Treatment of Lipoedema Using Liposuction

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Focus Lymphology – Original article 121

Treatment of lipoedema using l i p o s u c t i o n Results of our own surveys

S. Rapprich1; S. Baum2; I. Kaak3; T. Kottmann4; M. Podda5 1Dermatology Bad Soden, Bad Soden am Taunus/Germany; 2Dematological practiseim Vorderen Westen, Kassel/Ger- many; 3General Medicine Westerrönfeld/Germany; 4Medical Statistics Hamm/Germany; 55Dermatology Department, Darmstadt Hospital/Germany

Keywords tients liposuction significantly reduced pain, Epidemiologie wird vorgestellt. Als Therapie- Lipedema, liposuction, lipolymphedema, life bruising and the tendency of swelling in the möglichkeit stehen die Komplexe Physikali- quality, decongestive lymphatic therapy, extremities. It therefore led to a significant im- sche Entstauungstherapie und die Liposuktion sports, epidemiology provement in the quality of life of the patients. zur Verfügung. Nur durch die Liposuktion ist Conclusion: Lipedema is a relatively common eine dauerhafte Entfernung des Fettgewebes Summary disorder among women. Liposuction forms möglich. Ihre Wirksamkeit wird in einer weite- Background: Lipedema is a painful, geneti- part of an effective treatment plan, when it is ren Untersuchung aufgezeigt und die Bedeu- cally induced, abnormal deposition of subcu- used in conjunction with pre- and postoper- tung als Teil eines umfassenden Behandlungs- taneous fat in the extremities of women. The ative complex physical decongestive therapy, konzeptes dargelegt. pathogenesis is unknown. Also unknown is a sports program, treatment of concomitant Patienten und Methodik: Für die epidemiolo- the number of women affected in Germany. obesity, as well as psychological support, if gische Untersuchung wurden in einer ländli- This study presents the epidemiology of the needed. Therefore a comprehensive treatment chen Hausarztpraxis sämtliche Patientinnen disease. There are currently two treatment plan should be aimed at for a succesful result. bezüglich Beinleiden untersucht. Die Studie options available: Complex physical decon- zur Liposuktion umfasste die prä- und post- gestive therapy and liposuction. Liposuction operative Untersuchung von 85 Patientinnen is the only method that removes fat perma- mittels Beschwerdefragebogen. nently. An additional study proves its effec- Schlüsselwörter Ergebnisse: Bei 5 % aller Patientinnen einer tiveness and highlights its vital role as part of Lipödem, Liposuktion, Lipolymphödem, Le- Hausarztpraxis wurde ein Lipödem festge- a comprehensive treatment concept. bensqualität, konservative Therapie, Sport, stellt. Mittels Liposuktion konnten bei 85 Pa- Patients and methods: As part of the epi- Epidemiologie tientinnen Schmerzen, Druckschmerz, Häma- demiological research, all patients of a gen- tomneigung und Schwellungsneigung signifi- eral practioner were examined for leg prob- Zusammenfassung kant vermindert und die Lebensqualität ver- lems. The liposuction study included the pre- Hintergrund: Beim Lipödem handelt es sich um bessert werden. and postoperative examination of 85 pa- eine schmerzhafte, anlagebedingt übermäßige Schlussfolgerung: Das Lipödem ist eine rela- tients, which was carried out using a ques- Fettgewebsvermehrung der Extremitäten bei tiv häufige Erkrankung der weiblichen Bevöl- tionnaire. Frauen. Die Ursache ist unbekannt. Ebenso un- kerung. Die Liposuktion stellt zusammen mit Results: Lipedema were diagnosed in 5 % of bekannt ist die Zahl der betroffenen Frauen in der prä- und postoperativen komplexen phy- all patients of the GP practice. In all 85 pa- Deutschland. Eine eigene Untersuchung zur sikalischen Entstauungstherapie, einem Sportprogramm und der Behandlung einer begleitenden Adipositas sowie bedarfsweise Correspondence to: Therapie des Lipödems mittels Liposuktion im einer psychologischen Unterstützung ein Dr. med. Stefan Rapprich Rahmen eines umfassenden Behandlungs - wirksames Behandlungskonzept dar. Hautmedizin Bad Soden konzeptes Kronberger Straße 2, 65812 Bad Soden, Germany Ergebnisse eigener Studien Sie kann nur im Zusammenwirken mit diesen Tel. +49-6196/651550 Phlebologie 2015; 44: 121–132 anderen Therapien erfolgreich sein und daher E-Mail: [email protected] http://dx.doi.org/10.12687/phleb2265-3-2015 ist ein umfassender Therapieplan anzustre- Received: March 7, 2015 ben. Accepted: May 5, 2015

