast cancer.
In a systematic review of 72 studies (N=29,612 women), DiSipio et al. (2013) reported that approximately 1 in 5 women who survive breast cancer will develop arm lymphedema.2 Reviewers reported that risk factors for development of lymphedema that had a strong level of evidence were extensive surgery (i.e., axillary-lymph-node dissection, greater number of lymph nodes dissected, mastectomy) and being overweight or obese. The incidence of breast cancer-related lymphedema was found by DiSipio et al. as well as other authors to be up to 30% at 3 years after treatment.2,3,4
Management and Treatment
Early and ongoing treatment of lymphedema is necessary. Conservative therapy may consist of several features depending on the severity of the lymphedema. Patients are educated on the importance of self-care including hygiene practices to prevent infection, maintaining ideal body weight through diet and exercise, and limb elevation. Compression therapy consists of repeatedly applying padding and bandages or compression garments. Manual lymphatic drainage is a light pressure massage, performed by trained physical therapists or by patients, designed to move fluid from obstructed areas into functioning lymph vessels and lymph nodes.
Complete decongestive therapy is a multiphase treatment program involving all of the previously mentioned conservative treatment components at different intensities. Pneumatic compression pumps may also be considered as an adjunct to conservative therapy or as an alternative to self-manual lymphatic drainage in patients who have difficulty performing self-manual lymphatic drainage. In patients with more advanced lymphedema after fat deposition and tissue fibrosis has occurred, palliative surgery using reductive techniques such as liposuction may be performed.
Table 3. Physiologic Microsurgical Interventions for Lymphedema
|Bypass or reconstruct obstructed lymph vessels to improve drainage||Lymphatic-lymphatic bypas||Connects functioning lymphatic vessels directly to affected lymphatic vessels; healthy vessels come from donor site||
|Lymphovenous bypass and lymphaticovenular anastomosis||Lymphatic vessels in an affected limb are connected to the venous system||
|Transfer lymph tissue to re-establish lymphatic flow||Autologous lymph node transplantation and vascularized lymph node transfer||Healthy lymph nodes are transferred to the affected limb||
Reductive (Excisional or Ablative) Surgical Interventions
Reductive techniques remove fibrous, fatty tissue that has developed from sustained lymphatic fluid stasis. Reductive interventions include direct excision and liposuction procedures.
- Direct excision: There are several direct excision procedures for the treatment of extremity and genital lymphedema. Subcutaneous tissue is excised along with the skin and soft tissues to attempt to reduce the volume of the affected area. The resulting defects are then covered with tissue flaps or skin grafts. Wound healing complications and infections have been reported as side effects of this type of intervention along with sexual dysfunction, decreased sensation and urethral injury when performed on the genitalia.35
- Liposuction: Fibrous, fatty issue is removed through multiple small incisions of the affected extremity via a cannula attached to a powered suction device. Compression garments are worn postoperatively and may be required indefinitely to maintain the adipose tissue volume reduction obtained with this procedure. This technique is intended for patients with end-stage lymphedema who have not responded to conservative treatments. Minor complications such as occasional paresthesias and wound healing are reported with this technique. 35
Liposuction for the Treatment of Lipedema
Lipedema is a rare disorder in which increased adipose (fat) tissue builds up under the skin causing non-pitting, symmetric, bilateral swelling of the lower extremities; the upper extremities can also be affected. Hands and feet characteristically do not swell. It primarily affects women. The cause of lipedema is unknown and there is currently no curative treatment for this condition. Signs and symptoms typically present at puberty, pregnancy, or menopause. Because of this it is theorized that there is a hormonal influence on the disorder. Hereditary factors are also thought to play a role in its etiology. Lipedema is often painful and may present with bruising along with sensitivity to touch. This condition gradually worsens over time and may progress to a lipo-lymphedema due to the lymphatic load exceeding the lymphatic transport capacity. Lipedema is often misdiagnosed as obesity or lymphedema but does not generally respond to weight loss, exercise, or elevation of the limbs as do those disorders.
