Medical Policy

Policy Num:      07.001.164
Policy Name:    Liposuction for Lipedema and Lymphedema
Policy ID:          [07.001.164] [Ac / B / M+ / P+]  [7.01.169]

Last Review:       August 11, 2025
Next Review:      August 20, 2026
 

Related Policies:

08.001.029 - Pneumatic Compression Pumps for Treatment of Lymphedema and Venous Ulcers
02.001.048 - Bioimpedance Devices for Detection and Management of Lymphedema
07.001.119 - Surgical Treatments for Breast Cancer-Related Lymphedema

Liposuction for Lipedema and Lymphedema

Summary

Description

Lipedema is a disorder characterized by a large amount of subcutaneous fat in the extremities, typically the legs and thighs. The adipose tissue may be painful. In contrast, lymphedema is the accumulation of interstitial fluid due to impaired lymphatic flow. This increase in interstitial fluid may lead to the accumulation and hypertrophy of fat cells. Liposuction, consisting of the removal of fat cells with a cannula and tumescent anesthesia is being investigated as a treatment option for both lipedema and lymphedema.

Summary of Evidence

For individuals with lipedema who receive liposuction, the evidence includes systematic reviews and meta-analyses of observational studies. Relevant outcomes are symptoms, change in disease status, functional outcomes, and quality of life. The latest meta-analysis of 9 studies (N=635 patients) investigating the impact of various liposuction techniques for individuals with lipedema revealed improvements in the quality of life, pain, pressure sensitivity, bruising, cosmetic impairment, heaviness, walking difficulty, and itching among lipedema patients who underwent liposuction. This analysis was based on prospective cohort studies, which introduces a risk of publication bias. Insufficient detail in some reports contributed to potential data inconsistencies. All studies included in the meta-analysis originated from Germany, highlighting a significant geographical bias. The durability of the procedure is uncertain and no studies were identified that compared liposuction to continued decongestive therapy. To address these limitations, future investigations must prioritize RCTs to assess the safety and efficacy of various liposuction techniques. One such trial is currently in progress and will provide needed information on the benefits and harms of this procedure. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

For individuals with lymphedema who receive liposuction, the evidence includes systematic reviews, and 1 non-blinded small RCT on submental liposuction for cervical lymphedema following head and neck cancer treatment. Relevant outcomes are symptoms, change in disease status, functional outcomes, and quality of life. The available evidence suggests that arm volume can be reduced by the procedure, but follow-up duration is limited and the studies have a number of other limitations that include lack of blinding, subjective outcome measures, lack of a physiotherapy control, and small sample size. The latest systematic review of 12 observational studies (N=487 participants) investigating the impact of various liposuction techniques on treating breast cancer-related lymphedema revealed considerable variability in effect sizes across these studies. Due to the high risk of bias, this body of evidence is considered low quality. No trials were identified that compared liposuction to a decongestive therapy protocol with continued compression. Further study is needed to evaluate the impact of liposuction when compared to a decongestive therapy protocol. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Additional Information

2025 Input

Clinical input was sought to help determine whether the use of liposuction for individuals with lipedema or lymphedema would provide a clinically meaningful improvement in net health outcome and represents generally accepted medical practice in selected patients. In response to requests, clinical input was received from 3 respondents identified by the National Commission on Lymphatic Diseases (NCLD) or an academic medical center. In addition to this request, a plastic surgeon specializing in lymphedema research and reconstruction at a major academic medical center was interviewed.

For individuals with lipedema or lymphedema with progressive disease who failed to respond to conservative therapy, clinical input supports that use of liposuction is consistent with generally accepted medical practice and its use is expected to provide a clinically meaningful improvement in the net health outcome.

Further details from clinical input are included in the Appendix.

Objective

The objective of this evidence review is to determine whether liposuction improves the net health outcome in individuals with lipedema or lymphedema.

Policy Statements

Lipectomy or liposuction is considered medically necessary in individuals with documented lipedema when all of the following criteria are met (1 through 7):

1. A diagnosis of lipedema has been documented, including all of the following:

   1. Bilateral and symmetrical manifestation with minimal involvement of the feet, unless concomitant lymphedema is present; and

   2. Disproportionate adipocyte hypertrophy of the affected extremity; and

   3. Photographs of the area to be treated documenting disproportional adipose distribution consistent with diagnosis; and

   4. Pressure-induced pain and tenderness on palpation; and

   5. Failure of the limb adipose hypertrophy to respond to recommended medically supervised weight loss modalities or bariatric surgery, in concomitant class II or III obesity; and

   6. Extent of fibrotic tissue, if present, is expected to be amenable to liposuction; and

2. Signs and symptoms have not responded to at least 3 consecutive months of optimal conservative medical management, including one or more of the following:

   1. Compression garments; or

   2. Manual therapy; or

   3. Conservative management is not feasible due to the presence of contraindicating complications (eg, active infection); and

3. For each anatomical region being considered for treatment, either of the following criteria are met:

   1. There is documented significant functional impairment as a direct result of change in limb volume from lipedema; or

   2. There are documented medical complication(s) as a result of lipedema (eg, severe aching discomfort, pain or tenderness, severe maceration, severe recurrent skin infection, or severe venous insufficiency); and

4. Lipectomy or liposuction is reasonably expected to improve the functional impairment or medical complications; and

5. The plan of care includes the use of compression garments as instructed and to continue conservative treatment postoperatively to maintain benefits; and

6. Photographic documentation is consistent with the diagnosis of lipedema in the affected extremities, including limb symmetry; and

7. Surgical treatment is performed by a hospital credentialed, board-certified plastic surgeon experienced in the treatment of lipedema.

