Medical Policy

This document addresses a variety of surgical procedures of the trunk or groin that may be considered medically necessary, cosmetic or reconstructive in nature.

Note: Please see these documents for related topics:

• CG-SURG-12 Penile Prosthesis Implantation
• CG-SURG-71 Reduction Mammaplasty
• CG-SURG-88 Mastectomy for Gynecomastia
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures

Note: For information regarding excision of excess abdominal skin, please see CG-SURG-99 Panniculectomy and Abdominoplasty.

Medically Necessary: In this document, procedures are considered medically necessary if there is a significant functional impairment AND the procedure can be reasonably expected to improve the functional impairment.

Reconstructive: In this document, procedures are considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease, trauma, treatment of a disease or congenital defect.

Note: Not all benefit contracts/certificates include benefits for reconstructive services as defined by this document. Benefit language supersedes this document.

Cosmetic: In this document, procedures are considered cosmetic when intended to change a physical appearance that would be considered within normal human anatomic variation. Cosmetic services are often described as those which are primarily intended to preserve or improve appearance.

A.     Brachioplasty:

Brachioplasty is considered medically necessary when done in the presence of a significant functional impairment (for example, redundant or excessive skin is interfering with activities of daily living or causing persistent dermatitis, cellulitis, or skin ulcerations) and the impairment persists despite optimal medical management (for example, topical or systemic treatments for infection) and the procedure is reasonably expected to improve that significant functional impairment.

Brachioplasty is considered cosmetic and not medically necessary when done in the absence of a significant functional impairment or when not expected to improve a significant functional impairment.

B.     Buttock/Thigh Lift:

Buttock or thigh lifts are considered medically necessary when there is a significant functional impairment (for example, redundant or excessive skin is interfering with activities of daily living or causing persistent dermatitis, cellulitis, or skin ulcerations) and the impairment persists despite optimal medical management (for example, topical or systemic treatments for infection) and the procedure is reasonably expected to improve that significant functional impairment.

Buttock and thigh lifts are considered cosmetic and not medically necessary when done in the absence of a significant functional impairment or when not expected to improve a significant functional impairment.

C.     Congenital Abnormalities:

Correction of congenital abnormalities of the trunk and groin are considered medically necessary when there is evidence of a significant functional impairment and the procedure can be reasonably expected to improve the functional impairment.

Correction of congenital abnormalities of the trunk and groin that are a significant variation from normal are considered reconstructive in nature.

In the absence of a significant functional impairment or significant variation from normal, correction of congenital abnormalities is considered cosmetic and not medically necessary.

D.     Lipectomy/Liposuction:

Lipectomy or liposuction is considered medically necessary in individuals with documented lymphedema (primary or secondary, for example, related to surgical mastectomy) when all of the following criteria are met (1 through 5):

1. Signs and symptoms have not responded to at least 3 consecutive months of optimal medical management, including one or more of the following:
   1. Compression garments; or
   2. Manual lymph drainage; or
   3. Complex/complete decongestive therapy (CDT);
      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 from lymphedema accumulation (for example, difficulty ambulating, performing activities of daily living, or loss of function coincident with the volume change); or
   2. There are documented medical complication(s) as a result of lymphedema (for example, severe recurrent cellulitis or severe neurological symptoms [for example, numbness, tingling or paresthesia]), and both of the following criteria are met for the complication(s):
      1. Not amenable to conservative management; and
      2. Significant enough to warrant surgical intervention; 
         and
3. Lipectomy or liposuction is reasonably expected to improve the functional impairment (for example, volume reduction of extremity circumferences is expected to result in a significant improvement in mobility); and
4. The plan of care is to wear compression garments as instructed and 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.

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

1. A diagnosis of lipedema has been documented, including all of the following:
   1. Bilateral, symmetrical, disproportionate fatty tissue hypertrophy on the limbs sparing the hands and feet; and
   2. Negative Stemmer sign; and
   3. Marked tendency to bruise or form hematomas; and
   4. Stable limb circumference with weight reduction or caloric restriction (if applicable); and
   5. Pain on pressure and touch;
      and
2. Signs and symptoms have not responded to at least 3 consecutive months of optimal medical management, including both of the following:
   1. Compression garments; and
   2. Manual lymphatic drainage; 
      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 (for example, difficulty ambulating or performing activities of daily living); or
   2. There are documented medical complication(s) as a result of lipedema (for example, severe aching discomfort, pain or tenderness, severe maceration, severe recurrent skin infection, or severe venous insufficiency) and both of the following criteria are met for the complication(s):
      1. Not amenable to conservative management; and
      2. Significant enough to warrant surgical intervention;
         and
4. Lipectomy or liposuction is reasonably expected to improve the functional impairment or medical complications (for example, volume reduction of extremity circumferences is expected to result in a significant improvement in mobility); and
5. The plan of care is to wear compression garments as instructed and 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.

Correction of lymphedema (for example, related to surgical mastectomy) or lipedema using lipectomy or liposuction is considered reconstructive when done to address a significant variation from normal.

Lipectomy or liposuction is considered cosmetic and not medically necessary when the reconstructive criteria in this section are not met or when the medically necessary criteria in this section are not met for each anatomical region being considered for treatment, including for treatment of obesity in the absence of a documented diagnosis of lymphedema or lipedema.

Notes: Please refer to:

• CG-SURG-99 Panniculectomy and Abdominoplasty for information regarding lipectomy and liposuction of the abdomen.
• SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures for information regarding the Women’s Health and Cancer Rights Act of 1998.

E.     Pectus Excavatum/Carinatum:

Surgical repair of a significant pectus excavatum with either an open or a minimally invasive approach (Nuss procedure) is considered reconstructive for individuals with either of the following:

1. A Haller index (pectus severity index) of greater than or equal to 3.2; or
2. A Pectus Correction Index (PCI, also referred to as the Correction Index) of greater than or equal to 28%.

Surgical repair of a significant pectus carinatum is considered reconstructive for individuals with a Haller index (pectus severity index) of less than or equal to 2.0.

Surgical repair of pectus excavatum or carinatum is considered cosmetic and not medically necessary when the criteria above have not been met.

F.      Procedures on the Genitalia:

Procedures performed on genitalia when intended to address the sequelae of significant trauma, injury, disease, or congenital defect in the absence of a functional impairment, may be considered reconstructive in nature, including, but not limited to, surgical correction of ambiguous genitalia and buried penis

Procedures on the external genitalia intended to improve the appearance or enhance sexual performance are considered cosmetic and not medically necessary including, but not limited to, the following:

1. Labia minora reduction;
2. Labia major reshaping;
3. Clitoral reduction;
4. Hymenoplasty;
5. Pubic liposuction or lift;
6. Phalloplasty.

Vaginal rejuvenation or vaginal tightening procedures are considered not medically necessary under all circumstances.

Concepts of Medical Necessity, Reconstructive and Cosmetic

The coverage eligibility of medical and surgical therapies to treat musculoskeletal abnormalities is often based on a determination of whether repair of the abnormality is considered medically necessary, reconstructive or cosmetic in nature. In many instances, the concept of reconstructive overlaps with the concept of medical necessity. For example, services intended to correct a significant functional impairment as a result of trauma will be considered medically necessary and thus eligible for coverage, regardless of the contract language pertaining to reconstructive services, unless some other exclusion applies. Generally, reconstructive is often taken to mean that the service, “Returns the person to whole,” as a result of a congenital anomaly, disease or other condition including post trauma or post therapy. Cosmetic generally describes improving a physical appearance that would be considered within normal human anatomic variation. Categories of conditions without associated functional impairment that may be included as reconstructive definitions, include or may be due to the following: a) surgery, b) accidental trauma or injury, c) diseases, d) congenital anomalies, e) severe anatomic variants, and f) chemotherapy.

