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CADTH Health Technology Review
Authors; Khai Tran, and Jennifer Horton.
Lipedema is considered a chronic and progressive disease that is often unrecognized and misdiagnosed.1,2 It mainly affects women, with a prevalence of approximately 10%.2 The disease is characterized by abnormal fat deposition around the buttocks, the thigh, or the entire lower limb.2 Because the pathophysiology of the disease remains unclear, lipedema is diagnosed mainly based on clinical examinations of the skin and subcutaneous tissue.2 There are 3 clinical stages of lipedema based on morphological appearance.2,3 In stage 1, the skin surface is normal but with enlarged subcutis, maybe multiple small nodules on palpation.3 In stage 2, the skin surface is uneven with bigger nodules of the subcutaneous fatty tissue.3 In stage 3, the skin surface has lobular deformation due to increased adipose tissue with large nodules, deformities, bulging protrusion of fat mainly on the hips, thighs, and around the knees.3 The disease manifests at times of hormonal changes such as puberty, pregnancy, or menopause.2 Common symptoms of lipedema include pressure-induced pain, a feeling of discomfort, and easy bruising, which are associated with depression and impaired quality of life if untreated.4,5
Current treatment strategies focus on reducing pain and edema, maintaining mobility, and improving quality of life through conservative and surgical treatment.6 Standard conservative therapy includes lifestyle counselling, nutritional guidance, manual therapy, compression garments, pneumatic compression devices, and a home exercise program.6 Although conservative treatment can alleviate the symptoms, it does not achieve long-lasting benefits and cannot prevent progression of the disease.7 Surgical treatment, also known as lipedema reduction surgery or liposuction, is the only technique for removing abnormal lipedema tissues and slowing progression of the disease.7 Tumescent liposuction, which uses a solution injected into the tissue to decrease pain and bleeding, has become a standard procedure in surgical treatment of lipedema.8 Other surgical methods that may be used include water jet–assisted liposuction9 and power-assisted liposuction.10
A recent CADTH report11 that included 5 before-and-after studies found limited evidence that liposuction may be beneficial in patients with lipedema. A Dutch guideline included in the CADTH report11 recommended tumescent liposuction be considered the treatment of choice for patients with a suitable health profile or inadequate response to conservative and supportive measures. However, the guideline did not provide the quality of the supporting evidence and the strength of recommendations.
This report aims to update the previous CADTH report11 by summarizing any new evidence on the clinical effectiveness of liposuction compared with no treatment or to alternative treatments for the treatment of lipedema. Additionally, this report aims to summarize the new recommendations from evidence-based guidelines regarding the use of liposuction for the treatment of lipedema.
A limited literature search was conducted by an information specialist on key resources, including MEDLINE, Embase, the Cochrane Database of Systematic Reviews, the International HTA Database, the websites of Canadian and major international health technology agencies, as well as a focused internet search. The search strategy comprised controlled vocabulary, such as the National Library of Medicine’s MeSH (Medical Subject Headings), and keywords. The main search concepts were lipedema and liposuction. No filters were applied to limit the retrieval by study type. If possible, retrieval was limited to the human population. The search was completed on June 27, 2022, and limited to English-language documents published since January 1, 2018.
One reviewer screened citations and selected studies. In the first level of screening, titles and abstracts were reviewed and potentially relevant articles were retrieved and assessed for inclusion. The final selection of full-text articles was based on the inclusion criteria presented in Table 1.
Selection Criteria.
Articles were excluded if they did not meet the selection criteria outlined in Table 1, were included in the previous CADTH report,11 or were published before 2018. Before-and-after studies were excluded but are listed in Appendix 5.
The included guidelines were critically appraised by 1 reviewer using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.12 Summary scores were not calculated for the included studies; rather, the strengths and limitations of each included publication were described narratively.
A total of 106 citations were identified in the literature search. Following screening of titles and abstracts, 91 citations were excluded and 15 potentially relevant reports from the electronic search were retrieved for full-text review. Two potentially relevant publications were retrieved from the grey literature search for full-text review. Of these potentially relevant articles, 15 publications were excluded for various reasons, and 2 publications met the inclusion criteria and were included in this report. These comprised 2 evidence-based guidelines. Appendix 1 presents the Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA)13 flow chart of the study selection. Additional references of potential interest are provided in Appendix 5.
Additional details regarding the characteristics of included guidelines14,15 are provided in Appendix 2.
Both included guidelines were evidence-based, providing consensus statements on liposuction for chronic lipedema in the UK,14 and standard of care including surgery (i.e., liposuction) for lipedema in the US.15 The literature was reviewed by expert panels, and the recommendations were made by consensus. The recommendations in the UK guideline were developed according to NICE Health Technology Evaluations: The Manual.16 In the US guideline,15 the strength of recommendations was assessed and graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) instrument based on the balance between benefits, risks, burden, and cost; the degree of confidence in the estimates of benefits, risks, and burden; and the quality of the evidence.
In both guidelines, the target population was patients with lipedema, while the intended users were health care professionals responsible for treatment of lipedema.