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Lipoedema is a constitutional, dispropor- CPDT can bring relief for a short time, but Fundamentals of tionate accumulation of fat in the female this relief is not permanent and has no in- extremities (1–2). Pain at rest and on press- fluence on the course of the disease. lipoedema ure, a tendency for bruising to occur after Liposuction is the only way to achieve In the beginning of the 1940s, Hines and minimal trauma and an increase in oede- long-lasting removal of the fatty tissue. Allen described lipoedema for the first ma over the course of the day are charac- Since the development of techniques that time (1). Since then, numerous synonyms teristic. The disease shows a chronic, pro- protect lymphatic vessels using vibrating have appeared in the literature, but know- gressive course. microcannulas and local tumescence an- ledge about this still really unknown dis- The disproportionality between the aesthesia and water jet-assisted liposuction, ease is sparse (6–7). trunk and the affected extremities is even it has become possible to treat lipoedema Depending on the source, the following obvious in case of the frequently concomi- surgically. More than 20 years’ experience names for lipoedema can be found: lipal- tant obesity. The disease is diagnosed clini- of the method has now accumulated and its gia, adiposalgia, Adipositas dolorosa (Der- cally and should be differentiated from li- effectiveness has been confirmed scientifi- cum’s disease), Lipomatosis dolorosa, Li- pohypertrophy and lymphoedema in par- cally (3–5). pohypertrophia dolorosa, painful column ticular. However, experience also shows that, in leg and painful lipoedema syndrome (2). The recommended treatment is com- addition to the surgeon’s expertise, the plex physical decongestion therapy quality of the compression treatment and Definition and staging (CPDT), consisting of manual lymphatic of the pre- and post-operative lymphatic drainage (MLD) and compression, exercise drainage, as well as diet and physical activ- Lipoedema is a disease that almost exclus- during compression and skincare. This ity for overweight patients are also crucial ively affects women (8). It is characterized treatment is only effective against the oede- for the success of treatment. Psychological by a painful symmetrical increase in fatty ma component and the compression, in support is sometimes also important. tissue in the lower extremities. In about 1/3 particular, must be used long-term. MLD is Thus the treatment concept is multi-fa- cases the arms are also affected (9–10). The required for oedema that occurs despite ceted and is based on several mainstays. result is a characteristic disproportionality compression garments. The effects of MLD These will now be described and supported of the body’s silhouette between extremities on pain are unclear. For many patients, with new study data. and the trunk (▶ Fig. 1).

Fig. 1 Lipoedema of whole leg and upper arm type.

