“Surgery can help with long-term relief, but…”

Lipedema is a chronic progressive disease characterized by abnormal fat distribution in the extremities – its cause remains unknown. In their interview with Bauerfeind life, Adjunct Professor Dr. med. Mojtaba Ghods, Head of the Department of Plastic and Aesthetic Surgery of Ernst von Bergmann Group in Potsdam, Bad Belzig and Forst, Germany, as well as Resident Physician Dr. Jeremias Schmidt explain how a multi-modal treatment concept can still significantly improve patients’ quality of life.

The current research findings suggest that lipedema is a congenital condition that can be triggered by hormonal changes.¹ It almost exclusively affects women, usually during puberty, pregnancy or menopause, with disproportionate amounts of fatty tissue primarily increasing in the legs, but also in the arms. Another assumption is that fluid from the capillary system increasingly enters the interstitial tissue, affecting the lymphatic system. Furthermore, patient tend to notice more and more bruises even after trivial trauma and patients feel sudden pain or tenderness.

“We cannot expect to get a complete cure until the cause of the condition has been fully understood. We can only support our patients as effectively as possible, bearing many aspects in mind,” Adjunct Professor Dr. med. Mojtaba Ghods explains. “Lipedema may be a syndrome. The pathological fat deposits can be accompanied by other symptoms and conditions, such as depression, obesity, migraines, problems with menstrual bleeding or an underactive thyroid. That’s why we need an individual, multi-modal action plan to improve quality of life for those affected.”

Multi-level treatment

Despite limited evidence for long-term benefits, non-surgical management is currently the gold standard when treating this complex range of symptoms. The treatment approach consists of different elements: in addition to complex decongestive therapy (CDT) with manual lymphatic drainage, compression garments, therapeutic exercise and skin care, solid self-management including nutritional advice is recommended. “CDT and compression, in particular, help to alleviate symptoms because pressure the stockings exert pressure. The excess fatty deposits, however, cannot be reduced in this way. If the problems persist or worsen, we will decrease the amount of affected cells using liposuction,” Dr. Jeremias Schmidt explains.

Under the direction of Adjunct Professor Dr. med. Mojtaba Ghods, the Department of Plastic and Aesthetic Surgery at Ernst von Bergmann Hospital has made a name for itself when it comes to liposuction in cases of lipedema. Adjunct Professor Dr. med. Ghods has been focusing on this condition for 15 years. Since 2020, he has been in charge of the “Lipedema” working group that is part of the German Society for Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC) and is the first physician anywhere in the world who has recently qualified as a university lecturer on this subject. With his team of six surgeons, he performed around 500 liposuction procedures in the hospital locations in Potsdam, Bad Belzig and Forst last year. Consequently, research is of particular interest to this expert: his facility is currently taking part in the “LIPLEG”² study, which is conducted across Germany and funded by the G-BA, a German public health authority. This study is performed to generate evidence regarding the effectiveness of liposuction in cases of lipedema by comparing it to non-surgical treatment. Furthermore, other research projects on lipedema also take place at Adjunct Professor Dr. med. Ghods’ hospital, for example, basic research financed by the Lipedema Foundation.

Finding a definitive diagnosis

“The difficulty is definitively diagnosing lipedema. Unfortunately, the symptoms are all too often under-detected and misdiagnosed as obesity or lymphedema. In our experience, that means it often takes several years before lipedema is treated. On their painful journey to receiving treatment, patients sadly often only hear that they should eat less,” Dr. med. Mojtaba Ghods reports. Yet a change in diet is only a part of non-surgical treatment.

During the diagnosing process, which may eventually lead to liposuction, Adjunct Professor Dr. med. Ghods and his colleagues always rely on a dual-control principle. This means that in addition to the treating surgeon, an experienced phlebologist or vascular specialist will confirm the lipedema diagnosis. And not even then will they start scheduling surgery right away. “Patients should follow non-surgical treatment for at least six months beforehand. This allows us to put our diagnosis to the test, so to speak, because we still don’t have conclusive biomarkers for diagnosing lipedema,” explains Dr. Jeremias Schmidt.

Surgery that preserves the lymphatic system

Surgery usually takes place in two to three steps at an interval of three months: first, liposuction is performed on the front of the legs, then the back and, if necessary, the arms. During this process, the surgeons from Brandenburg work in parallel to the lymph vessels to preserve as much of the lymphatic structures as possible. After injecting tumescent solution into the subcutaneous tissue, thin, blunt-tipped water jet or vibrating cannulas are used. Adjunct Professor Dr. med. Ghods: “We use both methods, the decision is made on a case-by-case basis. The important thing is to proceed carefully. We treat the entire limb, from the ankle to the groin.”

When asked about how much fatty tissue needs to be removed, is answer is as follows: “There’s no clear evidence to base that on yet. That’s why we perform the pinch test during the procedure. It allows us to clinically determine whether a sufficient quantity of adipose tissue has been removed. We get the highest level of patient satisfaction in this way.” Right after surgery, compression products are essential. Dr. Schmidt: “We use flat-knit compression class 2 pantyhose. They also help prevent swelling around the dorsum of the foot and pooling in the groin and lower abdominal areas.”

Patients have to wear compression products 24/7 for six weeks after surgery, which can later be reduced hour by hour. Adjunct Professor Dr. med. Ghods continues: “Depending on the stage of the condition, compression garments may need to be worn permanently. Surgery can help with long-term relief, but not always fully eliminate all symptoms. Be it decongestion or advice on nutrition or exercise – patients require lifelong support in the management of the condition.”

1 A description can be found in the German S1 Lipedema Guidelines: www.awmf.org/leitlinien/detail/ll/037-012.html
2 www.g-ba.de/studien/lipleg-studie

Images: Thomas Lebie, private