Apolgie production.
Hi, my name's Beck Woodbine and welcome to Tenderness for Nurses. I'm grateful for the person that I have the opportunity to be.
So I hit it and parked it for nearly four years.
We always have free will, We always get to choose.
We are autonomous.
Welcome back to Tenderness for Nurses and part two of Beck's chat with Doctor Levine. In this episode, Beck goes through your questions submitted to doctor Devine about lipidemia. So I'm just going to start asking some of the questions that have been sent in to me.
Happy to answer that.
Okay, So, will lipidema ever be covered by Medicare? And who should the lipidema community talk to to get the word out.
So it's a very difficult question to answer because coverage of Medicare is basically acknowledgement of lepidema as a disease, as in a medical condition. And this is where there is no acknowledgment of lipedemas a disease condition. It's as a multiple mentions of lipedema as a rare quote unquote fat disease. And usually when people talk about rare, it's usually talk about point one percent point two percent. This is like one in ten, and average medical students do
not go through medical school learning about it. And my personal experience of lipedemas I went through specialist training and I didn't know about lapidema. We knew about lymphedema, but not lipidema. It's only when I started practicing as a specialist, when I'm kind of my first lip and patient, That's when I got to know about lipodma. And when you start to read the literature, there's plenty of papers around lipedema, but you have no ideas to how come this was hidden.
What was interesting was most of the papers when I first read. In fact, most of the papers still are based out of Germany, and doctors in Germany have a better understanding, or probably an early understanding of lipedema, and they have kind of been pioneers in treating lipedema. It is coming to the English speaking world gradually, little by little.
This is probably a question out of curiosity. Say you, as a parent have like p edema and you have a daughter, if you could control, you know, educate on diet, exercise, hormone, managing all of that side of things, can you control it? Can you manage it better, or at some stage will it just start to exploit explode.
Look, it's a it's a common question to get asked because, as you imagine, if you treat somebody who's got lepidema, there's a good chance that their daughter may have the tendency. So it's a very very delicate question to delicate subject to broach with a teenager because if you know, the typical age of flare up of lipideemer its when you
go through puberty. It also coincides with a lot of other changes in the teenager during the time, starting from being socially different, lack of exercise, so on and so forth. But at no point I tell my patients that you need to be focusing on the word diet, because that will make things very hard for the teenager, because we know that even if your diet, you will not see a reduction in your leg fat deposits of light padema.
And if you tell someone you're not seeing any deposits of fat disappear because you're dieting, you need to diet more, you can tip them over into a condition that is actually quite awkward. Right with the disorted eating habit, and we see this very commonly. So it's a very difficult and a very delicate one, and I don't have an
answer for that. So what I tell patients is, if you want to ever broach the topic with your young teenage daughter, will recommend that you somehow introduce the concept of restriction of sugar, restriction of processed food, go on a healthy diet, and maybe the entire family has a clean up diet. Right. Or if you're doing an exercise regime with your daughter, try and make it like it's a mom daughter yoga challenge, right, so you go with her to a yoga class or a pilates class, so
as opposed to making it like sound like a chore. Right, So then you have buying from them, which will be a much more sustainable practice without having to go through the process of embarrassing them or shaming them. Yeah. Absolutely, Okay, it's a very delicate one. I've seen a lot of patients of mind who have gone through disordered eating phases, and we usually tell them that and look, it's natural.
It's normal because you've been told diet, diet, diet, and you don't see no change, and you believe that you're not doing enough, and at one point when you draw the line is enough is enough?
Well, that's right, you know, and at the end of the day you've got to have happy kids. Say why does it hurt to press the skin with lipaedema?
Okay, this is nobody knows why. But there is a condition called in fat growth. Like we all know about lipomas, which is abnormal fat growth, there's a condition called angio lipomas where's a bit more clustered blood vessels. And these are small p shaped fat lumps in the body that are exquisitely tender. So there's some internal signaling that can trigger off either nerve increasing nerve sensitivity due to the
pattern of signaling. That's what we don't know, right, So there is, and these fat pockets can be tender and can be painful to the point that if a cat sits on your lap, you don't like it. If a dog runs into your legs, you hate it. And if you actually have someone tap your shoulder and say come beg let's go and have a drink ouch, it hurts you. So these are really tender spots.