Lipectomy or liposuction is considered medically necessary in individuals with documented lymphedema when all of the following criteria are met (1 through 6):

1. Signs and symptoms have not responded to at least 3 consecutive months of optimal conservative medical management, including one or more of the following:

   1. Compression garments; or

   2. Manual lymphatic drainage; or

   3. Complex/complete decongestive therapy (CDT); or

   4. Conservative management is not feasible due to the presence of contraindicating complications (eg, active infection); and

2. For each anatomical region being considered for treatment, either of the following criteria are met:

   1. There is documented significant functional impairment as a direct result of change in limb volume; or

   2. There are documented medical complication(s) as a result of lymphedema (eg, severe recurrent infection or neurological dysfunction); and

3. Lipectomy or liposuction is reasonably expected to improve the functional impairment; and

4. The plan of care includes the use of compression garments as instructed and to continue conservative treatment postoperatively to maintain benefits; and

5. Photographic documentation is consistent with the diagnosis of lymphedema in the affected extremities, including limb asymmetry; and

6. Surgical treatment is performed by a hospital credentialed, board-certified plastic surgeon experienced in the treatment of lymphedema.

Lipectomy or liposuction is considered investigational for the treatment of lymphedema or lipedema in all other situations where the above criteria are not met.

Policy Guidelines

Coding

See the Codes table for details.

Benefit Application

BlueCard/National Account Issues

Not applicable

Benefits are determined by the group contract, member benefit booklet, and/or individual subscriber certificate in effect at the time services were rendered.  Benefit products or negotiated coverages may have all or some of the services discussed in this medical policy excluded from their coverage.

Background

Lipedema

Lipedema, also known as lipoedema, is a rare disorder characterized by a large amount of subcutaneous fat in the extremities. The cause is unknown but is most frequently seen in women with a family history. The exact prevalence is uncertain as it does not have a diagnosis in the International Classification of Diseases (ICD-10). Lipedema is often misdiagnosed as obesity or lymphedema. Lipedema is typically observed in the legs and thighs without affecting the feet, and the adipose tissue is painful. The arms may also be affected without edema of the hands. Symptoms include heaviness, pain (particularly with pressure), loss of strength, easy bruising, and a reduction in daily activity levels that affects the health and quality of life of the individual. The excessive fat deposits are typically unresponsive to traditional weight loss interventions and there is no cure. Untreated lipedema may result in secondary problems including osteoarthritis and reduced mobility. Over time, the weight of the excessive fat build-up can impair the ability to walk. Initially, the lymphatic system can cope with the increased amount of interstitial fluid, but in the later stages, secondary lymphedema (lipolymphoedema) can occur if the fatty deposits compromise the lymphatic system.

Lymphedema

Lymphedema is an accumulation of fluid due to disruption of lymphatic drainage. It is characterized by nonpitting swelling of an extremity or trunk, and is associated with wound healing impairment, recurrent skin infections, and decreased quality of life. 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). Breast cancer treatment (surgical removal of lymph nodes and radiotherapy) is one of the most common causes of secondary lymphedema. In a systematic review of 72 studies (N=29,612 women), DiSipio et al (2013) reported that nearly 20% of breast cancer survivors will develop arm lymphedema.^1,The risk factors with robust evidence for the development of lymphedema included extensive surgical procedures (such as axillary lymph node dissection, a higher number of lymph nodes removed, and mastectomy) as well as being overweight or obese. 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 MRI, computed tomography, ultrasound, or lymphoscintigraphy, may be used to differentiate lymphedema from other causes of edema in diagnostically challenging cases. The International Society of Lymphology has provided guidance for staging lymphedema (2023) based on "softness" or "firmness" of the limb and the changes with an elevation of the limb.^2,

Notable differences between lipedema and lymphedema are described in Table 1.

Table 1. Characteristics of Lipedema and Lymphedema

  Adapted from Schavit et al (2018)3,

Treatment

Initial conservative therapy includes exercise and weight loss, compression garments, and manual lymphatic drainage. Complete decongestive therapy involves health professionals who address skin and nail care, therapeutic exercise, manual lymphatic drainage, and limb compression, which is performed daily for 5 days per week. The maintenance phase is intended to conserve the benefit in the first phase, and is self-administered. For those who have failed conservative measures, pneumatic compression pumps, and, occasionally, surgery are used as treatment options.

Liposuction has been proposed as a treatment option for both lipedema and lymphedema.

Regulatory Status

Liposuction is a surgical procedure and, as such, is not subject to regulation by the U.S. Food and Drug Administration (FDA).

Rationale

This evidence review was created in October 2021 with a search of the PubMed database. The most recent literature update was performed through June 16, 2025.

