The Pound of Cure Weight Loss Podcast
Hosted by obesity specialist Matthew Weiner, MD and dietitian Zoe Schroeder, RD, The Pound of Cure Weight Loss Podcast provides a comprehensive approach to weight loss. We cover nutrition, the new GLP-1 medications, and Bariatric Surgery in depth and answer tons of questions from our audience every week. Check out our website for video versions of the podcast: www.poundofcureweightloss.com/podcast
The Pound of Cure Weight Loss Podcast
Lipedema and Body Contouring Surgery with Dr. Larson
In Episode 54 of the Pound of Cure Weight Loss Podcast, Dr. Matthew Weiner and Zoë Schroeder sit down with Dr. Ethan Larson, a plastic surgeon specializing in lipedema care. Together, they delve into the complexities of lipedema, available treatment options, and the transformative role of plastic surgery for lipedema.
What is Lipedema?
Dr. Larson explains that lipedema is a chronic condition that primarily affects women. It manifests as an abnormal accumulation of fat in the legs, arms, and sometimes the abdomen, often triggered by hormonal shifts like puberty or menopause. Unlike normal fat, lipedema fat does not respond to diet or exercise, leaving patients frustrated.
Key Facts About Lipedema:
- Resistant to metabolic breakdown.
- Often accompanied by pain and swelling.
- Can coexist with obesity, which is treatable.
Lipedema Treatment Options
While diet and exercise support overall health, they do little to address lipedema fat. Dr. Larson highlights lymphatic-sparing liposuction as the most effective treatment, designed to:
- Remove abnormal fat while preserving the lymphatic system.
- Improve functionality and reduce pain.
- Enhance cosmetic appearance as a secondary benefit.
The Role of Plastic Surgery for Lipedema
Plastic surgery for lipedema is more than cosmetic; it’s a functional solution that addresses discomfort and mobility challenges. Dr. Larson answers common questions about the procedure:
- Does the fat return? Not in treated areas, but untreated regions may develop new fat pads.
- How much fat can be removed? Up to 8–10 liters per session, depending on individual needs.
- What about risks? Safety measures ensure optimal outcomes while minimizing complications.
Comprehensive Lipedema Care
Effective lipedema treatment often requires a multidisciplinary approach:
- Dietary Adjustments: Anti-inflammatory diets can help manage secondary symptoms.
- Surgical Interventions: Lymphatic-sparing liposuction is the cornerstone of treatment.
- Patient Advocacy: Self-education and persistence are key to navigating insurance challenges.
Addressing Barriers in Lipedema Treatment
Dr. Larson discusses systemic challenges, including:
- Limited awareness among healthcare providers.
- Lack of insurance coverage due to insufficient diagnostic and procedural codes.
- High out-of-pocket costs, with surgeries starting at $12,000 per session.
He stresses the importance of awareness and advocacy to improve access to care.
When to Consider Plastic Surgery for Lipedema
Dr. Larson advises patients to stabilize their weight for at least three months before surgery. For those using GLP-1 medications like Wegovy or Mounjaro, he recommends completing weight loss before planning surgery to ensure long-term success.
Lipedema Support and Resources
Organizations like the Lipedema Foundation are vital for raising awareness and advocating for systemic change. Dr. Larson encourages patients to utilize resources like Lipedema.org to connect with knowledgeable specialists and support networks.
Final Advice for Lipedema Patients
Dr. Larson’s key recommendations:
1. Get Diagnosed: Work with a specialist to confirm your condition.
2. Set Priorities: Identify treatment goals to guide your care plan.
3. Plan Ahead: Ensure long-term weight stability and realistic expectations.
Connect with the Experts
Visit www.larsonplasticsurgery.com or www.poundofcureweightloss.com to learn more
When people get the diagnosis of lipoedema, they get sort of a sense of hopelessness about their weight overall, and one thing that I think is important for everyone to understand is that there's lipoedema fat which you can't lose through diet and exercise but that's frequently in the same patient that has maybe obesity and that can be treated. And so we want to treat the obesity and the lipoedema to get the patient back to an optimized lifestyle state. Obesity and the lipoedema to get the patient back to an optimized lifestyle state.
