LYMPHEDEMA or LIPODEMA ?
lipedema, lipoedema and Lymphedema
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Lipodema is a medical condition that is often confused with lymphedema. The individual with this condition may appear to be simply obese and/or to have extremely swollen legs and swollen abdomen. The condition is an uneven distribution of fat cells in the sub-cutaneous regions generally in the legs or abdomen. One major frustration of people with lipodema is that they are accused of being simply "fat," which is absolutely not the case.
Perhaps one of the most critical complication is the acquisition of secondary lymphedema. The increased weight can crush the lymphatics causing blockages and hindrances to lymphatic flow. Another complication is deterioration of the joints and vertebrae from the excessive weight. Other complications may include varicose veins and/or the deep venous system. Many lipodema patients also experience a tremendous amount of pain due to the condition and the affects on the body's systems. Other complications may include "pins and needles" discomfort, decreased vascular flow in the affected limbs and a decreased skin temperature in the affected limbs.
There is no known "cure" for lipodema. Because it is not a medical condition caused by over-eating and improper nutrition habits, diets will not a much of an effect. Neither can the condition be treated with medicines or diuretics.
Treatments that have helped include massage therapy in conjunction with compression bandages, benzopyrones, which includes the use of coumarin. Liposuction has also been used, but the long term success is still open to debate.
Lipodema or Lymphedema:
The signs of lipodema are distinctly differant from lymphedema. First, swelling does not extend to the feet, but extends from the abdomen to the ankle. Second, the limb texture is rubbery not hard. Third, pitting edema is not present. Fourth, Stemmer's sign is negative and finally infections that plague lymphedema patients are generally not a problem with lipodema. The reason for this is that lipodema is not caused by a malformed or damaged lymphatic system.
No matter how you spell it, this is another very little understood and totally frustrating conditions out there. This will be a support group for those suffering with lipedema/lipodema. A place for information, sharing experiences, exploring treatment options and coping.
We now have almost 1,100 members in our group with many international respected doctors and experts participating.
Come join, be a part of the family!
Comprehensive blog site for brining together all information on lipedema to go with our Yahoo group Lipedema, Lipoedema, Lipodema.
This blog is now the only site that some of the best research articles can be found as other sites do not exist any longer.
Differential diagnosis protocol for lipoedema:
From a member post by "Itobo" of UK Lymph Forums - The link is no longer working
Proceed to Section B only if the answer is Yes to at least one of the following:
1. Pattern of fat concentrated in abdomen and thighs (pear shape)?
2. Ankles and feet, AND/OR wrists and hands are smaller than would be expected for the weight on the remainder of the body?
3. Reports consistent difficulty in losing weight after just one to four weeks of initial success?
Proceed to Section C if:
A. The answer to two or more of the first six questions is Yes; and/or
B. The answer to one or both of questions 7 or 8 is Yes; and/or
C. The patient is under 30, and the answer is yes to two or more of questions 9-12, and at least one of questions 1-8.
1. Based on your clinical experience, is this person's weight higher than you would have expected?
2. Is there adipose tissue evident in the affected areas, particularly the abdomen and/or the thighs? (cottage cheese skin extending below the buttocks)
3. Is there evidence of a weakened immune system (frequent colds, bronchial infections, onset of asthma, etc.) which is not otherwise explained?
4. Are there joint pains which cannot be otherwise explained (eg. Symptoms similar to gout, without high uric acid levels; pain in the knee, without evidence of arthritis or rheumatic condition).
5. Is the pattern of weight in each leg symmetrical?
6. Does the patient report pain emanating from the adipose tissue, particularly when pressure is applied?
7. Is there edema (pitting or non-pitting) evident on the ankle?
8. Is there a history of cellulitis, sensitivity to sun, and/or adverse reactions to insect bites?
9. Is there a family history of thyroid or hormonal disorders?
10. Is there evidence of flat feet?
11. Is there evidence of papilloma (skin tags) or peau d'orange skin (rough, resembling an orange peel), particularly between the thighs?
12. Is there a family history of obesity that is concentrated among female relatives (cousins, siblings, parents, children, aunts), or is there a diagnosis of lipoedema or lipo-lymphoedema among any close relatives?
In the above, questions 1-6 relate to both lipoedema and lipo-lymphoedema. Questions 7 and 8 relate more closely to lipo-lymphoedema. Questions 9-12 relate to indicators commonly reported by those with one of these conditions.
Continue to this section only if indicated by Section B.
Lipoedema or lipo-lymphoedema (if pitting edema or significant ankle/foot edema is present) should be suspected. Follow up with a one week treatment regimen involving 1.5 hour daily manual lymphatic drainage (MLD), accompanied by day and night-time compression bandaging using short stretch bandages. Treat the leg with the largest measurements. Compare measurements of the treated leg to its pre-treatment size, as well as to the untreated leg.
If treatment results in a reduction in limb volume in the treated limb, follow up with complex decongestive therapy regimen (MLD, short stretch bandaging, skin treatment, and compression garments following the completion of treatment). For lipoedema, the normal treatment period is 2-4 weeks with 1 - 1.5 hours of treatment daily, six days per week. For lipo-lymphoedema, the normal treatment period is 3-4 weeks with 1.5 - 3 hours of treatment daily, 6-7 days per week.
