Table 1. Basic demographics of the included articles.

Study ID	Study design	Country	Total number of patients	Age (years)	Clinical recommendations	Level of evidence
Cornely and Gensior, 2022 19	Retrospective cohort	Germany	504	16–78	• Immediate mobilization is a part of postoperative care for lipedema patients • Combined AMLD therapy and physical treatment are recommended for 4 weeks after the procedure • A 5-day course of antibiotics is prescribed as part of postoperative care • Thrombosis prophylaxis is administered for 3 days using low-molecular-weight enoxaparin sodium	II
Kruppa et al, 2022 5	Retrospective cohort	Germany	106	18–68	• Early surgical intervention improves long-term outcomes in managing the disease • Favorable long-term outcomes are achievable in younger individuals with a body mass index of 35 kg/m 2 or lower • The pinch test aids surgeons in assessing the surgical outcome and determining the necessary amount of lipoaspirate	II
Wright and Herbst, 2022 21	Case series	United States	3	Case 1: 55 Case 2: 38 Case 3: 62	–	I
Baumgartner et al, 2020 22	Prospective cohort	Germany	60	22–68	• Tumescent liposuction in lipedema improves pain, edema, bruising, and movement restriction • It reduces the need for additional conservative treatments and enhances quality of life • Specialized centers with experienced surgeons should perform the procedure	I
Sandhofer et al, 2021 23	Prospective cohort	Germany	41	–	• Study participants reported a long-lasting decrease in symptom severity • The need for conservative therapy was reduced in patients even after 12 years postprocedure • The findings suggest that liposuction is an effective treatment for lipedema	II
Schlosshauer et al, 2021 24	Prospective cohort	Germany	69	24–58	• Adhering to standard guidelines for liposuction ensures the safe performance of large surgical procedures on ambulatory lipedema patients	II
van de Pas et al, 2020 25	Prospective cohort	Netherlands	117	40.9–42.2	• Tumescent liposuction treatment for lipoedema, whether under local or general anesthesia, significantly improves health-related and disease-specific quality of life • The general health status shows positive improvement with an increased number of treatment sessions	II
Witte et al, 2020 26	Prospective cohort	Germany	63	–	• Lymphatic insufficiency significantly influences the pathophysiology of lipoedema • Tumescent liposuction does not appear to reduce lymphatic function in individuals with lipoedema	II
Bauer et al, 2019 27	Cross-sectional	Germany	209	20–68	• Implementing a standardized treatment plan is essential for consistent surgical outcomes and reducing complications • Early intervention is crucial to prevent lipolymphedema and irreversible damage to the lymphatic system, emphasizing the importance of initiating treatment for lipedema at an early stage	II
Wollina and Heinig, 2019 28	Prospective cohort	Germany	111	20–81	• Early intervention with liposuction is recommended to reduce reliance on conservative treatment and prevent irreversible sequelae of lipedema, such as irreversible damage to the lymphatics.	II
Dadras et al, 2017 29	Prospective cohort	Germany	25	23–64	• Liposuction is an effective treatment for lipedema • However, it is crucial to complement liposuction with conservative measures	II
Baumgartner et al, 2016 30	Prospective cohort	Germany	85	28–75	• Liposuction is the most effective treatment for lipedema • However, to achieve maximum benefit, it is crucial to implement a comprehensive treatment concept	II
Rapprich et al, 2015 31	Prospective cohort	Germany	85	–	• Tumescent liposuction is particularly effective when applied to younger patients in the early stages of the disease, compared with older individuals with a severe form of the disease • Controlled compression therapy plays a crucial role in the overall treatment of liposuction, both before and after surgical intervention	II
Wollina et al, 2014 32	Case series	Germany	3	Case 1: 55 Case 2: 72 Case 3: 77	• Older patients with advanced disease require careful postsurgical monitoring • Common adverse events in older patients with advanced disease include temporary methemoglobinemia and leukocytosis • Although better aesthetic outcomes are typically expected in younger patients, tumescent liposuction still shows promising results in older individuals	II
Rapprich et al, 2011 33	Prospective cohort	Germany	25	22–56	• Water jet-assisted liposuction, when used with an appropriate operative technique, leads to fewer complications related to lymphatic injury • The results achieved with water jet-assisted liposuction are comparable to those of tumescent liposuction	II
Wollina et al, 2010 34	Prospective cohort	Germany	2	Case 1: 29 Case 2: 48	• Tumescent liposuction is highly effective in enhancing the quality of life for patients with lipedema • However, it is important to note that lipedema is not curable, and the use of conservative measures such as physiotherapy and compression is still necessary • Expertise is required to perform tumescent liposuction procedures safely and effectively	II
Stutz and Krahl, 2009 35	Prospective cohort	Germany	30	21–63	• Liposuction has shown a significant improvement in the quality of life for lipedema patients, including pain reduction, weight reduction, improvement in clothing size, and enhanced walking ability • However, prospective studies are needed to further evaluate and assess potential complications associated with liposuction in lipedema patients	II
Schmeller and Meier-Vollarth, 2006 36	Prospective cohort	Germany	28	22–63	• To assess the risk of postsurgical lymphatic and other complications in women with lipedema, surgeons utilizing modified suction lipectomy techniques should provide comprehensive complication reports • Longitudinal studies are required to further investigate the incidence and long-term effects of complications associated with modified suction lipectomy in lipedema patients	kIV
Schmeller et al, 2012 37	Prospective cohort	Germany	112	20–68	• Lipedema is distinct from obesity as it is not linked to metabolic disorders like type 1 or type 2 diabetes, high blood pressure, or abnormal lipid levels • Postsurgical outcomes demonstrate a noteworthy enhancement in the quality of life for lipedema patients • Further investigation is required to determine if there is a causal relationship between hypothyroidism and lipedema, addressing the potential link between the two	IV
Herbst et al, 2021 38	Retrospective cohort	United States	148	42–62	• An individualized approach to lipedema is recommended, and it proves to be effective even in cases involving multiple comorbidities and elderly patients • For older patients with multiple comorbidities, the use of prilocaine instead of lidocaine is recommended to mitigate the risk of cardiotoxicity	IV

Abbreviation: AMLD, active manual lymphatic drainage.