Lipoedema and lipo-aspiration of the legs.

The WAL technique.

          Thomas WITTE, MD.,

Falk-Christian HECK,MD.

LipoClinic Dr. Heck, Zeppelinstr. 321, D - 45470 Mülheim an der Ruhr,


Lipoedema is a demographic disease with a significant impact and its characteristics have often been highlighted.  

Liposuction is - regardless of the health insurance company's judgment - the only method to reduce pathological fatty tissues, providing patients with great and lasting benefits.

Keywords : lipoedema, liposuction, quality of life, ALT method (local anesthesia by tumescence), WAL method (water jet assisted liposuction)


Lipoedema was first named in the medical literature in 1940 by Allen and Hines (1).  

The disease is now fully recognized and listed in the WHO International Classification of Diseases (ICD) with its own code (E88.xx) (20).

Today, the registry in medical databases is long when searching for lipedema. 

The "Deutsche Gesellschaft für Phlebologie" (German Society for Phlebology) has even developed its own guidelines on the subject. (8).

The causes of the disease are not yet fully explored.

  • In summary, it is assumed that the female hormone estrogen, due to increased production of growth factors, leads to an increase and enlargement of fat cells (29,30).

  • Because of the large increase in these fat cells, there is a lack of oxygen in the tissues so that some of the fat cells die (31).

  • This in turn causes chronic inflammation, which leads to tissue deterioration.

  • In addition, there is a higher permeability of the vessel walls, which allow a greater quantity of lymph to pass into the tissues, which can no longer be evacuated by the lymphatic system that has remained intact (called insufficiency due to the large volume of lymph to be evacuated).

  • This leads to a typical feeling of pressure and tension felt by the patients.

  • In addition, due to increased sensitivity of the pain receptors, the tissues change and cause spontaneous pain, which patients often complain about. There is also a tendency for hematomas to occur due to the greater fragility of the capillaries (35).

  • The prevalence in the female population is assumed to be 8 to 17% (11,18,23).

  • In France alone, this corresponds to a total of about 5 million women affected. 

  • The disease affects men only very rarely. In most cases, it is associated with hormonal disturbance. Currently, there are only a few individual reports on this subject (4,10).


The symptoms

  • Very often, it is a coincidence that leads to the diagnosis of lipedema. Patients recognize their symptoms, for example, through television reports and comments from their friends and family about the strange appearance of their legs.

  • Although the disease has been known for 80 years, knowledge about lipedema is still very underdeveloped in many places. Even in countries such as France, Germany, Spain or Belgium, there are only a few specialists dedicated to this subject.

  • The main symptom is pain (33).
    Pressure, touch, spontaneous, tension or movement pains may occur at the same time or independently of each other.

  • The tendency for hematoma without trauma persists (5,28).

  • The physical transformation of the arms and legs also contributes to the stigmatization of the patients.

  • It appears symmetrically and bilaterally.

  • Normally, the feet and hands are not affected.

  • Initially, no dip is seen in the Achilles heel (10).

It is on the basis of the clinical aspect that the stage of evolution of the disease is determined. Three stages are defined.

The evolution being very individual, it is not possible to make a prognosis. (7).

The diagnosis

Unlike those with obesity, lipoedema is either unresponsive or very responsive to weight loss attempts (1,13,34).  The Stemmer sign (the skin of the second toe no longer makes a fold when pinched) representing the limit between lymphedema and lipolymphoedema, is negative (13,37,42). At present, there are no devices that can reliably diagnose lipedema.

Ultrasound, magnetic resonance imaging (MRI), or computed tomography (CT) can only show large or condensed fat deposits (22,8,25,3,27).

The diagnosis is made using clinical criteria (21,33).

Even histological analysis of pathological cells is not specific, as shown by Stutz in 2009 on the basis of 30 patients with lipoedema who underwent liposuction according to the WAL method (40). Lipocytes were the main feature of the conditioning. In the case of pathological multiplication of subcutaneous fat cells, it is not clear whether this is adipocyte hypertrophy, hyperplasia, or a combination of both (33).

Clinical diagnosis is based on the history, which reveals that lipedema most often occurs at puberty, at the onset of pregnancy or menopause (1,43).

Very often, it is a positive family history, although the literature speaks of a range from 16 to 64%, thus with relative reliability (1,16,38). In 97% of cases, the legs were affected and in 31% the arms (19).  In our opinion, both areas, legs and arms, are always affected, but the development in the arms is often less or occurs later.

The treatment

As with the diagnosis, there are still few centers specialized in the treatment of lipedema. This leads to very different quality results. In order to obtain the best possible result, it is advisable to refer patients to a center specialized in lipedema surgery.

For many years, the combination of :

  • Physical decongestion through the use of straight, flat-mesh compression garments,

  • The practice of lymphatic drainage manual weight normalization

  • And if possible to complete with a domestic intermittent compression device.

  • These measures mainly lead to a reduction in edema, but fail to reduce pathological fat cells. Although physical decongestion is recommended in existing guidelines, there are no outcome-based studies (7,41). Patients' quality of life is greatly reduced (9) because they have to wear custom-made compression garments for life and perform regular manual lymphatic drainage.

Since 2004, liposuction for the treatment of lipedema has been performed with great success (23,32).

    • In this area, the ALT method (local anesthesia by tumescence), 30 years old, is increasingly replaced by the WAL method (water jet assisted liposuction) more modern. Comparative studies show that the WAL method ( Waterjet Assisted Liposuction) less pain and less swelling and that the patient can return to work more quickly.

    • In order to work efficiently while ensuring maximum patient safety, 2 to 3 operations are required for the lower limbs.

    • The arms are normally done in one operation.

The number of complications following this method using a standardized protocol is very low in the order of 1 to 2%, (36).

  • The standardization of the treatment allows for very good results to be reproduced (19) (Abb. 3 und 4). 

  • Our team was the first in the world to publish a standardized surgical protocol in 2018 that includes not only the surgery, but also the pre- and postoperative follow-up.

  • For example, in order to decongest the tissues, in preparation for the operation and in the postoperative period, it is imperative that patients wear straight, flat-mesh compression tights. Only these compression garments - thanks to their dynamic properties - contribute to the active decongestion of the tissue. Liposuction of the legs and arms can be performed in 3 or 4 procedures.

  • This depends on the patient's starting weight, the amount of fat and the distribution of fat cells.

  • When the volume to be removed from the thighs and buttocks is too large, 2 operations are required.

  • For this purpose, we only use the WAL technique (Water Jet Assisted Liposuction), which is currently the most modern method for treating lipedema.

Photo N° 3. WAL technique. Thanks to the water jet coming out of the cannula, the fat cells are gently detached from the tissues. In the same gesture, the detached pathological cells are sucked out through the other opening of the same cannula. 

In separate procedures, the legs, thighs and buttocks as well as the arms are decompressed in a circular fashion. (Photos N°4,5,6,7).

Photo N° 4. Lipoedema in stage II in the legs before the operation.

Photo N° 5. At the end of the operation. Liposuction of 2.3 l of pure fat.

Photo 6. Lipoedema in stage II. Beginning of the procedure before the injection of the tumescent solution.

Photo 7. After lipo-decompression of the legs. A total of 15 liters of fat removed in 3 procedures.


  • In Germany as well as in France, the costs are only covered by the health insurance company in exceptional cases, while the financial possibilities of the patients are becoming increasingly limited. 

  • In Germany, a prospective, multi-center, randomized study is currently underway to prove the benefits of liposuction.

  • The results will not be known until 2024. Only then will it be decided whether liposuction is covered by the health insurance or not. 


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