Lipedema in East Paris

The differential diagnoses of lipedema are mainly obesity, venous insufficiency, lymphedema and lipohypertrophy. Lack of awareness of lipoedema has often led to mismanagement and misdiagnosis.

In obesity, subcutaneous deposits are generalised and proportionate, affecting the whole body. The hands and feet are also affected, unlike lipoedema, where these anatomical areas are spared. BMI (body mass index) can help with diagnosis, but in most cases obesity is associated with lipedema.

As lipedema is resistant to dieting, there is a lack of volume reduction in affected areas after major dieting or bariatric surgery.

In venous insufficiency, edema is associated with hyperpigmentation of the leg.

In contrast to lipedema, symptoms often diminish with exertion and elevation of the limbs. Ankles and feet may also be affected.

Lymphedema is most often asymmetrical, affecting the extremities of the limb. However, it should not be forgotten that lymphedema is often associated with the severe stages of lipoedema, making diagnosis difficult.

Lipedema treatment is primarily conservative and symptomatic, based on patient education and lymphatic drainage.

However, recent studies have shown a growing interest in liposuction, both in terms of aesthetics and symptomatology.

The first step is patient education. The patient must first accept the disease and understand that the principle of treatment is symptomatological and has little effect on limb aesthetics.

It is based primarily on dietary hygiene, lymphatic drainage and compression, physiotherapy and psychotherapy.

The treatment achieves a minimal reduction in tissue volume (5-10%), but is particularly effective in reducing pain and the sensation of heaviness in the legs.

It also helps prevent complications such as advanced skin lesions.

In terms of weight control, diet has no impact on reducing the volume of affected areas.

However, as lipedema is a risk factor for obesity, patients must be able to control their weight. This aspect of the treatment has nevertheless been shown to have a beneficial effect on symptoms.

Anti-oxidant or anti-inflammatory diets have not been shown to improve the disease.

Lymphatic decongestive therapy, consisting of manual lymph drainage, compression therapy and exercises, can help improve symptoms, tissue tension and the progression of the lymphatic component of the disease.

Exercises should be adapted to the patient and the stage of the disease. Priority should be given to exercises that activate the leg muscles. They improve venous and lymphatic return by acting as a muscular pump.

In addition, because of the pressure gradient underwater, aquatic exercises improve edema and symptoms.

Initially seen as a second-line treatment, after conservative therapy has failed, surgery is increasingly accepted as a possible immediate treatment.

Two options are available:

Lipedema liposuction:

This can be performed in the early stages of the disease, because even if there are no lymphatic disorders clinically, histological abnormalities are already present. Fat reduction is a key factor in the management and prevention of edema.

It has been shown to benefit symptoms such as pain, tissue tension, haematoma formation and quality of life, as well as objective criteria such as limb circumference and reduced frequency of decongestion therapies.

However, it should not be forgotten that it is still not covered by social security and is not reimbursed.

The technique itself involves aggressive liposuction, which differs from aesthetic liposuction.

As mentioned above, a BMI < 32 is a prerequisite for surgery.

Surgery must be performed under general anaesthetic if several areas are involved.

In contrast to aesthetic liposuction, incisions must be made in several areas in order to reach all the surfaces concerned. Micro cannulas and abundant prior infiltration are required.

Post-operative care consists of resuming walking the day after surgery, lymphatic drainage as soon as possible, and resumption of decongestion therapy. Compression garments must be worn for 6 months[2].

Surgical debulking

In very advanced stages of the disease, with proven fibrosis of the tissues preventing liposuction, dermo-lipectomy may be indicated.