So this condition really impacts women's lives significantly.
Yes it does.
So is there research happening in this area.
There's a lot of research happening in this area, and Australia is actually one of the pioneering research places. And Dr Romin Scheine, who's a plastic surgeon in Melbourne, is pioneering a lot of original genetic research because Romen along with this wife Tartt, is run an adipose biology laboratory and you can't get more specific for lipitma than having an adipose lab. And they have got a global research group of people who know multiple countries in Europe and
US of course. And there's an American organization called the Lepidiema Foundation LF and they fund lepadema focused research in across the world. So I think there is lipidima research happening, but is it happening quick enough? The answer is we don't know, but it is surely showing evidence that this is a genetic based disease because they're isolating genes now little by little, so hopefully there will be some sort
of groundbreaking treatment in the future. But even what we're practicing today compared to what was being practiced twenty years ago is significantly different. So research of today will defind the medicine of tomorrow.
Yeah, gotta love that, don't you. Why are gps not informed about lipaedema?
It's I think back to the education and in medical school, this is not even recognized as a condition. And because it the appearance of lipedema fits into our understanding of fat and we're very easily kind of or very quick to say, oh that's only fat, God out an exercise. So every single passion of mind, we ask what's been your experience with a GP. Does a GPE noble epidema? Because what is very important is if you have a GP who understands slipidema and will be willing to look
after you and you care for you. If your GP does not understand lipidima, does not make any attempt to learn about lipidema, then you run the risk of being gaslighter, which is not a good therapeutic place to be. Okay, So my recommendation I tell patients like, if you've you, it is very critical for your success that every single practitioner is treating you has to be not only lepedema aware, but it has to be lipidma empathetic. It starts from
your personal trainer as well. You can't have your personal trainer say why are you not losing weight? Everyone else is losing weight, And that's not a nice thing to say because that shows a fundamental lack of understanding of the fundamental pathology of your patient.
I would imagine women that have suffered this condition have been gas a little lot.
Absolutely, Absolutely, I've suffer in silence. There's silence, silence terrible.
It makes me feel sick.
Actually, at least now in twenty twenty four, twenty five, you have information and thanks to social media and Instagram, when people start posting pictures, people look at the legs and say like, oh, this looks like my friend's legs, or they themselves look at the legs and say like, oh my god, they looks like mine, and then they start and Instagram is such a wonderful platform that we spend more than two seconds on one post, it'll start
feeding you relative stuff. So in some ways that has been very helpful to patients who could bypass the traditional channels of seeking knowledge and advice.
And what does the procedure usually do on patients?
Okay with lida, so Lepidima has got technically three stages, stage one, two, and three, and we never see a stage one at the age of fifty, and we never see a stage three at the age of twenty, implying that the longer you leave it, the worse it becomes. And if you look at the internet and look at stage one, two, and three, it's a progression in the size at a macroscopic photographic level, but at a microscopic level underneath the tissues, what happens is the fat cells
become bigger. Like if you say the fat cell is one by one in stage one, it'll be two by two in stage two, and three by three instat three. Right, I'm just picking numbers to illustrate the point. But in addition to that, there's additional College information as you incrementally go open the stages and as a consequence that you've got fibrosis. Right, so your outcomes are going to be
proportional to the tissues you're going to handle. Okay, So the targeted procedure to treat lip patients is accommodation of non surgical conservative treatment first followed by liposuction to get rid of the fat, followed by maintenance conservative treatment for life. Right, So if you haven't optimized your conservative treatment before the surgery, you will fail, and that operation will fail because the outcomes are not going to be as good as you
expect it to be. So I am a very strong believer in preparing, and I sometimes I use an actet of you know, if you want to run an Olympic marathon, you're not going to run the marathon the first day. If you have to prepare for a year. This is not different, right, so you but you can. It is complex when you look at it, but when you incorporate them one way one, it becomes almost a seamless process in your day to day life and lifestyle. And and people are done it very well and managed to keep
it at bay. Right. It's a combination of many things that will go through that in a second. And the aim of lip persuction is to take out as much pathological fat as possible, as much as possible.
How do you tell the difference between.
