b'improvement, 8 reported disappearance, and of tension, bruising, cosmetic impairment, andgeneral 2 reported no change in this symptom. All patientsimpairment of quality of life pre-and post-operatively. reported a significant increase in their quality of life 131 .These symptoms were significantly reduced in all but Few adverse effects seem to be present even afterone patient in the first post-operative follow up and multiple tumescent liposuction procedures. A studybetween the first and second postoperative follow-up, done by Wollina et al. demonstrated that out of only the severity of cosmetic impairment significantly 18 patients who had multiple microcannula tumescentincreased and there was significant improvement in all liposuction (MTL) procedures done, liposuction wassymptoms between the preoperative questionnaire tolerated well by all of them, and even after the firstand the second postoperative follow-up 133 . liposuction procedure, pain scores decreased, and eight women had no spontaneous or pressure- induced pain 2 weeks after completing their treatment.SECTION 2:Mobility also increased in 16 out of 17 patients. Later in the study, laser-assisted tumescent liposuctionLYMPHATIC AND (LATL) was added. Of the 6 patients who had bothVASCULAR ANOMALIESMTL and LATL, 5 reported preferring LATL because it was less invasive, less bruising, and patients healed faster, although there was no difference between theA. CLINICAL FEATURES & DIAGNOSIStwo procedures in the reduction of pain scores 127 .Author: Ionela Iacobas, MDLong term studies of tumescent liposuction being usedLymphatic anomalies cover a large spectrum of to treat lipedema have also been conducted and showdiseases responsible for causing lymphatic dysfunction. promising results. Rapprich et al. studied 25 patientsIf the lymphatic fluid (a clear yellowish fluid) is not who received liposuction treatment and followed up draining well via the lymphatic system and its vessels 6 months after their final liposuction treatment. Leg(either because they dont exist, are interrupted, or volume was measured by 3D imaging pre- and 6simply leak), then it can accumulate either diffusely months post-op in all patients, and there was a relativebetween tissues (causing lymphedema) or in abnormal volume reduction of 19.8%. In self-reported quality ofcystic spaces defined by their size as microcysticlife surveys conducted pre- and 6 months post-op,(small) or macrocystic (large) cysts; and classified as there was significant improvement in pain, sensitivitylymphatic malformations in the International Society to pressure, and bruising. The study found an averagefor the Study of Vascular Anomalies (ISSVA) of 58% improvement in overall quality of life 129 . classification system 134 . In addition, Schmeller et al. conducted a long-termIf the lymphatic fluid accumulates inside the pleural study of 112 patients who were evaluated at a mean space, pericardial space, or abdominal cavity, thenof 3 years and 8 months after their initial surgery it is called an effusion: pleural effusion, pericardial and a mean of 2 years and 11 months after their effusion, or ascites. And, when the lymphatic fluidlast surgery. There was a significant reduction ofhas already collected the lipid-rich nutrients fromsubcutaneous fatty tissue, and it helped in creating the gastrointestinal tract, as it passes through the a more proportionate body post-surgery. Using amesentery, then it is no longer a clear, yellowish7-question questionnaire they created for lipedema- fluid, but instead appears as a thicker, white fluidrelated complaints, there were significant(milky in color) and is called chyle: chylous effusion, improvements in scores of spontaneous pain, painor chylous ascites. attributable to pressure, amount of edema, bruising, reduction of movement, cosmetic impairment, Using the correct terminology to describe a and overall reduction of quality of life. Patients withcomplex lymphatic and/or vascular anomaly helps stage II and III lipedema had a larger improvementboth diagnosis and management purposes.than patients with stage I lipedema.In addition to improvement in quality of life, 80.6% Clinical example: In pediatrics, multiple complex of patients had some sort of reduction in the need vascular syndromes are described by the genetic for conservative management, with 22.4% no longermutation(s) responsible for the syndrome. needing any sort of conservative therapy 132 . Finally, Somatic genetic alteration (not inherited fromin a longitudinal study, Dadras studied 25 patients parents) causes multiple forms of lymphatic anomalies who underwent multiple liposuction procedures in the same patient. For example, PIK3CA-related and completed a standardized questionnaire. overgrowth syndrome (PROS) results in over-They followed up with each patient twice, with proliferation of the affected tissues resulting in mean follow-up times of 16 months and 37 months,structure and functional anomalies. In the same respectively. In the questionnaire, they were askedpatient, one can identify overgrowth of muscle or about spontaneous pain, pain upon pressure, feeling | Standardized Approach for the Diagnosis and Management of Lymphedema (LE) and Lymphatic Diseases (LD)|33'