NOTE: Lipoedema and lipo-lymphedema can also occur in the arms and chest. Normally, abdominal and thigh deposits will also be evident when this occurs. However, this is not always the case.
ASSOCIATION OF AUSTRALIA
Recognition, Diagnosis and Treatment of Lipodema Vs. Lymphoedema
Lipodema is a chronic disease of complex causes, many of which we understand little about. These include hormonal imbalance, an inability to metabolise exudate from blood vessels so that those proteins and cells that would normally be metabolised and returned to the circulation are deposited as adipose tissue in the subcutaneous tissue. The blood vessels themselves are affected, venous stasis and vasoconstriction occur and return is diminished especially at the subcutaneous level. This causes arterial constriction which accounts for the cold and often pale skin and leads to an increased lymphatic load(1). The condition worsens over years as tissue channels become progressively narrowed until the condition of a secondary lymphoedema, overlying the original lipodema, may lead to a situation where the patient may be either wheel-chair bound or bedridden. Weight gains can be up to or greater than 250 kgs. At this stage infections and intractable ulcers (or ones that necessitate skin grafts when lack of oxygenation to the skin causes problems with healing) which can be due to the simplest injury e.g. careless donning of a compression garment or other minor trauma, occur with an even higher frequency.
This condition occurs predominantly in women, and can in some cases be familial; the rare cases of men with lipodema always seem to include a hormonal imbalance which should be treated if possible. The macrophages themselves become overloaded and cease to play an active role in protein proteolysis and look like fat cells.
Lipodema is often misdiagnosed as obesity in its earlier stages but the symptoms are clear and distinctly recognisable clinically from this. In its later stages it may be more difficult to distinguish from lymphoedema, although the case history and distribution of excessive tissue should provide an indication. The overlying condition of lymphoedema may occur in the later stages. Lipodema can occur in the legs, buttocks and also, but not necessarily, in the arms. It does not involve either the feet or hands until the onset of lymphoedema. The mean age of diagnosis is approximately 35-36 years but it usually starts at puberty. Symptoms of onset, however, can start in childhood, and may be clinically detectable in adolescence. Cellulite, which is a very mild form of lipodema, usually occurs towards or after menopause. It has been suggested that a mixture of primary lymphoedema as well as lipodema can occur in some cases.
There is symmetrical bilateral enlargement of limbs, both in legs (with buttocks involved) or in both legs and arms, but with the obvious enlargement excluding the feet and hands, until the later stages. Enlargement is a gradual but continuous process.
There is no pitting with pressure. The tissue feels more like
"rubber", and is not as hard and fibrotic as in a grade II lymphoedema.
It does not, in the early stages, reduce with elevation.
There is pain on pressure, especially in the medial aspect of the thigh and the base of the spine. As the disease progresses, pain is often caused by the lightest of touches to the skin, particularly later in the day. Pain is also caused by "self pressure" e.g. crossing the legs or sitting with pressure on the spine. The abdomen may also be painful to pressure.
Stemmer's sign is negative; i.e. a skin fold test done on the second toe. If it comes up as a thin fold test when "pinched", no lymphoedema is present. If it is a "lump" this indicates lymphoedema.
Superficial capillaries are easily damaged i.e. the limb bruises easily.
Skin temperature is lowered. Hands may feel clammy (damp), but limbs are cold. General nourishment of the skin is also affected and may cause "patchy" skin, dry in one place, oily in others in the early stages. Skin elasticity is reduced and it usually has an "orange peel" appearance.
"Pins and needles" are common and movement seems to alleviate these to a large extent. A feeling of dizziness may be present. There seems to be a reduction of venous return in the legs when standing which can lead to fainting; this may be prevented by walking.
There is little or no loss of weight with rigorous diet. Many of these
have eaten low calorie diets for many years. In some cases their
been stapled because of misdiagnosis. In some of these cases, this
seems to have
lead to the onset of stomach cancer. It is not the answer to the
Obesity, caused by overeating, does respond to a proper dietary regime;
Joint pains (especially in knees) are common.
Infection of the limb, either bacterial or mycotic is not normally a problem.
Plantar support is reduced i.e. people have fallen arches.
The shape of lipodema may vary, from a inverted "pear" shape (like a classical Greek column) to a more bulbous shape from the ankles upward. (Figs. 1-2.) This also usually involves the buttocks.
Lymphoscintigraphy i.e. time of clearance of a radio-tracer injected into the feet to the inguinal nodes, is normal.
Secondary Lymphoedema Accompanying by Lipodema in the later stages.
Stemmer's sign becomes positive.
Pressure will cause pitting, and there may be a small reduction with elevation.
Folds of skin will further enlarge and feet will swell (Fig. 4.). If arms are affected hands also will swell. If the top of the body is affected the shoulders, thoracic and neck area may be affected as well.
Infection may become a problem.
Diagnosis can normally be achieved by the taking of a careful case history and clinical observation (see above). In the later stages lymphoscintigraphy may clarify this, but the picture is so different from primary lymphoedema that this should seldom be necessary.