Phlebologie 3/2015 © Schattauer 2015

Orthostatic oedema, sensitivity to pressure and touch and a tendency to bruise easily are typical of the disease picture (1–2, 9, 11–12) Based on its morphology, lipoedema is Leg Other Lip- Other reasons complaints leg oedema divided into three clinical stages or degrees n = 687 n = 126 complaints n = 41 of severity. In the first stage, the finding on Fig. 2 84.5% 15.5% n = 85 32.5% palpation is still of a soft consistency and Reason for consultati- 67.5% the structure is finely nodular and homo- on of 813 female pa- geneous; the surface of the skin is smooth tients in a rural general practice (own in- and the subcutis thickened. In the second vestigation). stage, the subcutis is harder on palpation, the fatty tissue feels more nodular and the first signs of unevenness appear on the skin surface. In the third stage, the palpation tients. Of these 126 patients, lipoedema pressure is present, as well as a tendency to finding is hard and the fat lobes grossly de- was diagnosed as the cause of the symp- develop haematoma after the slightest trau- formed (12). toms in 41 (32.5 %). Lipoedema had been ma. The course is always progressive, but previously diagnosed in only 4 patients; for Spontaneous pain in the affected areas is varies widely among individuals in time all the remaining women this was the first reported, as well as feelings of tightness and and cannot be predicted. time. 5 % (41 of 813) of the patients who at- swelling (2). There is no correlation be- tended the practice suffered from lipoede- tween the morphological stages and the ex- Localisation ma. It is not possible to extrapolate to the tent of the clinical symptoms. Any con- proportion in the total population, but the comitant obesity aggravates the symptoms. Lipoedema is always symmetrical and oc- proportion we found is close to the figure “Fat cuffs” above the ankle or knee de- curs in different forms in the lower extrem- reported by Marshall and Schwahn- velop and can cause difficulties when walk- ities. The figures quoted in the literature for Schreiber (16). ing. The fat bulges in the thighs lead, via involvement of the arms range from the adduction movement, to a pseudo X leg 30–80 % (13–14). There are three types that position with abnormal joint load, or even affect the legs: whole leg, thigh type and Symptoms arthritis and mechanical stress on the skin calf type. In the same way, lipoedema af- with chafing (19). fecting the arms is classified as whole arm, The disproportion between the slim upper Patients suffer massively from their ap- upper arm and lower arm type (4, 12, 15). body and the sturdy extremities is charac- pearance with not inconsiderable psycho- In our own population, the whole leg teristic. Sensitivity to touch and pain on social consequences (1–2, 20–21). Depend- type was the most common at 62.4 %, then ing on the severity of the findings, a sec- the thigh type at 30.6% followed by the calf ondary lymphatic drainage problem can type at 6 %. result and a lipo-lymphoedema develops, sometimes with liposclerosis ( Fig. 3). Lipoedema does not only occur in a Epidemiology pure form, but also as a mixed form in combination with other diseases, particu- There are no exact figures for the preva- larly lipolymphoedema, lipophleboedema lence of lipoedema. It is estimated that ap- and lipolymphophleboedema (9). prox. 7–9.7 % of the female population are ▶ Table 1 summarises the clinical crite- affected (16). The frequency of lipoedema ria. in specialist lymphology clinics is reported as 8–17 % (2, 12, 17–18). Over a period of one year (July 2011 to Aetiology July 2012) our own study on prevalence investigated 813 female patients who were at The causal pathogenesis is unknown. In least 15 years old and who had presented for a view of the familial accumulation in 60% of wide variety of diseases at a rural general cases, genetic factors are assumed (22). The practice in Schleswig-Holstein with a catch- fact that it most commonly manifests itself ment area of 15,000 inhabitants (▶ Fig. 2). in puberty, but also during pregnancy and Leg complaints were the reason for the the menopause, is suggestive of hormonal consultation in 126 (15.5 %) of the 815 pa- Fig. 3 Lipolymphoedema with liposclerosis influences.