Normal and leipadima fat? Yes, look, that's that's a good question because that's commonly get asked. There is no way of finding out right, Okay, So what we what I believe is based on my experience, is the fat you see in a lipid patient between your knee and your ankle is all lepidima fat. Okay, okay, The fat in your thigh between your knee and your hip is sixty forty, right,
but you want to debulk it as much as possible. Now, the reason you want to get rid of your normal adipose tissue or a normal fat in a lipiduma patient is what triggers lipodema growth formation. Nobody knows it is a genetic process that gets amplified bass something. But both your normal adipos tissue and your lipidima fat cell secrete hormones and mediators in the same level of which a
higher concentration comes out of lipidma cells. Right, So if you have more adipose tissue, you'll have a worse of lipoedema. So it is not in your interest to have lots of adipose tissue, normal adipos tissue or lipidima tissue, so you need to debulk all of them. So diet exercises an essential part of controlling lepidema, not directly, but indirectly. Liposuction is the only way you can get rid of lipedema tissue. Say, for example, if a patient goes and
has surgical weight loss procedures and loses eighty kilos. Right, they will lose fat everywhere except your leg. Just need to ankle. It will not change.
Is that right?
It will not change. I've never seen that change. Right, And your thigh will come down in size, but you'll still have residual epidema.
Facts YEP, which then has potential.
To beget more epidema fat. Yes, so it's a positive reinforcement, so I think. So the best best outcomes in summary is if you can get early. In other words, when patients on early stage one is early twenties because you've had a fat deposit for three, four, five, six, seven, eight years, because you haven't been heavy at that point, your tendency to put on normal atipost issues low, so
your amplification of your lipidema fat cells is less. So you can be quite aggressive and aggressive in the sense like it's a you know, take out as much lipidoma fat as possible, set them back on a healthy die, to exercise other non surgical modalities, which is plenty of them, and then they can lead a very very good, comfortable life for quite some time. The fat production of lipedima does not stop, never stops. It'll come back, but you
can slow down the rate of production. It's a bit like if you had a leaking tap, your aim is to control the rate of dripping or leaking, as opposed to shutting off the tap. Shutting off the tap is currently not an option because shutting implies cure.
It's a it's a really profound disorder for someone to have. Yes, it is because they must feel heavy and boggy and exhausted. This I'm kind of blun away with particularly these questions, but your answers, how is it that someone who is not a surgeon can perform live per suction in Australia?
Now, this is this is a very important question and according to the national law, if you're a registered medical practitioner can pretty much do whatever you think you're capable of doing, provided you are appropriately and adequately trained. So that is exactly the words that has been used. It's not been defined. It's not been defined. So what the government has done is says they do not regulate scope
of practice. In other words, if a newer surgeon tomorrow wants to do like persuction, the government can't say you can't do this, okay, right, If a cartithorised exigeon wants to lip persuction tomorrow. If a CRTI ex surgeon wants to brest augmentation tomorrow, the government is not going to say you can't do it, provided he's had adequate training. Right, So, every single medical practitioner is, according to the law, is capable of performing any procedure as long as they feel
they adequately trained and support it. Okay, So that's why we saw this with the cosmetic surgery regulations and the Four Corners episode and Cosmetic Cowboys. A lot of this page doctors were basic medical practitioners who are doing performing cosmetic surgery. So that has not been taken away. They can still perform cosmetic surgery, but now they cannot use the title cosmetic surgeon.
What about visitation rights? So what if something goes wrong at one of the practices that you are having bypersuction done that's by someone who isn't a surgeon or a plastic surgeon, and they don't have visitation rights and something goes significantly wrong, what happens? Who takes over the care of that patient and what happens? Then?
Okay, let's answer the question two points. Now. The first thing is all Professional Plastic Surgery Society is the Solution. Society of Esthetic Plastic Surgeons and ASPS Society of Plastic Surgeons believe that they are five pillars of safety surgery by surgeons and its theasy binis that is surgery to be performed in accredited, licensed facility, the surgeon to be available to provide after k in the post operative phase, and the surgeon to have the expertise to esclate care
should they need a rise. In other words, if you need to be admitted to a hospital to provide care due to excessive bleeding or excessive infection, you should have the ability not rely on the emergency department. So what happens is no hospital will give you admitting rights in
surgery if you're not a registered surgeon. So in some ways this patients should choose a non surgeon for a surgical procedure have an inherent disadvantage because in the event of an emergency, you'll be at the mercy of the emergency department and the personal provides care in the hospital someone totally different. And this is what used to happen when I work in a public hospital in city and
pre cosmic surgery reviews. We used to see a lot of patients being sent to emergency department following complications of cosmetic surgery because the primary proceduralists or the doctor who performed the cosmetic surgery did not have admitting rights in a hospital. Okay, then you come into the emergency department, then the department of plastic Surgery will look after you, but it is not the kind of care that you'd expect because you've gone through a surgeon or a person cosmetic surgery.
