10 minute read
Treating Lipoedema
Dr Aamer Khan discusses the treatment options available for patients presenting with lipoedema
Lipoedema is a condition that is being seen more commonly in our aesthetic practices. It was first described by Allen and Hines in 1940 as a condition characterised by abnormally poor resistance to the passage of fluid into the tissue from the blood, thus permitting oedema to occur.1 Many patients who present to clinics with this issue have already consulted with their GP and have been assessed by various specialties in NHS hospitals, with little to no satisfaction. There appears to be a general lack of recognition and understanding of the condition, with a survey of 251 members of the Vascular Society of Great Britain and Ireland revealing that only 46.2% of the consultants were able to recognise the disease.2 It is at a time like this that these patients may choose to see an aesthetic practitioner as a last resort. This is because they see it as an aesthetic, body contouring issue, and there has been an increased awareness of aesthetic body sculpting in the media over the past few years. As such, it is important for us to have some understanding of this not so uncommon but little understood condition, so that we can manage these patients to either treat them ourselves or refer them to appropriate peers.
What is lipoedema? Lipoedema is a progressive condition in which abnormal, excessive subcutaneous fat is deposited in the lower and sometimes upper limbs. Its distribution is symmetrical, and can cause pain with impairment of function, as well as psychological distress; both of which can affect daily activities and life.3 The differential diagnosis of lipoedema includes conditions presenting with swelling or excessive adiposity of lower limbs, mainly represented by lymphoedema and obesity.4 The incidence is approximately one in nine women of post-pubertal age, with the age of onset usually between 18 and 30. The condition is usually progressive.5,2
Causes of lipoedema Often, women who suffer from lipoedema are told that their leg girth is due to their excess of calorie intake, poor diet and lack of exercise, or that the women in their families just ‘have big legs’. Indeed, many of my patients say that they have seen their GP and have been told to lose weight and improve their diets. Many state that they have tried ‘everything’ and their limbs do not change. As their disease progresses, they return to their physicians with increasing leg swelling and weight. As a result of a fixation on their increasing weight and growing body habitus, coupled with today’s ‘fat-shaming’ society attitudes, women with lipoedema frequently suffer from significant psychosocial distress, and can develop anxiety, depression, eating disorders, and isolation.3 Though lipoedema can occur with concomitant obesity, it will not reduce in response to exercise or weight loss.3 Lipoedema adiposity is associated with limbs only, whereas adiposity of obesity is global. The actual cause of lipoedema is still unexplained, however there are various hypotheses about its pathophysiology:
• Genetic: the condition has repeatedly been described in familial clusters, so a genetic predisposition is assumed.6 • Hormonal: lipoedema usually first presents itself during pubescence so is generally thought to be estrogen-mediated.7 • Vascular/lymphatic: another pathophysiological hypothesis involves primary microvascular dysfunction in the lymphatic and blood capillaries.8 This, in turn, is thought to be due to a hypoxic stimulus brought about by excessive expansion of adipose tissue.8,9 • Inflammation: The perception of pain associated with lipoedema is thought to be due to hypersensitivity of the regional sensory nerve fibres through an inflammatory process. This theory is based on single case reports, and there is absence of any valid studies supporting the increase of proinflammatory markers in such patients.
Diagnosis The diagnosis is generally made on clinical grounds after the exclusion of differential diagnoses such as lymphoedema and obesity.4 In cases of more advanced oedema, other classical causes should be considered, such as:4
• Chronic venous insufficiency • Deep vein thrombosis • Idiopathic cyclic oedema • Oedema because of cardiac disease • Oedema of hepatic disease • Oedema of renal disease • Myxoedema • Orthostatic oedema
The diagnostic criteria of lipoedema are as follows:5 • Bilateral and symmetrical manifestation with minimal involvement of the feet or hands
• Minimal pitting oedema • Negative Kaposi-Stemmer sign (for lymphoedema) • Pain and tenderness on pressure • Easy bruising • Persistent enlargement despite elevation of the limbs • Persistent enlargement despite weight loss • Arms affected in 30% of the cases • Surface skin hypothermia • Orthostatic oedema worsens in the summer • Unaffected by caloric restriction • Telangiectasias
The clinical constellation of the major manifestations of the disorder appearing together that point toward the diagnosis of lipoedema include: tissue tenderness, a feeling of tightness, and an excessive tendency toward haematoma formation, with worsening symptoms over the course of the day, in a patient with a bilaterally symmetrical, disproportionate proliferation of fatty tissue on the limbs but not on the hands/feet. Particular attention should be paid to the timing of the onset of the symptoms (namely after puberty), and the course of progression over time. Therefore, a good history obtained from the patient is in the establishment of the correct diagnosis. Getting a medical summary from the patient’s GP is also a useful source of corroboration of the history, and any referrals to a specialist and results of investigations can prove to be invaluable. The advanced stages of lipoedema are associated with various problems, and it is at this time that it attracts more serious attention from doctors and surgeons:
• A fluid load exceeding the capacity of the lymphatic system can cause secondary lymphoedema (lipo-lymphoedema) in any stage of the disease.3 • Mechanical irritation from large fatty deposits near the joints can macerate the skin, causing sores and possible infection.10 • Deposits on the thighs and around the knee joints can also interfere with normal gait and cause secondary arthritis.10 Examination The three stages of lipoedema are characterised by progressive changes in the structure of the skin surface:
Stage I: small nodules, reversible oedema
Stage II: walnut-sized nodules, reversible or irreversible oedema
Stage III: folds and divots over deforming, larger fat masses and macro-nodular change
Stage IV: stage III, with accompanying lymphoedema, potentially
KaposiStemmer sign positive
Lipoedema is also classified by morphology:
Type I: affects buttocks
Type II: affects thighs
Type III: affects the entire lower limbs
Type IV: affects the arms
Type V: affects the lower legs
The symptoms and subjective degree of suffering are not necessarily correlated with the disease stage.10
Consultation If a provisional diagnosis of lipoedema is made, it is important to ensure that the patient has access to the correct care and follow up from a specialist (usually a vascular surgeon, or a lymphoedema specialist) who regularly treats such cases. We might have to find out who is experienced, and refer directly, as GPs may have little, or no knowledge in this area to be able to do this. Remember that psychological or psychiatric support may also be necessary.3 The specialist will then carry out further investigations, and offer management. Most investigations are to exclude differential diagnoses. Patients should be fully informed about the nature of the disease and the fact that it is chronic and progressive. They should be told in an open and honest way about all the treatment options and their effectiveness and about the ways they themselves can actively influence the disease, covered below in the conservative management section. They should also be offered the option of professional help in coping emotionally and physically with the disease. As lipoedema is a chronic, progressive condition, the patient should be given adequate informative material as soon as the diagnosis is made, along with contact data for the relevant self-help organisations such as Lipoedema UK.