All of these patients present with a variety of these problems ranging from lack of self-confidence to lack of confidence in their medical or health workers, often because of misdiagnosis and lack of sympathy, and then to real depression and anxiety and because of their appearance and the lack of understanding of the condition, particularly as their mobility decreases. The whole problem, of course, becomes worse if the onset of lymphoedema further exacerbates the condition.
They are "blamed" for being overweight, told they eat too much or are "cheating" on their prescribed diets. If they are hospitalised for a weight loss program when the situation becomes very serious and they don't lose weight, they are often met by the comment "I am surprised" by their health care professionals and are summarily dismissed as "patients for whom nothing can be done" or "we don't know what is wrong with you" or "you'll just have to live with it". This is not helpful to the patient who should be made aware that the condition is a genetic abnormality and that their obesity is not their fault. Of course, up to a point dieting can help but it will never cure this condition. They obviously, and for good reason, become discouraged and dismayed by their problems, which seem not even to be recognised. When lymphoedema occurs on top of the lipoedema this is a situation which is almost a problem that is so great for them (and again often undiagnosed as such) that they need to be very strong people to cope with it. Sadly, many are not able to do this. Psychological counselling can be helpful; for this poorly understood condition it is seldom offered. Invalid Pensions are not the answer for those that have, until they could not, lead an active and productive life. In many centres in Australia and I am sure worldwide, these patients are turned away from treatment centres (for lymphoedema) as untreatable cases. In some cases they resort to surgery in a final effort to improve their condition. The result of some of these operations (including liposuction and limb reduction) are so appalling that they have to be seen to be believed.
Lipodema can be treated and reduced with careful massage to the normal nodal groups after the truncal areas have been precleared i.e. the superficial inguinal and axillary nodes, then gentle superficial drainage towards these. and compression applied to the legs in the form of bandaging as garments. Although not as easy to treat as is lymphoedema, considerable reduction, easing of pain and improvement in mobility, can be of huge physical and psychological benefit to the patient. Compression bandaging is tolerable, especially after a few days of massage. The overlying lymphoedema, if present, can be greatly reduced. The improved mobility will increase the ability to exercise which will help the calf muscles pump and increase venous and lymphatic return. After the initial decongestion by manual drainage permanent compression causes a significant reduction in adipose tissue and also has a positive influence on the disturbed veno-arterial response.
Benzo-pyrones seem to help this condition considerably, presumably by their stimulation of macrophage numbers and activity. Many patients have reported a considerable weight gain when coumarin became unavailable in Australia. Interestingly, the Italian product CellaseneÔ which is recommended for cellulite, contains benzo-pyrones and other plant extracts that work in a similar way to benzo-pyrones, so despite medical scepticism, this may help in these conditions. Unfortunately the cost of these and other available benzo-pyrones are too high for many people who would benefit from them.
The only diet which may help is a very low protein only diet (250 mg per day) (and nothing else, except, of course, water), which will put the body into a state of ketosis where some of the excess fat may be metabolised. However this usually results in weight loss in already lean areas e.g. the waist and often the upper body. Operative procedures do not attack the cause of the problem. Careful liposuction may produce immediate reduction but considering the destruction of tissue it causes, long term results have not been clinically proven. Other reduction operations are contraindicated. Pumps are normally intolerable because of the pain they cause, and there is no published evidence of them ever being successful in this condition.
Causes of secondary lymphoedema are frequently obvious from case histories and have been discussed already. However primary lymphoedema varies from lipodema in the following aspects.
1. Swelling is a-symmetrical. Indeed, often only one limb is affected, and the swelling clinically apparent (Fig. 5.). If a leg is lymphoedematous the foot is involved. The hand is usually involved with primary lymphoedema of the arm. Lymphoedema all over may present as more symmetrical but the feet are involved from onset.
2. In the early stages pitting may be present and it may reduce with elevation.
3. It is not painful on pressure. The only time pain is experienced is during an episode of infection. If swelling is rapid in the early stages of secondary lymphoedema this is frequently painful.
4. Stemmer's sign is positive.
5. The limb does not bruise easily, as it does in lipodema.
6. Skin temperature is higher in the lymphoedematous limb/s.
7. "Pins and Needles" are rare in primary lymphoedema, (although both these and paraesthesia may occur in secondary lymphoedema). Venous return is usually normal.
8. Dieting will not reduce primary lymphoedema.
9. Knee joints may be affected by both lymphoedema and extra leg weight and may cause pain such as arthritis. The condition is often diagnosed as this and under investigation is pathologically similar.
10. Infection (both bacterial and mycotic), especially in the later grades of lymphoedema may be a considerable and ongoing problem, and cause an exacerbation of the lymphoedema.
As lymphoedema progresses from Grade I, there is excess fibrotic tissue (collagen), adipose tissue, (especially in primary lymphoedema), and a proliferation of other cellular and interstitial tissue elements. The limb ceases to pit with pressure, feels hard to the touch and much less "rubbery" than pure lipodema. As with lipodema, diagnosis can be clarified both with case histories and lymphoscintigraphy.
