Improvement of the sensation of heaviness of the legs that is obtained by liposuction under pneumatic tourniquet, while no other apparent cause outside of the adipose excess was in evidence, came as an unexpected event. This led us to a reflection on the physiopathology of heavy legs in general, as well as to propose an explanation of lipoedema. The notion of lipoedema is not new. It was mentioned in 1940 by Allen, who gave the name of lipoedema to this pathology. In 1949, he defined it as an anatomo-clinical entity, and attempted to establish specific criteria. The literature is scarce on this subject. It recognizes the existence of lipoedema, but does not explain the mechanism nor the treatment. In addition, no mention of lipoedema is found in present-day medical articles. However, the notion of obesity is often evoked in the etiology, and a slimming cure is part of the therapeutic attempts to cure lipoedema. The main data generated by the authors’ study are the following:
– The adipose excess of the lower limbs almost always concerns women (99% of our cases).
– The average age is 44 years.
– A family history of adipose excess is frequent.
– The sensation of heavy legs is found in 80% of cases.
– The adipose surcharge is rarely associated with an obvious veno-lymphatic insufficiency (absence of varicosities).
– The adipose surcharge is associated with simple edema rather than lipoedema.
– Large-scale adipose excess simulating the features of elephantiasis is associated with veno-lymphatic disorders. Such a notion is found in the literature.
The physiopathological mechanisms of edema of the lower limbs are well known in general etiologies such as cardiac, renal, and veno-lymphatic insufficiencies, hypoproteinemia, etc. However, they are still poorly known in cases of isolated adipose excess. Therefore, how can one explain these edemas and this heaviness of the legs in so many patients with no apparent venolymphatic pathology, and no cardiac or renal disorder? When an adipose dysmorphia exists, even discrete, the increase in the quantity of tissue that must be oxygenated and nourished augments the local arterio- veno-lymphatic flow in proportion. Likewise, the interstitial space increases in parallel to this augmentation of the flux of interstitial liquids. At this stage, the edema stays discrete in situ, but it is already symptomatic. Beyond a certain increase in the flux associated with larger adipose excess, the capacity of veno-lymphatic adjustment may be overrun. This occurs by outbreaks upon the occasion of a prolonged sitting or standing position (e.g., long-lasting flights), by water retention of alimentary origin (meal too rich in NaCl), or by a hormonal cause (pregnancy, second part of menstrual cycle). Edema with pitting on pressure or an impression left by the stocking can be observed. This edema can be resorbed by a reclining position or avoided by an elastic support (varicose stockings). In extreme adipose surcharges, the increase of the interstitial flux proportional to the quantity of tissue to nourish creates a larger edema that cannot be resorbed by rest or a change of position. The chronic functional lymphatic insufficiency finally results in organic lesions. This corresponds to the stage of elephantiasis, similar to a classical and unilateral one, which is secondary to an initial disorder of the lymph ducts.
In most cases the operation is performed under general anesthesia with endotracheal intubation. Sometimes a loco-regional anesthesia is administered (e.g., peridural) but never a purely local anesthetic. During the whole surgical intervention the patient is placed on dorsal decubitus. The pneumatic tourniquet is placed on the mid thigh. Two pneumatic tourniquets, one or two sterile Esmarch bandages, an aspiration pump, several cannulas of gauges 2, 3, 4, and 5 mm, or Fournier’s syringes are required for this intervention. The antiseptic must not erase the marks on the skin. The cosmetic surgeon should check that all the equipment is ready for use in order not to lose time, because the tourniquet imposes a limited operation time of 1 h maximum. The choice of approach is guided by two factors: (1) the cannula must stay parallel to the main axis of the leg and (2) the scars should be the least apparent possible and as few as possible. Eight incisional approaches of a diameter of approximately 3 mm are prepared without necessarily using all of them.
1. At the ankle there are four approaches: (a) Antero-internal: situated at one-finger width in front of the anterior edge of the malleolus internus (b) Postero-internal: situated in the middle of a line extending from the malleolus internus to the heel (c) Antero-external: situated at mid-distance between the malleolus externus and the anterior tendon of the leg at one-finger width towards the outside (d) Postero-external: situated in the middle of the line joining the malleolus externus to the heel
2. At the knee level there are three approaches: (a) Internal: situated at the junction of the internal and external meridians of the leg and the thigh (b) External: situated at one-finger width above the contour of the peroneal head (c) Sub-fibular: Situated at the level of the superior edge of the fibula
3. At the calf level there is one approach. Posterior: situated at the median part of the gastrocnemius muscle (calf) between the contours of the gemelli externus and internus at the level of their musculotendinous junction.
Starting at the inferior edge of the malleolus internus, the perimeters of the leg are measured every 5 cm with a measuring tape, and marked on the skin. These measurements are taken all along the leg up to the tourniquet.
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