Brachioplasty, Buttock/Thigh lift

Brachioplasty and buttock or thigh lifts have been proposed as a treatment for individuals with conditions related to excess skin and subcutaneous fat associated with significant functional impairment. Conditions, such as persistent infection or maceration resistant to conservative therapy, may be indications for brachioplasty, buttock lift or thigh lift when the condition poses a risk to the health of the individual.

Congenital abnormalities of the trunk and groin

Correction of a congenital abnormality, for example, ambiguous genitalia, congenital chordae or corporal disproportion, hypospadias, penile torsion, or congenital buried or concealed penis, may be considered when the procedure is intended to address a significant variation from normal. Procedures are also considered reconstructive when intended to address a significant variation from normal related to accidental injury, disease (for example, Peyronie’s disease), trauma, or treatment of a disease.

Pectus Excavatum and Carinatum

Validation of the medical necessity of surgical repair of pectus excavatum requires objective documentation of an associated functional impairment that is improved following surgical correction. In many cases, the motivation for surgical correction may be the restoration of a normal appearance. However, some individuals have reported associated cardiorespiratory symptoms, such as mild to moderate exercise limitation, respiratory infections or asthmatic symptoms.

A number of studies have evaluated the clinical impact of surgical correction of pectus excavatum on cardiac, pulmonary and other systems (Kaguraoka, 1992; Haller, 2000; Morshuis, 1994a and 1994b; Shamberger, 2000). These studies indicate that there is discordance between participants’ subjective assessment of improvement and objective measures of cardiorespiratory function. Some have suggested that discordance is due to the fact that improvements in cardiorespiratory function can only be seen during periods of exercise, and thus are not detected during routine pulmonary function tests.

Lawson and colleagues (2011) reported on the association of severity of pectus excavatum and the impact on pulmonary function. The authors concluded that individuals with pectus excavatum demonstrated an:

Increased depth of chest depression is related to an increased likelihood of below-normal pulmonary function, primarily with a restrictive pattern. Future studies should examine other measures in combination with depth of depression to increase our understanding of the mechanisms and impact of this deformity in cardiopulmonary function in both the resting and exercising states.

Zens (2022) reported the results of a case series study involving 345 participants that characterized the relationship between the degree of pectus excavatum and cardiopulmonary dysfunction. Symptoms were reported in 75% of participants, including shortness of breath, exercise intolerance, chest pain, and heart palpitations. Univariate analysis of cardiac systolic function revealed significant associations between all pectus indices measured and abnormal cardiac indications including right ventricular ejection fraction (RVEF) and RVEF Z-scores, including the Haller index and the Pectus Correction Index (PCI) (p<0.05 for all). Univariate analysis of PFTs demonstrated associations (p<0.05) with the Haller index and PCI, but not FEV1/FVC. The authors concluded that, the severity of pectus excavatum is associated with ventricular systolic dysfunction and that pectus excavatum impacts right and left ventricular systolic function and can also impact exercise tolerance. They concluded that the Haller index and PCI may be the most useful predictors of impairment.

The severity of pectus excavatum may be assessed in several ways, but two methods have emerged as providing the most accuracy and utility (Sujka, 2018, Rodríguez-Granillo 2019). The Haller index is the most commonly used scale for the measurement of chest deformity in individuals with pectus excavatum. Many studies have used a cut-off point of 3.2 to determine the appropriateness of surgery, and this has become the accepted standard for most individuals undergoing pectus repair procedures (Croitoru, 2012; Lawson, 2011; Nuss, 1998; Nuss, 2002). While the Haller index remains standard of care, the PCI is also commonly used, as it remains accurate in individuals with abnormal chest wall morphologies (e.g., significant discrepancies of anterior-posterior to medial-lateral dimensions of the chest wall). Several studies have reported that a PCI result of 28% correlates with the long-accepted standard Haller index ≥ 3.25 as the threshold for operative repair for pectus excavatum, even in nonstandard chest morphologies (Poston, 2014; St Peter, 2011).

Other indices of the severity of pectus deformity have been proposed, including caliper-based external measurements (Chen, 2022), the Volumetric Correction Index (Trò, 2022), and the Titanic index (Bellía-Munzón, 2023). However, there is currently insufficient published evidence at this time to support their use in clinical care.

As with pectus excavatum, the measurement of pectus carinatum, also called pigeon chest, is commonly done using the Haller index. Although there is far less published data for this condition when compared to pectus excavatum, it has been widely accepted that a Haller index of 2.0 or less is a reasonable threshold for consideration of surgical correction of pectus carinatum (Fonkalsrud, 2006, 2004, 2002).

Regarding the surgical outcomes of a minimally invasive approach to correction, (that is, the Nuss procedure), initial results suggested a good to excellent outcome in the majority of individuals among those who have completed the treatment with subsequent removal of the steel bar (Nuss, 1998; Morshuis, 1994).

Lymphedema

Lymphedema is a debilitating progressive, incurable condition characterized by painful swelling of the extremities (arms and/or legs) but can affect any part of the body. The excessive swelling is the result of lymphatic stasis and accumulation in the subcutaneous tissue, due to a chronic imbalance between the production and drainage of lymph fluid. Primary lymphedema is a congenital condition; however, in the developed world, secondary lymphedema is the most common type of lymphedema and may be caused by infection, trauma or, most commonly, treatment of cancer. The resultant accumulation of lymph fluid in the tissues, usually of the extremities, produces painful disability and interferes with mobility and activities of daily living for affected individuals with varying degrees of severity. The onset of symptoms is subject to individual variation and can occur shortly after the insult, for example, following mastectomy, or can occur years later.

Physical examination has an important role in the diagnosis of lymphedema, including limb circumference and volume measurements. The calculation of limb volume can be estimated by taking serial circumferential measurements at standard distances along the affected limb, water displacement measurement, optoelectronic volumetry, or use of truncated cone formula calculation. These methods are recognized as reasonably accurate and are commonly available. According to a respected textbook on the subject of lymphedema, a volume increase of ≥10% in the affected limb vs. the unaffected limb is indicative of the presence of lymphedema (Tidhar, 2022). Furthermore, the International Society of Lymphology (2020) defines “mild” lymphedema as a volume difference between the affected and contralateral limbs as greater than 10 percent but less than 40 percent.

First line conservative treatments for lymphedema include limb elevation, skin care, compression garments, manual lymph drainage and complex decompressive therapy (CDT). When conservative therapy is ineffective surgical options can be considered. These include reductive/ablative techniques, like liposuction and excisional lipectomy, for more advanced lymphedema where fat deposition and tissue fibrosis has occurred, resulting in significant functional impairment or serious complications, such as cellulitis. For advanced cases in which all conservative options have been exhausted, liposuction has been shown to safely restore function, as long as conservative therapy, (such as compression garments, elevation, and exercise), is maintained postoperatively.