Dr. Weiner:Welcome to the Pound to Cure Weight Loss podcast. I want to introduce Ethan Larson, a plastic surgeon and a friend of mine, really highly skilled. We're going to talk today about lipoedema and body contouring surgery and Ethan has been on our nutrition program and so, um, as part of our nutrition program, if you sign up, you can meet with him and talk about, you know, questions you have about either uh, treating life edema or the first steps in body contouring surgery, and so that's available on our website at poundacureweightlosscom. Slash nutrition, um and uh. Once you sign up, you'll be able to see the schedule, and it should be. She should be scheduled shortly after the release of the podcast. So welcome, ethan, good to have you.
Dr. Larson:Thank you very much for having me on. I appreciate it.
Dr. Weiner:So I think the first question that we need to answer is what is lipoedema.
Dr. Larson:So lipoedema is a disease that affects primarily women and what it represents is fatty tissue that usually starts in the legs and usually begins at a period of hormonal shift whether that be puberty, childbirth, menopause and that fatty tissue starts to grow. Unfortunately, it seems to not have the receptors that normal fat cells have. So when it comes time to try and break that tissue down to turn it back into energy, the body can't do it. The body recognizes that there's something wrong with the cells at that point and a low-grade inflammation starts and the abnormal fatty tissue, combined with the low-grade inflammation, over time can develop fibrosis. It can develop pain and we see just generalized swelling of the legs, not from fluid but from an accumulation of fat that's very hard to lose. It can also affect the abdomen and the arms.
Zoe:So what do people do to like? What is it to help that?
Dr. Larson:Well there's. There's not a whole lot of options to help it at this point. Diet and exercise can sometimes affect normal fat. The weight loss interventions that we have now, the new medications, weight loss surgery that affects normal fat but it doesn't really seem to have a profound effect on lipidema fat. So even after those interventions that fat is still there, it's still stuck in the legs, and so the only way to really affect it is to remove it surgically, and we do that with a special type of liposuction called lymphatic sparing liposuction, and it's really a debulking procedure.
Zoe:I was going to think of it as something like liposuction, yeah, so what's different Like what do you do?
Dr. Weiner:different Like, first of all, how's liposuction work traditionally and what's different about the liposuction you do for lipodema.
Dr. Larson:Sure. So traditional liposuction is basically a hollow rod that's connected to suction and it relatively easily removes fat cells while preserving the blood supply, the nerves, the stuff that keeps the overlying skin alive. When we do lipedema, that fat is different from normal fat. Normal fat has more of a buttery consistency. I say lipedema is more like like cheese it's. You have to sort of burrow through it. It needs to be separated.
Dr. Larson:A lot of times the lipoedema nodules are larger than the holes in the cannula. So I have to do a lot of manual breaking up of the tissue to make the nuggets of lipoedema small enough to remove. And then I'll also use my hands to actually remove it by milking the large nuggets out of the holes. And then part of this is we want people to get a really satisfying cosmetic result, and that's challenging when we're dealing with irregular large lumps of lipidematous tissue. So a big part of my procedure is smoothing things out at the end so people get the optimal cosmetic result. And remember, it's not a cosmetic surgery, it's a functional surgery. But we want people to look good when we're done.
Zoe:Also, so then with lipedema, does it come back after a certain period of time if they gain weight back, or is it more so just gone because those fat cells are now removed?
Dr. Larson:That's a fantastic question and there's a lot about lipedema that we don't understand and really recurrent lipoedema is one of those things the majority of the people that I treat. They don't get it back on a large scale, but if there are little pockets of lipoedema that are left behind, I've seen those grow and make little new lipoedema fat pads. More commonly, what I see is if we treat someone's legs, if they have lipoedema in their arms, that may actually start to grow at an accelerated rate when we've removed some of the lipoedema somewhere else. So once we start the process, we want to have a plan to see it through. Otherwise we can end up worsening other areas?
Dr. Weiner:How much fat can you remove in one setting? You know what are some of the risks of the liposuction. What are the limitations? I'm assuming you can't suck out all the fat right?
