November 09, 2026 | Body Contouring, Liposuction
Years of being told to lose weight. She did, more than once. Waist, gone. Thighs, exactly where they were, and they still bruise if she bumps the coffee table.
Lipedema. I wish more doctors said the word.
Saturday’s post was about a citrus pill a Daily Mail reader likes (here). This one is the operation, in my own words from a dictation I recorded for it last month.
What Lipedema Is, and What It Is Not
“Lipedema is usually symmetric, which is different from lymphedema, which usually only happens on one side of the body. Lipedema usually affects the thighs and the legs. It can be associated with tenderness to palpation, easy bruising, and decreased mobility. It does not affect the hands or the feet. It almost always happens in women, and it starts around puberty.”
“Lipedema usually doesn’t respond to diet and exercise. The patient can lose weight and they’ll lose it around the waistline, but the areas affected by lipedema do not respond. The usual patient has dealt with this problem for many years and has always been told to lose weight, but that in essence does not help.”
| Lipedema | Lymphedema | Ordinary weight gain | |
|---|---|---|---|
| Pattern | Both sides, symmetric | Usually one side | Everywhere, waist first |
| Where | Thighs and legs, sometimes arms; spares the hands and feet | Often includes the foot | Trunk, face, limbs together |
| Feel | Tender to pressure, bruises easily | Swollen, firm | Not tender |
| Who | Almost always women, from puberty | Either sex, any age, often after surgery or infection | Anyone |
| Diet | Waist shrinks, legs do not | Does not fix the swelling | Responds |
Conservative Care Comes First
Nobody gets booked for surgery on the first visit. Garments, walking, massage, the anti-inflammatory diet, keep the weight where it is or a bit lower. Months of that. If the legs still hurt and still bruise after months of that, we talk lipo. Any stage.
How I Do the Surgery
“I usually perform lipedema surgery through liposuction with a power-assisted device, as it has become much of the gold standard. I prefer to keep cannulas under four millimeters. The main objective is to spare the lymphatics, so as not to create lymphedema or worsen the problem. It is performed under general anesthesia, and the strokes are made longitudinally in order to preserve the lymphatic drainage.”
Up and down the leg, never across it. That one habit protects the lymph channels.
Why It Is Staged
“Preferably, the lipedema surgery is staged. Outer thighs and hips first, then inner thighs and knees, then the calves, and the arms last, typically four to eight weeks apart. The staging order is a general guideline, but some patients have an area that bothers them more than others, so these areas can be prioritized during the treatment.”
“The reason for staging is that the volumes of liposuction are usually high in lipedema. Also, we don’t want to overwhelm the lymphatic system all at once. For an outpatient procedure, we limit the lipoaspirate to five liters per case, and that is one of the reasons why we stage these procedures. Volumes greater than five liters can create big fluid shifts in the body and require a hospital overnight stay, which usually doesn’t outweigh the benefits. Therefore, repeated smaller sessions can be less costly.”
Five liters, home the same day. More than that means a hospital bed overnight, and I would rather you were in your own.
Insurance and Cost
“It’s important to note that neither Dr. Agullo nor Southwest Plastic Surgery works with insurance. Lipedema surgery is charged just like liposuction, and the fees can be checked on our fees page as of this writing. The cost is by areas treated. Because lipedema can be very voluminous, sometimes the surgery can be prolonged, and this is taken into consideration for OR time and anesthesia, which can increase the costs listed on the web page. Some patients will opt to have the procedure with us and then submit their claim to their insurance separately. Overall, it is a difficult procedure to have covered under insurance. If you wish to have a physician that takes your insurance, we would be more than happy to refer you to a board-certified plastic surgeon. Nonetheless, many times these procedures will not be approved.”
What a Year Out Looks Like
“Overall, the results will be maintained over time, as long as the patient also continues maintenance therapy like lymphatic massages, weight maintenance or weight reduction, and compression garments. The final result really depends on the stage of presentation, or how the patient shows up before surgery. The higher grades of lipedema have stretched and overhanging skin, which does not retract as much as we would want with liposuction. Nevertheless, the areas are debulked, they are smaller, and there is increased mobility. Most patients report improved mobility, less pain, and less bruising. The liposuction will remove the diseased fat or reduce the amount of it. The loose or overhanging skin may need an actual surgical procedure, an excision and lift, for a more cosmetic contour.”
“The timing of the skin excision or lift also depends on the patient presentation and stage of lipedema. For mild to moderate skin excess, the procedure could be performed at the same time. For more severe presentations and skin laxity, it’s usually staged and can be performed as soon as three months later, but ideally six months later.”
Mobility, pain, bruising. The mirror comes fourth, and my patients rank it the same way. The skin lift, when it is needed, is the one I talk through with patients after big weight loss too.
Who Is a Candidate
Both legs, sometimes both arms. Tender when I press. Bruises you cannot account for. Hands and feet normal. You wore the garments, you had the massages, it still hurts. Weight steady or dropping. That is the patient. Stage only changes how many sessions, and whether skin comes off later.
The Misconception
“Just lose weight.” Usually said by someone with a stethoscope. I ask for weight loss too, it helps everything else, but it has never once taken lipedema fat off a thigh. A cannula does.
Why Choose Dr. Agullo
Double board-certified, American Board of Plastic Surgery and American Board of Surgery. Mayo Clinic plastic surgery fellowship. Clinical Associate Professor of Plastic Surgery at Texas Tech University Health Sciences Center. Castle Connolly Top Doctor, 13 years running. Liposuction and body contouring are most of my week, outpatient, in El Paso. The short version of this post is on drworldwide.com and the garments-and-massage side is on Southwest Plastic Surgery.
Ready to Talk?
Bring the photos of your legs over the years. I will tell you in one visit whether this is lipedema. (915) 590-7900, text 1-866-814-0038, or book at agulloplasticsurgery.com/appointments. #StayBeautiful
@RealDrWorldWide on Instagram, TikTok, and Snapchat, @Agullo on X, or @AgulloPlasticSurgery on Facebook.