Types of Lipedema
- Type 1: Pelvis, buttocks and hips (saddle bag phenomenon)
- Type 2: Buttocks to knees with formation of folds of fat around the inner side of the knee
- Type 3: Buttocks to ankles
- Type 4: Arms
- Type 5: Isolated lower leg
Stages of Lipedema
- Stage 1: Even and smooth skin surface with enlarged subcutaneous fat tissue
- Stage 2: Uneven skin surface with nodular elevations and indentations of subcutaneous fat and lipomas
- Stage 3: Large deforming growths of nodular fat or hanging flaps of the thighs and around the knees
- Stage 4: Large overhangs of tissue, dysfunctional lymphatics with lipedema and lipolyphedema
Treatment is aimed at relieving the symptoms. Conservative care with combined decongestive therapy (manual lymphatic drainage and compression garments) is the mainstay treatment of choice. If there is an inadequate response to conservative or supportive measures, tumescent liposuction has been proposed as the next line of treatment. Tumescent liposuction is a technique whereby local anesthetic, such as diluted lidocaine and epinephrine, is injected into subcutaneous fat and a vibrating cannula associated with power-assisted liposuction removes the fat. Waterjet assisted liposuction is another method of liposuction that may be used to treat lipedema. This method uses a pressurized stream of saline to dislodge the fat and more gently loosen and remove the fat cells.
Summary of Evidence
For individuals who have breast cancer−related secondary lymphedema who receive physiologic microsurgery to treat lymphedema along with continued conservative therapy, the evidence includes a randomized controlled trial (RCT), observational studies, and systematic reviews. Relevant outcomes are symptoms, morbid events, functional outcomes, health status measures, quality of life, resource utilization, and treatment-related morbidity. Several physiologic microsurgeries have been developed; examples include lymphaticovenular anastomosis and vascularized lymph node transfer. No RCTs of lymphaticovenular anastomosis or similar surgeries involving the venous system were identified. One RCT of vascularized lymph node transfer with 36 participants has been conducted. Systematic reviews have indicated that the preponderance of the available evidence comes from single-arm clinical series from individual institutions. Surgical technique, outcomes metrics, and follow-up time have varied across these studies. These types of studies might be used for preliminary estimates of the amount of volume reduction expected from surgery, the durability of the reduction in volume, and the rates of adverse events. However, these studies are not adequate for determining the comparative efficacy of physiologic microsurgery vs conservative treatment or decongestive therapy, or the comparative efficacy of different microsurgery techniques. RCTs are needed. The evidence is insufficient to determine the effects of the technology on health outcomes.
For individuals who are undergoing lymphadenectomy for breast cancer who receive physiologic microsurgery to prevent lymphedema, the evidence includes an RCT, observational studies, and systematic reviews. Relevant outcomes are symptoms, change in disease status, morbid events, quality of life, and treatment-related morbidity. Lymphatic Microsurgical Preventing Healing Approach (LMPHA) is a preventive lymphaticovenular anastomosis performed during nodal dissection. One RCT including 46 patients has been conducted. The trial reported that lymphedema developed in 4% of women in the Lymphatic Microsurgical Preventing Healing Approach group and 30% in the control group by 18 months of follow-up. However, because the cumulative incidence of lymphedema after breast cancer treatment approximates 30% at 3 years, longer follow-up is needed to assess the durability of the procedure. The trial methods of randomization and allocation concealment were not described and there was no sham procedure or blinding, potentially introducing bias. The remaining evidence consists of two controlled observational studies with inadequate description of control selection and uncontrolled studies. The evidence is insufficient to determine the effects of the technology on health outcomes.
Randomized controlled trials are needed to prove the benefits of pedicled or laparoscopic free omental lymphatic flap for the management of lymphedema.
Reverse mapping using blue dye as a method for preserving the lymphatic drainage of the arm in breast cancer cases or indo-cyanine green as a technique to identify lymph node drainage patterns to localize lymph nodes in the surgical treatment of lymphedema are being investigated. Further studies are needed to determine the long-term outcomes of these techniques. The evidence is insufficient to determine the effects of the technology on health outcomes.
Results of the available studies provide limited evidence that suction-assisted protein lipectomy (SAPL) for the treatment of lymphedema that fails to respond to conservative therapy due to overgrowth of adipose tissue is a safe and effective technique. The best available evidence of efficacy was obtained in nonrandomized controlled studies. Liposuction combined with compression therapy reduced lymphedema volume versus compression therapy alone. Additional controlled studies are needed to confirm that liposuction for the treatment of lymphedema is a safe and effective therapy.
