Lipoedema: clinical aspects and treatment

Thomas WITTE MD

Falk-Christian HECK MD

Abstract

Lipedema is a high-impact demographic disease whose characteristics have often been highlighted.

Liposuction is – independent of the health insurance company’s judgement – the only method that can reduce pathological fatty tissue, providing patients with great and lasting benefits.

Keywords: lipedema, liposuction, quality of life, LTA (local tumescent anaesthesia), WAL (Waterjet Assisted Liposuction).

Introduction

Lipedema was first named in 1940 in the medical literature by Allen and Hines [1].

The disease is now fully recognized and listed in the WHO International Classification of Diseases (ICD) with its own code (E88.xx) [20].

Today, the register in medical databases is long when searching for lipedema.

The “Deutsche Gesellschaft für Phlebologie” (German Society for Phlebology) has even developed its own guidelines on the subject. [8].

The causes of the disease have not yet been fully explored.

  • To summarise, it is assumed that the female hormone estrogen, due to increased production of growth factors, leads to an increase and enlargement of fat cells [29, 30]. The large increase in fat cells leads to a lack of oxygen in the tissue, so that some of the fat cells die [31]. This in turn leads to chronic inflammation, which in turn leads to tissue damage.

  • In addition, there is a higher permeability of the vessel wall, which allows more lymph to pass through the tissue, which can no longer be evacuated by the lymphatic system that has remained intact (called insufficiency due to the large volume of lymph to be evacuated).

> This leads to the typical feeling of pressure and tension felt by patients.

> In addition, due to the increased sensitivity of the pain receptors, the tissue changes and causes spontaneous pain, which patients often complain about.

> There is also a tendency for haematomas induced by a high fragility of the capillary vessels [35].

It is assumed that the prevalence in the female population is 8-17% [11, 18, 23]. For France alone, this corresponds to a total of about 5 million women affected. The disease affects men only very rarely.

And is associated in most cases with hormonal imbalance. Currently, there are only a few individual reports on this subject [4, 10].

Symptoms

Very often, it is a coincidence that leads to the diagnosis of lipedema.

  • Patients recognize their symptoms, for example, through television reports and comments from those around them about the strange appearance of their legs.

  • Although the disease has been known for 80 years, knowledge about lipedema is still very underdeveloped in many places.

  • Even in countries such as France, Germany, Spain or Belgium, there are only a few specialists dedicated to the subject. The main symptom is pain [33].

  • Pain from pressure, touch, spontaneous, tension or movement can occur simultaneously or independently of each other.

  • The tendency to non-traumatic hematomas persists [5, 28].

  • The physical transformation of the arms and legs also promotes stigmatization of patients.

  • It appears symmetrically and bilaterally.

  • Normally, the feet and hands are not affected.

  • Initially, there is no dimpling of the Achilles heel [10]. During the course of the disease, the legs develop into a post with a clear demarcation at the wrists and ankles. A pronounced fat sleeve may appear at these places (photo 1) as well as small fat deposits typical of the malleolus [10,13]. Very often, a fatty area below the knee develops.

  • At a later stage, the altered morphology and weight gain in the legs can lead to deformity of the lower limb joints and arthrosis (photo 2) [39].

  • At an early stage, there is an increase and concentration of fat in the arms.

  • Later, there may be very pronounced deposits in the elbow and forearm, with the exception of a triangular area at the wrist on the inside.

The stage of the disease course is determined by the clinical appearance.

Three stages are defined. As the course is very individual, it is not possible to make a prognosis. [7].

Diagnosis

    • In contrast to obesity, lipedema does not respond at all or very much to attempts to lose weight [1,13,34].

    • Stemmer’s sign (skin of the second toe no longer folds when pinched), which represents the boundary between lymphedema and lipolymphedema, is negative [13, 37, 42].

    • Currently, there are no devices available to reliably diagnose lipedema. Ultrasound, magnetic resonance imaging (MRI), or computerized tomography, can only reveal large or condensed fat deposits [22, 8, 25, 3, 27].

The diagnosis is made using clinical criteria [21, 33].

Even the histological analysis of pathological cells is not specific, as Stutz showed in 2009 on the basis of 30 patients with lipedema who underwent liposuction using the WAL method [40].

The packaging was primarily composed of lipocytes. In the case of pathological subcutaneous fat cell multiplication, it is not clear whether it is adipocyte hypertrophy, hyperplasia, or a combination of both [33].

