Shockwave therapy in lipedema patients: A prospective study

Abstract

Background: Postoperative fibrosis is a common and significant complication following liposuction for lipedema, often leading to tissue induration, pain, and compromised aesthetic results. This fibrosis can jeopardize the overall success of the procedure by reducing skin elasticity and altering the intended body contour.Objective: This study aims to evaluate the efficacy of early shockwave therapy (SWT) initiated 1 week after surgery to reduce postoperative fibrosis and preserve the functional and aesthetic outcomes of liposuction in lipedema patients. Methods: A prospective study was conducted on 50 female patients with stage II–III lipedema who underwent power-assisted liposuction (PAL). Patients received SWT sessions three times per week for 3 weeks, starting 7 days postoperatively. Outcomes were compared to a control group of 25 patients who did not receive SWT. Primary endpoints included fibrosis severity assessed by ultrasound elastography, skin elasticity measurements, and patient-reported outcomes on pain and satisfaction. The SWT group exhibited a significant reduction in fibrosis (2.1 ± 0.3 vs 3.8 ± 0.5, p < .001), improved skin elasticity (1.5 ± 0.2 mm vs 1.0 ± 0.3 mm, p < .01), and lower pain scores (2.3 ± 0.8 vs 4.7 ± 1.2, p < .001) compared to the control group. Results: Patient satisfaction was also higher in the SWT group (92% vs 68%, p < .01). Conclusion: Early postoperative shockwave therapy is an effective and safe treatment to reduce fibrosis after liposuction for lipedema. By modulating fibroblast activity, reducing pro-inflammatory cytokines, and improving tissue perfusion, SWT preserves the surgical outcomes and enhances patient satisfaction. These findings suggest that integrating SWT into postoperative protocols could be a valuable strategy to optimize liposuction results in lipedema patients.

Keywords

Shockwave therapy lipedema fibrosis

Introduction

Lipedema is a chronic, progressive disorder of subcutaneous fat, predominantly affecting women and characterized by a disproportionate, symmetric accumulation of adipose tissue in the limbs, sparing the feet and the hands. Unlike obesity, lipedema is resistant to diet and exercise and is frequently associated with pain, spontaneous bruising, and impaired mobility. The disease significantly impacts the quality of life, leading to both physical and psychological distress.¹

Liposuction, particularly power-assisted liposuction (PAL), has emerged as the gold standard for the surgical management of lipedema.² By selectively removing pathological fat deposits, liposuction alleviates symptoms, improves mobility, and restores body contour. However, the postoperative period presents several challenges, the most notable being the development of fibrosis, a pathological wound healing response characterized by excessive deposition of extracellular matrix (ECM) components, particularly collagen.³

Postoperative fibrosis can compromise the aesthetic and functional outcomes of liposuction by causing tissue induration, reduced skin elasticity, and impaired lymphatic function. This complication is particularly problematic in lipedema patients, who are predisposed to chronic inflammation and lymphatic dysfunction, both of which exacerbate fibrotic processes.⁴

Given the need for effective strategies to prevent fibrosis, shockwave therapy (SWT) has emerged as a promising non-invasive adjunctive treatment.⁵ Originally developed for lithotripsy, SWT has been repurposed for various medical applications, including musculoskeletal disorders,⁶ chronic wounds,⁷ and fibrotic conditions. By delivering high-energy acoustic waves to the tissue, SWT exerts mechanical and biochemical effects that can modulate the wound healing process, inhibit fibroblast activity, and promote tissue regeneration.^8,9

This study aims to evaluate the efficacy of early postoperative SWT in preventing fibrosis following liposuction for lipedema. Specifically, we assess the impact of initiating SWT 1 week after surgery on fibrosis severity, skin elasticity, pain, and patient satisfaction.

Pathophysiology of postoperative fibrosis in lipedema

Fibrosis is a pathological wound healing response characterized by excessive deposition of extracellular matrix (ECM) components, primarily collagen, leading to tissue induration, decreased elasticity, and impaired function.¹⁰ In lipedema, the development of fibrosis is a multifactorial process driven by chronic inflammation, lymphatic dysfunction, and mechanical stress on the affected tissues,¹ as shown in Figure 1. These processes converge to create a pro-fibrotic microenvironment that perpetuates tissue stiffening and functional impairment. Understanding these mechanisms is essential for developing targeted interventions to prevent and manage fibrosis, thereby preserving the functional and aesthetic outcomes of liposuction in lipedema patients.^11–14

Figure 1.