Lymphoedema can cause psychological problems as well as lipodema. These range again from concern and depression about appearance, to anxiety about the worsening of the condition and of infection, to depression, break-up of relationships with partners, especially if genital lymphoedema is involved etc. etc. This is balanced by the fact that many patients are now aware that some forms of treatment can be obtained, especially if they can afford it, or have Health Cover to assist them. In many areas the public patient is very poorly catered for. Despite these problems lymphoedema patients are usually less "psychologically fragile" than those with lipodema, partly due to the psychological abuse and mockery that many of the latter have suffered.
Complex decongestive therapy (skin care, lymphatic drainage by massage, compression and exercises) are accepted as the best treatment for lymphoedema. Because of the inadequate lymphatic drainage and lack of nodes and with abnormal and fewer lymphatic vessels, drainage needs to be taken to truncal quadrants where lymphatic drainage is more normal. This of course depends on the individuals situation. What drainage that does exist in a limb should also be enhanced by massage. Pumps should never be used in primary lymphoedema. Surgery, unless in very skilled hands, is seldom beneficial in the long term.
THE LYMPHOEDEMA ASSOCIATION OF AUSTRALIA, INC.
Lipedema - status, new perspectives current
the German Dermatologi society
Volume 2 Issue 3 PAGE 181 - March 2004
Due to the lifelong, usually progredienten process and the pronounced suffering pressure the Lipoedem is an important dermatologisches disease picture. By years ago the complexes introduced as standard treatment physical Entstauungstherapie can be obtained a clear acceptance of illness-typical edemas. As new effective procedure the Liposuktion in Tumeszenz local anaesthesia with vibrating Mikrokanuelen proved. A purposeful and durable reduction of the disproportionate Fettgewebsanteile help the concerning due to the improved appearance, the edema reduction and the pain removal to a pronounced improvement of the quality of life.
Because OF the lifelong and often progressive course and the mentally trauma ton the patients, lipoedema is important on dermatologic more disorder. Complex physical therapy programs were introduced as A standard therapy years ago and CAN achieve to impressive oedema reduction. Liposuction in tumescent local anesthesia with vibrating microcannulas has proved tons A new effective treatment. A targeted and permanently reduction OF the fat tissue leads tons on increased quality OF life due ton on improved appearance, reduced tendency tons swelling and less pain.
-------------------------------------------------------------CELLULITE, LINFEDEMA And LIPEDEMA
Translated from Spanish
The cellulite has gotten to be, at least in our means, a true social problem. More and more young women concur to the different doctor's offices afflicted by their aesthetic deterioration that always, for who has it, is of greater severity. The patients, imbuídas in predominant the present currents of exaltación of the corporal aesthetic values, demand to the professional the solution of their problem in the smaller possible time and, if he is feasible, treating that are not left tracks of that cellulite that obsesses them. Not very often they consider a disease that, like any other, must be studied previously to the practice of any therapeutic procedure. We must be sincere and to say that in a great number of cases they are "successful", that is to say, are treated without more diagnosis than the resultant of the clinical impression. The great demand of the last years has generated a great supply of "services". On this aspect we want to remarcar that so certain it is that the cellulite is not considered like a pathological organization that an important percentage of the affected population is not treated by doctors, which is constituted in an atypical fact in which to health it talks about.
From the clinical point of view, according to our experience, it does not offer too many difficulties to differentiate clearly linfedema from the cellulite in the inferior members. This presents/displays to the palpación an irregular surface that can "be taken hold" (the same in the first stages where the surface is smooth) whereas in linfedema the distension of the skin makes difficult that this can be made. Basically, the distension of the skin makes the difference and this one is at the most made a long time more well-known of evolution have: in the cellulite there is an increase in the circumference of the affected member but the surface is irregular, nodules of different size and hardness can be felt and the cutaneous distension can be demonstrated in each subarea determined by characteristic the geographic irregularities this affection. In linfedema skin is, in general, distendida uniformly (sometimes it seems that it is on the verge of exploding), the hardness of weaves is rather uniform although to the palpación zones of greater consistency can be determined than others without that alters the visual sensation of homogeneity. The cellulite does not affect the back of the foot but linfedema yes can do it. Of course, in linfedema secondary the antecedent is conclusive. The dynamic radioisotópica linfografía will be an element very useful for the diagnosis. On the other hand, linfedema can be malignizar and the cellulite no.