So that is something I think is important to stress for the people that are listening to this that that is a really important question to whoever it is that you're going to have your treatment with, is that you need to ask them if they're a plastic surgeon, if they have visitation rights at a hospital, what happens if there is an emergency? What procedures do they have in place? But I think by asking the first two questions, you'll answer all the others.
That's correct. You can ask a question, are you a registered surgeon?
Yeah?
Then and if the answer is no, then you have to ask the next question to yourself, why am I going for a surgical operation by a person who's not a registered surgeon. It's a passion choice, but I think it has to be informed choice, and I think the honest, unfortunately is on the patient to know that information before the patient makes a choice.
Just having done some research and that sort of thing, what I have noticed is the disparity of cost as well, between what these people are are charging compared to what a plastic surgeon charges. And I just want to say that plastic surgeons are far more realistic with their pricing than what these other clinics are that are offering life a suction. It sometimes makes me feel like they're really targeting a very vulnerable group without you saying the wrong thing. Is that a fair assumption.
Look, we don't know, we're not prival to what people charge and how people charge, and individual businesses can choose to price things accordingly. But for someone to see value in a service provided a potentially consumable see value at multiple levels, value of the expertise, value of the cost, value of what information has been provided, sometimes unrealistic. And most of the time people get told a very very rosy picture of the post operative recovery so that they
can kind of be convinced to have search. I'm not saying that happens everywhere, but being accurate, especially when you understand something as complex as to our procedure three opposition and your downtime is going to be quite significant. How does that material impact? Your school can drop off? You're ability to drive the car, you're getting out of a car, how fast can you prepare lunches for your two kids
at home? All those things make a huge difference that they will materially impact you on These things have to be explicitly mentioned to patients before the operation, so that that's when we talk about informed choice. So I think to as plastic surgeons, we spend a lot of time trying to tell patients the right information so that they
can make the right choice. It is not my job for them to go through the procedure, but it is my job an obligation to provide you the right information for you to make the choice.
Yeah, that's very well said. Okay, what are the common comorbidities associated with lipidema?
This is a difficult question. There's no set answer, but let me let me start off by saying that there's a concept called metabolic health, and metabolic health is your basic cellular health, and the metabolic health markers are things like your blood pressure, your heart rate, your cholesterol, your tritless rights, your blood sugar and HP and AC and
all those things. And these are the things that ultimately impact your cellular health and ultimately decide if you are going to have a healthy life or not a healthy life. There are multiple drivers for metabolic health the abnormalities, and some of them are endocrine and the words hormonal health. Sometimes it's weight which is kind of a excessive weight, and obesity and so on and so forth, And unfortunately with labandin patients, a lot of these things go exist
and it is important to peel them. And we have a bias that if you've got the ideal body weight, you should be healthy. But research has shown that even people who are the perfect body weight for their height and the age, thirty percent of people are metabolically unwell right, and that number goes up when you are at the OH weight category on BMI, obesity Cat one, obesity category two, and morbid obs. So if you're heavier, your metabolic health
is kind of not suboptimal. Other issues like thirore issues, hormone issues, some people may have type of diabetes, no different other population, but migraines are sent to be more common in laban in patients and some patients may have disordered eating sleep apnea based on urbesity and joints would be yeah, join pain, joint pain, and because the knee joint in particular is the most vulnerable joint in my opinion, because knee joint relies on collagen ligaments, a good quality
collagen in your ligaments to be strong, and lipid human does affect collagen. And the reason lipidimen does affect collagen is it's evident if you look at your skin of your thigh compared to the skin of your tummy, the skin of your thigh looks different. It doesn't have the normal uniform tone of your tummy skin. And that is because the collagen content, the lymphatic content, and the blood
vessel content is all different. Patients when they're going to have a hot bath or a hot shower, come out of the shower, but the legs are red because the density of blood vessels and capitalis is significantly higher than the tummy or abdomen. Right. So that is why if you feel the temperature of your tummy and temperature of your thigh, one is warm, tummy is warm, and thigh is always cold always interesting.
