LIPOSUCTION FOR LYMPHEDEMA
The National Lymphedema Network defines lymphedema as an abnormal collection of lymphatic fluid in the tissues just beneath the skin. This swelling commonly occurs in the arm or leg, but it may also occur in other body areas including the breast, chest, head and neck, and genitals. Lymphedema develops when a body region, where lymphatic vessels and lymph nodes are missing or impaired, becomes overloaded with lymphatic fluid. Lymphatic fluid is normally transported in our body by an extensive network of vessels and nodes. When these vessels are damaged or malformed, there is a risk that lymphatic fluid will not be adequately transported and may result in fluid backing up in body tissues. When fluid congests in the tissue, swelling occurs. This swelling is called lymphedema. If the condition is left untreated, it leads to progressive tissue swelling over time. Lymphatic fluid congestion also reduces healthy blood flow to the tissue, interferes with wound healing, and enables bacteria to grow, which increases the risk for tissue infections.
There are two types of lymphedema. Primary lymphedema is caused by abnormal development of the lymph system in which symptoms may occur at birth or later in life. Secondary lymphedema is caused by damage to the lymph system. The lymph system may be damaged or blocked by infection, injury, cancer, removal of lymph nodes, radiation to the affected area, or scar tissue from radiation therapy or surgery. Lymphedema is staged by severity using the International Society of Lymphology (ISL) scale or the Campisi scale; both systems agree that lymphedema can be classified as subclinical, mild (early), moderate (intermediate), or severe (advanced).
The International Society of Lymphology (ISL) scale for lymphedema
Stage 0 – Stage 0 (or Ia) lymphedema is a subclinical or latent condition in which swelling is not evident despite impaired lymphatic transport. Most individuals are asymptomatic, but some report a feeling of heaviness in the limb. Stage 0 may exist for months or years before the onset of overt lymphedema (e.g., stage I, II, or III below).
Stage I – Stage I lymphedema is characterized by the accumulation of fluid relatively high in protein content that subsides with limb elevation, usually within 24 hours. The appearance is that of soft edema that may pit, with no evidence of dermal fibrosis. This is sometimes called reversible edema. Stage I corresponds to a mild grade of lymphedema above.
Stage II – Stage II lymphedema does not resolve with limb elevation alone. This reflects the evolution of dermal fibrosis. As the fibrosis progresses, the limb may no longer pit on examination. This is sometimes called spontaneously irreversible lymphedema. Stage II corresponds roughly to a moderate grade of lymphedema above.
Stage III – Stage III lymphedema is characterized by lymphostatic elephantiasis. On exam, pitting can be absent, and the skin will have trophic skin changes such as fat deposits, acanthosis, and warty overgrowths. Stage III corresponds to a severe grade of lymphedema above.
The Campisi scale for lymphedema
Stage I
A.“Latent" lymphedema, without clinical evidence of edema, but with impaired lymph transport capacity (provable by lymphoscintigraphy) and with initial immunohistochemical alterations of lymph nodes, lymph vessels, and extracellular matrix. B.“Initial" lymphedema, totally or partially decreasing by rest and draining position, with worsening impairment of lymph transport capacity and of immunohistochemical alterations of lymph collectors, nodes, and extracellular matrix.
Stage II
A. “Increasing" lymphedema, with vanishing lymph transport capacity, relapsing lymphangitic attacks, fibroindurative skin changes, and developing disability.
B. “Column shaped" limb fibrolymphedema, with lymphostatic skin changes, suppressed lymph transport capacity, and worsening disability.
Stage III
A. Properly called “elephantiasis," with scleroindurative pachydermitis, papillomatous lymphostatic verrucosis, no lymph transport capacity, and life-threatening disability.
B. “Extreme elephantiasis" with total disability
Liposuction has been proposed as a treatment for individuals with chronic advanced lymphedema (stage II/III) caused by an interruption in lymphatic drainage. This reductive technique involves the surgical removal of excess subcutaneous fat tissue through several small incisions of the affected limb. It can be performed under general or regional anesthesia. Cannulas connected to a vacuum pump are inserted into small incisions and lymphedematous fat tissue is removed by vacuum aspiration. Postoperative compression garments may be required for life to maintain surgical benefits. The goal of liposuction is to alleviate pain, restore function, reduce swelling, and limit deformity.
