Surgeries for lipedema

In the vast majority of patients with lipedema, conservative therapy with compression, exercise, weight management and, if necessary, psychosocial therapy will lead to a significant and satisfactory improvement of the symptoms. However, if you have not experienced any therapeutic success despite these measures, surgical treatment may be considered. There are two main surgical procedures for lipedema, which are completely different from each other:

1. Liposuction: Aimed at reducing discomfort and improving mobility by removing excess fatty tissue.
2. Bariatric surgery: Recommended for patients with severe obesity, focusing on long-term weight loss and overall health improvement.

Not every patient with lipedema will benefit from liposuction. Therefore, an international panel of lipedema experts has defined criteria in the International Lipoedema Consensus* that make the long-term therapeutic success of liposuction likely:

1. Persistent symptoms: Despite a conservative therapy lasting at least 12 months, symptoms persist.
2. Stable body weight: Body weight is largely stable for at least 12 months. This is important because weight gain after the operation would negate the effect of liposuction (or by yo-yo effects that are often experienced after diet attempts).
3. No pronounced abdominal obesity (in addition to lipedema): Body mass index (BMI) must not be greater than 35 kg/m², or the waist-to-height ratio (WtHR) indicates no abdominal obesity.
4. Psychological assessment: A psychological assessment is available that excludes eating disorders and mental illnesses that could endanger the success of liposuction.

The aim of liposuction is to reduce the discomfort in the soft tissue. Since the pain is caused by a mild (and completely harmless) inflammation in the fat tissue, local liposuction can help alleviate it. Additionally, liposuction can improve mobility by removing excess fatty tissue from the lower extremities.

Several techniques of liposuction are available, but three methods are most commonly used in treating lipedema:

Classic liposuction

At the beginning of the operation, a so-called tumescent solution, which consists of table salt, anesthetics, and adrenaline, is injected into the fat tissue. Adrenaline constricts blood vessels in the fat tissue to minimize blood loss during surgery. After approximately 15 minutes, the fat tissue is suctioned off using blunt metal cannulas connected to a liposuction device by a hose. These cannulas are inserted through small incisions in the skin and are moved back and forth vigorously by the surgeon to mechanically reduce and effectively suction off the fat tissue.

Vibration-supported liposuction

The key difference from standard liposuction is that the blunt cannulas vibrate slightly with the help of an electric handle. This vibration allows the surgeon to gently move the cannulas back and forth during the operation, making the method gentler. This technique enables surgeons to perform liposuction for extended periods, which is why it is primarily used in treating pronounced forms of lipedema. In some cases, these operations can last over three hours.

Water-jet assisted liposuction

In this surgical method, the tumescent solution is introduced using a fine jet of water. This process mechanically shreds the fat tissue, which is then immediately suctioned off with a blunt metal cannula. These cannulas do not vibrate and must be moved vigorously back and forth by the surgeon.

Although all three liposuction methods have their advantages and disadvantages, they are all suitable for the surgical treatment of lipedema. These techniques can deliver comparable results depending on the specifics of the case and the surgeon’s experience. It is crucial that the surgeon is well-versed in the method and has performed a large number of these operations.

All three surgical techniques can be performed under local anesthesia combined with twilight sleep or under general anesthesia. Surgery under twilight sleep is preferred wherever possible, as it is the least stressful for the body. However, at the explicit request of the patient, general anesthesia should also be offered.

After each liposuction, patients typically develop side effects that vary from patient to patient and generally resolve completely within 3-4 weeks.

• Bruises on the skin (superficial blood effusions)
• Swelling
• Pain in the treated areas

The pain sensation is different for each patient but is usually comparable to the pain after a severe bruise.

The risks and possible complications after liposuction include:

• Inflammation: May occur in the treated areas.
• Bleeding: Significant blood loss may result in some cases.
• Thrombosis and pulmonary embolism: The formation of blood clots that can travel to the lungs.
• Allergic reactions: Some patients may react to medications used during the procedure.
• Cosmetic impairments: Potential formation of dents and irregularities on the skin.

Before deciding on liposuction, carefully weigh the benefits against the risks and potential complications. When patients are selected appropriately and the procedure is performed by an experienced surgeon, the complications described above occur extremely rarely. However, it’s essential to remember that any surgery or medical treatment carries inherent risks that cannot be entirely eliminated.

Following liposuction for lipedema, you should consistently wear compression garments on the treated areas for about 6 weeks. You can usually shower after two days, but the compression garments should be removed during this time. Lymph drainage or special skin treatments, such as endermology, can accelerate the healing process, although these are not typically covered by health insurance.

Post-operation, you’ll be able to move, although there may be certain restrictions due to swelling and discomfort. It’s advisable to pause any sporting activities that involve the treated body regions until the symptoms have significantly improved. Generally, you should be able to return to a normal life after approximately 6 weeks.

The final visual result of liposuction can only be fully assessed after approximately 4-6 months. It is crucial to maintain a constant weight after the operation, as significant weight gain can deteriorate the surgical outcomes. Therefore, liposuction is not recommended for patients who are unable to maintain their weight. It is important to note that the improvement of lipedema symptoms through liposuction cannot be fully guaranteed. Current study data on the long-term effects of liposuction for lipedema are limited and insufficient. However, previous studies indicate that around 70% of patients continue to experience typical lipedema symptoms even after liposuction and need to continue wearing compression garments.

By Dr. Tobias Bertsch, MD, PhD (Foeldi Clinic Hinterzarten, European Centre for Lymphology)

Many patients with lipedema suffer from obesity – classified as a BMI of 30 kg/m² or more. Obesity is not a matter of personal fault or lack of discipline, but a disease recognized by the WHO. When severe obesity accompanies lipedema, liposuction is not an appropriate treatment and may even be considered malpractice. Instead, doctors should evaluate eligibility for bariatric surgery (i.e. obesity surgery).

Gastric sleeve or gastric bypass surgery is particularly recommended as they show the best results in studies. This option can be considered for individuals with a BMI of 35 kg/m² and is recommended for those with a BMI of 40 kg/m² or higher. Conservative weight loss strategies, including various diets, may have been tried multiple times and often resulted in a yo-yo effect. Patients should not pursue these strategies further. Many studies show that bariatric surgery is the most effective and long-term successful treatment for losing weight. Recent studies on women with both lipedema and severe obesity also show significant improvement in leg circumference and thus lipedema symptoms after bariatric surgery.

You can get reliable information on the various surgical techniques and additional facts about bariatric surgery on the UCLA bariatric surgery website.

* Bertsch, T., & Erbacher, G. (2020). Lipoedema: a paradigm shift and consensus. Journal of Wound Care Consensus Document, 29(Sup. 2, No. 11). MA Healthcare Ltd. https://theila.net/fileadmin/user_upload/ILA/JWC_Consensus_Lipoedema.pdf