Surgeries for Lipoedema

There are two completely different surgical procedures for lipoedema: liposuction and bariatric surgery.

Surgeries for Lipoedema

Surgical options for lipoedema treatment can be considered after failed conservative (non-surgical) treatment. Conservative therapy includes compression, exercise, weight management, and if necessary psychological support.

Dr. Tobias Bertsch (Foeldi Clinic Hinterzarten, European Centre for Lymphology) and Prof. Nestor Torio-Padron (Clinic for Plastic Surgery, Freiburg) summarised the most important facts about liposuction and bariatric surgery in the following article.

Surgical treatment for lipoedema

In the vast majority of patients with lipoedema, conservative therapy will lead to a significant and satisfactory improvement of your symptoms. However, if you have not experienced any therapeutic success despite these measures, surgical treatment may also be considered. There are two surgical procedures to consider:

  1. Liposuction
  2. Bariatric surgery

Liposuction

Not every patient with lipoedema will benefit from liposuction. Therefore, the international panel of experts at the “European Lipoedema Forum” has defined a criteria to ensure the likely long-term therapeutic success of liposuction for appropriate patients. Liposuction should be considered in patients with lipoedema if:

  1. Despite a conservative therapy lasting at least 12 months, symptoms persist
  2. 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. There is no pronounced central (i.e. abdominal) obesity in addition to lipoedema. Body mass index (BMI) must not be greater than 35 kg/m² or the age-dependent measured WHtR (waist-to-height ratio, the ratio between waist circumference and body size) indicates an abdominal obesity. Exceptions to this are the most severe disproportionate increase in fatty tissue in the legs, which can lead to considerable limitation of mobility
  4. A psychological assessment is completed before liposuction, which seeks to exclude 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. The reason for pain is usually caused by a very mild (and completely harmless) inflammation in the fat tissue; local liposuction can reduce the pain. Liposuction can also improve mobility by removing excessive fatty tissue from the lower extremities.

Liposuction methods

There are different techniques of liposuction, but three methods are most commonly used in the treatment of lipoedema:

Classic liposuction: At the beginning of the operation, the so-called tumescent solution, which is a special solution consisting of table salt, anesthetics and adrenaline, is injected into the fatty tissue. Adrenaline is a drug used to cause blood vessel constriction in the fat tissue region which minimises blood loss during surgery. After approximately 15 minutes, the fat tissue is then suctioned off using blunt metal cannulas. These are connected to a liposuction device by means of a hose which is inserted through small incisions in several places in the skin. In standard liposuction, the surgeon has to swing these cannulas back and forth with vigorous arm movements, in order to mechanically reduce the fat tissue and to be able to suction it off effectively.

Vibration-supported liposuction: The most important difference to standard liposuction is that the blunt cannulas vibrate slightly with the help of an electric handle, so that the surgeon only has to gently move them back and forth during the operation. This method is considered a little gentler. This technique enables surgeons to perform liposuction over a long period of time, which is why it is used primarily in the treatment of pronounced forms of lipoedema. 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. As a result, the fat tissue is mechanically shredded and immediately suctioned off with a blunt metal cannula. These cannulas do not vibrate and must also be moved vigorously back and forth by the surgeon.

Although all three liposuction methods can have advantages and disadvantages, all three are suitable for the surgical treatment of lipoedema. These three techniques can deliver comparable results depending on the nature of the findings and the experience of the surgeon. It is important that the surgeon is familiar with the method, has sufficient experience and can verify that he or she has performed a large number of these operations.

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

Risks and possible complications

After each liposuction, patients develop bruises on the skin (superficial blood effusions), swelling and pain in the treated areas. All of these three surgical side effects can vary from patient to patient and generally resolve completely within 3-4 weeks. The pain sensation is different for each patient, usually the symptoms after the operation are comparable to the pain after a severe bruise. The risks and possible complications after liposuction include inflammation, bleeding, which can lead to high blood loss, the development of thrombosis and pulmonary embolism, an allergic reaction to medication or cosmetic impairments due to the formation of dents and irregularities on the skin.

Before deciding on liposuction, you should weigh the benefits against the risks described above and possible complications. With a good selection criteria of patients and in the hands of an experienced surgeon, the complications described above occur extremely rarely. When making a decision, however, you should consider that any operation or medical treatment is associated with risks and these cannot be completely ruled out.

After the operation

After liposuction for lipoedema, you should consistently wear your compression garments on the treated areas for about 6 weeks. You can usually shower after two days; of course the compression garments can be removed for this. Lymph drainage or special skin treatments, e.g. endermology, can accelerate the healing process. After the operation you will be able to move, however there may be certain restrictions due to the swelling and discomfort. You should stop sporting activities on the treated body regions until the symptoms have significantly improved. You should be able to lead a normal life again after about 6 weeks.

Results

The final visual result of liposuction can only be assessed after approx. 4-6 months. It is extremely important that you keep your weight constant after the operation. A relevant increase in weight would lead to a deterioration in the result of the operation. For this reason, these operations are not recommended for patients who are unable to maintain their weight. Liposuction cannot fully guarantee whether you will achieve full or partial improvement to your condition. Current study data on liposuction is very limited and insufficient. However, previous studies indicate that around 70% of patients continue to have typical lipoedema symptoms even after liposuction and they need to continue wearing compression garments.

The images above show photos of a 30-year-old patient with thigh and lower leg lipoedema before the operation. The photos below show the same patient 10 years after liposuction was performed on her entire thighs and lower legs. Only by choosing an appropriate patient for these operations and by maintaining the patient's weight is it possible to maintain the result of liposuction in lipoedema patients in the long term (Prof Nestor Torio-Padron, MD, Clinic for Plastic Surgery, Freiburg).

Bariatric surgery

Many patients with lipoedema are severely overweight. A BMI of 30 kg/m² or more is classified as obese. Obesity is not a question of guilt, weakness of will or lack of discipline, but a disease recognised by the WHO and now also by the German Bundestag. If, in addition to lipoedema, you also suffer from severe obesity, liposuction would not be suitable. Instead, bariatric surgery should be considered.

Gastric sleeve or gastric bypass surgery is recommended if you are suffering from obesity, as these surgeries show the best results in studies. This option can be considered for a BMI of 35 kg/m² and above but recommended for a BMI of 40 kg/m² and above. Conservative weight loss strategies trying various diets may have  already been tried several times and resulted in a yo-yo effect and therefore it is not recommended to continue dieting in this way. Many recent studies have shown that bariatric surgery is the most effective and successful treatment for losing weight in the long term. More recent studies on women with both diseases, i.e. with lipoedema and severe obesity, show a significant improvement in leg circumference (and thus lipoedema) after bariatric surgery.

There is more information on the various surgical techniques and other facts about bariatric surgery on this website http://surgery.ucla.edu/bariatrics-patient-stories

 

Images above illustrate the positive influence of obesity surgery on lipoedema. There is less than a year between the two pictures. The circumference of the thigh halved, and the patient was symptom-free. A skin tightening could be considered after about a year of weight stability and is carried out by a plastic surgeon (Tobias Bertsch, MD, PhD, Foeldi Clinic Hinterzarten, European Centre for Lymphology)

By Tobias Bertsch, MD, PhD, Foeldi Clinic Hinterzarten, European Centre for Lymphology and Prof Nestor Torio-Padron, MD, Clinic for Plastic Surgery, Freiburg

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