Dr. Larson:That's a fantastic question and I think it's really variable. A few years ago I had an opportunity to write the United States Standard of Care on lipidema with a number of other experts in the field and those of us who do the surgery all agreed that the national standard, which is about don't remove more than five liters, falls short of treating the lipidema patients Because there is so much tissue that needs to be removed and because after you've operated once it creates sort of a scar tissue within the tissue, it makes future operations harder. The idea is try and treat to completion of whatever areas you're treating at that time. For people with advanced stage three lipedema, we might remove eight 10 liters at a time. It really depends on how things are looking operatively. Am I getting a lot of blood back or is it all lipedema? How healthy is the patient? How bad is their disease? How many operations do we have planned to treat it? All that sort of goes into the equation of how much can we safely remove for each individual person.
Dr. Weiner:What do you think causes it? What's the cause of lipoedema?
Dr. Larson:You know, we really don't know, since it only happens in women. It could be that it's something to do with estrogen, because it is something that is triggered at these hormonal milestones frequently. That could be the case. One of my own personal observations is that lipidema fat is much paler than normal fat. Normal fat's yellow Lipidema is almost a white gray color, which indicates maybe something to do with vitamin A storage and metabolism. But I mean, there's much smarter people than me who are working on this, you know, as a career, and we still don't really know.
Dr. Weiner:What's the Lipoedema Foundation? I see a lot of this. It seems to me like there's this kind of really active group of people out there trying to address this problem. Do you participate with them?
Dr. Larson:Well, not directly. It's more of an activism for not only getting the word out what is this disease? Because a lot of people don't know.
Dr. Weiner:Yeah, it's's about five years. Everybody's been talking about it for five years. I never learned about this in med school I didn't either.
Dr. Larson:I was a lady named karen herbst, who is one of the pioneers of this, came um and met with me when I was at the university and she was at the same time, and said have you heard of this? And I was like, well, I, I can answer test questions about it, but I don't know much about it. And she explained it to me and introduced me to some people who are already treating it and sort of got me interested in it. But you're right, it's something that most of us don't know much about, most physicians don't know a lot about, and so Lipidema Foundation is working to spread awareness. Because there are no ICD-10 codes, which are the diagnostic codes that provide for insurance coverage that specifically cover the disease. There's no CPT codes, which are the codes that doctors use to submit for reimbursement from insurance, that really adequately cover the magnitude of work that's involved in treating this disease. So until those pieces are in place, it gets very hard for these patients, who have unquestionably a medical diagnosis, to get appropriate care and insurance reimbursement for that care.
Zoe:Do you foresee that being something that get those codes being added soon, now that it does seem so widely spread and more talked about?
Dr. Larson:Ideally, yes. My understanding of the way that these codes are adopted is sort of a nebulous and very slow moving process. And so getting ICD-10 codes created I think that's on the horizon in the next few years. But then getting CPT codes, which are how the doctors get reimbursed, and getting them modulated to where there's real interest in physicians taking on these challenges, I think that's going to be a bigger issue, because my understanding is the pie is only so big. So if we're going to be carving out a little bit more for one thing, then someone else is going to be getting a smaller piece, and so there's politics involved. Stay tuned.
Dr. Weiner:Is there any insurance coverage for this?
Dr. Larson:There is sporadically insurance coverage. It can be very much an uphill battle. The patients have to really sort of advocate for themselves. Usually you need to have a full functional capacity examination by an independent person done. It'll take lots and lots of appeals and even with an authorization there's a chance on the back end that it gets denied and the patient gets stuck with a bill. So it's sort of fraught in a perilous process at the moment because there's just no guarantees and there's a lot of liability for the patient there.
Dr. Weiner:How much does it cost? Like how much is it you have significant lipidemia. Let's look at the average. How much would it cost to get?
Dr. Larson:treated. So I think the patient cost is depending on how involved their disease is and how many hours it's going to take in the operating room, how many hours after the fact it's going to take to get them fully recovered. It's somewhere between $12,000 and $16,000 per procedure. That's all in with anesthesia, operating room, garments, post-operative care. In my practice other physicians charge varying amounts. There's varying specialties that are involved in this. I've seen dermatologists doing this. I've seen obstetrics and gynec involved in this. I've seen dermatologists doing this. I've seen obstetrics and gynecologists doing this. I've seen internal medicine doctors doing this and then a few of us board-certified plastic surgeons also.