A 2019 Hayes Search and Summary on liposuction for the treatment of lipedema concludes that there is insufficient published evidence to assess the safety and health outcomes of liposuction for the treatment of lipedema.
Despite the lack of strong evidence, clinical guidelines recommend liposuction in patients with advanced lipedema and for chronic lymphedema, as there is limited treatment available when conservative measures have failed.
Practice Guidelines and Position Statements
Austrian Academy of Cosmetic Surgery and Aesthetic Medicine and the International Society for Dermatologic Surgery
Austrian Academy of Cosmetic Surgery and Aesthetic Medicine and the International Society for Dermatologic Surgery: Prevention of Progression of Lipedema with Liposuction Using Tumescent Local Anesthesia: Results of an International Consensus Conference. 2020. This consensus statement concludes: “Lymph-sparing liposuction using tumescent local anesthesia is currently the only effective treatment for lipedema.”
Canadian Agency for Drugs and Technologies in Health (CADTH)
In 2019 CADTH published A Review of Clinical Effectiveness and Guidelines for Liposuction for the Treatment of Lipedema. The guideline recommends that tumescent liposuction be considered the treatment of choice for patients with an inadequate response to conservative measures.
National Institute for Health and Care Excellence (NICE)
The National Institute for Health and Care Excellence (NICE, 2017) states that "Current evidence on the safety and efficacy of liposuction for chronic lymphoedema is adequate to support the use of this procedure provided that standard arrangements are in place for clinical governance, consent and audit."
“Microsurgical and supramicrosurgical (much smaller vessels) techniques have been developed to move lymph vessels to congested areas to try to improve lymphatic drainage. Surgeries involve connecting lymph vessels and veins, lymph nodes and veins, or lymph vessels to lymph vessels. Reductions in limb volume have been reported and a number of preliminary studies have been done, but there are no long-term studies of the effectiveness of these techniques.”
International Society of Lymphology
The International Society of Lymphology published a consensus document on the diagnosis and treatment of peripheral lymphedema in 2016.1 The document stated the following on lymphaticovenous (or lymphovenous) anastomoses (LVA):
LVA are currently in use at multiple centers around the world. These procedures have undergone confirmation of long-term patency (in some cases more than 20 years) and some demonstration of improved lymphatic transport (by objective physiologic measurements of long-term efficacy).
American Society of Breast Surgeons
The American Society of Breast Surgeons published recommendations from an expert panel on preventive and therapeutic options for breast cancer-related lymphedema in 2017.27 The document stated that "the Panel agrees that LVA and VLNT may be effective for early secondary breast cancer-related lymphedema."
U.S. Preventive Services Task Force Recommendations
No U.S. Preventive Services Task Force recommendations for lymphedema have been identified.
Ongoing and Unpublished Clinical Trials
Some currently ongoing and unpublished trials that might influence this review are listed in Table 4.
Table 4. Summary of Key Trials
|NCT No.||Trial Name||Planned Enrollment||Completion Date|
|NCT02790021||Improving Quality of Survivorship for Breast Cancer-related Lymphedema by Lymphaticovenous Anastomosis: A Randomized Controlled Trial||120||Aug 2022|
|NCT03941756||Lymphovenous Bypass Procedure Before Underarm Lymph Node Surgery in Preventing Lymphedema in Patients With Inflammatory or Locally Advanced Non-inflammatory Breast Cancer||50||Dec 2020|
|NCT03428581||Preventing Lymphedema in Axillary Lymph Node Dissection||264||Feb 2023|
NCT: national clinical trial.
Definition of Terms
When specific definitions are not present in a member’s plan, the following definitions will be applied.
Physical functional impairment: In this policy, physical functional impairment means either limitation from normal physical functioning or baseline level of functioning that may include, but is not limited to, problems with ambulation, mobilization, communication, respiration, eating, swallowing, vision, facial expression, skin integrity, distortion of nearby body part(s) or obstruction of an orifice. The physical functional impairment can be due to structure, congenital deformity, pain, or other causes. Physical functional impairment excludes social, emotional and psychological impairments or potential impairments.