A 2021 meta-analysis sponsored by the American Association of Plastic Surgeons evaluated the evidence on surgical treatment of lymphedema (Chang et al., 2021). Pooled analysis of two studies (n=48) showed a 63.95% greater reduction in volume, and pooled analysis of two studies (n=69) showed a greater reduction in volume by 895 mL for liposuction compared to compression therapy alone. Durability of the procedure was not addressed. The conference recommended, based on grade 1C (very low quality) evidence, that there is a role for debulking procedures such as liposuction and for liposuction combined with physiologic procedures in reducing the nonfluid component in lymphedema.
A qualitative systematic review of liposuction for lymphedema of the lower limb was published by Forte et al. (2019). The authors identified eight articles with 191 patients (four were case reports) that met the inclusion criteria of the review. Mean duration of lymphedema ranged from 10 to 20 years. Volume reduction of greater than 50% was reported following liposuction and compression therapy, with a greater volume reduction for secondary lymphedema compared to primary lymphedema. One study reported improvement in function, quality of life, and rate of infection. No comparative studies were identified.
Alamoudi et al. (2018) reported a nonblinded randomized controlled trial (RCT) on submental liposuction for cervical lymphedema following head and neck cancer treatment. Twenty patients with cervical lymphedema were randomly assigned into treatment with liposuction or to no treatment control. Patients filled out two surveys after consenting for the trial and at 6 months. Compared with the no-treatment group, patients in the liposuction group showed statistically significant improvement in patients' self-perception and subjective scoring of appearance. Limitations of the study include the lack of description of randomization and allocation concealment, lack of blinding combined with subjective outcome measures, lack of a physiotherapy control, small sample size, and short duration of follow-up to assess the durability of the procedure.
Hoffner et al. (2018), in a prospective registry study, evaluated the 5-year results after liposuction in combination with controlled compression therapy (CCT). Individuals consecutively operated on between 1993 and 2012 were identified from the lymphedema registry, comprising all individuals with nonpitting lymphedema treated with liposuction and CCT. Inclusion criteria was: (1) diagnosis of secondary arm lymphedema following breast cancer treatment; (2) a significant excess volume, that is the volume of the affected arm was at least 10% larger than that of the unaffected arm and concomitant subjective discomfort; (3) inability of previous conservative treatment to reduce the excess volume completely; (4) no or minimal pitting (less than 5 mm) as a sign of adipose tissue hypertrophy; and (5) accustomed to the use of compression garments preoperatively. Exclusion criteria included individuals with active cancer, wounds, or infections and individuals unwilling to undergo continuous postoperative CCT. For the majority of individuals, power-assisted liposuction was performed to facilitate liposuction. During the period between 1993 and 1997, the “dry technique" was used. During the period between 1997 and 2012, a tourniquet was utilized in combination with the tumescence technique to minimize blood loss. The primary outcome was excess volume reduction. Standardized forms were used to collect pre-, peri-, and postoperative data. A total of 105 women with nonpitting edema were treated. The mean interval between the breast cancer operation and lymphedema start was 2.9 ± 5.0 years, the mean duration of lymphedema was 10 ± 7.4 years, and the preoperative mean excess volume was 1573 ± 645 mL. The mean volume aspirated was 1831 ± 599 mL. Postoperative mean reduction 5 years postoperatively was 117% ± 26% as compared with the healthy arm. The authors concluded that liposuction is an effective method for the treatment of chronic, nonpitting, arm lymphedema resistant to conservative treatment. The volume reduction remained complete after 5 years. Limitations of this study include small sample size and no comparator.
Carl et al. (2017), n a systematic review and meta-analysis, evaluated the literature to develop a treatment algorithm based on the highest quality lymphedema research. Studies were categorized into five groups describing excision, liposuction, lymphovenous anastomosis (LVA), vascularized lymph node transfer (VLNT), and combined/multiple approaches. Studies were scored for methodological quality using the methodological index for nonrandomized studies (MINORS) scoring system. A total of 69 articles met inclusion criteria and were assigned MINORS scores with a maximum score of 16 or 24 for noncomparative or comparative studies, respectively. The average MINORS scores using noncomparative criteria were 12.1 for excision, 13.2 for liposuction, 12.6 for LVA, 13.1 for VLNT, and 13.5 for combined/multiple approaches. Loss to follow-up was the most common cause of low scores. Thirty-nine studies scoring > 12/16 or > 19/24 were considered high quality. In studies measuring excess volume reduction, the mean reduction was 96.6% (95% confidence interval [CI], 86.2%–107%) for liposuction, 33.1% (95% CI, 14.4%–51.9%) for LVA, and 26.4% (95% CI, −7.98%–60.8%) for VLNT. Included excision articles did not report excess volume reduction. The authors concluded that although the overall quality of lymphedema literature is fair, the MINORS scoring system is an effective method to isolate high-quality studies. These studies were used to develop an evidence-based algorithm to guide clinical practice. The authors noted the biggest limitation of this study is the heterogeneity of the included studies in terms of participants' lymphedema stage and etiology, method of assessing surgical outcomes, and inconsistent reporting of complications and QoL outcomes. Additionally, RCTs with homogenous participant populations in terms of etiology and stage that compare surgical treatments to conservative therapies would help further define the most appropriate interventions for individuals according to their clinical stage. Studies with a particular focus on participant follow-up will help improve the validity of lymphedema surgery research.