Is it better to wait until after you've had your children before considering surgery? But you sort of answer that before that, if you know early on, you're better off doing something about.
It, that's right. So the best analogy is to think of lipodima as a dripping tap that is dripping water into a bucket. So the question is if you let the bucket overflow, that's when things go wrong. So your aim is to try to get the bucket under control by lipersuction and the tap to slow down by all the non surgical stuff.
What are the proven conservative measures to help keep fat from progressing?
There's no answer. You question blood tests. There's no scan or a blood test to diagnose lipidema. That's what confuses people now now because every single disease or pathology has a scan or a blood test to diagnose that. But just take back, go back one hundred years when there was no scan, no blood tests, no nothing. The doctor or the physician had to rely on history and physical examination to come up with a diagnosis. Right, So this
is exactly what it is. There will be a time when you can get some smart diagnostic kits like energenetic markers and so on and so forth. But I think that that's coming, but as of today, there's nothing, okay, right, The conservative managements are very simply to understand what you need to do to control the triggers of lipedima. So, lipidima is a bit like juggling more than two balls. The first two balls, every single human being the planet
deals with. Increasing weight corresponds to decrease mobility, and decrease mobility influences increasing weight. That's a vicious cycle that feeds off each other. When you have lipidema, you have the third ball coming in where you increase your weight. Lipidima gets worse, Lipidima gets worse, you move less, you move less, your weight gets worse. It's a vicious cycle. They feed of each other. Yeah, okay, weight is not the primary trigger for lepidema. So I want you to visualize the
fourth ball now, it is your hormones. Okay, Hormones feed of lepidima. Hormones make you develop more adipose tissue and expand adipos tissue, and the vicious cycle is amplified now. So all of a sudden, you've gone from two balls to three balls to four balls. Lipoedima characteristic is you've got fluid in your leg, your lymphatic circulation is sluggish, so your time for the fluid to clear up frame
legs is slower than normal. So that's why libidum patients when they go on a long haul flight more than four US legs well quicker than the best trinsity next to them. It takes them three weeks for the swelling to come down after they reached London from Brisbane compared to the friend who takes about twenty four hours. Right, So that's circulation is sluggish, so that fluid build up is there, so they have to look after the fluid management.
The way you do the fluid management is two for one is passive, in other words, a compression stocking of appropriate pressure class two MLD therapy by lymphatic therapists. And also you can use artificial pumps like the lymphopress and other vas so come home with the even you can put the pump, it will help you to give lymphatic missige. These are passive. You can read a book, listen to music while that's being done. And the active method is
to be active. So walking is the best. Walking underwater is even better yoga is great, pilatus is excellent, Muscle turning is Running is not good because impact on your knee joint will take its toll. Yeah, So the combination of these five things as a critical element is a basic front line. And then if you have other issues like metabolic health, other medical issues, and psychological issues, you
need to optimize those balls. All of a sudden, you could have a scenario where the minimum number of balls juggling is five and it can go up to eight. And now you can see why your day becomes crowded and why it's become complex. All along you've been trying to lose weight, diet and exercise and not seeing any change. It's time to expand with thought process and increase the multidisipary interactions.
That is such good. Look, that's good advice for all of us, but it's imperative for these women that have It's critical for absolutely. Okay, is a PFO bubble test really necessary pre surgery?
