Abstract
Keywords
We read with great interest the paper by Bruno et al. 1 about shockwave therapy in patients with lipedema: A prospective study, which adds relevant information about post-lipedema reductive surgery (LRS) fibrosis prevention.
Recently, fibrosis has been described as a frequent and unpleasant complication after LRS, 2 in contrast to previous reports, where it was under-described, as these early descriptions were mainly tailored to describing the medical benefits of LRS and the potential major complications of the technique. Besides the importance of exercise, 3 healthy diet and compression therapy as daily habits 4 ; there are good data supporting LRS as beneficial in achieving improved quality of life (QoL) related to pain, mobility, and aesthetic psychological distress. 5
The Bruno et al study 1 concluded that shockwave therapy (SWT) diminished the rate of fibrosis appearance (measured by high-resolution ultrasound elastography) and improved skin elasticity (measured by a cutometer) after LRS with improved patient satisfaction (84% vs 71%) compared with the standard postoperative protocol group.
Whilst the outcomes achieved with the SWT protocol are very promising, we have some questions regarding the post-operative management of both groups; namely, (1) Some radiofrequency therapies are widely used for the prevention of fibrosis and edema, however as far as we are aware they are not evidence based, and clear protocols have not been established.
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Did any of the patients in the control group receive any other treatment when fibrosis was identified? (2) Hematoma leads to impaired lymphatic drainage and edema provides the perfect environment for pro-inflammatory processes to develop.
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Thus, was the presence of hematoma and edema quantified for each group and how was this done? (3) Your study mentioned that class two flat knitted garments were used at the post-operative period - but did you at any stage add additional compression? (4) Seromas, cellulitis, deep vein thrombosis / thrombophlebitis and skin ulcers may alter the protocols and thus outcomes. As much as we acknowledge your study was focused on fibrosis prevention, were there any of the above complications of the procedure? (5) With these results, will you consider SWT in preoperative LRS as a preconditioning fibrosis prevention?
The role of complex decongestive therapy in the post-operative LRS is currently widely accepted as necessary to avoid complications and achieve good outcomes. 8 As previously stated there are no protocols for LRS post-operative adjuncts; thus, some therapies are arbitrary used. Despite the limitations correctly described in the study, we congratulate the authors for bringing evidence in a clear scientific and clinical gap for all surgeons related to LRS; as calves and ankle fibrosis is frequently encountered (and its likely with any technique used for LRS treatment) 9 and further, its often poorly described and extremely hard to deal with.
Footnotes
Author contributions
Both authors contributed equally to the manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.