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No diagnostically relevant character- Tab. 1 Clinical criteria for the diagnosis of lip- diagnoses are lipohypertrophy, lymphoede- istics can be identified by histology. There oedema (after 12). ma, phleboedema, Dercum’s disease, Mad- is an unspecific hypertrophy and hyperpla- elung’s disease and obesity (2, 12) ( Table • Onset in puberty, pregnancy or menopause ▶ sia of fat cells (23–25). • Disproportional adipose tissue accumulation 2). In pathophysiological terms, it is as- (extremities – trunk) The connection between lipoedema and sumed that capillary permeability and fra- • Cuff or bulge formation in joint regions weight is a subject that is repeatedly dis- gility are increased (26). Due to the abnor- • Hands and feet unaffected cussed in the literature. On the one hand, mal capillary permeability and fragility, • Feeling of heaviness and tightness of the af- lipoedema must be differentiated from large amounts of tissue fluid are formed in fected extremities obesity (6), on the other – according to the interstitial spaces that have to be trans- • Pain on palpation or spontaneously – in- Bosman and Greer – lipoedema is overpro- ported away via the lymphatic vessels. In- creases during the day portionally frequently associated with Oedema – increases during the day itially, the lymphatic system compensates • obesity (39–40). In his 1974 investigation, • Tendency to bruise easily for the large volumes, but the reserve ca- • Stemmer’s sign negative Greer found more than 50 % obesity in li- pacity is quickly exhausted, so that conges- poedema patients; in his publication of tion of lymph occurs. 2007, Bosman reported that approx. 80 % High-volume insufficiency exists in this of his lipoedema patients were also obese case (27) and lymphatic flow is not ob- strated by high resolution sonography (32). (40). Using the body-mass index (BMI), in structed. The excessively large volumes of in- Hypoechoic fissures are present in oedema. 2012 Schmeller et al. classified 73.3 % of terstitial fluid cause the pressure in the system In clinically difficult cases, this investi- their 112 patients as overweight or obese to rise and lymphatic microaneurysms to gative method, coupled with compression and 17 % as markedly obese, with a BMI form (28). This is reflected clinically in a sen- sonography, provides a non-invasive differ- over 35 kg/m2 (3). sitivity to touch and pressure and a tendency entiation of lipoedema and lymphoedema; In our own investigation at the Derma- to bruise. The skin and subcutis thicknesses it is also suitable for objective follow-up tology Clinic in Darmstadt, almost 30 % of subsequently increase (29). Over the years, (33–34). 85 patients were of normal weight with a tissue fibrosis with lymphangiosclerosis and In some circumstances, a CT or MRI BMI of 20–25 kg/m2. Approx. 26 were pre- perilymphovascular fibrosis can develop. scan can be used for diagnosis. Such meth- obese with a BMI of 25–30 kg/m2 and 20 % This reduces the transport capacity. If the ods will show a thickening of the skin and of those investigated were obese with a lymphatic system is decompensated, the pic- subcutis in the case of lipoedema. Unlike BMI of over 30 kg/m2. Thus about 50 % of ture of lipolymphoedema develops and poss- lymphoedema, there is no “honeycomb- the patients studied were overweight and ibly also dermatoliposclerosis (30). like” structure of the subcutis or a collec- obese. tion of oedema fluid (29, 35–36). Among the general German population, Indirect lymphangiography enables 36 % of people have a BMI that is within Clinical diagnostics convoluted lymph collectors and pinnate or the overweight region and 15 % within the flame-like contrast medium depots to be obese. A little over 50 % of Germans have Diagnosis of lipoedema is based on a de- demonstrated, but these are also seen in BMI values of over 25 kg/m2 (41–44). With tailed history, inspection and palpation lymphoedema and obesity (26). almost 50% of patients overweight or (31). In the vast majority of cases, lipoede- Functional lymphoscintigraphy is used obese, our population of patients roughly ma can be diagnosed by the clinical exam- for the diagnosis of lymph drainage dis- corresponds to the German average and ination, without the aid of instrumental orders. In pure lipoedema, there is no our values are similar to those found by procedures (30). change or only small changes in lymph Greer in 1972. However we had consider- In terms of history-taking, the time of transport (37). At an early stage before the ably fewer obese patients than Schmeller occurrence and family history are an im- occurrence of high-volume insufficiency, and Bosman. portant guide. Patients often report feelings elevated lymph node uptake values can be In contrast to the group in Lübeck of tightness and swelling. measured with lymphoscintigraphy (38). where the prevalence of obese and over- The disproportion between the upper This technique can detect early signs of weight patients was elevated, the rate of body and the extremities and the bulges of lymphatic stasis with the onset of high-vol- overweight and obese patients in our fat above the ankles or knees are character- ume insufficiency (26). Darmstadt population was roughly the istic. There is a sensitivity to touch and same as in the population at large. Al- pressure and an increased tendency to though several studies have reported an in- bruise. Stemmer’s sign is negative. Findings Differential diagnostics creased occurrence of overweight and on palpation change from Stage I to Stage obese patients, this cannot be confirmed by II, from soft and finely nodular to hard and Lipoedema is frequently not diagnosed at our own investigation. No increased preva- grossly nodular (12). all, or misdiagnosed (6). It must be distin- lence of overweight and obesity in lipoede- A widened subcutis with homogeneous guished from other disorders of fat dis- ma compared to the general German and increased echogenicity can be demon- tribution. The most important differential population can be deduced from our data.

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Tab. 2 Differential diagnostics in lipoedema (after 2, 12).

♂/♀ Onset Location Symmetry Fat more Tender- Oedem Feet af- Diets success- Other ness a fected ful Lipoedema ♀ Puberty, Legs, arms Yes Yes Yes Yes No No Tendency to pregnancy, bruise menopause Lipohyper- ♀ Puberty, Legs, arms Yes Yes No No No No trophy pregnancy, menopause Lymph- ♂ /♀ Inherited or Legs, arms, Sometimes Fatty de- No Yes Yes No (except: pro- Lymph drainage oedema acquired trunk generation tein-rich diet in scintigraphy path- possible primary lip - ological. oedema with in- Stemmer’s sign testinal involve- positive, lympho- ment) cytes, pachy- dermia, papillo- matosis cutis Phleb-oede- ♂ /♀ Adulthood Legs No No No Yes No No Venous status ma pathological Dercum’s ♀ Postmeno- Legs No Yes Yes No No No Pain, muscle disease pausal weak ness, C2 abuse, depression Madelung ♂ Adulthood Neck, Yes Yes Yes No No No Liver cirrhosis, disease shoulder, pel- C2 abuse vis Obesity ♂ /♀ Any age Body Yes Yes No No/Yes No Yes BMI increased