Evidence reviews assess the clinical evidence to determine whether the use of a technology improves the net health outcome. Broadly defined, health outcomes are length of life, quality of life, and ability to function including benefits and harms. Every clinical condition has specific outcomes that are important to patients and to managing the course of that condition. Validated outcome measures are necessary to ascertain whether a condition improves or worsens; and whether the magnitude of that change is clinically significant. The net health outcome is a balance of benefits and harms.

To assess whether the evidence is sufficient to draw conclusions about the net health outcome of a technology, 2 domains are examined: the relevance and the quality and credibility. To be relevant, studies must represent 1 or more intended clinical use of the technology in the intended population and compare an effective and appropriate alternative at a comparable intensity. For some conditions, the alternative will be supportive care or surveillance. The quality and credibility of the evidence depend on study design and conduct, minimizing bias and confounding that can generate incorrect findings. The randomized controlled trial (RCT) is preferred to assess efficacy; however, in some circumstances, nonrandomized studies may be adequate. Randomized controlled trials are rarely large enough or long enough to capture less common adverse events and long-term effects. Other types of studies can be used for these purposes and to assess generalizability to broader clinical populations and settings of clinical practice.

Promotion of greater diversity and inclusion in clinical research of historically marginalized groups (e.g., People of Color [African-American, Asian, Black, Latino and Native American]; LGBTQIA (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual); Women; and People with Disabilities [Physical and Invisible]) allows policy populations to be more reflective of and findings more applicable to our diverse members. While we also strive to use inclusive language related to these groups in our policies, use of gender-specific nouns (e.g., women, men, sisters, etc.) will continue when reflective of language used in publications describing study populations.

Population Reference No. 1

Lipedema

Clinical Context and Therapy Purpose

There is no cure for lipedema. The goal of therapy is to reduce symptoms, disability, and functional limitations, and prevent disease progression. Conservative treatment includes manual lymphatic drainage, compression stockings, intermittent pneumatic compression, skin care, and exercise. Individuals with lipedema may have obesity as a comorbidity, and diet is frequently prescribed. Conservative care may alleviate symptoms but treatments are short-lived and may require repeat treatment within days. For individuals who do not respond to conservative treatment, liposuction may be recommended.

The purpose of liposuction in individuals who have lipedema is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The following PICO was used to select literature to inform this review.

Populations

The relevant population of interest is individuals with lipedema/lipoedema or lipolymphedema who have failed to respond to conservative therapy.

In stage I lipedema the skin is smooth and the subcutaneous layer is thickened, soft, and with an even structure. In stage II lipedema the skin becomes uneven and subcutaneous nodules develop. In stage III lipedema there are bulging protrusions of fat along with tender subcutaneous tissue. In an advanced stage, sometimes referred to as stage IV lipedema, the excess fat can impair lymphatic vessel function leading to secondary lymphedema (lipolymphedema).

Interventions

The therapy being considered is liposuction using specialized techniques. Tumescent infused in the subcutaneous tissues causes the fat cells to swell and vessels to constrict; micro-cannulas are then used to suction the fat. Procedures use local anesthetics in the tumescent fluid and do not require general anesthesia. Specialized techniques for liposuction may include power-assisted, which uses a variable speed motor for reciprocating motion, laser-assisted, ultrasound-assisted, radiofrequency-assisted, and water-assisted.^4, Water-assisted liposuction (WAL) is a technique that uses pulsating jets of tumescent solution to dislodge fatty tissue with simultaneous suction of the fat and tumescent fluid. A small randomized trial from 2007 on cosmetic indications suggests a reduction in pain and ecchymosis with WAL compared to traditional liposuction.^5,

Liposuction reduces the amount of fatty tissue but does not eliminate it, and multiple sessions may be needed.

Comparators

Conservative treatment (decongestive therapy) consists of manual lymphatic drainage, compression garments, intermittent pneumatic compression, skin care, and exercise. Diet is also used to prevent or treat obesity associated with lipedema.

Outcomes

The general outcomes of interest are symptoms, change in disease status, functional outcomes, and quality of life.

Reported outcomes for lipedema are reduction in size of extremities, circumferential measurement, restriction of movement, spontaneous pain or discomfort, sensitivity to pressure, edema/swelling, bruising, trophic skin changes, and quality of life.

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;

• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies;

• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought;

• Studies with duplicative or overlapping populations were excluded.

Review of Evidence

Systematic Reviews

The Canadian Agency for Drugs and Technologies in Health (2019) conducted a qualitative systematic review of liposuction for the treatment of lipedema.^6, The authors identified 5 uncontrolled before-and-after studies in the English language that suggested that liposuction may be effective in reducing the size of the extremities, symptoms, and functional limitations of lipedema. One of the publications was a follow-up to an earlier study, and no reports were identified outside of Germany. Limitations of the evidence included the lack of controlled trials and patient's self-assessment with scales that had not been validated for use in patients with lipedema.