Look, this is a very difficult question because I get asked this question all the time. Now. PFO is an underlying condition which is technically a hole in the heart, which is present when you're when you're feet in but as soon as you're born it shuts off. There are small persons of people that does not shut off. Sometimes have symptomatic It can be symptomatic, and sometimes it doesn't
be symptomatic. It doesn't reremin some dramatic But if you talk to a cardiologist, who are the people who deal with all in the heart, they usually say it is in the incidence of but one or less than one percent. That's about it for in the general population, and that don't recommend as a routine screening test for PFOS. And for the time I've been a surgeon surgical training surge in the last many many many years, seeing thousands of
surgical patients having different types of surgery. Not everyone gets tested for PER four as a routine. You may have a hemoglobin test as a routine, but not a peer for test as a routine. But having said that, if the patient has concerned, I usually refer them to cardiologists and said, look, it's not my air of expertise to you and a bubble test and you go and see a cardiologist and they can take it from there. And look, it's a fair call to say, if you're concerned, get
it checked out. What I do, though, is I extensively check your blood plotting screening thing, and I do all the tests, and you suddenly find because live belting patients, because of the nature of the surgery, the duration of the surgery, the discomfort post surgery, the lack of mobility, higher risk for clouding issues.
I was going to say, is is DBT's an issue.
It is a big issue. Yeah, it's not that more prevalent. But if you have an underlying respect factory five flight or any of those clouding factors issues, then you don't want to be missing that. So all my patients get extensively tested, and if there's any abnormality in either the bleeding factors or the clouding factors, that get an official
heematology consultation and some measures get taken in Right. So now we're equally scared of bleeding because you're creating a massive dead space, and we're equally scared of clotting because people don't move much. So I've had to treat patients who had a von Villebrand's disease once on a Jehovah's witness patient. Right, Ah, So if you picked that up early on, you had enough protocols to go through the procedure very well, and you discovered it the wrong way, You're in strife.
Big strife. Yeah, surgery takes a different level of care when once you know.
Yeah, and especially lypidema liposuction, because your caplaries are quite fragile. Because the college is you've got technically grandmother's collagen and in your blood vessels, right, and the trauma that causes those blood vessels will enough to pop them. At the lightest trauma, very little trauma, computer, non patient, You're creating
a massive dead space. You're creating a massive trauma. Your vessels are fragile, and the last thing you want to add to complicate the pictures that are beating disorder.
So wrapping all of this up, big take home I'm getting from you is, if your mom has it, or if you're a mom and you've got a daughter, get onto it early. Really healthy diet, start good exercise practices as a family, good diet as a family. If you are finding that your legs are starting to get that bulkiness, that fat, go and see a plastic surgeon that's that specializes in Yeah.
But I think the more important part is to I would recommend you see a lymphatic massage therapist or lipedema therapist or emphanema therapists. Yea. These are specialized people who are who treat patients who have got limp edema which is cancer rather worse, yes, and lipidima as well. So they're very they're content experts, they're knowledgeable in this process, they know exactly they'll give you the right advice, and they're far more accessible than trying to find a plastic
surgeon because lymphi dema therapists are all over the country. Okay, right, So go and see a lymphatic therapist first, and they can start initiating you with the conservative treatment, understanding you the right measurements of the garments, the right type of guns, right, and then you can then they will have a trusted network of who's who's a good person to start to can do. But that's a physio, it's a doctor, it's a plastic surgeon. And then that's that's when you tap into the ecosystem.
Okay. And then the other big take home I've got from chatting with you is that I can't stress this enough. In my clinic as an as practitioner, I only refer to plastic surgeons, dermatologists, specialists that you whoever you are going to see or choose to see, you ask the questions, are you a plastic surgeon? Are you a surgeon? Legally? Are you a surgeon? Do you have hospital rights? Just protect yourself because as we both know, things do happen
that are unexpected and things can go wrong. That is great, and you mitigate those risks by making sure you cover all your bases and asking the right questions.
Look, I think if you just look at a very basic metric, it's surgery by surgeons.
There you go, surgery by surgeons.
That's what it is.
That's the name of my podcast, that's what it is meant to be.
And I think if you if you perform a surgical procedure, does not make you a surgeon.
No, it doesn't. Thank you so much for taking time out of the conference to coming and chat with me. So I have learned so much today chatting with you, and I know my missing followers on tenantus for Nurses will absolutely love this chat. But thank you. I know how busy you are with these conferences and everyone wants to have a chat with you, So I feel a bit privileged that you took the time. Actually, you just probably wanted to sneak away, didn't you.
Thank you so bread day and Brisbane. Nice to get some warm weather.
I know it's beautiful today.
So thank you very much, Thank you, Thank you Beck, thanks for having me mine do We look forward to seeing you again at the NSS next year, twenty twenty five on the Gold Coast and on all your listeners too.