Therapy tionality between the upper body, which (MLD) followed by a lymphological com- becomes slimmer, and the lower half of the pression bandage is applied daily on an Therapeutic measures, conservative or sur- body, whose circumference remains un- outpatient basis or as inpatient therapy in gical, can stop or at least slow progress. changed, is potentiated (2). severe cases. In lipoedema, this can reduce There is no causal treatment, because the Sport and a healthy diet are certainly the circumference by a maximum of 10 %. pathogenesis is not known. sensible and part of the treatment concept. In the second phase of treatment, if the The aims of treatment are, in the first However there is a consensus in the litera- oedema cannot be prevented by the com- instance, to improve the symptoms and ture that the inherited fat distribution dis- pression garments, oedema-dependent prevent complications. Dermatological order in lipoedema cannot be “slimmed MLD is used. In this treatment phase, the complications range from congestive der- away” by sport or other weight-reducing aim is to conserve the result of the first matitis, oedema sclerosis, congestive der- measures (32, 46–48). This is strikingly il- phase and to improve it, if possible. In ad- matosis or even venous leg ulcers. Ortho- lustrated by the case of a woman patient dition to MLD and compression therapy, paedic complications can occur primarily who reduced her weight from 99 to 62 kg, CPDT includes good skincare, exercises at the knee joints through a Genu valgum i.e. achieved a weight loss of 37 kg. It is and, in the ideal case, regular decongesting (knock-knee) position caused by a fat pad clear that the lipoedema on the calves was self-treatments (49). (19). not affected (▶ Fig. 4a). Alongside MLD, instrument-based in- Concomitant obesity should be treated termittent compression (IIC) can be used according to the Obesity Guidelines (73). as adjuvant therapy. This consists of a leg Sadly, female lipoedema patients are re- Conservative treatment of sleeve with overlapping air compartments peatedly given treatment recommen- lipoedema (CPDT) that fill and empty in a wave-like manner. dations that apply from a medical view- Presumably through the change in press- point, to overweight patients (45). They are The conservative treatment is complex ure, the lymphangiomotor system is stimu- generally advised to adopt diets, physical physical decongestion therapy (CPDT). lated. This effect is utilised to maintain the training or even use diuretics or laxatives. This consists of two phases. In the first, the effect of treatment after MLD. These recommendations can even have patient is given intensive anti-oedema fatal consequences, since the dispropor- treatment. Manual lymphatic drainage

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The IIC can be used as a supplement to MLD and is generally reported as pleasant and helpful by lipoedema patients (50–51). Consistent MLD and compression garments are recommended in the literature (2, 52–59) even though the therapeutic effect, with a 10% reduction in circumference per leg, was rated as modest by Deri and Weisleder (14, 60). The maximum reduction in circumference of 10 % could only be achieved under frequently repeated treatment and only improved the symptoms for a short time (2, 4, 48, 61, 62). This means a high therapeutic effort, which is difficult to achieve under normal condi- tions of life. Moreover, in everyday practice, the therapeutic effect of CPDT did not meet patient expectations. a b Furthermore, conservative measures have to be undertaken for life and, accord- Fig. 4 a. Patient after weight reduction of 37 kg and resistant lipoedema of the calf type that was b. ing to Cornely, do not stop the further treated by liposuction. progress of the disease (14). Szolnoky et al. reported that MLD reduced the oedema component of lipoedema and the pain induced by oedema, as well as having a positive effect on the increased capillary permeability and reducing the bruising tendency (56–57). MLD is seen as symptomatic treatment in disorders of lymph drainage, which has no causal effect on the disease. Little is found in the literature about the therapeutic benefits of pure compression garments treatment in lipoedema. In their study, Reiche et al. reported that compression garments reduced oedema in the initial phase of treatment, without differenti- ating between lipoedema, lymphoedema and lipolymphoedema when drawing this conclusion (63).

In summary, there is a consensus in the literature that CPDT, consisting of MLD for marked oedema components and compression garments, should be recommended in lipoedema as conservative treatment (31). The basic treatment primarily consists of compression garments in this case.

Fig. 5 In their paper entitled “Tumescence lipo- Infiltration of tumes- suction in lipoedema yields good long- cence local anaesthe- term results”, Schmeller et al. reported on a sia group of patients similar to those of our