Pathogenesis of fibrosis in lipedema patients: (A) lipedema is associated with a state of low-grade chronic inflammation, which plays a central role in the initiation and progression of fibrosis. Adipose tissue in lipedema patients exhibits elevated levels of pro-inflammatory cytokines such as IL-1β, IL-6 and TNF-α. These cytokines activate immune cells, including macrophages and T-cells, which infiltrate the adipose tissue and further amplify the inflammatory response. TGF-β, a key fibrogenic cytokine, is overexpressed in lipedema and serves as a critical mediator of fibrosis. TGF-β promotes the differentiation of fibroblasts into myofibroblasts, the primary effector cells responsible for ECM synthesis and tissue contraction. Myofibroblasts secrete excessive amounts of collagen types I and III, leading to the formation of dense fibrotic tissue. In lipedema-associated fibrosis, the balance between ECM synthesis and degradation is disrupted, leading to excessive ECM deposition and impaired degradation. Matrix metalloproteinases (MMPs), enzymes responsible for ECM degradation, are often downregulated, while their endogenous inhibitors, tissue inhibitors of metalloproteinases (TIMPs), are upregulated. The abnormal distribution and mechanical properties of adipose tissue in lipedema generate increased mechanical stress on the surrounding tissues, which can trigger fibrosis through mechanotransduction pathways. Fibroblasts and myofibroblasts are mechanosensitive cells that respond to mechanical stimuli by upregulating ECM synthesis and contractile protein expression. Mechanical stress activates integrins and focal adhesion complexes, which in turn stimulate downstream signaling pathways such as the Rho/ROCK and TGF-β/Smad pathways. These pathways promote cytoskeletal remodeling, ECM deposition, and tissue stiffening, further exacerbating fibrosis and reducing tissue compliance. (B–C) Lymphatic impairment contributes significantly to the fibrotic process. This persistent fluid accumulation creates a hypoxic microenvironment, which further stimulates the release of TGF-β and other profibrotic and growth factors. Hypoxia also induces the expression of hypoxia-inducible factor-1 alpha (HIF-1α), a transcription factor that upregulates the synthesis of ECM components and promotes angiogenesis. However, the newly formed blood vessels in fibrotic tissue are often abnormal and contribute to further lymphatic and vascular dysfunction, perpetuating a cycle of fibrosis. (D–E) Hypoxia, interstitial fluid nutrients, and growth factors are all conditions that lead to adipose tissue hyperplasia and hypertrophy, further reducing oxygen availability, driving the production of HIF, ECM remodeling, and neoangiogenesis.

Mechanisms of action of shockwave therapy in fibrosis prevention

Shockwave therapy (SWT) is a non-invasive treatment modality that delivers high-energy acoustic waves to targeted tissues. Originally developed for lithotripsy, SWT has since been adapted for a variety of medical applications, including musculoskeletal disorders, wound healing, and the management of fibrotic conditions. Its therapeutic effects are mediated by a complex interplay of mechanical, biochemical, and cellular mechanisms that collectively disrupt fibrotic processes, enhance tissue regeneration, and restore normal tissue architecture (Figure 2).

Figure 2.

Here the mechanisms through which shockwave therapy can prevent postoperative fibrosis in patients with lipedema undergoing liposuction.

Shockwave therapy (SWT) employs mechanical forces to induce microtrauma in fibrotic tissues, disrupting adhesions and softening the dense extracellular matrix (ECM) through acoustic wave propagation and cavitation. These processes reduce tissue stiffness, creating an environment conducive to cellular migration and tissue remodeling.¹⁵ SWT also modulates inflammatory pathways by downregulating pro-inflammatory cytokines (e.g., IL-1β, IL-6, TNF-α) and upregulating anti-inflammatory mediators (e.g., IL-10), mitigating chronic inflammation that contributes to fibrosis.^16,17 Furthermore, SWT inhibits fibroblast proliferation and myofibroblast differentiation, primarily through the suppression of the TGF-β/Smad signaling pathway, reducing ECM synthesis and pathological fibrosis.¹⁸

SWT enhances angiogenesis by stimulating VEGF release, which promotes capillary formation, improving oxygenation and nutrient delivery while resolving hypoxia and supporting tissue repair. Mechanotransduction is activated through mechanosensitive ion channels (e.g., TRPV4) and focal adhesion kinase (FAK), driving intracellular signaling that facilitates ECM remodeling and cytoskeletal reorganization.⁸ Finally, SWT recruits and activates mesenchymal stem cells (MSCs) by increasing SDF-1 and CXCR4 expression, enabling MSC homing and differentiation into various cell types, thereby enhancing tissue regeneration and restoring structural integrity. These multifaceted mechanisms underscore SWT’s therapeutic potential in preventing fibrosis and promoting tissue recovery.¹⁹

Shockwave therapy exerts its antifibrotic effects through a multifaceted mechanism that includes mechanical disruption of fibrotic tissue, modulation of inflammatory pathways, inhibition of fibroblast and myofibroblast activity, enhancement of angiogenesis, activation of mechanotransduction pathways, and recruitment of stem cells. These combined effects not only prevent the development of postoperative fibrosis but also promote tissue regeneration and functional recovery, making SWT a valuable adjunctive therapy in the management of lipedema and other fibrotic conditions.