Mortada et al (2024) performed a systematic review and meta-analysis to assess the efficacy and safety of liposuction for individuals with lipedema.^7, The review included 20 studies (N=1785 patients) published up to March 2023. The selected studies comprised 14 prospective cohort studies, 3 retrospective studies, 2 case series, and 1 cross-sectional study. Based on data from 14 studies, the majority of patients were classified as stage 2 (503 individuals), followed by stage 3 (467 individuals), and a smaller number at stage 1 (64 individuals). There were no cases classified as advanced (Stage IV) disease. The most commonly reported comorbidities were hypothyroidism and allergies, followed by conditions such as depression, migraine, sleep disorders, arterial hypertension, asthma, and bowel disorders. Lipedema was most frequently observed in the outer and inner legs, as well as the arms. The most commonly utilized technique was tumescent liposuction (81%), followed by power-assisted liposuction (35%) and WAL (29%). The data analysis showed an average of 2.88 (± 1.30) treatment sessions per patient, with a mean aspirate volume of 4,429 mL per session. Liposuction sessions varied from 1 to 2.5 hours, and 11 (of 20) studies reported postoperative use of compression garments. A meta-analysis of 9 studies revealed improvements in the quality of life (standardized mean difference (SMD) 2.48, p<.0001), pain (SMD 2.04, p<.0001), pressure sensitivity (SMD 2.2, p<.0001), bruising (SMD 1.61, p<.0001), cosmetic impairment (SMD 2.07, p<.0001), heaviness (SMD 2.01, p<.0001), walking difficulty (SMD, 1.34, p<.00001), and itching among lipedema patients who underwent liposuction. Although complications such as inflammation, thrombosis, seroma, hematoma, and lymphedema-related skin changes were reported, severe complications were rare. No instances of shock, recurrence, or mortality were reported. The mean follow-up duration for the patients across studies was 15 months, (range, 1 to 96 months).

The above systematic review by Mortada et al (2024) was based on prospective cohort studies, which introduces a risk of publication bias. Insufficient detail in some reports contributed to potential data inconsistencies. Moreover, 70% (14 of 20) of the studies originated from Germany, highlighting the possibility of important differences in the approach to clinical care that may limit generalizability. Studies are ongoing with one RCT (with estimated enrollment of 450 patients) currently being conducted across multiple German centers, comparing wet liposuction techniques with decongestive therapy alone, with results expected by 2026.^8, (see Table of Summary of Key Trials).

A meta-analysis by Fijany et al (2024) aimed to evaluate the efficacy and safety of different liposuction techniques in patients with lipedema, incorporating 10 studies with post-operative outcomes and complication data.^9, The studies comprised of two using traditional tumescent liposuction (TTL), five utilizing power-assisted liposuction (PAL), one employing WAL, and two studies featuring both PAL and WAL. In total, 2,542 procedures performed on 906 patients were analyzed. Consistent with the findings of Mortada et al. (2024), the combined outcomes for all techniques showed significant improvements in pain relief, reduction of bruising and edema, decreased tension, reduced pressure sensitivity, and enhanced cosmetic and general impairment (all p<0.00001). TTL, PAL, and WAL each significantly contributed to reducing pain, bruising, swelling, pressure sensitivity, and cosmetic impairment (all p<0.05). WAL was particularly effective in alleviating tension and general impairment (all p<0.005); however, the heterogeneity for these outcomes was high. The overall complication rates reported were low, with TTL at 1.5%, PAL at 4.0%, WAL at 0%, and studies using both PAL and WAL at 2.3%.

Section Summary: Lipedema

The evidence on liposuction for lipedema includes systematic reviews and meta-analyses of observational studies. The latest meta-analysis of 9 studies (N=635 patients) investigating the impact of various liposuction techniques for individuals with lipedema revealed improvements in the quality of life, pain, pressure sensitivity, bruising, cosmetic impairment, heaviness, walking difficulty, and itching among lipedema patients who underwent liposuction. This analysis was based on prospective cohort studies, which introduces a risk of publication bias. Insufficient detail in some reports contributed to potential data inconsistencies. All studies included in the meta-analysis originated from Germany, Generalizability to other other clinical care settings may be limited. The durability of the procedure is uncertain and no studies were identified that compared liposuction to continued decongestive therapy.

Summary of Evidence

For individuals with lipedema who receive liposuction, the evidence includes systematic reviews and meta-analyses of observational studies. Relevant outcomes are symptoms, change in disease status, functional outcomes, and quality of life. The latest meta-analysis of 9 studies (N=635 patients) investigating the impact of various liposuction techniques for individuals with lipedema revealed improvements in the quality of life, pain, pressure sensitivity, bruising, cosmetic impairment, heaviness, walking difficulty, and itching among lipedema patients who underwent liposuction. This analysis was based on prospective cohort studies, which introduces a risk of publication bias. Insufficient detail in some reports contributed to potential data inconsistencies. All studies included in the meta-analysis originated from Germany, highlighting a significant geographical bias. The durability of the procedure is uncertain and no studies were identified that compared liposuction to continued decongestive therapy. To address these limitations, future investigations must prioritize RCTs to assess the safety and efficacy of various liposuction techniques. One such trial is currently in progress and will provide needed information on the benefits and harms of this procedure. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Clinical input was sought to help determine whether the use of liposuction for individuals with lipedema or lymphedema would provide a clinically meaningful improvement in net health outcome and represents generally accepted medical practice in selected patients. In response to requests, clinical input was received from 3 respondents identified by the National Commission on Lymphatic Diseases (NCLD) or an academic medical center. In addition to this request, a plastic surgeon specializing in lymphedema research and reconstruction at a major academic medical center was interviewed.