Lipedema, however, produces doubts of identity in relation to the cellulite. Földi says that "interesting analogies between the cellulite and lipedema exist" and it sends to us to Ryan and Curri for greater details. Frederic Vines says that the cellulite is "lipedema exclusively located in thigh and glútea zone of many women" and lipedema is "acúmulo of fat located fundamentally in the legs, from the ankles to the hips" (of "the lymph and its manual drainage"). Let us think that the concepts of Vines deserve to deepen themselves to make a suitable interpretation. Caesar Sanchez only speaks of cellulitis and says that he can be generalized or be located being able to take, in the case of the inferior members, a zone or all the extremity; he does not mention to lipedema (of "Cellulite. Its medical and cosmetológico treatment"). Jordi Latorre ("Symposium Zyma on linfedema, Buenos Aires, May of 1992") says:"Lipedema: located in the inferior extremities, it is characterized by acúmulo abnormal of fat, mainly in glútea region, thighs and legs ". It does not mention in his exhibition to the cellulite. Leibaschoff, and col., say: "... These alterations in the capillaries of the fatty weave will increase the permeability of such, as well as a greater hair fragility with the consequent appearance of edemas interstitial interadipocitarios (lipedema)". Soon it says that following Sergio Curri, they classify to the cellulite in diverse estadíos and in first estadío or estadío I it says: "... Histológicamente, we found edema interstitial interadipocitario, formed by the exit of trasudado due to the alteration of the permeability of the capillaries "(Leibaschoff and col.: "Lipoesclerosis (Cellulite)", publication of the School Argentina de Aesthetic Medicina, Buenos Aires, 1988). As we see the difference between cellulite and lipedema presents/displays some difficulty, according to it is come off the exposed thing. Authors have coincidences between different in some aspects, like for example in which the name of cellulite is incorrect (more the names of subcutaneous paniculopatía edematosa or fibroesclerótica or fibroedema geloide or liposclerosis would be adapted), which the most affected they are the women (for some he is exclusive of feminine sex) and mainly in which the geographic place where the pathological facts of the cellulite, lipedema and also of linfedema are originated and triggered, is the circulatory microcosm . Let us think that we would approach enough the reality if we considered to the cellulite and lipedema as a same disease although we recognize that it would not be easy to us to associate them in those cases of obese patients, with great deformation of the thighs, mainly, expensa of formation grasocutáneas that even takes the knees altering their forms (they are artrósicas generally knees and the patients have little mobility by all it). Habitually they coexist with linfedema that pronounces clearly in legs and feet (lipolinfedema). We would say that the members in the conditions you decipher suffer lipedema and not a cellulite. Anyway, surely it will be a discussion subject during some time.
If we accepted that the problem is born in the disturbance of the microcirculation, we understand and thus we do it, that the treatment of lipedema, the cellulite and linfedema must be Complex the Descongestiva Therapy (Földi Method). The results obtained in the cases of lipedema/celulite have been beside the point satisfactory. The treated young patients respond to a large extent in excellent form and those that have more years of evolution sometimes they must resort a posteriori to other complementary procedures to improve definitively his aesthetic one (lipoescultura, lifting, etc.).
In all those presumably carrying patients of a lipedema/celulitis we solicitd of routine:
We have found a very important number of patients with subclinical hipotiroidismo and that is the cause by which we requested the test of Tsh-trh. Obvious, the patients are derived (according to she corresponds) the different specialists.
By all the aforesaid one we think that our position is well clear:
The women (or men) carrying of lipedema/celulite have a disease that, in addition, affects its aesthetic one. Therefore they must be studied and treated by doctors since in our society, therefore they even say the laws to it, only the authorized one for it they are the professionals of the art to cure. The people with recognized technical capacity will be able to act only under supervision of a doctor. We give by sobrentendido that this is valid also for the linfedema.Preconizamos that to these patients study them meticulously and according to the results it treats them properly. We are not in agreement with certain present tendency for which to the patient who requires an immediate aesthetic solution, without repairing that she is ill, she is responsible herself to him, without further a do, with a procedure (surgical or similar) that does not consider the etiológico treatment of bottom. She must at least notice to it him on the matter.
ABC online: 6.30pm on 7/5/2002
Presented by Dr Norman Swan
Lipoedema is an abnormal accumulation of fat cells which usually occurs in the legs and almost always in women. Unlike obesity the woman’s legs increase in size but not their feet, and the skin is often painful to touch and easily bruised. If there is only a small amount of lipoedema it does not create a health problem but large accumulations of fat can block the lymphatic system and cause lymphoedema (an accumulation of fluid). Unfortunately there are no effective treatments as yet but the Lymphoedema Assessment Clinic at Flinders Medical Centre in Adelaide is currently testing new treatments.
is a word that many women dread, something that was invented by the
industry to make money out of women's fears.
But there is another kind of fat involving women's legs that can cause serious problems.
And they've been trying to find solutions for it in Adelaide.
I went to see what they came up with.
SWAN: A few years ago it would
have been unthinkable for Margie Broomhead to show her legs on national
And although she is a keen swimmer, she was even too embarrassed to show them at the beach.
BROOMHEAD, PATIENT: I reached
the stage where I thought -- "Blow this.
It's something I can't do anything about.
"I'll go down in bathers."
I thoroughly enjoyed it but I could still see people looking at me and you know, "Ooh, look at that!"
and I didn't do it any more.
NORMAN SWAN: As a young woman, Margie had no problem keeping her slim figure but after the birth of her daughter, she needed a series of abdominal operations and she began to put on alarming amounts of weight.
MARGIE BROOMHEAD: The gynie just said "You've got to have, this and you've got to have that, you've got to have -- " and it was endless but nobody was doing anything about me putting on weight.
He did put me on a diet, umpteen other doctors put me on a diet, Every doctor I met put me on a diet.
(Laughs) We got nowhere.
SWAN: Margie's problem wasn't
her eating. It was lipodema.
Lipodema is an abnormal accumulation of fat, almost always in the legs and almost always in women
usually inherited, so Margie's
operations weren't the cause.
In fact, it usually starts to occur when you put on a bit of weight.