In a descriptive study, Lamprou and colleagues (2017) reported on circumferential suction-assisted lipectomy (CSAL) for end-stage lymphedema (primary or secondary) of the lower extremity. The researchers included subjects that did not respond to conventional therapy and had a volume difference of at least 1500 ml between the affected and non-affected extremity or a relative volume difference of more than 15% of the unaffected extremity volume. Exclusion criteria included bilateral lymphedema, active malignancy, or persistent open wounds. A total of 88 subjects (47 with primary lymphedema and 41 with secondary lymphedema) were included. Lower extremity volume was measured before surgery and at 1, 6, 12, and 24 months postop. In the primary lymphedema group, the median preoperative volume difference between the affected and unaffected lower extremity was 3686 ml. At 2 years, the difference was reduced to 761 ml (79% reduction). In the secondary lymphedema group, the median preoperative volume difference between the affected and unaffected lower extremity was 3320 ml. At 2 years, the difference was reduced to –38 ml (101% reduction). Cellulitis attacks in the primary and secondary group were significantly reduced (8/year to 0.2/year and 6/year to 0.3/year, respectively). There was a significant relationship between preoperative volume difference and the eventual outcome after 2 years in both groups (p<0.001). In addition, men with primary lymphedema had a significantly greater volume reduction than women (median 1629 versus 275 ml; p<0.001). The researchers concluded that CSAL was effective for treating end-stage, non-pitting lymphedema of the lower extremity. However, postoperative physical therapy, weight control, and lifestyle changes are needed to maintain the benefits.

In a consecutive cohort study, Hoffner and colleagues (2017) evaluated health-related quality of life (HRQoL) following liposuction (combined with postop conservative therapy) for individuals with post-mastectomy upper extremity lymphedema. Between 1999 and 2013, the researchers gave 90 consecutive individuals a 36-item short-form health survey (SF-36) to fill out before liposuction and at 1, 3, 6, and 12 months postop. A total of 30 individuals did not answer all surveys and were excluded from the final cohort. Inclusion criteria included a minimum 10% increase in volume of the affected extremity compared to the non-affected side, subjective discomfort, failure of conservative treatment to reduce excess volume completely, and no or minimal pitting edema (less than 5mm). Exclusion criteria included generalized disease, local ulcers, and unwillingness or doubts about undergoing continuous conservative therapy after surgery. Lymphedema volume was measured by water displacement, and aspirate volumes were collected in 2000 ml canisters and measured within a 10 ml accuracy. The total aspirated volume was 1361 ± 66 ml, with fat volume totaling 1373 ± 56 ml. The mean ± standard error of the mean (SEM) was reduced from 1365 ± 73mL preoperatively to –213 ± 35 ml at 1-year follow-up. No minor or major complications were reported. In 49 individuals (82%), excess volume was completely reduced. After 1 year, SF-36 scores were significantly improved for functional impairments, bodily pain, vitality, social functioning and mental health. The authors concluded that liposuction combined with conservative therapy improves HRQoL. The study was limited by a small sample size.

In 2018, Hoffner and colleagues published a prospective study on the 5-year results of liposuction for arm lymphedema following breast cancer treatment. A total of 127 women received liposuction and conservative therapy between 1993 and 2012. A total of 105 women with non-pitting edema remained in the study after 27 were lost to follow-up, 18 died, 1 had recurrence of breast cancer, 1 stopped postoperative conservative treatment, 1 moved abroad, and 1 had missing data. The researchers used standardized forms to collect pre-, peri-, and post-operative data. Inclusion criteria included the diagnosis of secondary arm lymphedema following breast cancer treatment, significant excess volume at least 10% larger than the unaffected arm, discomfort, failure of conservative treatment to reduce the excess volume completely, and no or minimal pitting edema (less than 5 mm). Exclusion criteria included active cancer, wounds, infections, and unwillingness to undergo post-operative conservative therapy. The post-operative mean reduction at 5 years was 117% ± 26% (range 25–191) as compared with the unaffected arm. There were no reported complications. The authors concluded that as long as post-operative conservative therapy is maintained, liposuction is effective for treating chronic, non-pitting arm lymphedema.

Lipedema

Lipedema is a painful, chronic, incurable disease that almost exclusively affects women after puberty and is characterized by abnormal bilateral enlargement of subcutaneous adipose tissue of the legs or arms but with normal hands and feet. The cause of lipedema is unknown, but evidence suggests it may be genetically inherited and triggered by hormonal changes, such as puberty, pregnancy, or menopause. The lymphatic system is not typically affected by lipedema; however, in severe cases, the lymphatic system can become overloaded and secondary lymphedema, (referred to as lipolymphedema or lympho-lipedema), can develop. In addition, advanced cases of lipedema can affect the venous system (venolipedema). The major symptoms are painful sensation in the involved limbs, impaired mobility and disfigurement with lipoma-like lumps under the skin. First line treatment is conservative, including complex decongestive therapy (CDT). CDT combines several approaches including manual lymph drainage (a massage technique), compression therapy, and physical mobilization. When symptoms persist and worsen, surgical options are considered. Although the condition is rare, there is some published evidence to support surgical treatment techniques, such as liposuction and excisional lipectomy. For individuals afflicted with lipedema, liposuction helps to reduce volume, inflammation and pain; restore or maintain mobility; slow disease progression; and has had a positive impact on the quality of life. However, there is no cure for lipedema, and ongoing postoperative conservative treatment is usually necessary to retain the benefits gained by liposuction.

According to the National Center for advancing translational sciences (NIH):

Classical guidelines for diagnosing lipedema include the following criteria: occurrence almost exclusively in women; bilateral and symmetrical presentation with minimal involvement of the feet; minimal pitting edema, pain, tenderness, and easy bruising, and persistent swelling of lower extremities despite elevation or weight loss. Updated guidelines propose a diagnosis of lipedema with the criteria as classically defined, in addition to symptoms of the upper leg(s) and arm(s), such as a circularly thickened layer of fat affecting the skin…Treatment for lipedema is focused on managing the symptoms. There is no one effective treatment for lipedema. Management to alleviate symptoms and prevent progression involves exercise, diet and nutrition, emotional support, and management of co-existing health problems that may cause leg-swelling. The main conservative treatment is CDT. Surgery may be considered if conservative and supportive therapies are not effective. Surgical options may include liposuction using specialized techniques for lipedema, (such as water jet-assisted liposuction) and excision (surgical removal of large deposits of affected tissue) (Bauer, 2019; Canning, 2018; Halk, 2017).

Staging of lipedema is based on physical presentation of the disease focusing on the upper and lower extremities and does not take into account functional impact of disease such as pain, mobility, or impact on quality of life. According to the Lipedema Foundation and detailed by Herbst (2021), the stages of lipedema are defined as below:

Stage 1: Smooth skin with an increase of enlarged subcutaneous fat tissue.
Stage 2: Uneven skin with indentations in the fat tissue and larger mounds of fat tissue (lipomas) able to be seen and felt.
Stage 3: Large extrusion of fat tissue causing deformations especially on the thighs and around the knees.
Stage 4: Development of lipolymphedema - a condition where both Lipedema and lymphedema are present in the body - with large overhangs of tissue on legs and/or arms.