For individuals with lipedema or lymphedema with progressive disease who failed to respond to conservative therapy, clinical input supports that use of liposuction is consistent with generally accepted medical practice and its use is expected to provide a clinically meaningful improvement in the net health outcome.

Population Reference No. 2

Lymphedema

Clinical Context and Therapy Purpose

Lymphedema is a chronic condition that is managed with lifelong care. Care is aimed at improving comfort, reducing limb volume, and slowing the rate of progression. For the relatively few individuals who fail conservative treatment, surgical options may be recommended. Surgical approaches include lymphatic surgery and soft tissue reduction.

The purpose of liposuction in individuals who have lymphedema is to provide a treatment option that is an alternative to or an improvement on existing therapies.

The following PICO was used to select literature to inform this review.

Populations

The relevant population of interest is individuals with lymphedema who have failed to respond to conservative therapy or present with more advanced lymphedema with fat deposition and tissue fibrosis.

Interventions

The therapy being considered is liposuction using specialized techniques to remove the deposited fibrofatty tissue with cannulas. Tumescent infused in the subcutaneous tissues causes the fat cells to swell and vessels to constrict; micro-cannulas are then used to suction the fat. Procedures use local anesthetics in the tumescent fluid and do not require general anesthesia. Specialized techniques for liposuction may include power-assisted, which uses a variable speed motor for reciprocating motion, laser-assisted, ultrasound-assisted, radiofrequency-assisted, and water-assisted.^4, WAL is a popular technique that uses pulsating jets of tumescent solution to dislodge fatty tissue with simultaneous suction of the fat and tumescent fluid. Compression garments must be worn following liposuction to prevent the rapid reaccumulation of fibrofatty tissue.

Liposuction reduces the amount of fatty tissue but does not eliminate it, and multiple sessions may be needed.

Comparators

Conservative treatment consists of skin care, exercise and weight reduction, compression garments, manual lymphatic drainage, and in more severe cases intermittent pneumatic compression. Decongestive therapy involves intensive treatment by a health care professional for 5 days a week.

Outcomes

The general outcomes of interest are symptoms, change in disease status, functional outcomes, and quality of life.

Reported outcomes for lymphedema are reduction in size of extremities, direct circumferential measurement, restriction of movement, spontaneous pain or discomfort, edema/swelling, trophic skin changes, and quality of life. Assessment of the fat layer with magnetic resonance imaging, bioimpedence spectroscopy, and perometry have also been reported.

Study Selection Criteria

Methodologically credible studies were selected using the following principles:

• To assess efficacy outcomes, comparative controlled prospective trials were sought, with a preference for RCTs;

• In the absence of such trials, comparative observational studies were sought, with a preference for prospective studies;

• To assess long-term outcomes and adverse events, single-arm studies that capture longer periods of follow-up and/or larger populations were sought;

• Studies with duplicative or overlapping populations were excluded.

Review of Evidence

Systematic Reviews

Literature on the use of liposuction to treat lymphedema is limited.

A 2021 meta-analysis sponsored by the American Association of Plastic Surgeons evaluated the evidence on surgical treatment of lymphedema.^10, Pooled analysis of 2 studies (n=48) showed a 63.95% greater reduction in volume and pooled analysis of 2 studies (n=69) showed a greater reduction in volume by 895 mL for liposuction compared to compression therapy alone. Durability of the procedure was not addressed.

A qualitative systematic review of liposuction for lymphedema of the lower limb was published by Forte et al (2019).^11, The authors identified 8 articles with 191 patients (4 were case reports) that met the inclusion criteria of the review. The mean duration of lymphedema ranged from 10 to 20 years. Volume reduction of greater than 50% was reported following liposuction and compression therapy, with a greater volume reduction for secondary lymphedema compared to primary lymphedema. One study reported improvement in function, quality of life, and rate of infection. No comparative studies were identified.

Lilja et al. (2024) conducted a systematic review to assess the efficacy of three distinct surgical approaches for the treatment of breast cancer-related lymphedema: lymphovenous anastomosis, vascularized lymph node transfer, and liposuction.^12,A total of 12 studies (16%) investigated the effects of liposuction (n=487 participants) on breast cancer-related lymphedema, with publications up to June 2023. These studies were conducted in Sweden (10 studies), the Netherlands (1 study), and South Korea (1 study). Eleven studies were prospective, and one was retrospective. The primary outcome assessed was excessive arm volume reduction across all studies. The average duration of lymphedema before surgery was 9.3 ± 2.0 years. Techniques used included dry liposuction, power-assisted liposuction, and tumescent liposuction. A meta-analysis was not performed due to significant heterogeneity in effect sizes across studies (I² =.99). Most of these studies (83%) followed participants for 12 months. Qualitative analysis of the included studies showed a consistent reduction in arm volume with long-term benefits and reported no major complications. The current data, derived from articles with a high risk of bias, is of low evidence quality.