But as opposed to general obesity, the weight accumulates, as I said, in the legs and sometimes the arms and dieting won't shift it.
NEIL PILLER, FLINDERS MEDICAL
CENTRE: The interesting thing with this group of people is that they
to respond to diet.
In other words, they can be put on a low-calorie diet and nothing much will happen, they won't lose the weight. They may lose the weight around here on their chest area or their tummy area but their legs will stay the same.
NORMAN SWAN: Researchers at the Flinders Medical Centre in SA became interested in lipodema because it can cause lymphoedema, a pooling of lymphatic fluid in the legs which makes them swell even more.
PROFESSOR NEIL PILLER: In a mild form its OK, but if you get a severe form then the individual fat cells become so large and so significant that they begin to impact on the lymphatic system.
SWAN: Lipodema is poorly
recognized and commonly dismissed as obesity.
To the frustration of women with lipodema, medical science has few solutions.
PROFESSOR NEIL PILLER: I must say with lipodemas, they're very, very difficult to manage.
you've got them, what you can do
is minimise the lymphatic component of them.
It's very hard to manage the fatty component of them.
NORMAN SWAN: But, the news is better for women like Margie whose lipodema is causing lymphatic fluid retention.
Lasers and massage machines are improving the treatment for lymphoedema, significantly reducing the pain and the size of their legs.
MARGIE BROOMHEAD: I still haven't got anywhere near Betty Grable's legs.
PROFESSOR NEIL PILLER: We're working on it.
Lipedema – what do we know?
Professor Horst Weissleder
Allen and Hines described in 1940 (1) “a clinical syndrome, lipedema of the legs, which is frequently very distressing. In our experience it affects solely women. The chief complaint is of swelling of the legs and feet. On questioning, the physician may elicit that enlargement of the limbs has always been generalized and symmetrical. The swelling below the knees is accentuated when patients are on their feet much and in warm weather. Aching distress in the legs is common.”
Since then most of the articles dealing with lipedema have been published in Europe.
(painful fat syndrome) can be defined as a chronic disease that occurs
patients and is characterized by bilateral, symmetrical fatty tissue
augmentation mainly in the hip region and upper and lower leg combined
tendency to orthostatic edema. In male patients lipedema is extremely
Fat cells have
a spherical shape and like any other cells contain fat deposits covered
micro filament-reinforced cell membrane. Groups of fat cells form lobes
are surrounded by fibrous tissue. The septa between the lobes contain
lymph vessels and nerves. Fatty tissue has an excellent blood supply
cell-associated lymph capillaries are not present. Lipedema is likely
by a microangiopathy with an increased fragility of the blood
increased capillary permeability then leads to a protein-rich
edema. In subsequent stages, inflammation sets in leading to
fibrosis, afew areas of fatty tissue necrosis, oil cysts and an
increase in the
number of the macrophages. Prominent mast cell recruitment and other
inflammatory effects eventually lead to interstitial fibrosis (4).
Right now, the
pathogenesis of lipedema and other types of fatty tissue enlargement
and obesity) is still unclear. According to the literature, the
the fat metabolism seems to be a very complex process. There might be
interaction with the nervous system, different hormones and the
(3). Genetic factors may play a role too. Details regarding the
the different systems and the possible influence of drugs have yet to
clarified. In addition, it is not known exactly if the increase of
is caused by hypertrophy or hyperplasia of the fat cells (adipocytes).
increased blood flow and an increased angiomotoricity support fat
contrast a reduced blood flow seems to increase the storage of fat. The
be true in cases of a reduced lymph flow.
diagnostic procedures including medical history, inspection and
additional laboratory tests provide the basis for further examinations
might be necessary to finally assess the disease. In most cases,
(symmetrical, pillar like volume augmentation) develops during puberty
years later. Heavy hips and thighs are obvious signs. Women with
frequently complain about pain by compression independent of the extent
tissue proliferation. Small injuries that cause no macroscopic lesions
healthy people can result in hematoma due to an increased fragility of
vessel wall. When the lymphatic system is not damaged the feet are
the Stemmer sign negative. Lipedema is frequently seen in female
mother, grandmother, sisters).
Based on inspection and palpation lipedema can be graded into three stages:
Stage I: has a normal skin surface. The subcutaneous fatty tissue has a soft consistency but multiple small nodules can be palpated. This stage can last for several years.
Stage II: the skin surface becomes uneven and harder due to the increasing nodular structure (big nodules) of the subcutaneous fatty tissue (liposclerosis).
