Liposuction for chronic lipoedema

Evidence-based recommendations on liposuction for chronic lipoedema in adults. This involves using suction to remove abnormal fat.

# Recommendations
Evidence on the safety of liposuction for chronic lipoedema is inadequate but raises concerns of major adverse events such as fluid imbalance, fat embolism, deep vein thrombosis, and toxicity from local anaesthetic agents. Evidence on the efficacy is also inadequate, based mainly on retrospective studies with methodological limitations. Therefore, this procedure should only be used in the context of research. Find out what only in research means on the NICE interventional procedures guidance page.
Further research should report:
patient selection, including age, effects of hormonal changes (which should include effects seen during puberty and menopause) and the severity and site of disease
details of the number and duration of procedures, the liposuction technique used (including the type of anaesthesia and fluid balance during the procedure), and any procedure-related complications
long-term outcomes, including weight and body mass index changes
patient-reported outcomes, including quality of life.
Patient selection should be done by a multidisciplinary team, including clinicians with expertise in managing lipoedema.
The procedure should only be done in specialist centres by surgeons experienced in this procedure.# The condition, current treatments and procedure

# The condition
Lipoedema is characterised by an abnormal, usually symmetrical, accumulation of fat in the legs, hips, buttocks, and occasionally arms. It is a different condition from obesity and from lymphoedema. The aetiology of lipoedema is unknown, but hormonal changes, weight gain and genetics are each thought to be involved. Lipoedema is considerably more prevalent in women and very rarely affects men. Symptoms include swollen, heavy legs that are painful to touch and bruise easily. Feet do not usually have fat accumulation. The size and shape of legs, and the resultant mobility issues and pain, can have a profoundly negative effect on quality of life, and physical and mental health.

# Current treatments
Treatment typically involves healthy lifestyle changes, conservative therapy and, in severe cases, surgery. The fat associated with lipoedema is usually resistant to diet modification and exercise. Conservative therapy, including compression and manual lymphatic drainage (a specialist type of light massage that is mainly used to reduce swelling caused by fluid) is sometimes used to treat lipoedema, but is ineffective at removing abnormal fat. The main surgical treatment for lipoedema is liposuction. In people who also have obesity, there is emerging evidence that bariatric surgery may help reduce fat from both lipoedema-affected and unaffected areas of the body.

# The procedure
The aim of liposuction for lipoedema is to reduce limb bulk, reduce pain, and to improve mobility and functioning. Liposuction for chronic lipoedema can be done under general or local anaesthesia. Several small incisions are made in the limb. Liposuction for chronic lipoedema usually involves infiltrating the limb with large volumes of fluid (tumescence) to allow the cannula to glide through the tissue with minimal damage to blood vessels and lymphatics. Liposuction can also be done using a tourniquet with no or minimal initial fluid infiltration. Tumescent liposuction needs an infiltration pump to deliver the tumescent fluid. Cannulas, connected to a vacuum pump, are then inserted into the incisions and oedematous adipose tissue is removed by vacuum aspiration. Using vibrating cannulas (power-assisted liposuction) or water-jet-assisted liposuction can help remove fat more easily. Water-jet-assisted liposuction needs less initial infiltration because fluid is simultaneously infiltrated and aspirated during liposuction. Liposuction is done around and all the way along the limb. In tumescent liposuction, both fat and tumescent fluid are suctioned out together.
The procedure can take 1 to 4 hours depending on the size of the treatment area. Immediately after liposuction, a compression bandage is applied to the limb to control any bleeding and to prevent postoperative oedema. Antibiotics are typically prescribed as prophylaxis after the operation. When the wounds are healed after the procedure, a custom-made compression garment is worn. This may need to be revised until the oedema volume has been reduced as much as possible.