Table 1. Comparison of Findings in Lipedema, Lymphedema, and Lifestyle-induced Obesity
|Sex||Women||Women and men||Women and men|
|Adiposity||Bilateral extremities symmetic||Unilateral or bilateral extremities asymmetic||Whole body, propertionate symmetric|
|Pam||Tender to palpation||Usually nntender||None|
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5055019/ Accessed November 24, 2020
- International Society of Lymphology Executive Committee. The Diagnosis and Treatment of Peripheral Lymphedema: 2016 Consensus Document of the International Society of Lymphology. 2016; https://journals.uair.arizona.edu/index.php/lymph/article/view/20106 . Accessed November 24, 2020.
- DiSipio T, Rye S, Newman B, et al. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and metaanalysis. Lancet Oncol. May 2013; 14(6): 500-15. PMID 23540561
- Ribeiro Pereira ACP, Koifman RJ, Bergmann A. Incidence and risk factors of lymphedema after breast cancer treatment: 10 years of follow-up. Breast. Dec 2017; 36: 67-73. PMID 28992556
- Zou L, Liu FH, Shen PP, et al. The incidence and risk factors of related lymphedema for breast cancer survivors post-operation: a 2-year follow-up prospective cohort study. Breast Cancer. May 2018; 25(3): 309-314. PMID 29397555
- Pusic AL, Cemal Y, Albornoz C, et al. Quality of life among breast cancer patients with lymphedema: a systematic review of patient-reported outcome instruments and outcomes. J Cancer Surviv. Mar 2013; 7(1): 83-92. PMID 23212603
- Coriddi M, Dayan J, Sobti N, et al. Systematic Review of Patient-Reported Outcomes following Surgical Treatment of Lymphedema. Cancers (Basel). Feb 29 2020; 12(3). PMID 32121343
- Leung N, Furniss D, Giele H. Modern surgical management of breast cancer therapy related upper limb and breast lymphoedema. Maturitas. Apr 2015; 80(4): 384-90. PMID 25747119
- Cornelissen AJM, Beugels J, Ewalds L, et al. Effect of Lymphaticovenous Anastomosis in Breast Cancer-Related Lymphedema: A Review of the Literature. Lymphat Res Biol. Oct 2018; 16(5): 426-434. PMID 29356596
- Scaglioni MF, Fontein DBY, Arvanitakis M, et al. Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema. Microsurgery. Nov 2017; 37(8): 947-953. PMID 28972280
- Carl HM, Walia G, Bello R, et al. Systematic Review of the Surgical Treatment of Extremity Lymphedema. J Reconstr Microsurg. Jul 2017; 33(6): 412-425. PMID 28235214
- Salgarello M, Mangialardi ML, Pino V, et al. A Prospective Evaluation of Health-Related Quality of Life following Lymphaticovenular Anastomosis for Upper and Lower Extremities Lymphedema. J Reconstr Microsurg. Nov 2018; 34(9): 701- 707. PMID 29689576
- Ozturk CN, Ozturk C, Glasgow M, et al. Free vascularized lymph node transfer for treatment of lymphedema: A systematic evidence based review. J Plast Reconstr Aesthet Surg. Sep 2016; 69(9): 1234-47. PMID 27425000
- Forte AJ, Cinotto G, Boczar D, et al. Omental Lymph Node Transfer for Lymphedema Patients: A Systematic Review. Cureus. Nov 25 2019; 11(11): e6227. PMID 31807393
- Demiri E, Dionyssiou D, Tsimponis A, et al. Donor-Site Lymphedema Following Lymph Node Transfer for Breast Cancer-Related Lymphedema: A Systematic Review of the Literature. Lymphat Res Biol. Feb 2018; 16(1): 2-8. PMID 29087763
- Dionyssiou D, Demiri E, Tsimponis A, et al. A randomized control study of treating secondary stage II breast cancer-related lymphoedema with free lymph node transfer. Breast Cancer Res Treat. Feb 2016; 156(1): 73-9. PMID 26895326
- Nguyen AT, Suami H, Hanasono MM, et al. Long-term outcomes of the minimally invasive free vascularized omental lymphatic flap for the treatment of lymphedema. J Surg Oncol. Jan 2017; 115(1): 84-89. PMID 27439587
