A Treatment Algorithm for Patients with Lipedema

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PURPOSE: Lipedema is a debilitating disease involving chronic accumulation of subcutaneous fat that is resistant to compression garments and lifestyle change. Lipedema affects approximately 19% of women. Past research has examined outcomes and patient satisfaction post liposuction for lipedema treatment at various individual institutions, but there remains limited literature on lipedema treatment algorithms and staging recommendations. We present a treatment algorithm based a single institution experience, including patient treatment of various obesity classes. METHODS: We utilized a treatment algorithm whereby patients were first assigned one of four stages of disease progression as described by Herbst(figure 1). In order to rule out other concurrent pathology, if indicated, we recommend lymphoscintigraphy, venous ultrasound, or CT/MRI. Patients with Stage I/II lipedema with single areas involved (bilateral upper extremities or bilateral lower extremities involving hips but not buttocks) undergo single stage LVL where both extremities are treated within the same operative session. Patients with Stage III/IV and multiple affected anatomical regions (such as lower extremities involving hips and buttocks, all extremities, and any involvement of the abdomen) undergo staged treatment. that the most affected area is treated first. Typically, the hips and legs are more affected so we begin with the hips, anterior, medial, and lateral thigh, followed by liposuction bilaterally below the knee, the buttock and posterior thighs, the abdomen, and the arms. A maximum of 10 L of fat is removed per operative session or can be achieved within 3 hours of operating time. We limit operating time to 3 hours or less to minimize risks of thromboembolic events. Timing between each procedure is 3-4 months. A retrospective chart review was performed for all patients diagnosed with lipedema at a single institution from 2016 to 2024. Number of liposuction procedures and the volume collected per procedure was collected. All liposuction procedures were performed by one surgeon (DN). RESULTS: A total of 76 patients with a total of 126 liposuction procedures were included in this study. Maximum collected lipoaspirate volume was 10L. BMI average was 36.68 ± 7.93 kg/m2 (range 19.7-56.5 kg/m2. Average outpatient follow up time was 101.4 ± 113.42 days. BMI was not a significant predictor of the likelihood of complications in this analysis (OR = 0.17, 95% CI: 0.006–4.59, p = 0.226). Patients who had liposuction reported having none or less limitations in usual work, household, or school activities (61.5%), vigorous activities (53.8%), moderate activities (69.2%), bathing(69.2%) than before surgery. Upper extremity (61.5%), lower extremity (61.5%), and hip (53.8%) pain was reported to be less severe than before surgery. CONCLUSIONS: We propose a treatment algorithm that allows for safe large volume liposuction and staged treatment, even in the setting of high patient BMI, and high lipoaspirate volume collected. Our approach successfully improved patient mobility, completion of daily activities, and pain.

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