Loose skin in lipoedema: liposuction, arm lift or thigh lift in Thessaloniki and Athens, Greece

Usually not. Well-planned liposuction does not, on its own, make the skin loose. Laxity appears mainly when the tissues were already very loose before surgery, or when fat was removed too close to the skin. Most of my patients with lipoedema do not need any skin tightening afterwards.

Liposuction became linked with loose skin for two reasons. First, in very lax tissue the fat cannot be removed evenly, and the result is uneven. Second, removing fat too superficially destroys the thin layer of fat that supports the skin, and the skin then wrinkles.

To prevent laxity, I follow two rules when I plan and perform liposuction for lipoedema. First, I always leave an even layer of fat under the skin, so that it keeps its natural support. Second, I plan the operation area by area, after assessing the quality of the tissues, the elasticity of the skin and the extent of the lipoedema. If the skin is already very loose, I tell you from the start, and we decide together whether and when tightening will be needed.

Many patients see their arms or thighs hanging and assume the skin has gone loose. Often, though, it is the weight of the fatty tissue that pulls everything down. Once liposuction lightens the area, the shape improves without any incision. This is why a surgeon has to recognise lipoedema, even when laxity is also present.

For the technique and recovery of the liposuction itself, see the page on liposuction for lipoedema.

I distinguish two kinds of laxity, and they are treated differently. Laxity of the skin itself gives a wrinkled surface and, when it is marked, needs skin removal. Laxity of the underlying tissues, the fat and connective tissue, makes the limb look as if it has dropped, and is treated mainly with correct liposuction.

Skin laxity

The skin loses its elasticity and wrinkles. The causes are ageing, poor collagen quality, major weight loss and destruction of the superficial fat layer by incorrect liposuction. Removing fat does not correct it; when it is marked, an arm lift (brachioplasty) or a thigh lift is needed. In lipoedema I see it more often in older patients, after major weight loss and in stage 3, where a large volume is removed over two or more sessions.

Laxity of the underlying tissues

Here the skin may be in good condition, but the fat and the ligaments beneath it have dropped, usually because of the weight of the diseased fat. It improves mainly with correct liposuction; only severe cases also need tightening. Many patients have both kinds, which is why I assess them separately in each area.

Liposuction is enough when the “loose skin” is mainly the weight of lipoedema fat and the skin still has some elasticity. An arm lift or a thigh lift is needed when the skin itself has become very loose. In every case the lipoedema is treated first, and the need for tightening is judged afterwards.

At consultation I examine each area separately: the quality of the tissues, the elasticity and surface of the skin, the extent of the lipoedema and your body weight. I ask whether you have had liposuction or other surgery before and whether your weight is stable. When laxity is borderline, I prefer to start with liposuction and reassess afterwards, because skin removal can often be avoided. I do not recommend skin removal while the lipoedema is untreated, while your weight has not settled, or for a heavy smoker who cannot stop. In lipo-lymphoedema my approach is more conservative and tailored to each patient.

Less often than most patients think. With lipoedema of the arms, my first step is always to treat the lipoedema with liposuction. I perform an arm lift (brachioplasty) only when the skin itself has become truly loose, and never without liposuction of the same area.

Why do so many arm lifts fail in women with lipoedema?

Because the underlying condition often goes unrecognised. Lipoedema can affect the upper arms and extend below the elbows or towards the armpits. The excess fat makes the arms heavy and look loose, so the patient is sent for an arm lift. Skin is removed, but the diseased fat stays. The result is an operation that could have been avoided, arms that remain out of proportion, and often recurrence or deformity. In most patients, correct liposuction lightens the tissues enough for the laxity to be treated without an incision.

When is an arm lift needed?

When the skin laxity is extensive, because of ageing or poor collagen quality, or when the lipoedema is very extensive or combined with marked obesity, so that the elasticity of the tissues is not enough. I perform the arm lift through a lengthwise incision on the inner side of the arm, from the armpit towards the elbow. The scar may be straight or zigzag, and may reach or pass the armpit or the elbow, depending on how far the laxity extends. A mini arm lift, with a short incision in the armpit only, rarely suits lipoedema.

I can perform the arm lift at the same time as the liposuction or later. I prefer two stages when the laxity is borderline, because we can often avoid cutting away skin, or when the lipoedema is very extensive and a large amount of fat will be removed. The operation is done under general anaesthesia as a day case and takes about 2 hours. The initial recovery takes about 10 days; you wear a compression garment with bolero-style sleeves for 4 to 6 weeks, and the scars need 3 to 6 months to become less noticeable.