The clinical diagnosis is based on the history, which shows that lipedema occurs most often at puberty, early pregnancy or menopause [1, 43]. 

Very often, it is a positive family history, although the literature speaks of a range from 16 to 64%, thus with relative reliability [1, 16, 38].

In 97% of cases, it is the legs that are affected and in 31% the arms [19].

In our opinion, both areas, legs and arms, are always affected, but the development in the arms is often less or occurs later.

The treatment

As with diagnosis, there are still few centres specialising in the treatment of lipedema.

This leads to results of very different quality. In order to obtain the best possible result, it is advisable to refer patients to a centre specialised in lipedema surgery.

For many years it was considered the best treatment option [12, 19, 41] the combination of :

  • Physical decongestion through the use of straight, flat-knit compression garments,

  • The practice of manual lymphatic drainage

  • Weight normalization

  • And if possible to supplement with a domestic intermittent compression device.

These measures mainly lead to a reduction in oedema, but do not reduce pathological fat cells.

Although physical decongestion is recommended in existing guidelines, there are, however, no evidence-based studies [7, 41].

Patients’ quality of life is greatly reduced [9] because they must :

  • Wear custom-made compression garments for life,

  • And do regular manual lymphatic drainage. 

Since 2004, liposuction in the treatment of lipedema has been practiced with great success [23, 32]. 

In this area, the 30-year-old LTA method (local tumescent anaesthesia) is increasingly being replaced by the more modern WAL method (water jet assisted liposuction).

Comparative studies show that the WAL method causes less pain and swelling and that the patient can return to work more quickly.

In order to work efficiently and ensure maximum patient safety, 2 to 3 operations are required for the lower limbs. The arms are normally done in one operation.

The number of complications following this method using a standardized protocol is very low, in the order of 1-2%, [36].

Standardization of treatment allows very good results to be reproduced [19] (abb. 3 and 4).

Our team was the first in the world to publish in 2018 a standardised operating protocol that includes not only the operation, but also the pre- and post-operative follow-up.

  • For example, to relieve tissue congestion in preparation for the operation and in the postoperative period, it is imperative that patients wear straight, flat-knit compression tights.

  • Only these compression garments – thanks to their dynamic properties – contribute to active tissue decongestion.

  • Liposuction of the legs and arms can be performed in 3 or 4 operations.

  • This depends on the starting weight of the patient, the amount of fat and the distribution of fat cells.

  • When the volume to be removed in the thighs and buttocks is too large, then 2 operations are required.

  • For this purpose, we only operate using the WAL technique (water jet assisted liposuction), which is currently the most modern method in the treatment of lipedema.

  • In separate operations, the legs, thighs and buttocks as well as the arms are decompressed in a circular fashion. (photos 3, 4, 5, 6, 7).

Multiple studies confirm the effectiveness of liposuction in the treatment of lipoedema.

  • Dutch guidelines state that abnormal fat tissue can only be removed by surgery [15].

  • In the “S1” guidelines of the German Society of Phlebology, surgery is named as a treatment option for all stages of lipedema [7].

  • Other studies not only confirm the benefits of liposuction but also show positive long-term effects [2,5,26,36,44].

  • In summary, all studies show a significant reduction in pain, on average 70%.

  • All the studies done so far are monocentric and non-randomized studies.

The quality of life of patients who have undergone liposuction to treat lipedema has increased significantly.

 
  • This is what Frambach says in a study of 164 patients reviewed in consultation between 4 and 8 years after the operation [14].

Most of the painful symptoms had disappeared, as had the feeling of pressure, the tendency to edema and reduced mobility.

In addition, there was no increase in subcutaneous fat tissue in these patients.

  • Our own study, which is still ongoing, confirms the very good results and highlights improvements in various criteria (pain, swelling, reduced quality of life or work capacity, etc.) in 77% to 96% of cases following liposuction with the WAL method.

  • Finally, liposuction can help eliminate the need to wear compression garments and lymphatic drainage [36].

Conclusion

Today – both in Germany and in France – cost coverage by the health insurance company is only carried out in exceptional cases, while the financial possibilities of patients are becoming increasingly restricted.

In Germany, a prospective, multicenter, randomized study is currently underway to prove the benefits of liposuction.

The results will not be known until 2024. 

Only then will it be decided whether liposuction is covered by the health insurance company or not.

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