Dr. Weiner:It seems like your first surgery is your best bet. We see that a lot with surgery. I remember when I did my pediatric surgery rotation. We're talking about a certain condition and the I remember my attending surgeon said there's only one surgeon in the world who can do this surgery right and it's the first surgeon wisdom yeah, and and I think that you know, is there something to that with lipidema as well?
Dr. Larson:I think unquestionably, when you're treating an area of the tissue that has not been operated on before, you have a much greater likelihood of success. After any sort of aggressive debulking procedure which is really what a lot of lipidema requires almost a honeycomb of fat form or sort of honeycomb of fibrous tissue forms around the fat, sort of imprisoning those fat lobules, and it can be very, very hard to free those and it becomes even harder to get a nice, confluent and smooth result. So revision surgeries are always more challenging. But frequently in lipedema we do end up needing to remove some skin. So the sequence is usually debulk the area, give the skin time to retract. If we get satisfactory retraction we're done. If not, we might need to do something like a thigh lift or an arm lift, very similar to what we have to do for people that have significant weight loss.
Zoe:Speaking of skin removal or thigh lifts, arm lifts, those sorts of things. Talk to us a little bit about your experience and your practice, what you're seeing with patients who have lost a significant amount of weight Maybe they come to you from our practice or another bariatric surgeon and what are some of the common procedures that you're doing for the skin removal and what are some of the common procedures that you're doing for the skin removal.
Dr. Larson:I think you know skin removal procedures after weight loss are incredibly bespoke. They're really tailored to the patient, their priorities and how much resources, time they have to spend on healing from these things. Frequently in men it's going to be their overlapping paniculus or the hanging skin that can sometimes cause hygiene issues will be the priority and then we'll address that. Doing circumferential lifting is possible. We get rid of the stomach and then if there's sagging of the buttocks redundant tissue there that's frequently done in a unit redundant tissue there that's frequently done in a unit Then we can do arms or legs at a neck surgery and then the opposite limb at another surgery. Some people will combine it all.
Dr. Larson:I think safely combining all the procedures probably requires more of an operative team, because the time on the table really becomes an issue and I don't love to go over five, six hours at a given operation because complications start to go up. So, by the same token, when people have had weight loss they're usually in a catabolic state where they're used to breaking down tissue and that's not super conducive to wound healing, which requires an anabolic or building up tissue. And so the more stress you put on that system by doing a bunch of procedures at once that can cause some significant wound healing issues. So I like to break it up into manageable bits that are easier to take care of, easier to heal from, and just sort of come up with a plan for each person based on their goals.
Dr. Larson:In women, breasts are frequently part of what loses mass, and so we have to come up with a plan to either lift and augment the breasts or just lift the breasts, depending on what their volume goals are. And then the face is a big part of it. You know weight loss can age the face, it can age the breasts, it can age the buttocks. And so finding ways to meet patients', goals with either restoring volume with fillers we have a structural biostimulator, something like Sculptra, which can cause your own body to simulate or synthesize some more tissue to add fullness to your face. I can transfer any remaining fat to the face or sometimes we just need to do a facelift or consider some implants in order to get the volume back that we've lost.
Dr. Weiner:So if someone has lost a lot of weight after weight loss surgery, what's the right time? When should they have the surgery done? You know, right after they reached their lowest weight? Is there a certain amount of time? You want to wait? What if they're about to start GLP-1s and might lose another 20 or 30 pounds? Should they have the surgery before they lose the weight or after? Like, how do you work out the timing of these surgeries?
Dr. Larson:Sure, great question. So for surgery, we like to see the patient has reached their nadir or their low weight and they've maintained it for at least three months before we talk about doing the first surgery. And I think of it almost like landing a plane. You know, we're breaking down tissue, we're breaking down tissue and then we want to get on the runway, let the body reset, because we're going to have to take off again and we're going to have to build tissue to get you to heal, and so we don't want that to be jagged, we want it to be a nice gentle sleep. So at least three months more would probably be better, just for the patient to be reassured that there's not going to be any weight gain which can also compromise the results in the end.
Dr. Larson:As far as the GLP-1 medications, that's a little bit trickier, because we have to decide as a team what the patient wants to do in the long term, because we know that when patients come off these medications there can be some weight gain.