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Downloaded from www.phlebologieonline.de on 2016-01-05 | IP: 151.204.226.100 For personal or educational use only. No other uses without permission. All rights reserved. S. Rapprich et al.: Treatment of lipoedema using liposuction 127 own study, where out of 112 patients, 67 had received CPDT preoperatively, 18 compression garments, 8 MLD and 19 none of the above. Over 60 % of the patients who presented at the Dermatology Clinic in Darmstadt had previously undergone lymph drainage. Enquiry as to its efficacy showed that this had achieved a positive therapeutic effect in approx. half of the patients, of which approximately one quarter of the women treated showed a satisfactory result. On the other hand, MLD had had no effect in almost half of Fig. 6 the patients. Liposuction using vi- The second conservative measure that bration microcannulas was enquired about, was compression garments. Almost 80 % of the patients had worn compression stockings preoperatively; more than half of them (57.7 %) on a regular basis. 22.5 % of the women used no compression garments. Thus more than half of the patients reported a positive therapeutic effect from MLD and/or compression garments. One reason why only half of the patients benefitted from conservative treatment is possibly that such treatment can only be effective if a relevant oedema component is present. In our own investigation, almost all patients had pain and symptoms of conges- tion after all conservative treatments had been exhausted. Fig. 7 Check in the standing Surgical treatment of position and removal of the residual tumes- lipoedema – liposuction cence fluid at the end of liposuction To date, there is no alternative to liposuction for the permanent removal of fat cells. This procedure has been become possible for lipoedema in the last 20 years through the development of tissue-friendly techniques. So far, in the case of two techniques it has been proved that lymphatic vessels in particular are not injured: • Liposuction under local tumescence anaesthesia with vibrating microcannulas (power-assisted liposuction) • Water jet-assisted liposuction (64–65). Fig. 8 Several studies have demonstrated the ef- Compression bandage fectiveness in terms of symptom improve- postoperatively

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The tumescence solution was infiltrated 1.3% 2.6% using Sattler’s method with a continuously operating roll pump system. Infiltration Number continued until the skin developed a hard 10.4% 16.9% of sessions elastic turgor; the tissue was blanched by 1 the tissue pressure and the proportion of 2 adrenaline in the tumescence solution 3 (“blanching effect”) (68) ( Fig. 5). 4 ▶ 26.0% 5 The rate of infusion was adjusted according to the pain felt by the patient and 42.9% 6 amounted to between 120 and 200 ml/min. After adequate contact time of the tumes- n = 85 Fig. 9 Number of sessions cence solution, the subcutaneous fat was per patient suctioned off in a longitudinal direction to avoid damage to the lymphatic tract. A criss-cross technique was avoided. In a ment (3–5). The rate of complications is gard to the change in various symptom pa- longitudinal direction, lymph vessels are very low (66, 67), while there is a very rameters after liposuction. All the patients comparatively robust against shear forces, great gain in quality of life for the patient in this study had been operated on by the whereas they are vulnerable transversally which is not achievable with any other first author using tumescence anaesthesia (4, 69–70). A blunt, 4 mm thick vibrating method. and the vibration technique in sometimes microcannula with three blunt openings in several sessions. a Mercedes star arrangement was used as aspiration instrument (▶ Fig. 6). Own investigations Material and methods Tumescence local anaesthesia enables the results to be checked in the standing posi- In our own study, 85 patients were sur- Where required, the patients were given tion (▶ Fig. 7). Residual fluid can be mass- veyed between 4/2003 and 2/2011 with re- 5–10 mg diazepam i.v. as premedication. aged away. Finally, compression stockings, absorbent dressings and a compression bandage on the top are applied ( Fig. 8). Tab. 3 Questionnaire ▶ Patients received postoperative anti- Questions Results biotic prophylaxis for 3 days with ciproflo- VAS-mean values xacin 2 x 250 mg or cefuroxime 2 x 250 mg, together with enoxaparin 1 x 40 mg s.c. for Pre OP 6 months Signifi- 5 or 10 days as thrombosis prophylaxis de- post-OP cance pending on the risk profile. Compression Do you have pain in the affected regions? 6.5 2.1 p<0.001 treatment was prescribed postoperatively. Is sensitivity to touch or tenderness present? 6.5 2.4 p<0.001 The patients were to wear compression Do you bruise easily? 8.1 4.3 p<0.001 stockings 24 hours a day for 1 week and only during the daytime for a further 4 to 6 Do your legs feel tight? 6.9 2.6 p<0.001 weeks. MLD sessions were prescribed as Do your legs feel hot? 2.8 1.2 p<0.001 further follow-up treatment, two to three Do your legs feel cold? 3.4 1.6 p<0.001 times a week over a period of at least 6 Do you have muscle cramps? 2.7 1.3 p<0.001 weeks. The treatment of the legs was done in at Do your legs feel heavy? 7.8 3.1 p<0.001 least 3 sessions. The regions were generally Do your legs feel tired? 7.4 3.1 p<0.001 treated in the following order: Do your legs swell? 6.3 3.2 p<0.001 1. Inner surfaces of thigh and knee, Are there skin complications? 3.2 1.1 p<0.001 2. outer surface of thigh, with hip if necessary, Do your legs itch? 2.8 1.3 p<0.001 3. lower leg. Is your walking restricted? 4.1 1.2 p<0.001 How would you assess the reduction in your quality of life? 8.5 3.3 p<0.001 Results Are you satisfied with the appearance of your legs? 9.2 5.0 p<0.001 The required number of liposuctions per Total 86.2 36.8 p<0.001 patient is shown in ▶ Fig. 9; this ranged