Materials and methods

Study design

This was a prospective, randomized, controlled study. A total of 75 female patients with stage II–III lipedema were enrolled and randomly assigned in a 2:1 ratio to either the shockwave therapy (SWT) group (n = 50) or the control group (n = 25) using a computerized randomization sequence. Allocation concealment was ensured through sealed opaque envelopes prepared by an independent research coordinator. Randomization aimed to reduce selection bias and ensure the comparability of groups.

• SWT Group: 50 patients who received SWT starting 1 week after surgery.

• Control Group: 25 patients who did not receive SWT and followed standard postoperative care.

The classification of lipedema into stages in our study is based on widely accepted clinical staging systems, particularly those proposed by German expert consensus and endorsed by the German Society of Phlebology (Deutsche Gesellschaft für Phlebologie).²⁰

All patients underwent power-assisted liposuction (PAL) performed by the same surgeon to ensure procedural consistency. The study was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants.

The imbalance between the treatment and control groups occurred due to factors such as patient selection, treatment availability, and specific inclusion/exclusion criteria (Table 1). However, this difference did not compromise the validity of the results. To address potential biases, appropriate statistical methods, including regression analysis and matching techniques, were employed to ensure the findings were robust. Additionally, while the groups may have differed in terms of treatment allocation, they were balanced on key clinical characteristics such as the severity of lipedema, which could have influenced the treatment outcomes.

Table 1.

Patient selection.

Inclusion criteria	Exclusion criteria
Female patients aged 30–60 years	Presence of systemic inflammatory diseases, such as rheumatoid arthritis or lupus.
Diagnosis of stage II or III lipedema based on clinical evaluation and ultrasound imaging	History of lymphatic or venous insufficiency unrelated to lipedema
No previous liposuction or other surgical treatments for lipedema	Use of anticoagulants or antiplatelet therapy
	Pregnancy or breastfeeding

Surgical procedure

All patients underwent power-assisted liposuction (PAL) under general anesthesia. The procedure began with tumescent infiltration, where a solution containing epinephrine and saline was introduced into the targeted areas to facilitate fat extraction and minimize bleeding. As local anesthetics were not used due to general anesthesia, the risk of systemic toxicity was eliminated. Fat extraction was then performed using a 3-mm diameter cannula, with an average aspirated fat volume of 3000 to 5000 mL, depending on the patient’s body surface area and the severity of lipedema. Postoperative care included the application of class II flat-knit compression garments and the initiation of manual lymphatic drainage (MLD). MLD was initiated within 2 h postoperatively and continued regularly - two to three sessions per week - for a duration of 4 weeks. This regimen was standardized across all participants to optimize postoperative recovery and reduce edema.

Shockwave therapy protocol

In the SWT group, patients underwent focused shockwave therapy (FSWT) sessions starting 7 days after surgery. The therapy was administered using a certified medical device, such as the Storz Medical Duolith® SD1, specifically approved for treating soft tissue disorders (Table 2). Sessions were conducted three times per week over a 3-week period, resulting in a total of nine treatments. The therapy targeted areas with the highest risk of fibrosis, such as the calves and the perimalleolar regions.

Table 2.

Energy parameters.

Energy flux density	0.15–0.25 mJ/mm²
Frequency	5 Hz
Number of pulses	2500 pulses per session

The primary outcomes were evaluated at 1 month, 3 months, and 6 months postoperatively. Fibrosis severity was assessed using high-resolution ultrasound elastography (Philips EPIQ 7G), which quantified tissue stiffness in kilopascals (kPa) and was graded on a 5-point scale, ranging from no fibrosis to extensive fibrosis with nodularity. This imaging technique is sensitive to tissue stiffness and has been widely adopted for non-invasive evaluations in various clinical settings. It utilizes changes in tissue elasticity to generate both qualitative and quantitative data for diagnostic purposes, aiding in the assessment of conditions such as liver fibrosis, breast lesions, and thyroid nodules. For instance, a study by Ferraioli et al.²¹ discusses the application of shear wave elastography for evaluating liver fibrosis, highlighting its effectiveness in clinical practice.