Dr. Larson:So the idea would be to decide either to stay on them for potentially in perpetuity, and at that point, okay, then this is going to be your new weight. Let's do surgery after, again, about a three-month wait period. If the patient's going to use them as a stepping stone and then try and get off and then maintain through some other means, my recommendation is see where that takes you Because you know frequently we're going to see weight gain and gaining weight against the scars of the body contouring procedure can be painful and you know I've seen literature reports where there's actually wounds opening up because people gain enough weight that it strains their old scars to the breaking point. So these are areas that we're really just sort of feeling our way through, because it's a newer branch of weight, the way people lose weight, and people from all walks of life are losing significant weight like this. So stay tuned. I haven't really seen any real hard and fast recommendations from the societies on this yet.
Dr. Weiner:I've seen some people are just so happy Post-plastic surgery, weight body contouring, the post-weight loss surgery, body contouring and really thrilled. I think the majority of people are. But sometimes I see people who are not happy. I certainly see people you know who maybe go overseas or kind of seek out some less expensive options. I think what you know, what makes someone most likely to be happy and satisfied after their surgery? Because I think everybody's almost everybody who sees you is going to have a limited budget, right. My guess is people come in and they want everything done and you're like, well, that's a lot of money. And they're like, well, okay, I got to spend a little less. So how do you decide where you should be spending your money? How do you get your money's worth out of plastic surgery?
Dr. Larson:Well, I think it's going to be expectations versus reality, which is something that I spend a lot of time with people on. When you've had significant weight loss, the quality of the skin that's going to be left behind from any operation is likely going to be compromised. What I'm seeing reports of now is that people that have been on the GLP-1s for weight loss their skin, the actual thickness of the skin, is diminished from what we would expect to see in patients of sort of an age-match group. So what we're working against is a lower quality skin that's going to be left behind. We really can't unspill the milk on some of these things, and so understanding that there are limitations and that the surgery has certain goals, but that we can't just turn back the clock and make you thin and 21 again is a great place to start.
Dr. Larson:I think looking at before and afters on the internet is another great way to sort of get an image in your head of what's possible.
Dr. Larson:Talk to a plastic surgeon, talk to more than one plastic surgeon, and get their realistic evaluation of expectations so that you can get a number of opinions on what can be done.
Dr. Larson:As far as going overseas, you know there's great surgeons all over the world, but there's also terrible ones, and I feel like in the United States we do a pretty good job at weeding out the terrible ones and other countries not so much. The other thing that I see is that when people go overseas for their operation, the post-op care is pretty hit or miss. I've seen patients get abandoned afterwards, sort of desperately trying to find someone else to take care of them and that's hard to do when you've had surgery somewhere else and then coming back to the US and expect a US surgeon to assume your care when they weren't part of the original operation. So those are some of the challenges I see and those are the risks that people take on when they go outside the country. I mean, there's certainly risks in the USA as well, but I feel like it may be a little easier to vet people that have a bunch of you know Google reviews from you know other people that they've treated versus you know maybe less transparent things.
Dr. Weiner:Yeah, I think, if you, you know, and we do see this we're in Tucson, so obviously we're not far from the, from Mexico, and uh, we do quite frequently see people come from Mexico who've had plastic surgery down there and now have a wound complication and you know, sometimes they'll go to the emergency room thinking, well, I'll just have you know, whatever plastic surgeons on call will take that. And what I think most people will find is that in most hospitals there really isn't a plastic surgeon on call and so you end up getting a general surgeon which is kind of, you know, gallbladder hernia type surgeon, which again, that's what I am. So I certainly have nothing against that group of people, but we're not plastic surgeons when it comes to wound care and comes to cosmetic results and optimizing it, and you may end up having, you know, a second surgery by a general surgeon, just kind of the breeding tissue, and it's very likely that you're not going to get the same result that you would get if you had it done by someone.
Dr. Larson:You know Very, very similar. The first surgeon has the best shot. You probably see something similar. I know people do medical tourism for weight loss surgery as well. Oh yeah.