Treatments
Radiofrequency-assisted liposuction In my personal experience as a member of the British Association of Body Sculpting, and using radiofrequency-assisted liposuction (RFAL) since 2009, I have seen and treated more than 500 cases of pre-diagnosed lipoedema. Radiofrequency targets water molecules and sets up an electromagnetic resonance, which heats them up. The area for treatment is tumesced to turgor and the heated water molecules in turn heat the tissues. There is an internal and external thermistor, so that the energy is cut off at predetermined levels. The internal target temperature is 70 degrees Celsius and the surface skin temperature is 40 degrees Celsius. These temperatures achieve a number of goals by targeting the tissues between the thermistors:11
1. Sub-necrotic tissue trauma and coagulation resulting in lipolysis 2. Interstitial fibrous band contraction with the stimulation of microfibrosis, which holds the tissues tight like an internal compression system 3. Tissue remodelling and tightening
In my experience, RFAL is a useful tool in treating and remodelling skin tissues. The ideal cases are stages 1 and 2, of all morphologies of lipoedema, and multiple treatments may be necessary to achieve the desired outcomes. Late stage 3 will require a complex management approach, with tissue debulking. In my experience, benefits are still there after 11 years. This appears to be a better outcome than with liposuction alone and may be due to the additional benefit of radiofrequency-induced tissue remodelling. However, there are no direct comparative studies of the two techniques.
Conservative management Ever since lipoedema was first described, the consensus medical recommendation has been that patients should be advised to accept the condition and modify their mode of living accordingly.12 The classic components of conservative management as follows: manual lymph drainage, on a regular basis if necessary:
• Appropriate compression therapy with custom-made, flat-knitted compressive clothing (compression classes II–III) • Physiotherapy and exercise therapy • Psychological/psychiatric therapy • Dietary counselling and weight management • Patient education on self-management
However, reports that several weeks of in-patient treatment (with complex decongestive physiotherapy, manual lymphatic drainage and intermittent pneumatic compression, along with multi-layered compression bandaging) can be beneficialand do not imply any longterm benefit compared with outpatient treatment.13 Cryotherapy With advances in exercise technology, there is new evidence that cryotherapy and exercising cryo-chambers target and reduce white fat content of the body and hyperbaric oxygen chamber sessions that improve tissue oxygenation may play a part in managing patients with lipoedema in the future.14,15 Other developments with microwave, deep impact therapies, and even electrical myo-stimulation therapies may hold hope of some benefit. Further evidence is still required as to the effectiveness of these therapies.
Liposuction If the symptoms persist and impair the patient’s quality of life, the potential indication for liposuction should be considered. Its therapeutic benefit has not yet been evaluated in any randomised, controlled trials. The long-term therapeutic benefits of surgery are now being investigated in a prospective, randomised multicenter trial sponsored by the German Joint Federal Committee (Gemeinsamer Bundesausschuss, G-BA). For the time being, surgical treatment is only available privately.
Surgical debulking In advanced stages of the disease, with accompanying lymphoedema, the involved tissue is so fibrotic that liposuction cannot adequately reduce its volume. In such cases, open surgical debulking (dermato-fibro-lipectomy) may be indicated. In cases where there is excess overgrowth of tissues, surgical excision of the skin may also be necessary.
Conclusion With it often being a misunderstood condition, it is important for medical and surgical aesthetic practitioners to be aware of what treatments are available to help patients who present to their clinics in hope of finding a solution to lipoedema. I feel that further research into the different types of energy-assisted liposuction and their effects on lipoedema would be useful is assessing which would benefit patients with lipoedema. This requires time and resource, as well as experienced practitioners carrying out the treatments.
Dr Aamer Khan graduated from The University of Birmingham in 1986 and has knowledge in areas including human psychology, psychiatry, surgery and dermatology. He decided to become a full time aesthetic practitioner in 2005 because of his love for aesthetic and regenerative treatment. Dr Khan is the co-founder of the multi-award winning clinic Harley Street Skin and has dedicated the past 15 years to performing cosmetic and non-surgical procedures. Qual: MB,ChB
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