Randomized Controlled Trials

Alamoudi et al (2018) reported a non-blinded RCT on submental liposuction for cervical lymphedema following head and neck cancer treatment.^13, Twenty patients with cervical lymphedema were randomized into treatment with liposuction or to no treatment control. Patients filled out 2 surveys after consenting for the trial and at 6 months. Compared to the no-treatment group, patients in the liposuction group showed statistically significant improvement in patient's self-perception and subjective scoring of appearance. Limitations of the study include the lack of description of randomization and allocation concealment, lack of blinding combined with subjective outcome measures, lack of a physiotherapy control, small sample size, and short duration of follow-up to assess the durability of the procedure.

Section Summary: Lymphedema

The evidence on liposuction for lymphedema includes systematic reviews, and 1 non-blinded small RCT on submental liposuction for cervical lymphedema following head and neck cancer treatment. The available evidence suggest that arm volume can be reduced by the procedure, but follow-up is limited and the studies have a number of other limitations that include lack of blinding, subjective outcome measures, lack of a physiotherapy control, and small sample size. The latest systematic review of 12 observational studies (N=487 participants) investigating the impact of various liposuction techniques on treating breast cancer-related lymphedema revealed considerable variability in effect sizes across these studies. Due to the high risk of bias, this body of evidence is considered low quality. No trials were identified that compared liposuction to a decongestive therapy protocol with continued compression. Further study is needed to evaluate the impact of liposuction when compared to a decongestive therapy protocol.

Summary of Evidence

For individuals with lymphedema who receive liposuction, the evidence includes systematic reviews, and 1 non-blinded small RCT on submental liposuction for cervical lymphedema following head and neck cancer treatment. Relevant outcomes are symptoms, change in disease status, functional outcomes, and quality of life. The available evidence suggests that arm volume can be reduced by the procedure, but follow-up duration is limited and the studies have a number of other limitations that include lack of blinding, subjective outcome measures, lack of a physiotherapy control, and small sample size. The latest systematic review of 12 observational studies (N=487 participants) investigating the impact of various liposuction techniques on treating breast cancer-related lymphedema revealed considerable variability in effect sizes across these studies. Due to the high risk of bias, this body of evidence is considered low quality. No trials were identified that compared liposuction to a decongestive therapy protocol with continued compression. Further study is needed to evaluate the impact of liposuction when compared to a decongestive therapy protocol. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.

Clinical input was sought to help determine whether the use of liposuction for individuals with lipedema or lymphedema would provide a clinically meaningful improvement in net health outcome and represents generally accepted medical practice in selected patients. In response to requests, clinical input was received from 3 respondents identified by the National Commission on Lymphatic Diseases (NCLD) or an academic medical center. In addition to this request, a plastic surgeon specializing in lymphedema research and reconstruction at a major academic medical center was interviewed.

For individuals with lipedema or lymphedema with progressive disease who failed to respond to conservative therapy, clinical input supports that use of liposuction is consistent with generally accepted medical practice and its use is expected to provide a clinically meaningful improvement in the net health outcome.

Supplemental Information

The purpose of the following information is to provide reference material. Inclusion does not imply endorsement or alignment with the evidence review conclusions.

Clinical Input From Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise stated.

2025 Input

In response to requests, clinical input was received from 3 respondents identified by the National Commission on Lymphatic Diseases (NCLD) or an academic medical center. Respondents affirmed that the use of liposuction in individuals with lymphedema or lipedema who failed to respond to conservative treatment provides a clinically meaningful improvement in net health outcome and represents generally accepted medical practice. Additional details are available in the Appendix.

Practice Guidelines and Position Statements

Guidelines or position statements will be considered for inclusion in ‘Supplemental Information' if they were issued by, or jointly by, a US professional society, an international society with US representation, or National Institute for Health and Care Excellence (NICE). Priority will be given to guidelines that are informed by a systematic review, include strength of evidence ratings, and include a description of management of conflict of interest.

American Association of Plastic Surgeons

A 2021 consensus document sponsored by the American Association of Plastic Surgeons evaluated the evidence on surgical treatment of lymphedema.^10, The conference recommended, based on grade 1C (very low quality) evidence, that there is a role for debulking procedures such as liposuction and for liposuction combined with physiologic procedures in reducing the nonfluid component in lymphedema.

International Society of Lymphology

In 2023, the International Society of Lymphology updated a consensus document on the diagnosis and treatment of peripheral lymphedema.^14, The consensus of the panel was that liposuction has been shown to completely reduce non-pitting lymphedema due to excess fat deposition, but long-term management requires strict patient adherence to compression garments.

International Consensus Conference on Lipedema

A 2017 international consensus conference on lipedema identified studies from Germany that reported long-term benefits for up to 8 years following liposuction, concluding that lymph-sparing liposuction is the only effective treatment for lipedema.^15,

National Institute for Health and Care Excellence

The National Institute for Health and Care Excellence (NICE) issued clinical guidance addressing the use of liposuction for chronic lymphedema in 2022.^16, The guidance reviewed the evidence and concluded that current evidence on the safety and efficacy of liposuction for chronic lymphedema is adequate to support the use of this procedure provided that standard arrangements are in place for clinical governance, consent, and audit. The evidence on safety shows that the potential risks include venous thromboembolism, fat embolism, and fluid overload. Patient selection should only be done by a multidisciplinary team with expertise in managing lymphedema. The procedure should only be done in specialist centers by clinicians with training and expertise in liposuction for lymphedema following agreed perioperative protocols.