The UK guideline14 provided recommendations on the use of liposuction for treatment of chronic lipedema. The US guideline15 provided consensus statements on standard of care for lipedema, including medical, surgical (i.e., liposuction), vascular, and other therapeutic procedures.
The UK guideline14 considered all efficacy and safety outcomes of the liposuction procedure. Patient-reported outcomes, including quality of life and reduction in the volume of lipedema, were also considered. The US guideline15 considered all outcomes related to benefits, risks, burden, and costs of the standard of care for lipedema.
Additional details regarding the strengths and limitations of included guidelines14,15 are provided in Appendix 3.
Both guidelines14,15 are explicit in terms of scope and purpose (i.e., objectives, health questions, and populations), and have clear presentation (i.e., specific and unambiguous recommendations, and easy-to-find key recommendations). In terms of stakeholder involvement, both guidelines14,15 clearly define the target users and the development groups. However, it is unclear if the views and preferences of the patients were sought in the US guideline.15 Regarding rigour of development, both guidelines14,15 do not report the systematic methods used to search for evidence or the criteria for selecting evidence. Both guidelines14,15 provide explicit links between the recommendations and the supporting evidence, and the methods of formulating the recommendations. In formulating the recommendations, both guidelines14,15 considered the health benefits, side effects, and risks, and were externally peer-reviewed before publication. One guideline15 used GRADE methodology to assess and grade its recommendations, while the other14 developed and graded its recommendation according to NICE Health Technology Evaluations: The Manual.16 Regarding clarity, the recommendations in both guidelines are specific and unambiguous, and are easily identifiable. One guideline15 provides different options for management of lipedema, while the other guideline16 focuses on liposuction. Regarding applicability, both guidelines14,15 are not explicit in terms of facilitators and barriers to application, advice and/or tools on how the recommendations can be put into practice, and the monitoring or auditing criteria are not clear. However, resource implications (e.g., considering costs in recommendations) are considered in both guidelines.14,15 For editorial independence, both guidelines14,15 report competing interests of the guideline development group members, but do not report whether the views of the funding body had any influence on the content of the guidelines. Overall, both the included guidelines14,15 are of moderate methodological quality.
Appendix 4 presents the summary of guideline recommendations.
The UK guideline14 recommends that liposuction should only be used to treat lipedema in the context of research due to inadequate efficacy and safety data. The recommendation was made based on 8 before-and-after studies with methodological limitations. The guideline recommends that the procedure, including patient selection, requires a research ethics committee’s approval and should be conducted in specialized centres by a multidisciplinary team, including clinicians with expertise in managing lipedema.
The US guideline15 provided 85 consensus statements on standard of care for lipedema, of which 23 consensus statements were on lipedema reduction surgery (liposuction). The guideline recognizes that liposuction is currently the only available technique for removing abnormal lipedema tissue. The consensus statements were made on the patient selection and indications for liposuction (e.g., candidates should be in good health, there is no limit on age, and patients should be first treated with conservative therapy), the procedure, the technique, the precautions for procedure-related adverse events, and the pre- and post-surgical management. Details of the recommendations are presented in Table 4. The strength of recommendations was rated as strong or weak based on the balance between benefits, risks, burden, and cost, and the degree of confidence in the estimates of benefits, risks, and burden; and quality of evidence was ranked as high, moderate, or low.
This report identified 2 guidelines.14,15 There was no evidence regarding the clinical effectiveness of liposuction compared to no treatment or to alternative treatments for the treatment of lipedema.
The UK guideline14 recommends that the liposuction procedure for treatment of lipedema should only be used in the context of research because of inadequate efficacy and safety data. The US guideline15 recognizes that liposuction is currently the only technique for treatment of lipedema in people who have inadequate response to conservative therapy and provides a series of guidance pertaining to patient selection, indication for liposuction, the procedure, the technique, the safety concerns related to the procedure, and the pre- and post-surgical management. Both guidelines recommend the procedure should be performed at a specialized centre by a multidisciplinary team including surgeons experienced in the care of people with lipedema.
A recent CADTH report11 on liposuction for the treatment of lipedema identified 5 uncontrolled before-and-after studies and 1 guideline. This current report also found 7 before-and-after studies, which were excluded and are presented in Appendix 5. Given the inadequate clinical and safety data on liposuction, and the limitations of the identified guidelines, it is still unclear if this technique should be implemented as an option among the standard procedures for treating people with lipedema in Canada. Areas of further research should focus on patient selection, long-term outcomes, patient-reported outcomes including quality of life, pre- and post-surgical protocols, and how to optimize treatment to improve care for people with lipedema. Well-designed trials on the efficacy of liposuction compared with no treatment or to alternative treatments are also needed.
Appraisal of Guidelines for Research and Evaluation II
Grading of Recommendations Assessment, Development and Evaluation
Selection of Included Studies.
Note that this appendix has not been copy-edited.
Characteristics of Included Guidelines.
Note that this appendix has not been copy-edited.
Strengths and Limitations of Guidelines Using AGREE II.
Note that this appendix has not been copy-edited.
Summary of Recommendations in Included Guidelines.
Note that this appendix has not been copy-edited.
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