Dr. Weiner:I don't know for sure. We see it Like you said. There's some good surgeons out there and there's some people who have some good results and we certainly have talked to them and met them. And then there's also I've seen some kind of crazy stuff, absolutely, and I just I did an endoscopy last week on a patient who went to Mexico for her sleeve and I finished the endoscopy and I was like, did they actually do a sleeve? It didn't look like they really had done much of much surgery at all. I mean I could they did something, but they, yeah, they didn't take out very much stomach. It looked to me like she still had about where we normally take out two thirds of the stomach. It looked to me like maybe they took where we normally take out two-thirds of the stomach. It looked to me like maybe they took, maybe they took out a third of the stomach.
Dr. Larson:So and with the sleeve it's really you got to get the whole thing it's definitely by or be where I you know I've taken breast implants out of people's bottoms, that they've got put in unbeknownst to them. So there's there's strange things that can happen when there's not as much oversight as we have in the US.
Dr. Weiner:They use a breast implant instead of a.
Dr. Larson:Breast implants are a lot softer than the buttock implants are, so they're easier to potentially rupture and cause problems.
Dr. Weiner:Reminds me of the show Botch when you sit on them. Yeah, they have a bariatric Botch now. Oh, do they? I haven't seen it yet. I got to check it out. So if you're out there and you're looking for plastic surgery in Tucson, looking for lipoedema care, we strongly recommend Ethan Larson. We send all of our patients over Ethan. If someone out there is thinking about plastic surgery or care of their lipoedema, you know what advice can you give them. You know I'm just getting started. I'm thinking like maybe I should have the skin contouring surgery, maybe I'm looking at some liposuction for my lipoedema. What should they be thinking? What research should they be doing? Where should they be looking? What should they be learning about?
Dr. Larson:So for Lipoedema there's a number of websites. You can always text my office and I can give you those, but Lipoedemaorg is a great place to start looking into it. If you haven't received a diagnosis yet, there is a lady in town. Her name is Karen Herbst. She works at the Roxbury Institute. She's here in town. Her name is Karen Herbst. She works at the Roxbury Institute. She's here in Tucson. She's wonderful. She can diagnose you Frequently more and more. Family doctors can make the diagnosis, vascular surgeons can make the diagnosis, bariatric surgeons can make the diagnosis.
Dr. Larson:But you'll want to get a diagnosis of lipedema, and if you are sure that you've got it, then give me a call and we can talk about what your treatment options are. One of the things that I see frequently is that when people get the diagnosis of lipedema, they get sort of a sense of hopelessness about their weight overall, and one thing that I think is important for everyone to understand is that there's lipedema fat which you can't lose through diet and exercise, but that's frequently in the same patient that has maybe obesity or is significantly overweight, and that can be treated, and so we want to treat the obesity and the lipidema to get the patient back to an optimized lifestyle state, expand their joy span, potentially extend their lifespan, and so having a teamwork like ours is going to be very essential to getting people optimized that have both of those diseases. If people are post-weight loss and they're looking for body contouring surgery, then you want to be stabilized on your weight and you'll want to have a long-term plan for how you're going to maintain that weight in place that is realistic for you, something that you can really maintain in perpetuity. And once that's all in place, come see me and we can talk about what your various options are. I would come with a priority list.
Dr. Larson:Most important thing to me is getting this hanging skin off my stomach or having my breasts fixed or making my face look less gaunt, and then we can really focus on that, because a lot of times people come in and say fix everything and we've got an hour to talk about it. Well, that's not enough to talk about everything, so we're going to have to break it up into bite-sized pieces and really get into each individual part. So come with a priority list, have a long-term plan to maintain your weight loss and then be healthy. You know surgery takes a lot out of people, so we want to make sure that your health is totally optimized. So being physically active and having a primary doctor you know getting regular checkups is going to be important also and having a primary doctor.
Dr. Weiner:you know getting regular checkups is going to be important also. Love it All right. A lot of great, a lot of great wisdom there, ethan. Thank you so much. What's your website, ethan? Or your Instagram?
Dr. Larson:It's wwwlarsenplasticsurgerycom is the website and the Instagram. There's two. I have Ethan Larson Plastic Surgeon and L and Larson plastic surgery, az, but if anyone wants, they can just text my office and we can send them more information on his stuff. It's 520-771-0177.
Zoe:Thanks so much for joining us.
Dr. Weiner:Great Thanks, ethan, good to see you. My pleasure. Good to see you guys, thank you.
Dr. Larson:Absolutely.
Dr. Weiner:Take care.
