Lipoedema

Key Points

• Outpatient procedure (no general anaesthetic)
• Safer tumescent anaesthetic technique
• Lymphatic sparing
• Significant symptom reduction
• Improves biomechanics (walking, bending etc)
• Long term disease reduction

Dr Beulink’s Personal Comments – Lipoedema and Liposuction

My comments regarding lipoedema and liposuction thereof, are based on the last several years of clinical observation and impression performing liposuction on many lipoedema cases. These comments are based on my opinions and may not align with what others may say. Lipoedema is a relatively new diagnosis and awareness and research is thankfully growing. My opinions may change with time as we learn more about this condition and ways to treat it. However, until that time, this is the best I've got.

Just as no two people are the same, I have found that no two persons fat is the same. In fact, even the fat texture throughout ones body can be different from one area to another. And that's what I say about the "normal" fat situation. Lipoedema takes this difference to a whole new level!

In situ, lipoedema fat feels different to the touch. The fat tissue in the thighs and upper arms can feel lumpy or nodular, often described by the patient as being like marbles. It is often tender, particularly to pressure (this in itself is very unusual physiologically). The "cat" or "dog can't sit on my lap" is a typical comment.
The fat itself looks and behaves differently. "Normal" fat is soft and homogenous, a mango/peach colour.  Lipoedema fat is hard, fibrotic, inconsistent and pale/white in colour.
During liposuction, "normal" fat slurries down the vacuum tube. Lipoedema fat rattles down the tube, like little "marbles".
In "normal" liposuction, the cannula moves relatively smoothly through the tissue. In lipoedema, the cannula is met with a significant amount of resistance due to the inflammatory fibrosis.
In Stage 1 lipoedema, this fibrosis tends to start in the outer thigh affecting the surface fat. By Stage 3 the fibrosis has progressed across to the inner thigh and down to the knee (and beyond), and is continuous from the surface to the deep layers (see below regarding deep fascia).
All of this creates a very inconsistent and difficult liposuction environment, quite unlike "normal" liposuction, and requires a great deal of liposuction experience to effectively deal with. Plainly put, lipoedema liposuction is THE most difficult liposuction I do.
In inexperienced hands, lipoedema fat can be an extremely difficult medium to work with. It is essential that you choose a liposuction specialist who is well experienced in lipoedema liposuction and is fully adaptable to customise the treatment to the individual, their condition and needs.

Due to the significant fibrosis, pocking and dimples associated with lipoedema, I will often use my very own combination technique to re-seed or distribute fat. This little "trick" is something I've developed over 30 years of cosmetic fat transfer, and is a little like sprinkling sand over cobblestones to fill in the cracks and divots. In lipoedema, the fibrotic "cellulite" divots can similarly be eased.

Recovery from lipoedema liposuction will generally take longer than that of normal fat liposuction. Allow up to 2 weeks to get over the initial "hump". 50% of my patients have coined it the 2 week "swell hell", but not everyone gets this. The other end of the spectrum are those that are slowed down (considerably) for 5 days eating regular panadol, and then onwards and upwards. Everyone's journey is different and specific to them. But overall, yes that journey is slower than normal liposuction. This is because in lipoedema the tissues are already inflamed and swollen before liposuction is performed. We are literally 8 steps on the back foot before we start....that's lipoedema. The only way to reduce this recovery time, is to do less liposuction each time, but do it multiple times. I don't see the point of this. It's more time consuming for all involved, likely more expensive because of this, and runs into actual liposuction difficulties due to the healing fibrosis in the overlap zones.

Why the pressure  tenderness in lipoedema? What I have noticed in advancing lipoedema, is the inflammatory fibrotic process generally starts superficially in early lipoedema, developing mild dimpling, and slowly progresses deeper with increasing severity of inflammation and fibrotic thickening. By Stage 2 and then 3 lipoedema, the dimples become divots with widespread irregularities. This is because the underlying fibrous bands contract like scar tissue pulling down on the skin surface and forming  "compartments" that become increasingly "squeezed" and pressurised. These bands eventually extend all the way down to the deep fascia (the grissle layer that separates the fat tissue from the underlying muscle) and this layer in turn also becomes increasingly involved, inflamed and fibrotic. This fascia layer becomes so thickened that it can feel like "concrete" when I'm putting in the anaesthetic prior to the liposuction. All of this results in a compartmentalised, inflamed, contracted and pressurised fat tissue tethered to a deep inflamed fascia all just waiting for a simple pressure touch to trigger.

I see this fibrotic and compartmental structure on ultra sound scanning of lipoedema legs. More on the importance of ultra sound scanning before liposuction below.

As such, I believe lipoedema is a fibro-connective disorder, probably with an immune or more specifically, an auto immune basis. This would also explain why lipoedema is often a genetic/family trait. It may also explain the relation to inflammatory foods and their play on the immune system. Interestingly, 50% of the women I see with lipoedema have varicose or vein related problems in their legs. Varicose veins are also a  fibro-connective disorder. More on that below.

So if lipoedema is fibro-connective, why does it affect certain fat and why does liposuction improve it? I don't know why it specifically affects the fat tissue of the thighs. In fact I don't believe it just affects the proximal limbs as traditionally thought. I have seen and felt in in abdomens and buttocks but this is far less common. However, there will be a reason for this, we just don't know why yet. Further research will hopefully enlighten us. Obviously the fat tissue as a whole becomes involved, but I feel that perhaps the fat cells themselves are merely bystanders that are caught up in the process.
Liposuction only removes fat, not the fibro-connective component. And yet despite this, liposuction can give a long term resolve. The only logic I can conclude from all this, is that liposuction reduces the compartment pressure by (permanently?- and I don't like that word) reducing the compartment volume. The weight and pressure problem is alleviated, but the disease is surely not cured. Ongoing conservative measures and management post liposuction would obviously slow down recurrence of a non-cured disease.

I believe pre liposuction ultra sound assessment of the legs, is a mandatory part of the initial assessment. It not only helps visualise the density and fibrotic nature of the fat, can easily identify even the mildest of oedema or lymphoedema (a consequence of advancing liupoedema), but is used to assess for varicose and vein related disorders, present in up to 50% of lipoedema cases. I have been dealing with varicose veins for over 30 years and unfortunately they can sometimes be a little sneaky and not always show themselves to the naked eye (up to 20% will be like this).
Varicose veins are a problem in lipoedema for two reasons. Firstly they are the great mimicker of lipoedema symptoms: heavy legs, feeling of congestion, irritability and fluid swelling are all possible with varicose veins  treating lipoedema when there are underlying vein problems is obviously going to have limited success. Secondly, and most importantly to liposuction, waiving a canula around in a snake pit of veins is fraught with safety concerns regarding uncontrolled bleeding. Tumescent liposuction by definition should  imply minimal bleeding and increased safety. However, the tumescent fluids anti-bleed properties will be severely challenged or even totally negated if there are varicose veins present. I have seen one such case in which liposuction for lipoedema was performed (not by me) that caused significant blood loss.

And on the topic of blood loss during liposuction. I have seen and heard of several cases of liposuction for lipooedema performed overseas under general anaesthetic with consequential blood loss and blood transfusions being necessary. Though some people may prefer a general anaesthetic over local anaesthetic with sedation, unlike tumescent local anaesthetic that numbs the localised area AND prepares the local tissues to prevent bleeding, general anaesthetic only numbs the head and does nothing to prepare the local tissue: end result is it's always game on for bleeding.