Lamprou et al. (2017) reported the results of individuals with end-stage primary and secondary lymphedema treated with circumferential suction-assisted lipectomy (CSAL) (n=88). Inclusion criteria included individuals with end-stage lymphedema not responding to decongestive lymphatic therapy, excess volume of at least 1500 mL (volume difference between affected and healthy limb, or more than 15% of the affected limb); individuals on anticoagulants were included if these could be stopped around the time for surgery, and agreement to wear custom-made compression garments after surgery. Compression therapy was resumed after surgery. Leg volumes were measured before surgery, and at 1, 6, 12 and 24 months after the procedure. Forty-seven individuals with primary lymphoedema had a median preoperative volume difference between affected and unaffected legs of 3686 (i.q.r. 2851–5121) mL. Two years after surgery, this volume difference was reduced to 761 mL—a 79% reduction. In the 41 individuals treated for secondary lymphoedema, the median preoperative volume difference was 3320 (i.q.r. 2533–4783) mL, decreasing after 2 years to −38 mL (101% reduction). The preoperative volume difference and the sex of the individual significantly influenced the final outcome after 2 years. The outcome was not related to body mass index (BMI) or other individual characteristics. The authors concluded that CSAL is an effective method for treating both primary and secondary lymphedema of the leg. Limitations of this study include small sample size and no comparator.
The National Comprehensive Cancer Network Guidelines™ (NCCN Guidelines™) on Survivorship (Version 2.2020) does not specifically mention surgical treatments for lymphedema. The guideline recommends referring to a certified lymphedema therapist for consideration of compression garments, progressive resistance training under supervision, manual lymphatic drainage, and physical therapy for range-of-motion exercises.
The International Society of Lymphology (2020) states that liposuction (or suction-assisted lipectomy) using a variety of methods has been shown to completely reduce nonpitting, primarily nonfibrotic, extremity lymphedema due to excess fat deposition (which has not responded to nonoperative therapy) in both primary and secondary lymphedema. However, it is noted that this surgical technique and follow-up are very different from cosmetic liposuction and should be performed by an experienced team of surgeons, nurses, occupational therapists and physiotherapists to obtain and sustain optimal outcomes.
The National Institute for Health and Care Excellence (2020) performed a rapid review of the literature relevant to liposuction for chronic lymphedema. NICE concluded that current evidence on the safety and efficacy of liposuction for chronic lymphedema is adequate to support the use of this procedure provided that standard arrangements are in place for clinical governance, consent and audit. Individual selection should only be done by a multidisciplinary team as part of a lymphedema service. Evidence to support this guideline consisted of small non-randomized studies with no long-term follow up which included 8 case series and 1 systematic review and meta-analysis.
The National Cancer Institute (2019) Lymphedema (PDQ)-Health Professional Version states that "surgery is rarely performed on individuals who have cancer-related lymphedema. The primary surgical method for treating lymphedema consists of removing the subcutaneous fat and fibrous tissue with or without creation of a dermal flap within the muscle to encourage superficial-to-deep lymphatic anastomoses. These methods have not been evaluated in prospective trials, with adequate results for only 30% of individuals in one retrospective review. In addition, many individuals face complications such as skin necrosis, infection, and sensory abnormalities. The oncology patient is usually not a candidate for these procedures. Other surgical options include the following: microsurgical lymphaticovenous anastomoses in which the lymph is drained into the venous circulation or the lymphatic collectors above the area of lymphatic obstruction, liposuction, superficial lymphangiectomy, fasciotomy."