- Ciudad P, Agko M, Perez Coca JJ, et al. Comparison of long-term clinical outcomes among different vascularized lymph node transfers: 6-year experience of a single center's approach to the treatment of lymphedema. J Surg Oncol. Nov 2017; 116(6): 671-682. PMID 28695707
- Gennaro P, Gabriele G, Salini C, et al. Our supramicrosurgical experience of lymphaticovenular anastomosis in lymphoedema patients to prevent cellulitis. Eur Rev Med Pharmacol Sci. Feb 2017; 21(4): 674-679. PMID 28272717
- Drobot A, Bez M, Abu Shakra I, et al. Microsurgery for management of primary and secondary lymphedema: First experience in Israel. J Vasc Surg Venous Lymphat Disord. May 21 2020. PMID 32446874
- Cemal Y, Pusic A, Mehrara BJ. Preventative measures for lymphedema: separating fact from fiction. J Am Coll Surg. Oct 2011; 213(4): 543-51. PMID 21802319
- Armer JM. The problem of post-breast cancer lymphedema: impact and measurement issues. Cancer Invest. 2005; 23(1): 76-83. PMID 15779870
- Armer JM, Stewart BR. A comparison of four diagnostic criteria for lymphedema in a post-breast cancer population. Lymphat Res Biol. 2005; 3(4): 208-17. PMID 16379589
- Jorgensen MG, Toyserkani NM, Sorensen JA. The effect of prophylactic lymphovenous anastomosis and shunts for preventing cancer-related lymphedema: a systematic review and meta-analysis. Microsurgery. Jul 2018; 38(5): 576-585. PMID 28370317
- Boccardo FM, Casabona F, Friedman D, et al. Surgical prevention of arm lymphedema after breast cancer treatment. Ann Surg Oncol. Sep 2011; 18(9): 2500-5. PMID 21369739
- Hahamoff M, Gupta N, Munoz D, et al. A Lymphedema Surveillance Program for Breast Cancer Patients Reveals the Promise of Surgical Prevention. J Surg Res. Dec 2019; 244: 604-611. PMID 29397949 Page | 15 of 18 ∞
- National Lymphedema Network Medical Advisory Committee. The Diagnosis and Treatment of Lymphedema. Position Statement of the National Lymphedema Network 2011; http://lymphedemamdofamerica.com/wpcontent/uploads/2018/09/NLN-PAPERtreatment.pdf. Accessed November 24, 2020.
- McLaughlin SA, DeSnyder SM, Klimberg S, et al. Considerations for Clinicians in the Diagnosis, Prevention, and Treatment of Breast Cancer-Related Lymphedema, Recommendations from an Expert Panel: Part 2: Preventive and Therapeutic Options. Ann Surg Oncol. Oct 2017; 24(10): 2827-2835. PMID 28766218
- Scaglioni MF, Arvanitakis M, Chen YC, et al. Comprehensive review of vascularized lymph node transfers for lymphedema: Outcomes and complications. Microsurgery. Feb 2018;38(2):222-229. PMID 27270748
- Abbas S, Seitz M. Systematic review and meta-analysis of the used surgical techniques to reduce leg lymphedema following radical inguinal nodes dissection. Surg Oncol. 2011;20(2):88-96.
- Ochoa D, Korourian S, Boneti C, et al. Axillary reverse mapping: five-year experience. Surgery. 2014;156(5):1261-1268.
- Seyednejad N, Kuusk U, Wiseman SM. Axillary reverse lymphatic mapping in breast cancer surgery: A comprehensive review. Expert Rev Anticancer Ther. 2014;14(7):771-781.
- Dayan JH, Dayan E, Smith ML. Reverse lymphatic mapping: A new technique for maximizing safety in vascularized lymph node transfer. Plast Reconstr Surg. 2015;135(1):277-285.
- Gebruers N, Tjalma WA. Clinical feasibility of axillary reverse mapping and its influence on breast cancer related lymphedema: A systematic review. Eur J Obstet Gynecol Reprod Biol. 2016;200:117-122.
- Beek MA, Gobardhan PD, Schoenmaeckers EJ, et al. Axillary reverse mapping in axillary surgery for breast cancer: An update of the current status. Breast Cancer Res Treat. 2016;158(3):421-432.
- Granzow JW, Soderberg JM, Kaji AH, Dauphine C. An effective system of surgical treatment of lymphedema. Ann Surg Oncol. 2014;21(4):1189-94. PMID 24522988.
