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This Letter to the Editor documents several verifiable internal inconsistencies in the article by Bruno and D’Antimi, including contradictory statements on study design, a level-of-evidence rating incompatible with the stated methods, contradictory informed-consent statements, and references to a procedure and outcome domain that do not correspond to the study performed. A correction or clarification is requested.

BACKGROUND: Lipedema is a chronic adipose tissue disorder characterized by abnormal and disproportionate fat accumulation in the extremities, leading to pain, edema, and functional impairment. Liposuction has become a central component of surgical management. However, postoperative complications, particularly seroma formation, remain a concern. OBJECTIVES: To evaluate the incidence of postoperative seroma and associated risk factors in patients undergoing liposuction for lipedema treatment, based on procedures performed by a single surgical team in a single institution. METHODS: This retrospective observational study included 93 female patients who underwent liposuction for lipedema between April 2019 and January 2024. Data collected included demographic variables, body mass index (BMI), anesthesia type, volume of aspirated fat, percentage of body weight removed, use of adjunct technologies (ultrasound or laser), association with other surgeries such as varicose vein surgery, and prior conservative treatment. The primary outcome was the development of postoperative seroma. Statistical analysis included Chi-square and Student's t-tests and multivariable logistic regression, with significance set at p ≤ 0.05. RESULTS: Among 93 cases, 17 patients (18.3%) developed postoperative seroma. Higher volumes of aspirated fat (% body weight) were significantly associated with seroma formation (7.27% vs. 5.84%, p = 0.005). Concomitant minor procedures were also linked to increased seroma incidence (p = 0.035). No seromas occurred in patients treated using ultrasound-assisted liposuction. Minor complications included one infection and one hematoma (1.07%). CONCLUSIONS: Liposuction for lipedema is a safe and effective surgical option with a low rate of major complications, but seroma remains a relatively frequent postoperative finding. Higher aspirated fat volumes relative to body weight and the presence of concomitant procedures increase the risk of seroma. No seromas were observed in the ultrasound-assisted group; however, this difference did not reach statistical significance and should be considered only as hypothesis-generating. Further studies are needed to validate these findings and guide surgical decision-making. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background  The Questionário de avaliação sintomática do lipedema (QuASiL – Lipedema Symptom Assessment Questionnaire) assesses 13 distinct inflammatory symptoms of lipedema, but whether these symptoms resolve and recur simultaneously or follow a consistent order remains unknown. Objectives  To characterize the persistence hierarchy of the 13 QuASiL inflammatory symptoms in a retrospective lipedema cohort under heterogeneous conservative treatment, using 6 complementary rank-order analyses and testing the null hypothesis that symptoms resolve with equal magnitude. Methods  This retrospective longitudinal study included 1,300 patients who were clinically diagnosed with lipedema by a vascular surgeon and who completed the QuASiL on at least 2 occasions (minimum 14-day interval; median follow-up 181 days, IQR 92–380, maximum 1,787 days). A consensus ranking was computed across all analyses. A sensitivity analysis was conducted using the conventional T0 = first visit, T1 = last visit convention, and a Kaplan-Meier survival analysis estimated the time (in absolute days) to ≥ 50% reduction from baseline per symptom. Results  The symptoms did not resolve simultaneously (Friedman χ2 (12) = 168.08, p < 0.001). All 13 symptoms improved during follow-up, showing a consistent order across the 6 analyses. A slower-resolving core was identified: bruising (consensus rank 1.7), swelling (2.0), touch sensitivity (4.3), leg heaviness (4.7), and fatigue (4.7). A rapidly-responding group comprised skin irritation (66.4% proportional reduction), itching (62.0%), and walking difficulty (62.6%). Even the most resistant symptom (bruising) achieved a mean 39.1% proportional reduction, with half of patients reaching ≥ 50% improvement. During worsening, swelling and pressure/tension re-emerged first. The sensitivity analysis (T0 = first, T1 = last) produced an essentially identical ranking (Spearman ρ = 0.945, p < 10−5). The Kaplan-Meier analysis estimated a median of 546 days for bruising vs 207 days for itching to reach ≥ 50% reduction from baseline (log-rank χ2 = 44.6, p < 10−10); the fastest-resolving symptom was heat/burning at 203 days. Conclusions  In this retrospective cohort of patients under heterogeneous conservative treatment, the 13 QuASiL inflammatory symptoms improved following a consistent order across 6 independent analyses, with bruising and swelling as the most persistent symptoms. Keywords: lipedema; inflammatory symptoms; resolution order; bruising; patient-reported outcomes; longitudinal study

SUMMARY OBJECTIVE: The aim of this study was to characterize global scientific output on lipedema from 2000 to 2025 and identify emerging thematic trends, with emphasis on the emergence of immunological research. METHODS: Publications indexed in Google Scholar, PubMed, Crossref, OpenAlex, and Scopus were retrieved using the terms "lipedema" OR "lipoedema." Records were deduplicated by normalized title matching and DOI cross-referencing. Bibliometric indicators computed included publication volume, citation metrics, field h-index, exponential growth rate, geographic distribution, author metrics, specialty classification (journal-name keyword matching supplemented by OpenAlex concept tags), and immunological content (regular-expression pattern matching against a predefined term list). RESULTS: A total of 942 unique publications were identified, accumulating 13,688 citations (field h-index=60; mean 14.5 citations per article; median 2 citations per article). Annual output grew from below 12 per year through 2009 to 145 in 2025, with a doubling time of 3.6 years (R2=0.90; p<0.001). The United States, Germany, and Brazil were the most productive countries. Karen Lynn Herbst (USA) was the most influential researcher (46 papers; h-index=20; 1,586 citations). Lymphology and phlebology formed the dominant classifiable domain (17.1%), with 69.3% of publications spanning multiple disciplines. Publications with immunological content totaled 30 (3.2%), grew from essentially zero before 2019 to 4.8% of annual output in 2025, and received higher mean citations than non-immunological articles (16.6 vs. 14.5). CONCLUSION: Lipedema research is undergoing rapid exponential expansion driven by growing global recognition of a historically neglected condition. The accelerating immunological trend, with consistently higher citation impact, indicates an accelerating paradigm shift toward chronic adipose tissue inflammation as a unifying pathophysiological framework.