Stage III: is characterized by lobular deformation due to increased fatty tissue. The palpable nodules varying in size from a walnut up to a fist and can be distinguished from the surrounding tissue by palpation. When the skin is pushed together, the so called peau d’orange or mattress phenomenon can be demonstrated.
common mistake in the assessment of lipedema is diagnosis as
false diagnosis is usually based on the fact that the entire set of
symptoms are often not known and cannot be found in many textbooks.
massive lipedematous volume increases in the legs are commonly
obesity or lymphostatic elephantiasis (7, 8). On the other hand
lipedema can be
seen quite often combined with other diseases e.g. obesity, chronic
insufficiency and lymphedema. With lipo-lymphedema, the tissue is
pretibial indentations can be made. Contrary to simple lipedema, the
the ankle and the dorsal foot are edematous. Natural skin creases are
and a positive Stemmer sign confirms damage of the lymphatic system (7,
till now lipedema could only be treated using conservative methods with
physical therapy and exercises. By this, a reduction of edema and a
elimination of tension and pain could be reached. Nowadays the
volume can be removed by surgical therapy with liposuction in tumescent
anesthesia. However, an existing lymphangiopathy must be considered as
contraindication. Liposuction is the most frequently used cosmetic
only in the United States but also in Germany. Cosmetic surgery is
is increasingly being performed by non-plastic surgeons and
of whom have little more experience than a weekend seminar. The public
perception of this cosmetic procedure as minor cosmetic surgery fails
consider the possibility that major complications may result from this
could cause fatal outcome according to recent publications. Therefore
strongly recommended that liposuction in lipedema be performed only in
specialized centers using modern techniques (5, 6). Finally, it should
mentioned that lipedema is not caused by excessive consumption of
hence calorie reduction will not be beneficial. Dietary measures are
only with obesity.
E V, Hines E A, Lipoedema of the legs. A syndrome characterized by fat
edema. Proc Staff. Meat. Mayo Clinic 1940; 15:184
2) Chen, S. G., Hsu, S. D., Chen, T. M., Wang, H. J. Painful fat syndrome in a male patient. Br J Plast Surg 2004;57(3):282-286
3) Fasshauer,M., Klein J., Blueher M., Paschke R., Adipokine: Moegliches Bindeglied zwischen Insulinresistenz und Adipositas.Dtsch Arztebl 2004;101:A3491-3495
4) Kaiserling E. Morphologische Alterationenen, in M.Foeldi, S.Kubik, Lehrbuch der Lymphologie, 5.Auflage, Urban & Fischer 2002
5) Lehnhardt, M. Homann,H.H., Druecke, . D., Palka, P., Steinau, H.U. Liposuktion–kein Problem? Majorkomplikationen und Todesfälle im deutschsprachigen Raum zwischen 1998 und 2002. LymphForsch 2004;8(2):74-78
6) Schmeller W., Meier-Vollrath I. Moderne Therapie des Lipödems: Kombination von konservativen und operativen Maßnahmen. LymphForsch 2004;8(1):22-26
7) Stroessenreuther R.H.K. Lipoedem und Cellulitis. Koeln, Viavital 2001
8) Weissleder H. , Schuchhardt C., Lipedema in H.Weissleder, C.Schuchhardt, ed. Lymphedema – Diagnosis and Therapy. Köln, Viavital 2001:247-265
------------------------------------------------------------Lymphatic and venous function in lipoedema.
PMID: 8745878 [PubMed - indexed for MEDLINE]
Lipedema, Lipedema, Lipoedema
P.A. Bacci , F. Albergati
Author Affiliation(s): University of Siena, Siena, Italy
OBJECTIVE(s): Lipoedema and lipo-lymphedema are aesthetic pathologies and real infirmities with various etiologies. Thus, they require precise classification of the various pathological forms and then suitable integrated treatment with various methods
METHOD(s): Recent experience has shown the scientific worth of four major treatments whose integration offers the best possible solution:
Lipodema - An Overview
The misunderstood condition
by Pip Sharpe, Research Nurse, St George’s Hospital Medical School
What is lipoedema?
Allan and Hines first described Lipoedema in 1940 as a
of the legs thought to be due to abnormal deposition of subcutaneous
fat and the
accumulation of fluid in the lower legs. They also classified it as
syndrome'. It was not until 1949 that Wold et al would define
criteria for lipoedema that included bilateral, symmetrical leg
excluding the feet, which remain normal in size; minimal pitting
and bruising in the swollen areas and large legs, thighs and buttocks
dieting. In addition, the condition occurs almost exclusively in
females and is
normally first noticed at puberty or pregnancy.
Unfortunately, lipoedema is often not diagnosed and can be mistaken for several conditions including lymphoedema or obesity. Lipoedema can manifest with both physical and psychological problems including: discomfort at sites of swelling, spontaneous bruising and tenderness as well as a hatred for the disproportionally large legs while Western culture values the perception of slender legs.
What is lymphoedema?
The function of the lymphatics is to clear protein and water
tissues. Fluid accumulation can be due to the absence, damage to, or
of lymphatic vessels affecting the transporting capacity of the
fluid formation is increased to a point that it overwhelms the capacity
lymphatics absorptive system, oedema (swelling) occurs.
Lymphoedema of the legs tends to occur after puberty (but can occur at any age) with foot and ankle swelling. It can affect both males and females. In the early stages of chronic (long-term) lymphoedema, the swelling can be reversible. Pitting of the skin is invariably present. Swelling can disappear after a night's rest, although not in established lymphoedema. Yet, if this swelling continues and is left untreated, it will continue to increase and the skin may become hardened, dry and scaly in appearance.