For individuals with lymphedema who receive liposuction, the evidence includes a few small controlled trials and an uncontrolled observational study with 5-year follow-up. Relevant outcomes are symptoms, change in disease status, functional outcomes, and quality of life. The available studies suggest that arm volume can be reduced by the procedure, but follow-up is limited and the trials have a number of other limitations that include lack of blinding, subjective outcome measures, lack of a physiotherapy control, and small sample size. The most rigorous evidence to date is a consecutive series of over 100 patients with detailed methodology. This series indicates that patients who have failed conservative therapy can have complete reversal of excess volume in the short term and that gains can persist through 5 years of follow-up when compression therapy is continued after surgery. However, no studies were identified that compared liposuction to a decongestive therapy protocol with continued compression. Further study is needed to evaluate the impact of liposuction when compared with a decongestive therapy protocol. The evidence is insufficient to determine that the technology results in an improvement in the net health outcome.
LIPOSUCTION FOR LIPEDEMA
Lipedema is a chronic progressive condition characterized by abnormal fat distribution resulting in symmetric enlargement of the legs and often the arms. There are conflicting data regarding its prevalence; however, the Genetic and Rare Diseases Information Center characterizes lipedema as a common condition occurring almost exclusively in women (affecting up to 11% of women). Lipedema is often misdiagnosed as other conditions such as obesity, lymphedema, Dercum's disease, or chronic venous insufficiency.
The cause of lipedema is unknown; however, there is evidence of hormonal and hereditary influences. Many people with lipedema have a family history of similarly enlarged legs. Lipedema is reported to start or worsen during puberty and other periods of hormonal changes, such as pregnancy and menopause.
Lipedema can affect overweight and normal weight individuals. Symptoms vary but usually include abnormal deposits of body fat in both legs, extending from the buttocks to the ankles. Lipedema is relatively unresponsive to diet and exercise. Classical guidelines for diagnosing lipedema include the following criteria: occurrence almost exclusively in women; bilateral and symmetrical presentation with minimal involvement of the feet; minimal pitting edema, pain, tenderness, and easy bruising; and persistent swelling of lower extremities despite elevation or weight loss.
In the early stages of lipedema, most individuals have a normal appearance above their waist. As the disorder progresses, the chest, torso, abdomen, and upper extremities may also become enlarged. People with lipedema tend to bruise easily, possibly because of the increased fragility of small blood vessel within the fat tissue. The stages of lipedema are described as follows:
Stage I: Smooth skin with an increase of enlarged subcutaneous fat tissue
Stage II: Uneven skin with indentations in the fat tissue and larger mounds of fat tissue (lipomas) able to be seen and felt
Stage III: Large extrusion of fat tissue causing deformations especially on the thighs and around the knees
Stage IV: Development of lipolymphedema, a condition where both lipedema and lymphedema are present in the body, with large overhangs of tissues on legs/and or arms
Treatment for lipedema includes therapies that aim to reduce symptoms, disability, and functional limitations to improve quality of life and prevent disease progression. Treatment involves conservative and supportive therapies such as exercise, diet and nutrition, emotional support, and management of coexisting health problems that may cause leg swelling. The main conservative treatment is complex decongestive therapy (CDT), which combines several approaches including manual lymph drainage (a massage technique), compression therapy, and physical mobilization. Liposuction utilizing specialized techniques has been suggested as a treatment for lipedema.
A prospective cohort of water-assisted liposuction (WAL) was reported by Witte et al. (2020), consultants for the producer of the WAL device. The 130 patients enrolled in the study had stage I or II lipedema diagnosed by two specialists. No patients with advanced lipedema were included. Patients underwent weight loss, exercise, and treatment of varicose veins in addition to WAL. Manual lymphatic drainage and compression garments were worn for 8 weeks after the procedure. At a mean of 22 months after the procedure, all symptoms decreased in severity, and use of conservative therapy (compression garments or manual lymphatic drainage) was reduced in these patients from 100% pre-treatment to 44% after liposuction. However, only 63 of the 130 patients completed the follow-up questionnaires. Interpretation of this study is limited by the early stage of disease, the complex treatment protocol, and the high loss to follow-up.
The Canadian Agency for Drugs and Technologies in Health (Peprah and MacDougall, 2019) conducted a qualitative systematic review of liposuction for the treatment of lipedema. The authors identified five uncontrolled before-and-after studies in the English language that suggested that liposuction may be effective in reducing the size of the extremities, symptoms, and functional limitations of lipedema. One of the publications was follow-up to an earlier study, and no reports were identified outside of Germany. Limitations of the evidence included the lack of controlled trials and patients' self-assessment with scales that had not been validated for use in patients with lipedema.