In 2019, Wollina and colleagues published a case series on liposuction for the treatment of lipedema (n=111; stage 1=7, stage II=50, stage III=48). Participants were treated consecutively at a single center between 2007 and 2018. Most individuals were treated by micro-cannula liposuction in tumescent anesthesia, but some were treated with laser-assisted liposuction. Reduction of circumference was assessed using a tape measure. Pain was measured by a 10-point VAS, and mobility and reduction of bruising was evaluated using a 3-point scale. All participants had been treated with CDT for at least 6 months prior to surgery and had lipedema of the legs (27 individuals also had involvement of the arms). The mean follow-up was 2.0 ± 2.1 years. An improvement in the perception of mobility was achieved in all subjects; marked improvement or a complete reversal of impairment was reported in 86% of trial subjects. At follow-up, the median reduction of limb circumference was 6 cm. The median pain level before treatment was reduced from 7.8 to 2.2. Bruising after minor trauma improved somewhat in 20.9% of individuals and completely or almost completely in 29.1% of individuals. A total of 16.4% of individuals no longer needed CDT. For 18 individuals, a follow-up of 5-7 years was available and showed no relapse in lipedema. Common adverse events included temporary methemoglobinemia (100%), bruising (98%), and burning sensations (82%). Less common adverse events included mild arm-vein phlebitis (2 cases), noninfectious panniculitis (1 case), arm edema from toluidine blue extravasation (1 case), epileptic attack during methemoglobinemia (1 case), postsurgical anemia requiring a blood transfusion (1 case), pulmonary fat embolism 2 days after surgery (1 case), and acute pulmonary edema 24 hours after surgery (1 case). There were no fatalities, wound infections, or surgical interventions. In 4.5% of cases, liposuction was completed with other surgical procedures, such as thigh lifts, laser lipolysis, or debulking surgery. The authors concluded that an improvement of mobility could be achieved in all subjects and that liposuction is an effective treatment for painful lipedema. The authors also noted that centers performing liposuction should carefully monitor individuals for 24 hours and must be able to deal with possible complications.

Lymphedema vs. Lipedema

Lipedema is characterized by symmetric enlargement of the limbs, combined with tenderness and easy bruising. Unlike lymphedema, lipedema is not caused by a disorder of the lymphatic system. While lipedema always affects both legs symmetrically (bilateral appearance), primary lymphedema usually affects one leg only. If both legs are involved in primary lymphedema, the swelling appears asymmetric. The feet are not involved in lipedema; the symmetrical distribution of fat is located between the hips and the ankles. In contrast, the feet in lymphedema are involved in the swelling, and a diagnostic indicator known as the Stemmer sign* is positive. Lymphedema involves pitting edema, and the tissue feels firmer than what is present in lipedema. The cause for the onset of lymphedema is malformations of the lymphatic system, while the underlying cause of lipedema remains unknown and is thought to be associated with hormonal disorders.

There are several distinct differences between the presentation of lipedema and primary lymphedema which are part of the differential diagnosis process, and are provided in the table** below.

** adapted from Shavit, 2018.

* The Stemmer Test is done by trying to lift a skin fold on the back of the second toe or middle finger. If you are able to gently pinch and lift the skin fold, the Stemmer Sign is negative. If it is not possible to gently pinch and lift the fold, this may be an indication of protein accumulation in the tissue. In this case, the Stemmer Sign is positive and serves as an indication that lymphedema may be present.

The term “hematoma” has been used in place of “bruising” by some authors when discussing the diagnosis of lipedema (Kruppa, 2020). This sign is due to capillary damage related to primary microvascular dysfunction in the lymphatic and blood capillaries that has been hypothesized to underly the pathophysiological basis for the formation of edema and bruising in individuals with lipedema.

Female Genital Procedures

In 2020 the American College of Obstetricians and Gynecologists (ACOG) published a Committee Opinion, Elective Female Genital Cosmetic Surgery. This document addresses several important issues on this topic, including:

• Patients should be made aware that surgery or procedures to alter sexual appearance or function (excluding procedures performed for clinical indications, such as clinically diagnosed female sexual dysfunction, pain with intercourse, interference in athletic activities, previous obstetric or straddle injury, reversing female genital cutting, vaginal prolapse, incontinence, or gender affirmation surgery) are not medically indicated, pose substantial risk, and their safety and effectiveness have not been established.
• Women should be informed about the lack of high-quality data that support the effectiveness of genital cosmetic surgical procedures and counseled about their potential complications, including pain, bleeding, infection, scarring, adhesions, altered sensation, dyspareunia, and need for reoperation.

ACOG (2022) has also published a statement of policy on the use of female genital mutilation. That document sates the following:

Female genital mutilation (FGM), sometimes annotated as female genital cutting or female circumcision, is described by the World Health Organization (WHO) as comprising “all procedures that involve partial or total removal of the external female genitals, or other injury to the female genital organs for non-medical reasons (1,2).” Although these procedures are more commonly performed in Africa, the Middle East, and Asia, it is estimated that more than 513,000 girls and women in the U.S. have experienced or are at risk of FGM (3,4). People may arrive in the U.S. having already had the procedure performed, but there are reports of these procedures being performed in immigrant populations by traditional practitioners, or children being sent to the family’s home country to have the procedures performed.

Female genital mutilation is internationally recognized as a human rights violation and is considered an extreme form of discrimination against women (1,2). According to U.S. federal law (18 U.S. Code § 116), it is illegal to perform FGM in the U.S. on anyone under the age of 18 years; it is also illegal to knowingly transport a girl out of the U.S. for the purpose of having FGM performed. Many state laws also prohibit FGM on minors, and some states prohibit the practice on adult women. The American College of Obstetricians and Gynecologists condemns the practice of FGM and supports all efforts to eliminate the practice of FGM in the U.S. as well as internationally. This position is aligned with those of the World Health Organization, the American Medical Association, and the American Academy of Family Physicians (1,2,5,6).

In 2017ACOG published a Committee Opinion for Breast and Labial Surgery in Adolescents which has guidance on the topic. Specifically, the following:

• When adolescents seek medical treatment, the first step is often education and reassurance regarding normal variation in anatomy, growth, and development.
• Appropriate patient counseling and assessment of the adolescent’s physical maturity and emotional readiness are necessary before surgical management or referral.
• Individuals should be screened for body dysmorphic disorder. If an obstetrician- gynecologist suspects an adolescent has body dysmorphic disorder, referral to a mental health professional is appropriate.

Surgical correction (labiaplasty) in girls younger than 18 years should be considered only in those with significant congenital malformation, or persistent symptoms that the physician believes are caused directly by labial anatomy, or both. Physicians should be aware that surgical alteration of the labia that is not necessary to the health of the adolescent, who is younger than 18 years, is a violation of federal criminal law 10. At least half of the states also have laws criminalizing labiaplasty under certain circumstances, and some of these laws apply to minors and adults. Obstetrician–gynecologists should be aware of federal and state laws that affect this and similar procedures.

Several laser devices have been marketed to tighten lax vaginal anatomy. The safety and efficacy of these laser systems has not been demonstrated in clinical trials with peer-reviewed published evidence for the indication of vaginal atrophy. The U.S. Food and Drug Administration (FDA) has issued a warning about use of these energy-based devices as follows:

To alert patients and health care providers that the use of energy-based devices to perform vaginal “rejuvenation,” cosmetic vaginal procedures, or non-surgical vaginal procedures to treat symptoms related to menopause, urinary incontinence, or sexual function may be associated with serious adverse events. The safety and effectiveness of energy-based devices for treatment of these conditions has not been established…The FDA has not cleared or approved any energy-based medical device for vaginal “rejuvenation” or vaginal cosmetic procedures, or for the treatment of vaginal symptoms related to menopause, urinary incontinence, or sexual function (FDA, 2018).