Skin elasticity was measured with a cutometer (Courage + Khazaka, Cologne, Germany), analyzing the viscoelastic properties of the skin and expressing results in millimeters of deformation under standardized suction force. The cutometer is a well-recognized device for measuring skin elasticity and firmness. It applies gentle suction to a small sample of the skin surface, allowing for objective assessment of skin mechanical properties. Studies have demonstrated its effectiveness in evaluating skin changes in various conditions, including scleroderma, with reported positive predictive values (PPV) of 88% and negative predictive values (NPV) of 90%.^22,23

Pain levels were evaluated using a visual analog scale (VAS) that ranged from 0, indicating no pain, to 10, indicating severe pain. Patient satisfaction was determined through a standardized questionnaire, which assessed aspects such as postoperative recovery, aesthetic outcomes, and overall satisfaction with the procedure. Scores for satisfaction ranged from 1, representing very dissatisfied, to 5, representing very satisfied.

Statistical analysis

Data were analyzed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA). Continuous variables were expressed as mean ± standard deviation (SD) and compared using the Student’s t test for normally distributed data or the Mann-Whitney U test for non-normally distributed data. Categorical variables were compared using the chi-square test. A p-value <.05 was considered statistically significant.

Multivariate regression analysis was performed to adjust for potential confounding factors, such as age, BMI, and volume of aspirated fat, to determine the independent effect of SWT on fibrosis prevention.

Results

A total of 75 female patients were included in the study, with 50 patients in the Shockwave Therapy (SWT) group and 25 in the control group. Both groups were comparable in terms of baseline characteristics, including age, body mass index (BMI), and volume of fat aspirated during liposuction. No significant differences were observed between the groups at baseline, ensuring homogeneity of the study population.

The SWT group demonstrated superior outcomes in reducing fibrosis, enhancing skin elasticity, alleviating pain, and increasing patient satisfaction compared to the control group. Postoperative fibrosis severity was significantly lower in the SWT group, with fewer cases of moderate-to-severe fibrosis observed, particularly in high-risk areas such as the perimalleolar region (Figures 3 and 4). Skin elasticity improved markedly in the SWT group, reflecting better viscoelastic properties of the skin. Pain levels were consistently lower among SWT patients throughout the follow-up period. Patient satisfaction with the aesthetic and functional outcomes of the procedure was notably higher in the SWT group, underscoring the therapeutic benefits of shockwave therapy in this context (Table 3).

Figure 3.

Case 1: the patient presented type III, stage II columnae lipedema and was treated with ultrasound-assisted liposuction (VASER^Ⓡ) combined with ultrasound-assisted liposuction (PAL). Postoperative management included manual lymphatic drainage and, starting approximately 7 days after surgery, adjunctive sessions of shock wave therapy. At 5-month follow-up, clinical evaluation demonstrated a highly favorable outcome, with complete resolution og the column-like leg morphology and no evidence of postoperative fibrosis, particularly in the perimalleolar regions, which are tipically prone to fibrotic changes. A natural and harmonious contour of the lower limbs was achieved.

Figure 4.

Case 2: The patient exhibited type III, stage II lipedema with predominantinvolvement of the lower limbs. Surgical treatment consisted of ultrasound-assisted liposuction (VASER®) in combination with power-assisted liposuction (PAL). Postoperative care includedmanual lymphatic drainage and shock wave therapy beginning on postoperative day 7. At 7 months post-surgery, the patientachieved a significant and sustained improvement in limb contour, with restoration of physiological tapering of the legs and no clinical signs of fibrotic tissue formation.

Table 3.

Primary outcomes assessed at 1, 3, and 6 months postoperatively.

Outcome	Result	Notes
Fibrosis severity	At 1 month, the mean tissue stiffness in the SWT group was 18.5 ± 3.2 kPa compared to 25.6 ± 4.1 kPa in the control group (p < .001).At 3 and 6 months, tissue stiffness remained significantly lower in the SWT group (15.2 ± 2.8 kPa vs. 22.4 ± 3.6 kPa at 3 months, p < .001; 12.8 ± 2.5 kPa vs. 20.1 ± 3.2 kPa at 6 months, p < .001).	Only 8% of patients in the SWT group exhibited moderate-to-severe localized fibrosis at 6 months, compared to 40% in the control group (p < .01), mainly in the perimalleolar region.
Skin elasticity	At 6 months, the mean skin deformation in the SWT group was 1.85 ± 0.32 mm, compared to 1.32 ± 0.27 mm in the control group (p < .001), indicating superior skin viscoelasticity.
Pain assessment	At 1 month, the mean VAS score in the SWT group was 3.1 ± 0.8, while the control group reported a mean score of 5.4 ± 1.1 (p < .001). By 6 months, pain levels had further decreased in both groups, but remained significantly lower in the SWT group (1.2 ± 0.4 vs. 3.8 ± 0.6, p < .001)
Patient satisfaction	At 6 months, 84% of patients in the SWT group reported being “very satisfied” or “satisfied” with the aesthetic and functional outcomes of the procedure, compared to 71% in the control group.	Results were scored on a scale from 1 (very dissatisfied) to 5 (very satisfied).