- Granzow JW, Soderberg JM, Kaji AH, Dauphine C. Review of current surgical treatments for lymphedema. Ann Surg Oncol. 2014;21(4):1195-201. PMID 24558061.
- Hayes, Inc. Health Technology Brief (ARCHIVED). Liposuction for lymphedema. Published August 11, 2010. Updated August 6, 2012. Archived September 11, 2013.
- Hayes, Inc. Medical Technology Directory. Surgical treatment for lymphedema: a review of reviews. Published May 11, 2017. Updated May 24, 2018..
- Hayes, Inc. Search & Summary (ARCHIVED). Axillary reverse mapping to limit the incidence of breast cancer related lymphedema.. Published May 18, 2017. Archived June 18, 2018.
- Mehrara, B. Surgical treatment of primary and secondary lymphedema.In UpToDate Collins, K (Ed). UpToDate. Waltham, MA. Last updated October 3,, 2019. https://www.uptodate.com Accessed November 24, 2020.
- Basta MN, Gao LL, Wu LC. Operative treatment of peripheral lymphedema: a systematic meta-analysis of the efficacy and safety of lymphovenous microsurgery and tissue transplantation Plast Reconstr Surg 2014; 133 (4): 905-13. PMID: 24352208.
- Raju A, Chang DW. Vascularized lymph node transfer for treatment of lymphedema: a comprehensive literature review. Ann Surg 2015; 261 (5): 1013-23. PMID 24950271.
- Scaglioni MF, Uyulmaz S. Lymphovenous anastomosis and debulking procedure for treatment of combined severe lower extremity and genital lymphedema: a case report. Microsurgery 2018 Nov; 36(8): 907-911. PMID: 29719080.
- Ogunbiyi SO, Modarai B, Smith A, et al. Quality of life after surgical reduction for severe primary lymphodema of the limbs and genitalia. Br J Surg. 2009 Nov; 96(11): 1274-9. PMID 19847880.
- Baumgartner A, Hueppe M, Schmeller W. Long-term benefit of liposuction in patients with lipoedema: a follow-up study after an average of 4 and 8 years. Br J Dermatol. 2016 May;174(5):1061-7
- Lamprou DA, Voesten HG, Damstra RJ, Wikkeling OR. Circumferential suction-assisted lipectomy in the treatment of primary and secondary end-stage lymphoedema of the leg. Br J Surg. 2017 Jan;104(1):84- 89. Page | 16 of 18 ∞
- Buck DW 2nd, Herbst KL. Lipedema: A Relatively Common Disease with Extremely Common Misconceptions. Plast Reconstr Surg Glob Open. 2016;4(9): e1043. PMID: 27757353.
- Dadras M, Mallinger PJ, Corterier CC, Theodosiadi S, Ghods M. Liposuction in the Treatment of Lipedema: A Longitudinal Study. Arch Plast Surg. 2017;44(4):324-331. PMID:28728329.
- Forner-Cordero I, Szolnoky G, Forner-Cordero A, Kemény L. Lipedema: an overview of its clinical manifestations, diagnosis and treatment of the disproportional fatty deposition syndrome - systematic review. Clin Obes. 2012;2(3-4):86-95. PMID: 25586162.
- Halk AB, Damstra RJ. First Dutch guidelines on lipedema using the international classification of functioning, disability and health. Phlebology. 2017;32(3):152-159. PMID: 27075680.
- Hayes, Inc. Hayes Search and Summary. Liposuction for the treatment of lipedema. February 15, 2019
- Okhovat JP, Alavi A. Lipedema: A Review of the Literature. Int J Low Extrem Wounds. 2015;14(3):262-7. PMID: 25326446.
- Peled AW, Slavin SA, Brorson H. Long-term outcome after surgical treatment of lipedema. Ann Plast Surg. 2012;68(3):303-307. PMID: 21629090.
- Rapprich S, Dingler A, Podda M. Liposuction is an effective treatment for lipedema-results of a study with 25 patients. J Dtsch Dermatol Ges. 2011;9(1):33-40. PMID: 21166777.
- Reich-Schupke S, Schmeller W, Brauer WJ, et al. S1 guidelines: Lipedema. J Dtsch Dermatol Ges 2017;15(7): 758-767. PMID: 28677175.