Brachioplasty is a surgical procedure used to remove excess fat and skin from the back of the upper arm. This procedure is done primarily to improve an individual’s appearance. However, when associated with significant functional impairment, this procedure may be necessary to protect the individual’s health.

Buttock and thigh lifts are surgical procedures used to remove excess fat and skin from the buttocks and thighs. These procedures are primarily intended to enhance the appearance and have no known medical benefits, although these procedures may be necessary when the excessive tissue presents a significant functional impairment despite optimal medical management.

Congenital abnormalities in children include a wide variety of physical abnormalities present at birth. In many cases, the abnormality is not associated with any functional impairment. However, its correction can be considered reconstructive in nature. In most severe cases, immediate surgical care is needed to save a child’s life.

Cosmetic surgery is defined as any surgical procedure conducted solely to enhance an individual’s appearance. Such surgical procedures have no impact on an individual’s physical health.

Liposuction, (also known as lipoplasty, suction-assisted lipectomy, circumferential suction-assisted lipectomy [CSAL], liposuction in lymphedema and lympho-liposuction), is a surgical procedure performed to recontour the individual’s body by removing excess fat deposits that have been resistant to reduction by diet or exercise. There are multiple techniques for performing liposuction, including gentler methods like tumescent, power-assisted, ultrasound-assisted, laser-assisted, and water-jetted liposuction. These procedures have been used successfully on many body locations, including the buttocks, thighs, chin and lower abdomen, while they do remove large quantities of fat, they are not intended as a weight reduction technique. Liposuction is also used to treat advanced symptomatic lymphedema when there is a significant variation from normal, such as of the breast related to surgical mastectomy.

Excisional lipectomy, (also referred to as longitudinal debulking excisional surgery), is another surgical technique that involves the invasive surgical removal of excess subcutaneous adipose tissue that accumulates as a result of lipedema or lymphedema. Excisional lipectomy has been used to treat advanced cases with large localized deposits of lipedematous tissue, serious mechanical difficulties, valgus deformity of the knees, or the inability to walk (Halk, 2017).

Pectus excavatum, also known as funnel chest, is the most common chest wall deformity; this abnormality is present at birth, consisting of a depression in the center of the chest over the sternum. It is caused by excessive growth of the cartilage (connective tissue) joining the ribs to the breastbone, with the result being an inward deformity of the sternum. Although it has been proposed that pectus excavatum can be associated with various cardiopulmonary dysfunctions, this relationship has not been confirmed in the published literature. Until recently surgical correction of pectus excavatum involved the resection of the involved costal cartilages and osteotomy of the sternum with placement of a metal bar behind the sternum. The metal bar may be removed in 1 to 2 years. In the past several years, a minimally invasive approach has been developed that involves the placement of a convex steel bar beneath the sternum through small bilateral thoracic incisions. The bar may be removed after 2 years when remolding of the cartilage is complete. This procedure, which may be referred to as the Nuss procedure or MIRPE (minimally invasive repair of pectus excavatum) does not require cartilage resection or sternal osteotomy. The degree of deformity in individuals with this condition is commonly measured using the Haller index or the PCI. Both indices are calculated using chest dimension measurements obtained with computed tomography (CT scan) or magnetic resonance imaging (MRI). A Haller Index of at least 3.2 is generally recognized to indicate a pectus excavatum of sufficient severity to consider surgical repair. Similarly, a PCI of greater than or equal to 28% indicates a pectus excavatum of sufficient severity to consider surgical repair.

Pectus carinatum is the second most common congenital chest wall deformity, a condition where the breastbone protrudes out from the chest, often described as giving the person a bird-like appearance. Pectus carinatum may occur as a solitary abnormality or in association with other genetic disorders or syndromes. Although it has been proposed that pectus carinatum can be associated with various cardiopulmonary dysfunctions, this relationship has not been confirmed in the published literature. As with PE, the degree of deformity is measured using the Haller index. A Haller Index of 2.0 or less is generally recognized to indicate a pectus carinatum of sufficient severity to consider surgical repair.

A wide variety of procedures have been proposed to alter the appearance, size, or function of the external and internal vaginal anatomy. Surgical procedures to alter the size or shape of the labia or clitoris, restore the hymen, and other such measures do not provide any physical health benefits.

The labia minora is part of the external structure of the vagina. In some individuals, the labia minora may be enlarged or asymmetrical leading to mild discomfort with wearing certain clothing or during some activities. Reconstructive surgical procedures have been proposed to reduce enlarged labia minora. These procedures have not been well studied in the medical literature, and the possible risks they present have not been adequately assessed in relation to the potential benefits. In addition, fractional carbon dioxide (CO₂) lasers are new non-surgical treatments purported to relieve vulvovaginal atrophy. This laser therapy is proposed as a means of delivering thermal energy to the vaginal walls resulting in thickening and tightening to improve vaginal atrophy. One such device is the MonaLisa Touch^® (Cynasure, Hologic, Inc. Marlborough, MA), which is a CO₂ laser system which is performed in several sessions in the provider’s office and promoted as a treatment for the symptoms of vaginal atrophy

Phalloplasty is a surgical procedure to reconstruct or enlarge the penis. Reconstruction may be required in cases of traumatic injury or loss due to disease, in the absence of a functional impairment. Enlargement may be desired in cases of abnormally small penis size.

Perineoplasty is a procedure intended to correct injury, defect or trauma of the of perineum or vulva; it is commonly used as a part of vaginal tightening procedures (Triana, 2022). Perineoplasty may also be a component of procedures addressing cystocele, and retrocele, or prolapse of the vagina or colon, with use intended to address a significant variation from normal.

Cellulitis: An infection that spreads to deep tissues of the skin and muscle and may cause warmth, tenderness, fever, chills, swollen lymph nodes, and blisters.

Complex decongestive therapy: A multimodality program that consists of manual lymphedema drainage therapy, low-stretch bandaging, exercises, and skin care. This approach has been recommended as a primary treatment by consensus panels and as an effective therapy for lymphedema when it is unresponsive to standard elastic compression therapy.

Excisional lipectomy: A surgical technique that involves the invasive surgical removal of excess subcutaneous adipose tissue that accumulates as a result of lipedema or lymphedema.

Functional impairment: Significant functional impairment may include physical, social, emotional, and psychological impairments or potential impairments. Examples of limits on normal physical functioning include problems with: ambulation, mobilization, communication, respiration, eating, swallowing, vision, facial expression, skin integrity, distortion of nearby body parts, or obstruction of an orifice. The cause of a functional impairment can be due to pain, structural integrity, congenital anomalies or other factors.

Haller index (pectus severity index or PSI): One measure of the severity of a pectus deformity that compares the ratio of the transverse diameter of the chest between the internal rib margins divided by the minimal antero-posterior depth as measured from the internal aspect of the sternum to the anterior cortex of the subjacent vertebral body, at the point of maximal depression. In individuals with pectus excavatum a Haller Index of at least 3.2 is generally recognized to indicate a pectus excavatum of sufficient severity to consider surgical repair. In individuals with pectus carinatum, a Haller Index of 2.0 or less is generally recognized to indicate a pectus carinatum of sufficient severity to consider surgical repair.

Lipedema: A chronic disease affecting almost exclusively women after puberty, characterized by painful abnormal enlargement of subcutaneous adipose tissue of the arms and legs.

