Lipedema in Paris

The diagnosis of lipedema is based above all on the history of the disease and the clinic, after eliminating other differential diagnoses. It should be made by an experienced angiologist (phlebologist).

Lipedema affects the lower limbs, the upper limbs or both, symmetrically, but does not affect the hands or feet.

The limbs are very sensitive, with a feeling of heaviness and tension in the affected areas, which worsens as the day progresses.

There is also pain when the limb is touched and an increased tendency to haematoma.

Diagnosis is therefore based on clinical presentation and ultrasound of the limbs.

The differential diagnoses of lipedema are mainly obesity, venous insufficiency, lymphoedema and lipohypertrophy. Lack of awareness of lipedema has often led to poor management of the disease and misdiagnosis.

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

As lipedema is resistant to diet, there is no reduction in volume in the affected areas after a major diet or bariatric surgery.

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

In contrast to lipedema, symptoms often diminish with effort and elevation of the limbs. The ankles and feet may be affected.

Lymphoedema is most often asymmetric, affecting the extremities of the limbs. However, it should not be forgotten that lymphoedema is often associated with the severe stages of lipedema, 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 for both aesthetic and symptomatic purposes.

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

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

This treatment results in a minimal reduction in tissue volume of 5-10%, but above all has an effect on pain and the feeling of heaviness in the legs.

It also helps prevent complications such as advanced skin lesions.

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

In terms of weight control, diet has no impact on reducing the volume of the 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 nonetheless been shown to have a beneficial effect on symptoms.

Antioxidant 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 suit 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 help to improve oedema and symptoms.

Initially seen as a second-line treatment, after conservative treatment 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. Reducing the volume of fat is a key point in the management and prevention of oedema.

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 consists of 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 affected.

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

The post-operative period consists of a return to walking the day after the operation, lymphatic drainage as soon as possible and a return to decongestion therapy. Compression garments must be worn for 6 months.

Surgical debulking

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