For the first time, a large randomized controlled trial has provided reliable evidence on liposuction for lipedema. Twelve months after treatment was completed, 68% of patients in the liposuction group achieved a clinically significant reduction in pain compared with 8% of those who received conservative therapy alone. However, this benefit is accompanied by a higher rate of adverse events. These findings come from the German LIPLEG study, funded by the Federal Joint Committee and published in The Lancet.

Speaking with Science Media Center Germany, Gabriele Faerber, MD, general practitioner specializing in lymphology, phlebology, and nutritional medicine at the Center for Vascular  Medicine in Hamburg, Germany, said, “In my opinion, the results are clear: Liposuction is superior to conservative therapy consisting solely of compression and manual lymphatic drainage.”

However, Faerber identified the potential limitations of the study. “I see a bias in the fact that only women who wanted liposuction from the outset applied for the study.” Women who managed their condition well with conservative treatment may have been less likely to participate. “In addition, diet was not considered as another important treatment option in the study design. Another point of criticism is the short follow-up period.”

A Common Condition

Lipedema is a chronic, painful condition of subcutaneous fatty tissue that affects women almost exclusively. Typical symptoms include symmetrical fat deposits, particularly in the lower extremities, pain with pressure or touch, and a pronounced tendency to bruise. The Lancet publication cites data estimating the prevalence among adult women to be approximately 10%.

Establishing a definitive diagnosis is challenging. “The diagnosis of lipedema is purely clinical. There is no laboratory value or imaging test that can confirm it,” said Stefan Rapprich, MD, dermatologist and phlebologist at MVZ Hautmedizin Bad Soden GmbH, Bad Soden, Germany.

Conservative treatment includes compression, manual lymphatic drainage, physical activity, and skin care. These measures can relieve symptoms such as pain and feelings of tension and pressure but are intended for long-term use. However, their effect on pain, which is the main symptom, is particularly limited. To date, evidence supporting liposuction has largely come from small, uncontrolled case series, and retrospective cohort studies. High-quality evidence from large, randomized trials is largely lacking.

Surgical Comparison

The LIPLEG study was designed to address this gap in evidence. This multicenter, randomized controlled trial included women aged 18 years or older with stage I-III lipedema at 11 centers in Germany. Participants were required to have an average leg pain score of at least 4 points on a 0-10 numeric rating scale.

Before randomization, all participants received up to 7 months of conservative decongestive therapy. A total of 410 patients were then randomized; 278 were assigned to liposuction with optional accompanying conservative therapy, while 132 continued to receive conservative treatment alone. Liposuction could be performed in up to four procedures.

The primary endpoint was defined using clinically relevant terms. Treatment success was defined as a reduction of at least 2 points in average leg pain on a scale of 0-10. In the liposuction group, the endpoint was assessed 12 months after the final liposuction procedure. In the conservative therapy group, which received complex decongestive therapy alone, the endpoint was assessed 12 months after randomization.

Rapprich rated the study design highly. “The methodology was consistently tailored to the research question: Is surgical treatment superior to conservative treatment? It answers this question with a high level of validity through a randomized, controlled, multicenter design with blinded assessors and a 7-month conservative treatment phase.”

More precisely, the endpoint assessors were blinded. The patients themselves could not be blinded because of the nature of surgical intervention. To help keep assessors unaware of the treatment assignment, possible surgical scars were covered during visits, and patients in the control group also received patches. However, the authors noted that visible changes in body contour may still have revealed the treatment assignment.

Pain Reduction

At 12 months, 190 of 278 patients in the liposuction group, or 68%, achieved the primary endpoint. In the group receiving conservative treatment alone, 10 of 132 patients, or 8%, achieved the endpoint. The odds ratio was 26.2 (95% CI, 13.1-52.5; P < .0001).

The effect was observed across all three disease stages. In stage I, 67.8% of patients achieved a clinically relevant reduction in pain after liposuction compared with 9.5% with conservative treatment. In stage II, the figures were 72.6% and 6.7%, respectively; in stage III, they were 64.5% and 6.7%, respectively.

The changes in pain intensity were also significant. Mean pain intensity decreased from 6.2 to 2.6 points in the liposuction group, whereas it increased slightly from 6.3 to 6.6 points in the conservative treatment group.