- Reich-Schupke S, Altmeyer P, Stücker M. Thick legs - not always lipedema. J Dtsch Dermatol Ges. 2013;11(3):225-33. PMID: 23231593.
- Schmeller W, Hueppe M, Meier-Vollrath I. Tumescent liposuction in lipoedema yields good long-term results. Br J Dermatol. 2012;166(1):161-8 PMID: 21824127.
- Stutz JJ, Krahl D. Water jet-assisted liposuction for patients with lipoedema: histologic and immunohistologic analysis of the aspirates of 30 lipoedema patients. Aesthetic Plast Surg. 2009;33(2):153-62. PMID: 18663515.
- Warren Peled A, Kappos EA. Lipedema: diagnostic and management challenges. Int J Womens Health. 2016;11(8):389-95. PMID: 27570465.
- Wollina U, Heinig B. Treatment of lipedema by low-volume micro-cannular liposuction in tumescent anesthesia: Results in 111 patients. Dermatol Ther. 2019;32 (2): e12820. PMID: 30638291.
- Wollina U. Lipedema-An update. Dermatol Ther. 2019; 32(2): e12805. PMID: 30565362.
- Sandhofer, M, Hanke, CW, Habbema, L, Podda, M, Rapprich, S, Schmeller, W, Herbst, K, Anderhuber , F, et al. Prevention of Progression of Lipedema With Liposuction Using Tumescent Local Anesthesia: Results of an International Consensus Conference. Dermatol Surg. 2020;46(2):220-228. PMID: 31356433.
- Peprah, K, and MacDougall, D. Liposuction for the Treatment of Lipedema: A Review of Clinical Effectiveness and Guidelines. CADTH Rapid Response Reports. Liposuction for the Treatment of Lipedema: A Review of Clinical Effectiveness and Guidelines. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health. 2019. PMID: 31479212.
- Bauer, AT, von Lukowicz, D, Lossagk, K, Aitzetmueller, M, Moog, P, Cerny, M, Erne, H, Schmauss, D, et al. New Insights on Lipedema: The Enigmatic Disease of the Peripheral Fat. Plast Reconstr Surg. 2019;144(6):1475-1484. PMID: 31764671.
- Austrian Academy of Cosmetic Surgery and Aesthetic Medicine (AACMS) and the International Society for Dermatologic Surgery (ISDS): Prevention of Progression of Lipedema with Liposuction Using Tumescent Local Anesthesia: Results of an International Consensus Conference. 2020.
- ECRI Institute. Hotline Response. Liposuction for Treating Lipedema. Plymouth Meeting, PA. ECRI Institute Published March 12, 2020. https://www.ecri.org/ Accessed November 24, 2020.
- National Institute for Health and Care Excellence (NICE). Liposuction for chronic lymphoedema. [IPG588]. 2017; https://www.nice.org.uk/guidance/IPG588. Accessed November 24, 2020.
|CPT||15832||Excision, excessive skin and subcutaneous tissue (includes lipectomy); thigh|
|Excision, excessive skin and subcutaneous tissue (includes lipectomy); leg|
|15836||Excision, excessive skin and subcutaneous tissue (includes lipectomy); arm|
|15839||Excision, excessive skin and subcutaneous tissue (includes lipectomy); other area|
|15877||Suction assisted lipectomy; trunk|
|15878||Suction assisted lipectomy; upper extremity|
|15879||Suction assisted lipectomy; lower extremity|
|38999||Unlisted procedure, hemic or lymphatic system.|
|76499||Unlisted diagnostic radiographic procedure|
Note: CPT codes, descriptions and materials are copyrighted by the American Medical Association (AMA). HCPCS codes, descriptions and materials are copyrighted by Centers for Medicare & Medicaid Services (CMS).
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each olicy. They may not be all-inclusive.
This medical policy was developed through consideration of peer-reviewed medical literature generally recognized by the relevant medical community, U.S. FDA approval status, nationally accepted standards of medical practice and accepted standards of medical practice in this community, Blue Cross Blue Shield Association technology assessment program (TEC) and other non-affiliated technology evaluation centers, reference to federal regulations, other plan medical policies, and accredited national guidelines.
"Current Procedural Terminology © American Medical Association. All Rights Reserved"
History From 2020 Forward
Annual review, no change to policy intent.