The NICE also issued guidance for liposuction in lipedema in 2022.^17, They recommend liposuction for lipedema should be used only in the research setting because the safety data for liposuction in lipedema is inadequate but concerning.

U.S. Preventive Services Task Force Recommendations

Not applicable.

Medicare National Coverage

There is no national coverage determination. In the absence of a national coverage determination, coverage decisions are left to the discretion of local Medicare carriers.

Ongoing and Unpublished Clinical Trials

Some currently ongoing and unpublished trials that might influence this review are listed in Table 2.

Table 2. Summary of Key Trials

  NCT: national clinical trial. a Denotes industry-sponsored or cosponsored trial.

References

1. DiSipio T, Rye S, Newman B, et al. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol. May 2013; 14(6): 500-15. PMID 23540561
2. International Society of Lymphology Executive Committee. The Diagnosis and Treatment of Peripheral Lymphedema: 2023 Consensus Document of the International Society of Lymphology. 2023; https://journals.librarypublishing.arizona.edu/lymph/article/id/6372/. Accessed November 23, 2024.
3. Shavit E, Wollina U, Alavi A. Lipoedema is not lymphoedema: A review of current literature. Int Wound J. Dec 2018; 15(6): 921-928. PMID 29956468
4. Chia CT, Neinstein RM, Theodorou SJ. Evidence-Based Medicine: Liposuction. Plast Reconstr Surg. Jan 2017; 139(1): 267e-274e. PMID 28027260
5. Araco A, Gravante G, Araco F, et al. Comparison of power water--assisted and traditional liposuction: a prospective randomized trial of postoperative pain. Aesthetic Plast Surg. 2007; 31(3): 259-65. PMID 17380360
6. Peprah K, MacDougall D. Liposuction for the treatment of lipedema: A review of clinical effectiveness and guidelines. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health. Jun 7, 2019. https://www.ncbi.nlm.nih.gov/books/NBK545818/pdf/Bookshelf_NBK545818.pdf PMID: 31479212
7. Mortada H, Alaqil S, Jabbar IA, et al. Safety and Effectiveness of Liposuction Modalities in Managing Lipedema: Systematic Review and Meta-analysis. Arch Plast Surg. Sep 2024; 51(5): 510-526. PMID 39345998
8. Podda M, Kovacs M, Hellmich M, et al. A randomised controlled multicentre investigator-blinded clinical trial comparing efficacy and safety of surgery versus complex physical decongestive therapy for lipedema (LIPLEG). Trials. Oct 30 2021; 22(1): 758. PMID 34717741
9. Fijany AJ, Ford AL, Assi PE, et al. Comparing the safety and effectiveness of different liposuction techniques for lipedema. J Plast Reconstr Aesthet Surg. Oct 2024; 97: 256-267. PMID 39173577
10. Chang DW, Dayan J, Greene AK, et al. Surgical Treatment of Lymphedema: A Systematic Review and Meta-Analysis of Controlled Trials. Results of a Consensus Conference. Plast Reconstr Surg. Apr 01 2021; 147(4): 975-993. PMID 33761519
11. Forte AJ, Huayllani MT, Boczar D, et al. Lipoaspiration for the Treatment of Lower Limb Lymphedema: A Comprehensive Systematic Review. Cureus. Oct 15 2019; 11(10): e5913. PMID 31754590
12. Lilja C, Madsen CB, Damsgaard TE, et al. Surgical treatment algorithm for breast cancer lymphedema-a systematic review. Gland Surg. May 30 2024; 13(5): 722-748. PMID 38845835
13. Alamoudi U, Taylor B, MacKay C, et al. Submental liposuction for the management of lymphedema following head and neck cancer treatment: a randomized controlled trial. J Otolaryngol Head Neck Surg. Mar 26 2018; 47(1): 22. PMID 29580298
14. Executive Committee of the International Society of Lymphology. The Diagnosis and Treatment of Peripheral Lymphedema: 2023 Consensus Document of The International Society of Lymphology. Lymphology. 2023; 56(4): 133-151. PMID 39207406
15. Sandhofer M, Hanke CW, Habbema L, et al. Prevention of Progression of Lipedema With Liposuction Using Tumescent Local Anesthesia: Results of an International Consensus Conference. Dermatol Surg. Feb 2020; 46(2): 220-228. PMID 31356433
16. National Institute for Health and Care Excellence (NICE). Liposuction for chronic lymphoedema. Interventional procedures guidance. IPG723. 2022. https://www.nice.org.uk/guidance/ipg723. Accessed November 26, 2024.
17. National Institute for Health and Care Excellence (NICE). Liposuction for chronic lipoedema. Interventional procedures guidance. IPG721. 2022. https://www.nice.org.uk/guidance/ipg723. Accessed November 25, 2024.