Lymphatic fluid: A clear fluid that contains white blood cells (lymphocytes) and plasma.

Lymph nodes: Small, bean-shaped structures, found in the axilla, pelvis, neck, abdomen, and groin, that filter lymphatic fluid and store white blood cells.

Lymphatic system: A network of lymph vessels, tissues, and organs that carry lymphatic fluid throughout the body and return it to the bloodstream.

Lymphedema: Abnormal accumulation of interstitial fluid and fibro-adipose tissues resulting from injury, infection, or congenital abnormalities of the lymphatic system.

Lymphoscintigraphy test: A test to evaluate the presence of lymphedema involving the use of small amounts of radioactive material called a radiotracer. The radiotracer is introduced into the skin where it travels through the area being examined. Radioactive energy from the radiotracer is detected by a special camera to create images which are used to identify the presence or absence of lymphatic disease.

Liposuction also known as lipoplasty or suction-assisted lipectomy: A surgical technique performed to recontour the individual’s body by removing excess fat deposits that have been resistant to reduction by diet or exercise.

Pectus correction index (PCI): One measure of the severity of a pectus deformity. It is calculated by measuring, on the same slice of CT image, the minimal antero-posterior depth as measured from the internal aspect of the sternum to the anterior cortex of the subjacent vertebral body (A), and the maximum distance between inner margin of the most anterior portion of the ribcage and the anterior vertebrae (B), and then using this equation: PCI=100×(B–A)/B. A PCI of ≥ 28 percent is correlated with Haller index of ≥ 3.25, and is recognized as a threshold for surgical correction for pectus excavatum.

Stemmer sign: A physical examination used to diagnose lymphedema involving the examiner pinching the skin of the dorsum of the foot or hand. The inability to pinch the skin of the dorsum of the foot or hand is a positive finding of the presence of lymphedema.

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member’s contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

Procedures for excessive skin and subcutaneous tissue, lipectomy and liposuction (includes brachioplasty, buttock/thigh lifts)

Note: see SURG.00023 Breast Procedures; including Reconstructive Surgery, Implants and Other Breast Procedures for information regarding the Women’s Health and Cancer Rights Act of 1998.

When services may be Medically Necessary when criteria are met:

When services may be Reconstructive when criteria are met:
Note: for criteria for breast reconstructive procedures, see SURG.00023.

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above when medical necessity or reconstructive criteria are not met.

When services are also Cosmetic and Not Medically Necessary:
For the following procedure codes:

Repair of Pectus Excavatum or Pectus Carinatum
When services may be Reconstructive when criteria are met:

When services are Cosmetic and Not Medically Necessary:
For the procedure codes listed above, when reconstructive criteria are not met.

Procedures on genitalia
When services may be Reconstructive or Cosmetic and Not Medically Necessary based on criteria:

When services are Not Medically Necessary

Peer Reviewed Publications:

1. Basta MN, Gao LL, Wu LC. Operative treatment of peripheral lymphedema: a systematic meta-analysis of the efficacy and safety of lymphovenous microsurgery and tissue transplantation. Plast Reconstr Surg. 2014; 133(4):905-913.
2. Bauer AT, von Lukowicz D, Lossagk K, et al. New insights on lipedema: The enigmatic disease of the peripheral fat. Plast Reconstr Surg. 2019; 144(6):1475-1484.
3. Baumgartner A, Hueppe M, Schmeller W. Long-term benefit of liposuction in patients with lipedema: a follow-up study after an average of 4 and 8 years. Br J Dermatol. 2016; 174(5):1061-1067.
4. Bellía-Munzón G, Sanjurjo D, Toselli L, et al. Novel index to estimate the cephalocaudal extent of the excavation in pectus excavatum: The Titanic index. J Pediatr Surg. 2023; 58(4):605-607.
5. Boyages J, Kastanias K, Koelmeyer LA, et al. Liposuction for advanced lymphedema: a multidisciplinary approach for complete reduction of arm and leg swelling. Ann Surg Oncol. 2015; 22 Suppl 3:S1263-1270.
6. Canning C, Bartholomew JR. Lipedema. Vasc Med. 2018; 23(1):88-90.
7. Carl HM, Walia G, Bello R, et al. Systematic review of the surgical treatment of extremity lymphedema. J Reconstr Microsurg. 2017; 33(6):412-425.
8. Chen T, Chen C, Zeng Q, et al. Use of caliper-based external measurement of body surface in assessing the severity of pectus excavatum. Front Pediatr. 2022; 10:1015026.
9. Ciudad P, Manrique OJ, Bustos SS, et al. Comparisons in long-term clinical outcomes among patients with upper or lower extremity lymphedema treated with diverse vascularized lymph node transfer. Microsurgery. 2020; 40(2):130-136.
10. Coln E, Carrasco J, Coln D. Demonstrating relief of cardiac compression with the Nuss minimally invasive repair for pectus excavatum. J Pediatr Surg. 2006; 41(4):683-686.
11. Cornelissen AJM, Beugels J, Ewalds L, et al. Effect of lymphaticovenous anastomosis in breast cancer-related lymphedema: a review of the literature. Lymphat Res Biol. 2018 Oct; 16(5):426-434.
12. Croitoru DP, Kelly RE Jr, Goretsky MJ, et al. Experience and modification update for the minimally invasive Nuss technique for pectus excavatum repair in 303 patients. J Pediatr Surg. 2002; 37(3):437-445.
13. Dadras M, Mallinger PJ, Corterier CC, et al. Liposuction in the treatment of lipedema: a longitudinal study. Arch Plast Surg. 2017; 44(4):324-331.
14. Damstra RJ, Voesten HG, Klinkert P, Brorson H. Circumferential suction-assisted lipectomy for lymphedema after surgery for breast cancer. Br J Surg. 2009; 96(8):859-864.
15. Daunt SW, Cohen JH, Miller SF. Age-related normal ranges for the Haller index in children. Pediatr Radiol. 2004; 34(4):326-330.
16. Del Frari B, Blank C, Sigl S, et al. The questionable benefit of pectus excavatum repair on cardiopulmonary function: a prospective study. Eur J Cardiothorac Surg. 2021; 61(1):75-82.
17. Del Frari B, Sigl S, Schwabegger AH, et al. Impact of surgical treatment of pectus carinatum on cardiopulmonary function: a prospective study. Eur J Cardiothorac Surg. 2021; 59(2):382-388.
18. De Oliveira Carvaldo PE, de Silva MVM, Rodrigues OR, Cataneo AJM. Surgical interventions for treatment pectus excavatum. Cochrane Database of Sys Rev. 2014; (10):CD008889.
19. DiSipio T, Rye S, Newman B, et al. Incidence of unilateral arm lymphedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol. 2013; 14(6):500-515.
20. Eroglu E, Gundogdu G. Isolated penile torsion in newborns. Can Urol Assoc J. 2015; 9(11-12):E805-E807.
21. Fallahian F, Tadisina KK, Xu KY. Efficacy of Microsurgical Treatment of Primary Lymphedema: A Systematic Review. Ann Plast Surg. 2022; 88(2):195-199.
22. Fonkalsrud EW, Anselmo DM. Less extensive techniques for repair of pectus carinatum: the undertreated chest deformity. J Am Coll Surg. 2004; 198(6):898-905.
23. Fonkalsrud EW, DeUgarte D, Choi E. Repair of pectus excavatum and carinatum deformities in 116 adults. Ann Surg. 2002; 236(3):304-12; discussion 312-314.
24. Fonkalsrud EW, Mendoza J. Open repair of pectus excavatum and carinatum deformities with minimal cartilage resection. Am J Surg. 2006; 191(6):779-784.
25. Forte AJ, Khan N, Huayllani MT, et al. Lymphaticovenous anastomosis for lower extremity lymphedema: a systematic review. Indian J Plast Surg. 2020; 53(1):17-24.
26. Frantz FW. Indications and guidelines for pectus excavatum repair. Curr Opin Pediatr. 2011; 23:486-491.
27. Ghods M, Georgiou I, Schmidt J, Kruppa P. Disease progression and comorbidities in lipedema patients: A 10-year retrospective analysis. Dermatol Ther. 2020; 33(6):e14534.
28. Granzow JW, Soderberg JM, Kaji AH, Dauphine C. An effective system of surgical treatment of lymphedema. Ann Surg Oncol. 2014; 21(4):1189-1194.
29. Greene AK, Goss JA. Diagnosis and staging of lymphedema. Semin Plast Surg. 2018; 32(1):12-16.
30. Guiotto M, Bramhall RJ, Campisi C, et al. A systematic review of outcomes after genital lymphedema surgery: microsurgical reconstruction versus excisional procedures. Ann Plast Surg. 2019; 83(6):e85-e91.
31. Haller JA, Loughlin GM. Cardiorespiratory function is significantly improved following corrective surgery for severe pectus excavatum. Proposed treatment guidelines. J Cardiovasc Surg. 2000; 41:125-130.
32. Hebra A, Swoveland B, Egbert M, et al. Outcome analysis of minimally invasive repair of pectus excavatum. Review of 251 cases. J Pediatr Surg. 2000; 35:252-257.
33. Hoffner M, Bagheri S, Hansson E, et al. SF-36 shows increased quality of life following complete reduction of postmastectomy lymphedema with liposuction. Lymphat Res Biol. 2017; 15(1):87-98.
34. Hoffner M, Ohlin K, Svensson B, et al. Liposuction gives complete reduction of arm lymphedema following breast cancer treatment-a 5-year prospective study in 105 patients without recurrence. Plast Reconstr Surg Glob Open. 2018; 6(8):e1912.
35. Johnson WR, Fedor D, Singhal S. Systematic review of surgical treatment techniques for adult and pediatric patients with pectus excavatum. J Cardiothorac Surg. 2014; 9:25.
36. Kaguraoka H, Ohnuki T, Itaoka T, et al. Degree of severity of pectus excavatum and pulmonary function in preoperative and postoperative periods. J Thoracic Cardiovasc Surg. 1992; 104:483-488.
37. Kowalewski J, Brocki M, Dryjanski T, et al. Pectus excavatum: increase of right ventricular systolic, diastolic, and stroke volumes after surgical repair. J Thorac Cardiovasc Surg. 1999; 118(1):87-92.
38. Kruppa P, Georgiou I, Biermann N, et al. Lipedema-pathogenesis, diagnosis, and treatment options. Dtsch Arztebl Int. 2020; 117(22-23):396-403.
39. Lamprou DA, Voesten HG, Damstra RJ, Wikkeling OR. Circumferential suction-assisted lipectomy in the treatment of primary and secondary end-stage lymphedema of the leg. Br J Surg. 2017; 104(1):84-89.
40. Lawson ML, Barnes-Eley M, Burke BL, et al. Reliability of a standardized protocol to calculate cross-sectional chest area and severity indices to evaluate pectus excavatum. J Pediatr Surg. 2006; 41(7):1219-1225.
41. Lawson ML, Mellins RB, Paulson JF, et al. Increasing severity of pectus excavatum is associated with reduced pulmonary function. J Pediatr. 2011; 159:256-261.
42. Lawson ML, Mellins RB, Tabangin M, et al. Impact of pectus excavatum on pulmonary function before and after repair with the Nuss procedure. J Pediatr Surg. 2005; 40(1):174-180.
43. Lee M, Perry L, Granzow J. Suction assisted protein lipectomy (SAPL) even for the treatment of chronic fibrotic and scarified lower extremity lymphedema. Lymphology. 2016; 49(1):36-41.
44. Malek MH, Berger DE, Housh TJ, et al. Cardiovascular function following surgical repair of pectus excavatum: a meta-analysis. Chest. 2006; 130(2):506-516.
45. Marchica P, Bassetto F, Pavan C, et al. Retrospective analysis of the predictive factors associated with good surgical outcome in brachioplasty in massive weight loss patients. J Plast Surg Hand Surg. 2022; 56(6):326-334.
46. Micha JP, Nguyen DH, Goldstein BH. Successful management of persistent lower extremity lymphedema with suction-assisted lipectomy. Gynecol Oncol Rep. 2017; 23:13-15.
47. Morshuis WJ, et al. Exercise cardiorespiratory function before and one year after operation for pectus excavatum. J Thorac Cardiovasc Surg. 1994a; 107(6):1403-1409.
48. Morshuis W, Folgering H, Barentsz J, et al. Pulmonary function before surgery for pectus excavatum and at long-term follow up. Chest 1994b; 105:1646-1652.
49. Nuss D, Croitoru DP, Kelly RE Jr, et al. Review and discussion of the complications of minimally invasive pectus excavatum repair. Eur J Pediatr Surg. 2002; 12(4):230-234.
50. Nuss D, Kelly RE, Croitoru DP, Katz ME. A 10-year review of a minimally invasive technique for the correction of pectus excavatum. J Pediatr Surg. 1998; 33:545-552.
51. Obermeyer RJ, Goretsky MJ. Chest wall deformities in pediatric surgery. Surg Clin N Am. 2012; 92:669-684.
52. Peled AW, Kappos EA. Lipedema: diagnostic and management challenges. Int J Womens Health. 2016; 8:389-395
53. Peled AW, Slavin SA, Brorson H. Long-term outcome after surgical treatment of lipedema. Ann Plast Surg. 2012; 68(3):303-307.
54. Peterson RJ, Young WG, Godwin JD, et al. Noninvasive assessment of exercise cardiac function before and after pectus excavatum repair. J Thorac Cardiovasc Surg. 1985; 90:251-260.
55. Poston PM, Patel SS, Rajput M, et al. The correction index: setting the standard for recommending operative repair of pectus excavatum. Ann Thorac Surg. 2014; 97(4):1176-1179.
56. Rapprich S, Dingler A, Podda M. Liposuction is an effective treatment for lipedema-results of a study with 25 patients. J Dtsch Dermatol Ges. 2011; 9(1):33-40.
57. Rodríguez-Granillo GA, Martínez-Ferro M, Capuñay C, et al. Preoperative multimodality imaging of pectus excavatum: State of the art review and call for standardization. Eur J Radiol. 2019; 117:140-148.
58. Rosian K, Stanak M. Efficacy and safety assessment of lymphovenous anastomosis in patients with primary and secondary lymphedema: A systematic review of prospective evidence. Microsurgery. 2019; 39(8):763-772.
59. Salgarello M, Mangialardi ML, Pino V, et al. A prospective evaluation of health-related quality of life following lymphaticovenular anastomosis for upper and lower extremities lymphedema. J Reconstr Microsurg. 2018; 34(9):701-707.
60. Schalamon J, Pokall S, Windhaber J, Hoellwarth ME. Minimally invasive correction of pectus excavatum in adult patients. J Thorac Cardiovasc Surg. 2006; 132(3):524-529.
61. Schmeller W, Hueppe M, Meier-Vollrath I. Tumescent liposuction in lipedema yields good long-term results. Br J Dermatol. 2012; 166(1):161-168.
62. Schmeller W, Meier-Vollrath I. Tumescent liposuction: a new and successful therapy for lipedema. J Cutan Med Surg. 2006; 10(1):7-10.
63. Shamberger RC. Cardiopulmonary effects of anterior chest wall deformities. Chest Surg Clin N Am. 2000; 10(2):245-252.
64. Shavit E, Wollina U, Alavi A. Lipoedema is not lymphoedema: a review of current literature. Int Wound J. 2018; 15(6):921-928.
65. Sigalet DL, Montgomery M, Harder J. Cardiopulmonary effects of closed repair of pectus excavatum. J Pediatr Surg. 2003; 38(3):380-385.
66. Sigalet DL, Montgomery M, Harder J, et al. Long term cardiopulmonary effects of closed repair of pectus excavatum. Pediatr Surg Int. 2007; 23(5):493-497.
67. Sigl S, Del Frari B, Harasser C, Schwabegger AH. The effect on cardiopulmonary function after thoracoplasty in pectus carinatum: a systematic literature review. Interact Cardiovasc Thorac Surg. 2018; 26(3):474-479.
68. St Peter SD, Juang D, Garey CL, et al. A novel measure for pectus excavatum: the correction index. J Pediatr Surg. 2011; 46(12):2270-2273.
69. Sudduth CL, Maclellan RA, Greene AK. Study of 700 Referrals to a Lymphedema Program. Lymphat Res Biol. 2020; 18(6):534-538
70. Sujka JA, St Peter SD. Quantification of pectus excavatum: Anatomic indices. Semin Pediatr Surg. 2018; 27(3):122-126.
71. Tanner H, Bischof D, Roten L, et al. Electrocardiographic characteristics of patients with funnel chest before and after surgical correction using pectus bar: A new association with precordial J wave pattern. J Electrocardiol. 2016; 49(2):174-181.
72. Triana L, Liscano E. Vaginal Tightening. Clin Plast Surg. 2022; 49(4):473-478.
73. Trò R, Martini S, Stagnaro N, et al. A new tool for assessing Pectus Excavatum by a semi-automatic image processing pipeline calculating the classical severity indexes and a new marker: the Volumetric Correction Index. BMC Med Imaging. 2022; 22(1):30.
74. Witte T, Dadras M, Heck FC, et al. Water-jet-assisted liposuction for the treatment of lipedema: Standardized treatment protocol and results of 63 patients. J Plast Reconstr Aesthet Surg. 2020; 73(9):1637-1644.
75. Wollina U, Heinig B. Treatment of lipedema by low-volume micro-cannula liposuction in tumescent anesthesia: results in 111 patients. Dermatol Ther. 2019; 32(2):e12820.
76. Wynn SR, Riscoll DJ, Ostrum NK, et al. Exercise cardiorespiratory function in adolescents with pectus excavatum. Observations before and after operation. J Thorac Cardiovasc Surg. 1990; 9:41-47.
77. Zens TJ, Casar Berazaluce AM, et al. The Severity of pectus excavatum defect is associated with impaired cardiopulmonary function. Ann Thorac Surg. 2022; 114(3):1015-1021.