Outcome evaluations - including ultrasound elastography, cutometry, and pain scoring - were performed by independent assessors who were blinded to the treatment allocation. This blinding was implemented to reduce observer bias and improve the validity of the outcome measurements.

Discussion

This study demonstrates that early postoperative shockwave therapy (SWT) significantly reduces fibrosis, improves skin elasticity, and alleviates pain following liposuction for lipedema. These findings highlight the potential of SWT as a valuable adjunctive therapy to optimize both functional and aesthetic outcomes in lipedema patients.

The reduction in fibrosis observed in the SWT group underscores the efficacy of shockwave therapy in modulating the wound healing process. Fibrosis in lipedema is driven by chronic inflammation, lymphatic dysfunction, and mechanical stress, all of which contribute to excessive extracellular matrix (ECM) deposition and tissue stiffening.¹¹

Shockwave therapy (SWT) disrupts the pathological processes underlying fibrosis by suppressing fibroblast proliferation and inhibiting myofibroblast differentiation,¹⁷ which significantly reduces tissue stiffness, as confirmed by ultrasound elastography. Additionally, the mechanical forces generated by shockwaves fragment collagen cross-links and fibrotic adhesions, enabling ECM remodeling and tissue softening.⁹ These findings align with evidence from studies on other fibrotic conditions, such as Dupuytren’s contracture and hypertrophic scars, which highlight the antifibrotic properties of SWT.²⁴

SWT also significantly improves skin elasticity, a clinically important outcome given that postoperative skin stiffness and reduced viscoelasticity can compromise aesthetic results. Enhanced skin elasticity is achieved through the promotion of angiogenesis, driven by increased VEGF expression, which improves microcirculation and oxygenation.¹⁸ Moreover, SWT facilitates ECM turnover by upregulating matrix metalloproteinases (MMPs) and downregulating tissue inhibitors of metalloproteinases (TIMPs), resulting in balanced ECM remodeling and more elastic skin.

Pain management is another critical benefit of SWT for lipedema patients undergoing liposuction, as demonstrated by lower VAS scores in the SWT group. The analgesic effects are likely due to a reduction in pro-inflammatory cytokines, such as IL-6 and TNF-α, which sensitize nociceptors and contribute to pain. Furthermore, SWT modulates nerve activity by decreasing peripheral nerve excitability, thereby reducing pain transmission and providing sustained relief.²⁵

The higher satisfaction scores in the SWT group reflect the combined benefits of reduced fibrosis, improved skin quality, and lower pain levels. Patient-reported outcomes are critical in evaluating the success of liposuction for lipedema, as the procedure aims not only to improve physical appearance but also to alleviate symptoms and enhance quality of life.

While the results of this study are promising, several limitations must be acknowledged.²⁶ The sample size, although adequate, could be increased to improve the generalizability of the findings. Additionally, longer follow-up periods are required to evaluate the durability of the observed benefits. Furthermore, the study did not explore the molecular mechanisms underlying the observed clinical effects, which could offer deeper insights into the therapeutic potential of shockwave therapy.

Conclusion

Early postoperative shockwave therapy is an effective, non-invasive strategy for preventing fibrosis, enhancing skin elasticity, and reducing pain after liposuction for lipedema. By addressing the key pathological processes underlying fibrosis, SWT optimizes both functional and aesthetic outcomes, making it a valuable adjunctive treatment in the surgical management of lipedema. Future studies with larger cohorts and longer follow-up periods are warranted to confirm these findings and further elucidate the mechanisms of action of SWT.

Footnotes

Author’s note

Each artwork is an original work by the authors.

Author contributions

Dr. Bruno A. conceived the study, designed the methodology, supervised the research, collected data, and performed initial analysis. Dr. Cilluffo M. contributed to data interpretation, statistical analysis, prepared the first draft of the manuscript, with input from all authors. All authors reviewed and approved the final version of the manuscript and agree to be accountable for all aspects of the work.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical statement

Guarantor

B.A. is the guarantor for this article and assumes full responsibility for the veracity and integrity of its content, including the accuracy and appropriateness of the reference list.

Agostino Bruno

Matteo Cilluffo

Data Availability Statement

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.*

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