A thigh lift corrects loose skin on the inner thigh or around the whole thigh. It was designed mainly for patients after major weight loss. In lipoedema I recommend it only in selected cases, always after the lipoedema has been treated properly, and usually as a second operation after liposuction.

Mini or full thigh lift?

In a mini thigh lift I make a horizontal incision at the top of the thigh, from the crease under the buttock to the groin. It mainly improves the inner thigh down to about its midpoint, and the scar hides fairly well. In a full thigh lift I add a lengthwise incision on the inner side, from the top of the thigh to the knee, to correct laxity along the whole length; this also removes the excess skin on the inner knee.

Why is the thigh lift done as a second operation?

For three reasons. First, liposuction lightens the thigh; in lipoedema the inner thigh is often swollen and heavy, and this lightening is often enough for a thigh lift not to be needed at all. Second, a lighter thigh heals better: the scar does not have to carry a heavy weight, so it stays in place and does not widen. Third, extensive liposuction for lipoedema causes a lot of fluid to leak into the tissues. Combined with a thigh lift, in which the tissues are lifted off their base, it significantly raises the risk of seroma, haematoma and infection, and recovery becomes much harder and longer. For this reason I do not combine liposuction for lipoedema with a thigh lift of this size. The thigh lift is done once all liposuction sessions are complete and the result has settled, usually at least 6 months after the last one.

Recovery and scars

• Anaesthesia: general
• Hospital stay: day case
• Operating time: 2 to 2.5 hours
• Compression garment: 4 to 6 weeks
• Difficulty walking: 10 to 15 days
• Scar treatment: from month 3 to 4

For the first days, avoid stretching the scars and opening your legs wide. After a mini thigh lift the scar is hidden at the top of the thigh; after a full thigh lift, the lengthwise scar on the inner thigh is more visible. We start improving it with laser or other treatments after 3 to 4 months. You can usually return to office work after about 2 weeks. Light walking is fine from the start; gym and sport usually after about 6 weeks.

Both an arm lift and a thigh lift are done as a day case, so you do not stay overnight in hospital. How long you then stay in Greece depends on your wound check, when the stitches come out and when it is safe for you to fly: plan 10 to 15 days in Greece after either operation.

External stitches are removed at 5 to 7 days, at the practice, before you fly. After an arm lift, the initial recovery takes about 10 days. After a thigh lift, walking is difficult for 10 to 15 days, so plan the journey home with this in mind and avoid stretching the scars or opening your legs wide in the first days.

Once you are home, you keep wearing the compression garment for 4 to 6 weeks in total. Follow-up continues by video call at 10 days, 1 month, 6 months and 1 year. Before you travel, arrange help for the first days; nursing care at home for wound care can be arranged if you would like it.

If you also need liposuction for lipoedema, plan for more than one trip. An arm lift can sometimes be done at the same time as liposuction of the arms, but a thigh lift is a separate operation, done usually at least 6 months after your last liposuction session.

Yes, in most cases. I often see women with lipoedema who have already had liposuction, an arm lift or a thigh lift and have functional or cosmetic problems. In most of them the lipoedema had not been diagnosed, so the symptom was treated rather than the condition. I correct most of these cases with further liposuction.

After skin tightening, the most common case is an arm lift performed on lipoedema arms. The arms stay out of proportion with the rest of the body, the scars are wide, and healing was often difficult. In other patients tissue was removed from the upper arm, but on either side, towards the elbow and the armpit, an hourglass shape forms. In others only the inner side was treated, while marked lipoedema remains on the outer side. The same happens after a thigh lift, when lipoedema was treated as obesity or as simple laxity.

Overall, the most common problem follows previous liposuction: the lipoedema was not diagnosed, too little fat was removed, or the skin was left with irregularities and dents.

Depending on the problem, I perform further liposuction to correct the imbalance, fat transfer to fill the dents, a repeat arm lift or thigh lift, or scar revision. At consultation I ask for the records of the previous operation, where available, and I examine the remaining lipoedema, the scars and the skin quality separately before I suggest any correction. The best correction, though, is prevention: before any operation on the arms or legs, liposuction or skin tightening, lipoedema should be ruled out. For the symptoms and the self-assessment questionnaire, see the lipoedema page.