Wollina and Heinig (2019) reported on 111 female lipedema participants in a single-center study, treated consecutively between 2007 and 2018. The median age of the participants was 44 years (range, 20–81 years). Participants' conditions had not responded to at least 6 months of previous CDT. Seven individuals had lipedema Stage I, 50 individuals had Stage II, and 48 individuals had Stage III. Eighty percent of participants had at least one comorbidity. There was an association of long-standing and advanced disease to obesity and diseases of the metabolic syndrome‐spectrum. The intervention was microcannula liposuction in tumescent anesthesia, using mechanical liposuction or laser-assisted liposuction. The procedure was performed as low-volume liposuction with less than 4 L lipoaspirate per session during several sessions 6 to 8 weeks apart. The primary outcomes were reduction of limb circumferences, pain (on a visual analogue scale [VAS]), bruising, improvement of mobility and adverse events. The median (SD) follow-up was 2.0 (2.1) years. Eighteen individuals had follow-up of between 5 and 7 years. The median total amount of lipoaspirate was 4700 mL, with a range of 950 to 14,250 mL. The median reduction of limb circumference was 6 cm. The median pain level before treatment was 7.8 and 2.2 at the end of the treatment. An improvement of mobility could be achieved in all individuals. Bruising was also reduced. Serious adverse events were observed in 1.2% of procedures, the infection rate was 0%, and the bleeding rate was 0.3%. The authors concluded that liposuction is an effective treatment for painful lipedema and note that the procedure should be performed in specialized centers. Limitations of this study include lack of a comparator group, small participant population, participant-reported outcomes with data collected based on a standardized questionnaire, using a VAS score to assess severity, and loss of participants to long-term follow-up.
Wollina and Heinig (2019) noted a German language study by Munch (2017) that reported an improvement of pain, bruising, mobility, and quality of life using WAL in 141 patients. An English language abstract of the study indicates that out of 141 patients treated between 2010 and 2016, 71 could be re-evaluated after a mean of 35.9 months. The 50% of patients who had follow-up reported improvement in the 10 complaints from 6.1 to 3.1 on a VAS, and in 38.3% of cases, conservative therapy was reduced or found to be more effective.
Dadras et al. (2017) analyzed data from 33 individuals treated with liposuction from July 2010 to July 2013 in a plastic surgery clinic. The median age of the participants was 45 years (range, 23–64 years). One individual had stage I lipedema, 11 individuals had stage II lipedema, and 13 individuals had stage III lipedema. Individuals had already received at least 6 months of CDT without improvement of symptoms. The intervention was tumescent liposuction using saline with epinephrine (1:1,000,000). The procedure was performed under general anesthesia. Individuals received an average of three procedures (range, one to seven procedures). The mean volume of removed fat per liposuction was 3106 mL (range, 1450–6600 mL). A standardized questionnaire was completed in 25 (75.6%) of the 33 individuals who underwent liposuction for lipedema. Lipedema-associated complaints and the need for CDT were assessed for the preoperative period and during two separate postoperative follow-ups using a VAS and a composite CDT score. The mean follow-up times for the first postoperative follow-up and the second postoperative follow-up were 16 months and 37 months, respectively. Individuals showed significant reductions in spontaneous pain, sensitivity to pressure, feeling of tension, bruising, cosmetic impairment, and general impairment to quality of life from the preoperative period to the first postoperative follow-up, and these results remained consistent until the second postoperative follow-up. A comparison of the preoperative period to the last postoperative follow-up, after four individuals without full preoperative CDT were excluded from the analysis, indicated that the need for CDT was reduced significantly. An analysis of the different stages of the disease also indicated that better and more sustainable results could be achieved if individuals were treated in earlier stages. The authors concluded that liposuction is effective in the treatment of lipedema and leads to an improvement in quality of life and a decrease in the need for conservative therapy. Limitations of this study include the lack of a comparator group, small sample size, and participant-reported outcomes with data collected by means of a standardized questionnaire that had not been validated for the assessment of lipedema-related complaints.