Quality Outcomes

The benefits of liposuction extend to other outcomes. Clinically relevant improvements in physical health measured with the 36-Item Short Form Health Survey (SF-36), a 36-question self-reported questionnaire used to measure a person’s overall health and quality of life, were substantially more common after liposuction than with conservative treatment (odds ratio, 18.4; 95% CI, 10.0-33.8; P < .0001). The liposuction group also showed an overall benefit in the mental component of the SF-36 (odds ratio, 2.6; 95% CI, 1.6-4.3; P = .0002).

Several measures of quality of life, depressive symptoms, and susceptibility to bruising also improved. However, not all quality-of-life domains showed significant improvement across all disease stages.

Liposuction also does not necessarily eliminate the need for conservative treatment. Among the patients randomly assigned to the liposuction group, 73% continued to receive conservative therapy alongside the procedure. Among those who underwent surgery, 69% continued conservative treatment after their final liposuction procedure. The study therefore did not simply compare “surgery vs conservative therapy.” Instead, it compared liposuction with optional accompanying conservative therapy with conservative therapy alone.

Surgical Risks

The significant therapeutic benefit must be weighed against the high rate of adverse events. In the safety analysis, 124 of 265 patients who underwent liposuction (47 %) reported at least one adverse event. In the conservative treatment group, 30 of 145 patients (21%) reported an adverse event. The absolute risk difference was 26.1 percentage points.

Serious adverse events were more common after the surgery. They occurred in 20 of 265 patients (approximately 7.5 %) vs 5 of 145 patients (approximately 3.4 %) in the liposuction group vs the conservative treatment group. The abstract reports these figures as 8% vs 3%. Common complications included postoperative decreases in hemoglobin levels and surgical-site infections.

Rapprich nevertheless viewed the benefit-risk balance positively. “The benefit-risk assessment is clearly positive. Adverse events occurred more often than with conservative therapy, as expected, at 46.8% vs 20.7%. However, they were mostly mild to moderate, and there were no unexpected or life-threatening complications.”

Clinical Implications

The LIPLEG study strengthens the evidence supporting liposuction for lipedema. For the first time, a large multicenter randomized trial showed that liposuction with optional accompanying conservative therapy was significantly more effective than conservative treatment alone in achieving a clinically relevant reduction in pain at 12 months. The effect was observed across all three stages of lipedema included in the study.

These findings also have health policy implications. The authors of The Lancet publication noted that the study results contributed to the inclusion of liposuction in Germany’s statutory health insurance coverage. However, the specific requirements for the reimbursement and delivery of care were determined by the applicable statutory health insurance regulations and were not the subject of the LIPLEG study.

Insurance Coverage

Since 2026, liposuction for lipedema in all three disease stages has been included in Germany’s statutory health insurance coverage under certain conditions. Previously, coverage was generally limited to patients with stage III lipedema.

One requirement for coverage is that patients must first undergo at least 6 months of conservative treatment, such as compression and exercise therapy, without adequate relief of symptoms. Additional requirements apply to treatment indications, performance, and quality assurance. Patients with coexisting obesity must also meet additional criteria.

According to Tobias Hirsch, however, a gap remains between coverage eligibility and actual access to treatment: “The transition of surgical treatment into standard care has not yet been fully implemented because treatment is only possible under the conditions of the quality assurance guideline. This means that only specific hospitals and practices are permitted to provide the service. Furthermore, the reimbursement structure is so poor that there are hardly any treating facilities within the statutory health insurance system.”

Long-Term Outcomes

Despite these clear results, an important question remains: How long do the benefits of liposuction last? The current publication reports outcomes at 12 months, but the study was designed to include follow-up over a total of 36 months.

At 12 months, LIPLEG provides evidence that in appropriately selected patients, liposuction with optional accompanying conservative therapy produces a significantly greater reduction in pain than conservative treatment alone. Simultaneously, the procedure was associated with more adverse events.

Hirsch therefore advises a nuanced assessment: “Although surgery can alleviate symptoms in the long term, as of today, lipedema is a chronic condition that patients will have to live with for the rest of their lives.”

On the basis of the data published to date, it is not yet possible to definitively determine whether the benefits will persist over the long term, how often symptoms recur, whether additional procedures will be needed, or how the need for conservative treatment will change over several years. Long-term data from the LIPLEG study is expected to address these questions.

This story was translated from Medscape’s German edition.