Phlebologie 3/2015 © Schattauer 2015

Downloaded from www.phlebologieonline.de on 2016-01-05 | IP: 151.204.226.100 For personal or educational use only. No other uses without permission. All rights reserved. S. Rapprich et al.: Treatment of lipoedema using liposuction 129 from one to six. Almost half (42.9 %) of patients were treated with three sessions. An- 10 other 42.9 % of patients were treated with either one (16.9 %) or two (26.0 %) liposuc- 8 tions. More than three sessions were needed in only a small proportion of the 6 women (14.3 %). The median number of sessions needed to treat lipoedema with li- 4

posuction was three, with a mean of (points) Pain VAS 2.61 ± 1 sessions. 2 To evaluate the results, the patients were Fig. 10 given a questionnaire of 15 questions pre- 0 Pain preoperatively and 6 months postoperatively ( Table 3). preoperative after 6 months ▶ and after 6 months The intensity of symptoms could be reported on a visual analogue scale (VAS) from 0 (absent) to 10 (very severely pro- nounced). Spontaneous pain, tenderness, 10 bruising tendency, swelling tendency, re- striction when walking and quality of life 8 were some of the parameters measured. Prior to surgery, the patients rated their 6 pain with a median score of 7 points (mean 6.5 ± 3 points) ( Fig. 10). Six months post- ▶ 4 operatively, the median pain score had reduced to 1 (mean 2.12 ± 2 points). Overall, 2 a significant improvement in leg pain could Fig. 11 Sensitivity to touch VAS be achieved (Wilcoxon test, p <0.001). Contact sensitivity pre- 0 The sensitivity to touch and tenderness operatively and after 6 preoperative after 6 months of the areas affected by lipoedema was months rated preoperatively with a median score of 8 points (mean 6.5 ± 3.0). Fig. 11 shows that liposuction significantly reduced the sensi- initial score of 4.1 ± 3.5 points was signifi- after liposuction is shown in Fig. 15. The tivity to touch (Wilcoxon test p<0.001) by cantly reduced (Wilcoxon test p<0.001) preoperative median score of 9 points was ¾ to 2 points (mean 2.4 ± 2.4 points). after the operation to 1.2 ± 1.9 points the highest of any of the questions The patients were asked to assess the (▶ Fig. 14). The median preoperative value measured by the VAS. The high burden of tendency of the legs to bruise before and fell from 4 to 0 postoperatively. The score suffering of the patients is also reflected in after surgery. Pre-operative values were of 0 signifies that the majority of patients the mean value, which, at 8.5 ± 2.0 points, high, with a median score of 8 points and a became free of symptoms after liposuction. was also the highest of all mean VAS mean of 8.1 ± 2.2 points. The bruising ten- The reduction in quality of life of lip- scores. Quality of life was improved by 2/3 dency improved significantly postoper- oedema patients before and six months after liposuction, with the median score atively (Fig. 12), with a reduction of more than 50 % in the symptoms to a median score of 3 points and a mean of 4.3 ± 31.1 10 (Wilcoxon test p<0.001). Figures 10 and 14 show that the ten- ▶ 8 dency of the legs to swell was rated on the VAS preoperatively at a median of 7 points 6 and a mean of 6.33 ± 3.2. When questioned 6 months after liposuction, the median 4 score was given as 3 points and the mean as 3.2 ± 2.5. The operation significantly re- 2 duced leg swelling by almost half (Wilcox- Fig. 12 Haematoma (points) VAS on test p<0.001). Haematoma preopera- 0 Symptoms when walking were surveyed tivly and after 6 preoperative after 6 months in a general way using the VAS. The mean months

Downloaded from www.phlebologieonline.de on 2016-01-05 | IP: 151.204.226.100 For personal or educational use only. No other uses without permission. All rights reserved. 130 S. Rapprich et al.: Treatment of lipoedema using liposuction

Thus the scores for the symptoms of heavy 10 legs, pain, tightness and satisfaction with the appearance improved significantly 8 postoperatively. Analagous to the report by Rapprich, Dingler and Schmeller et al. 6 (3–4), the greatest improvement was ob- served in the quality of life. The main 4 symptoms of lipoedema were once again in this study those which responded best to