Government Agency, Medical Society, and Other Authoritative Publications:

1. The American College of Obstetricians and Gynecologists (ACOG). Committee Opinion No. 686. January 2017. Reaffirmed 2020. Breast and Labial Surgery in Adolescents. Available at: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2017/01/breast-and-labial-surgery-in-adolescents. Accessed on April 29, 2024.
2. The American College of Obstetricians and Gynecologists (ACOG). Committee Opinion No. 795. January 2020. Reaffirmed 2023. Elective Female Genital Cosmetic Surgery. Available at https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2020/01/elective-female-genital-cosmetic-surgery. Accessed on April 29, 2024.
3. The American College of Obstetricians and Gynecologists (ACOG). Female Genital Mutilation. Statement of Policy. Approved 2019, Amended and Reaffirmed July 2022. Available at: https://www.acog.org/clinical-information/policy-and-position-statements/statements-of-policy/2022/female-genital-mutilation. Accessed on April 29, 2024.
4. 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. 2021; 147(4):975-993.
5. Tidhar D, Armer JM, Anbari AB, et al. Clinical evaluation of lymphedema. In: Cheng MH, Chang DW, Patel KM, editors. Principles and practice of lymphedema surgery, 2 ed. St. Louis, MO: Elsevier, Inc.; 2022. Ch 9, 68-77 p.
6. Herbst KL, Kahn LA, Iker E, et al. Standard of care for lipedema in the United States. Phlebology. 2021; 36(10):779-796.
7. Halk AB, Damstra RJ. First Dutch guidelines on lipedema using the international classification of functioning, disability and health. Phlebology. 2017; 32(3):152-159.
8. International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2020 consensus document of the International Society of Lymphology. Lymphology. 2020; 53(1):3-19.
9. Lipedema Foundation. Staging of Lipedema. Available at: https://www.lipedema.org/staging. Accessed on April 29, 2024.
10. Nagrath N, Winters R. National Library of Medicine. StatPearls: Brachioplasty. July 25, 2023. Available at: https://www.ncbi.nlm.nih.gov/books/NBK585115/#:~:text=Brachioplasty%20is%20an%20operation%20performed,onto%20the%20lateral%20chest%20wall. Accessed on May 15, 2024.
11. National Cancer Institute. Lymphedema (PDQ^®) – health professional version. September 13, 2023. Available at: https://www.cancer.gov/about-cancer/treatment/side-effects/lymphedema/lymphedema-hp-pdq. Accessed on April 29, 2024.
12. National Lymphedema Network (NLN). National Lymphedema position papers. Available at: https://lymphnet.org/position-papers/. Accessed on April 29, 2024.
13. Reich-Schupke S, Schmeller W, Brauer WJ, et al. S1 guidelines: lipedema. J Dtsch Dermatol Ges. 2017; 15(7):758-767.
14. U.S. Food and Drug Administration (FDA) warns against use of energy-based devices to perform vaginal “Rejuvenation” or Vaginal Cosmetic: FDA Safety Communication Procedures. August 18, 2018. Available at: https://www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-efforts-safeguard-womens-health-deceptive-health-claims#:~:text=The%20procedures%20use%20lasers%20and,concerned%20women%20are%20being%20harmed.. Accessed on April 29, 2024.

1. American Cancer Society. Lymphedema. Available at: https://www.cancer.org/treatment/treatments-and-side-effects/physical-side-effects/lymphedema.html. Accessed on April 29, 2024.

Brachioplasty
Buttock
Circumferential Suction-assisted Lipectomy (CSAL)
Congenital Abnormalities
Labia Minora
Lipectomy
Lipedema
Lipoplasty
Liposuction in Lymphedema
Lymphedema
Lympho-Liposuction
MonaLisa Touch Laser
Pectus Carinatum
Pectus Excavatum
Phalloplasty
Suction-assisted Lipectomy
Thigh

The use of specific product names is illustrative only. It is not intended to be a recommendation of one product over another, and is not intended to represent a complete listing of all products available.