In a single-center study by Baumgartner et al. (2016), 85 individuals with lipedema had already been examined after 4 years. A mail questionnaire, often in combination with clinical controls, was repeated after another 4 years (8 years after liposuction). Compared with the results after 4 years, the improvement in spontaneous pain, sensitivity to pressure, edema, bruising, and restriction of movement persisted. The same held true for participant self-assessment of cosmetic appearance, quality of life, and overall impairment. Eight years after surgery, the reduction in the amount of conservative treatment (combined decongestive therapy, compression garments) was similar to that observed 4 years earlier. The authors concluded that these results demonstrate for the first time the long-lasting positive effects of liposuction in individuals with lipedema. Limitations of this study include nonrandomized design and data that were collected by means of a mail questionnaire that had not been validated for the assessment of lipedema-related complaints.
In a single-center study by Schmeller et al. (2012), 164 individuals who had undergone conservative therapy over a period of years were treated by liposuction under tumescent local anesthesia with vibrating microcannulas. In a monocentric study, 112 could be re-evaluated with a standardized questionnaire after a mean of 3 years and 8 months (range, 1 year and 1 month to 7 years and 4 months) following the initial surgery and a mean of 2 years and 11 months (8 months to 6 years and 10 months) following the last surgery. All individuals showed a distinct reduction of subcutaneous fatty tissue (average 9846 mL per person) with improvement of shape and normalization of body proportions. Additionally, they reported either a marked improvement or a complete disappearance of spontaneous pain, sensitivity to pressure, edema, bruising, restriction of movement, and cosmetic impairment, resulting in a tremendous increase in quality of life; all these complaints were reduced significantly (P<0.001). Individuals with lipedema stage II and III showed better improvement compared with individuals with stage I. Physical decongestive therapy could be either omitted (22.4% of cases) or continued to a much lower degree. No serious complications (wound infection rate, 1.4%; bleeding rate, 0.3%) were observed following surgery. The authors concluded that tumescent liposuction is a highly effective treatment for lipedema with good morphological and functional long-term results. Limitations of this study include the nonrandomized design, data collected by means of a standardized questionnaire that had not been validated for the assessment of lipedema-related complaints, and the results were considered exploratory because the statistical analysis was performed without alpha adjustments.
Follow-up out to 12 years of Schmeller et al. (2012) was reported by Baumgartner et al. (2021). Sixty patients (36%) had returned questionnaires at 4, 8, and 12 years. All of the patients who were included in the follow-up had stage I or stage II lipedema; no patients with stage III lipedema had returned questionnaires at all follow-up times. In those who returned questionnaires, improvements were maintained over the 12 years of follow-up. It is uncertain whether these patients are representative of all patients treated; therefore, findings of durability are limited to the approximately one third of patients who remained in the study.
Rapprich et al. (2011) examined data from 25 individuals examined before liposuction and 6 months thereafter. The survey included the measurement of the volume of the legs and several parameters of typical pain and discomfort. The parameters were measured using VAS scale (0–10). The volume of the leg was reduced by 6.99%. Pain, as the predominant symptom in lipedema, was significantly reduced from 7.2 ± 2.2 to 2.1 ± 2.1 (P< 0.001). Quality of life as a measure of the psychological strain caused by lipedema improved from 8.7 ± 1.7 to 3.6 ± 2.5 (P< 0.001). Other parameters also showed a significant improvement and the overall severity score improved in all individuals. The authors concluded that liposuction reduces the symptoms of lipedema significantly. Limitations of this study include the nonrandomized design; severity of the participants' conditions, as indicated by lipedema stages, were not reported; and data were collected by means of a standardized questionnaire that had not been validated for the assessment of lipedema-related complaints.
A consensus statement by the the Austrian Academy of Cosmetic Surgery and Aesthetic Medicine and the International Society for Dermatologic Surgery: Prevention of Progression of Lipedema with Liposuction Using Tumescent Local Anesthesia: Results of an International Consensus Conference (2020), concludes that “lymph-sparing liposuction using tumescent local anesthesia is currently the only effective treatment for lipedema." The purpose of the consensus conference was to review the current guidelines and make recommendations especially with respect to long-term benefits that may occur after treatment of lipedema with liposuction using tumescent local anesthesia. The authors stated that expert opinion is important because of the limited evidence-based data on lipedema. Although the authors of this guideline noted that the recommendation was based on available evidence and the experience of the members of the guideline's development task force, details about the evidence base and the strength of evidence supporting the specific recommendations were not provided.
LIPECTOMY AND LIPOSUCTION FOR LIPOMAS