VAS Swelling (points) VAS 2 the surgical therapy, namely tired legs, fol- Fig. 13 lowed by sensitivity to touch, with a mean Leg swelling preopera- 0 of up to 4.7 points. The bruising tendency tivly and after 6 preoperative after 6 months was likewise greatly improved by a mean of months 3.8 points. Due to their rather low initial scores, the symptoms of feelings of hotness, coldness, muscle cramps, skin itching and symptoms 10 on walking showed only a moderate degree of suffering. They also improved after lipo- 8 suction, although the improvements were not as great as with the more prominent 6 symptoms. After completion of the liposuction for 4 lipoedema, a significant improvement in symptoms could be demonstrated for all 15 2 Fig. 14 questions in the survey. The improvement Walking complaints in quality of life was the most impressive. 0 VAS Symptoms when walking (points) VAS preoperative after 6 months preoperatively and In this investigation, liposuction was found after 6 months to be an overwhelmingly effective treatment for lipoedema, with an improvement in symptoms that lasted at least 6 months now 3 points and the mean 3.3 ± 2.8. The ma after liposuction required revision. (▶ Fig. 16). increase in quality of life is significant After one liposuction a seroma that (Wilcoxon test p<0.001). The improvement required treatment occurred and one pa- Discussion in quality of life postoperatively is the high- tient suffered thrombophlebitis. est of all changes recorded using the VAS. Further studies with a one-year follow-up Postoperative bruising occurred in 12 On average, liposuction produced signifi- period should subsequently be undertaken. patients in a total of 168 operations (7.1 %). cant improvements in all symptoms. The An attempt should also be made to record In 5 of these patients, the haematoma was overall symptom score was more than the quality of life in a standardised manner, mild, in 4 moderate and in 2 the haemato- halved. which has not been done to date. In this re- spect, it is remarkable that up till now there is no specific questionnaire for recording quality of life for lipoedema, so that at pres- 10 ent a validation is still pending.

6 Accompanying aspects Diet 4 So far there is no lipoedema-specific diet. If

VAS Impairment of VAS obesity is also present, then dietary recom-

quality of life (points) 2 Fig. 15 mendations should be based on the Ger- Impairment of quality man Obesity Guidelines (73). 0 preoperative after 6 months of life preoperatively and after 6 months

In addition, the water has a massaging effect on the skin and subcutis. Studies on the effectiveness of aqua cycling in lipoedema have not yet been conducted.

Psychological aspects Patients suffer massively from their appearance, with considerable psychosocial consequences (1–2, 20, 71–72). Depression and eating disorders are also common.

Treatment concept

A comprehensive treatment concept includes diet, sport, liposuction, compression, MLD and if necessary, psychotherapy (▶ Fig. 17). However, liposuction can only be successful if effective CPDT is carried out pre- and postoperatively and an accompanying exercise and dietary pro- gramme, especially in the case of obesity, is carried out.

Liposuction should be undertaken as part of the overall concept if, despite intensive a b conservative treatment, progression occurs in terms of findings and symptoms. The Fig. 16 Lipoedema patient before and after liposuction (3 sessions) above-mentioned questionnaire is offered as an instrument to measure this progression.

Treatment of lipoedema After successful liposuction, further conservative treatment can be avoided in the majority of patients. However, appropriate dietary management and physical activity should be continued. Psycho- Lipo- Com- Diet Sport MLD logical suction pression support References 1. Allen EV, Hines EA. Lipedema of the legs: A syndrome characterized by fat legs and orthostatic Fig. 17 edema. Proceedings of the staff meetings 1940; 15: Lipoedema treatment 184–187. concept 2. Meier-Vollrath I, Schneider W, Schmeller W. Lipö- dem: Verbesserte Lebensqualität durch Therapie- kombinationen. Deutsches Ärzteblatt 2005; Physical activity Water sports (aqua jogging, aqua cycling) 102(15): 1061–1067. are especially recommended, because here 3. Schmeller W, Hueppe M, Meier-Vollrath I. Tumes- cent liposuction in lipoedema yields good long- Inactivity and obesity potentiate the the buoyancy relieves the load on the term results. Br J Dermatol 2012; 166(1): 161–168. formation of oedema and have negative ef- joints, the water pressure causes a lymph 4. Rapprich S, Dingler A, Podda M. Liposuction is an fects on the course of the lipoedema. Exer- drainage effect and calories are consumed effective treatment for lipedema-results of a study cise is an important part of the treatment by the exercise against the water resis- with 25 patients. J Dtsch Dermatol Ges 2011; 9(1): 33–40. concept of lipoedema and obesity. tance. 5. Cornely M. Update Lipödem 2014: Kölner Lipöd- emstudie. LymphForsch 2014; 18(2): 66–71.

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