Modern treatment of lipedema today
Until the end of the last century, surgery was of limited success. Lipectomies or liposuction under general anesthesia without subcutaneous infiltration (“dry technique”) and with large sharp cannulas caused considerable tissue damage, often in combination with unacceptable cosmetic and functional results. In several patients, persisting or increasing edema with additional symptoms to those experienced before surgery were observed. Therefore, surgical management was harshly criticized from many sides.
A new understanding of lipedema and new developments in anesthesia and surgery have changed conditions and opinions. The introduction of tumescent local anesthesia (TLA) in the 1990s with the infiltration of large amounts of fluid has made liposuction a safe procedure; currently, the “wet technique” is used all over the world. Blunt vibrating microcanulas of 2-4 mm diameter (power-assisted liposuction, PAL) hardly cause any tissue damage.
In addition, new insights into the nature of lipedema have demonstrated that it is neither primarily nor mainly a lymphatic disease. Lymphoscintigraphies in the early stages of the disease have revealed not a reduction, but rather an increase of lymphatic flow. Lymphatic insufficiency attributable to secondary tissue changes seems to play a significant role only after decades of insufficient treatment in the latest stages of the disease, and lipolymphedema may develop. Investigations by anatomists have not demonstrated any significant damage to lymphatic vessels following liposuction.
Presently, a surgical approach is supported by dermatologists and lLiposuctionymphologists. Liposuction has become an important and integrated part of therapy in the new standards of care for lipedema not only by the German Phlebological Society. Liposuction has even been labeled “the treatment of choice” for lipedema. Follow-up periods of more than 8 years have shown neither negative side effects nor serious complications such as the damage of lymphatic vessels with increases or persistence of edema. Moreover, in all our patients, we have observed only minor hematomas and post-operative swelling for a few days; induration of the subcutaneous fat as a result of scar formation about 3 weeks postoperatively disappeared completely over time. All patients reported a much more pronounced improvement of symptoms following surgery with a remarkable increase in the quality of life compared with the amelioration following conservative treatment. It should be pointed out that surgery, like any other therapy, cannot cure lipedema completely; physiotherapy and compression are still necessary, although at longer intervals and to a much lower degree. So the combination of conservative and surgical therapy is the new standard in the treatment of lipedema.
Finally, we wish to point out that liposuction in lipedema is a safe and highly effective method. But: The procedure should only be performed with vibrating microcannulas and the modern technique of tumescent local anesthesia. Because often big amounts of TLA-solution are needed and extensive volumes of fat per body area are removed, a considerable degree of experience is required. Therefore patients should only be treated in specialized centres.
Wilfried Schmeller, MD
Ilka Meier-Vollrath, MD