Codes

Policy History

Appendix

2025 Clinical Input

Objective

Clinical input was sought to help determine whether the use of liposuction in individuals with lymphedema or lipedema who have failed conservative therapy provides a clinically meaningful improvement in net health outcome and represents generally accepted medical practice in selected patients. In response to requests, clinical input was received from 3 respondents identified by the National Commission on Lymphatic Diseases (NCLD) or an academic medical center. In addition to this request, Dr. Wei Chen, MD, FACS, professor and attending of plastic surgery and Co-Director of the Center for Lymphedema Research and Reconstruction at Cleveland Clinic, was interviewed.

Respondents

Clinical input was provided by the following specialty societies and physician members identified by a specialty society or clinical health system:

• Stanley G. Rockson, MD, identified by the National Commission on Lymphatic Diseases (NCLD)
• Babak Mehrara, MD, identified by the NCLD
• David W. Chang, MD, University of Chicago Medicine

Ratings

Respondent Profile

Respondent Conflict of Interest Disclosure

Specialty Society respondents provided aggregate information that may be relevant to the group of clinicians who provided input to the Society-level response.

Clinical Input Responses

Question 1: We are seeking your rationale on whether using liposuction in individuals with lymphedema provides a clinically meaningful improvement in net health outcome.

Question 2: Do you agree with the following patient eligibility criteria for liposuction in individuals with lymphedema?

• Documentation by the referring primary care provider or vascular specialist (different from the treating surgeon) confirming that lymphedema is an independent cause of physical functional impairment

• Failure to respond to three consecutive months of conservative medical management (e.g., compression garments, manual lymphatic drainage)

• Patient consents to wear compression garments postoperatively as prescribed to maintain treatment effects

Question 3: Are there scenarios where a clinical benefit is observed from excisional procedures such as debulking or liposuction when performed to sites other than the upper or lower extremities in individuals with lymphedema (e.g., trunk, chest, waist, hip, buttocks, back, head, neck)?

Question 4: Please describe clinical scenarios (e.g., clinical signs and symptoms) used to determine whether microsurgical treatment (e.g., microsurgical lymphatico-venous anastomosis, lymphathic-capsular-venous anastomosis, lymphovenous bypass) or vascularized lymph node transfer supports a treatment benefit in individuals with lymphedema. Examples may include pain or weakness in the affected extremity or a history of skin conditions.

Question 5: Please describe any quantitative measurements or thresholds used to determine whether microsurgical treatment (e.g., microsurgical lymphatico-venous anastomosis, lymphathic-capsular-venous anastomosis, lymphovenous bypass) or vascularized lymph node transfer supports a treatment benefit in individuals with lymphedema. Examples may include thresholds for volumetry differentials in the affected limb or the role of preoperative lymphoscintigraphy.

Question 6: Are there any lymphatic physiologic microsurgery techniques for lymphedema that are currently not supported by the evidence?

Question 7: Is there a role for lymphatic physiologic microsurgery performed during nodal dissection or breast reconstruction to prevent lymphedema?

Question 8: What are some clinical characteristics distinguishing lymphedema from obesity? Does bioimpedance spectroscopy aid in this differential?

Question 9: We are seeking your rationale on whether using liposuction in individuals with lipedema provides a clinically meaningful improvement in net health outcome.

Question 10: Do you agree with the following patient selection criteria for excisional surgery (e.g., liposuction, excision, debulking, lipectomy) in individuals with lipedema?

• A diagnosis of lipedema meeting all of the following criteria:

• Absence of pitting edema

• Bilateral and symmetrical manifestation with minimal involvement of the feet

• Disproportionate adipocyte hypertrophy of the affected extremity

• Photographs of the area to be treated documenting disproportional adipose distribution consistent with diagnosis

• Negative Stemmer sign

• Pressure-induced pain and tenderness on palpation

• Failure of the limb adipose hypertrophy to respond to recommended medically supervised weight loss modalities or bariatric surgery, in concomitant class II or III obesity

AND

• Failure to respond to at least 3 consecutive months of conservative medical management (e.g., compression or manual therapy)

• Documentation by the referring primary care provider or vascular specialist (different from the treating surgeon) confirming that lipedema is an independent cause of physical functional impairment

• Patient consents to wear compression garments postoperatively as prescribed to maintain treatment effects

• Surgical treatment is performed by a hospital credentialed, board-certified plastic surgeon

Question 11: Do you agree with the following statement?

Liposuction for lipedema may need to be completed in stages when the total volume of liposuction exceeds clinical standard of 5000cc total aspirate during the initial procedure and may be considered medically necessary when expected to be completed within a 12-month period.

Question 12: Are there clinical scenarios where repeat treatment of lipedema with liposuction in areas that have been previously fully treated is clinically appropriate?

Question 13: Are there scenarios where a clinical benefit is observed from excision (with lipectomy) or liposuction when performed at sites other than the upper or lower extremities in individuals with lipedema (e.g., abdomen, trunk, head, neck, chin)?

Question 14: Please describe clinical characteristics distinguishing lipedema from obesity. Should weight loss interventions be trialed prior to treatment escalations in individuals with concomitant class II or III obesity?

Question 15: Please describe contraindications to liposuction and excisional surgeries.