The increase in weight can cause joint problems, leading to a reduction in mobility and pain occurring in the affected limbs. As a result of the swelling and altered local immunity, cellulitis may occur. This manifests as hot, red skin that can break down because of blistering. The individual may become systemically unwell and experience flu-like symptoms. A prescribed course of antibiotics as soon as possible is required. If very unwell, the patient may require intravenous antibiotics in hospital.Multiple episodes of cellulitis can occur leading to treatment using long term prophylactic antibiotics.
How does lipoedema differ from lymphoedema?
To further explain lipoedema, it is necessary to compare this condition to lymphoedema. Lymphoedema is usually asymmetrical and can be either acquired (through injury to the limb or tumours) or congenital (hereditary). Lipoedema on the other hand, is seen as the symmetrical enlargement of both lower limbs, beginning at the ankle and extending proximally as far as the waist and appears to be hereditary. The table below further highlights the obvious differences.
||females only||males & females|
|Age of onset||puberty||usually pubertal|
|Family history||around 40% of cases||around 20% of cases|
|(Harwood et al 1996)||(Harwood et al 1996)|
|Symmetry||usually symmetrical||always symmetrical|
|Skin consistency||normal or thinner||thicker & firmer|
|Pitting of skin||usually absent||always pits|
|Easy bruising||often||no increase|
|Pain & discomfort||often||infrequent|
|Effect of dieting||little effect on legs||even loss from trunk & legs|
The sparing of the feet causes a 'bracelet effect' at the ankle. Unlike lymphoedema, lipoedema does not appear to cause skin thickening. The individual will often complain of extreme aching and tenderness within the affected limbs, especially around the knees due to the extra weight. Pain may be much more of a feature than with lymphoedema.
How does lipoedema differ from obesity?
Body fat is made up of adipose tissue that is important as a store of energy. This fat can be mobilised quickly in response to metabolic demands. Obesity can be thought of as excess body fat. This can cause health problems including; high blood pressure and diabetes. If an obese individual attempts to diet, the weight will be lost uniformly from all over the body. Yet, an individual with lipoedema will lose weight preferentially from upper body and face. The reason for this at present is not known.
What causes the fluid retention to occur in lipoedema?
Whilst fluid retention appears to occur to a significant degree with lymphoedema, it has been recognised with lipoedema that in the early stages the oedema may be minimal but over time this will increase and an individual may present with lipoedema and lymphoedema. So both conditions may coexist.
This condition is often misdiagnosed and treatment can be haphazard. Individuals are advised to diet and lose the excess weight. This can in the short-term, help if the individual is obese. If the individual is not overweight and just disproportionally large from the waist down, this can potentially lead to a state of anorexia. The individual will attempt to lose weight, unfortunately, due to the nature of the condition, the individual will remain large from the waist down, whilst losing the weight from the upper body and face. This can exacerbate the disproportionate nature of the condition, leading to increased feelings of depression and disturbed body image.
Exercise is essential not just for 'burning fat' but also for enhancing any 'sluggish' lymph drainage, which likely co-exists. The best exercise to undertake is water aerobics. This will support the joints whilst allowing resistance to occur which will increase your heart rate. If this is not appropriate then walking can be of benefit either on a treadmill or outside. However, this may put added stress onto already painful knee joints.
Alternatively, diuretics are prescribed, in the belief that the swelling is caused by fluid retention, but very little, if any, benefit will be gained.
Perhaps the most successful treatment currently available is the use of surgical support stockings in combination with movement and exercise. These stockings, whilst expensive, can usually be obtained via the GP. The benefits of stockings include; helping redefine the shape of the limb and encouraging improved venous and lymphatic drainage helping to prevent aching, providing exercise is pursued.
Lymphoscintigraphy can distinguish swelling due to lymphoedema from lipoedema. The test involves injecting a very small amount of radioactive material between the toes of the affected limbs. The radioactive tracer is monitored as it is taken up by the lymph glands. If the individual has lymphoedema, this test usually demonstrates that the lymphatic collecting channels are abnormal. In lipoedema, lymph drainage routes are patent and functional.
Liposuction is a commonly undertaken procedure for excess fat (and even in certain cases of lymphoedema). It is best used for localised areas and not over large regions such as a limb. The likelihood of achieving an even effect (liposculpture) is small and cosmetically there may be no improvement.
Treatment is still largely unavailable to many individuals
through a lack of understanding as to the causes of the condition.
continues to play an important part in helping to find a cause. The
Study Group is undertaking one such study at St George's Hospital
in London. Through the use of blood samples given by individuals with
this study aims to identify genes that can predispose an individual to
lipoedema within their lifetime. Currently this study is in the early
but it is anticipated over the next few years enough families with one
affected relatives will be located to provide the necessary blood
genetic analysis. Individuals can either be referred to the study by
their GP or
can contact Miss Pip Sharpe, Research Nurse.
It is hoped that the study will help to bring further awareness of lipoedema and help individuals with the condition to cope better both physically and psychologically with its effects.
In conclusion, it has been shown how hard it is to make an
of lipoedema. Often, individuals will present with a combination of
symptoms, which may overlap with lymphoedema, making a straightforward
very difficult. The key factor to come out of the research so far has
individuals with a diagnosis of lipoedema need to have both physical
psychological support to help them overcome the mental anguish, which
accompanies the abnormally large limbs. These individuals need to know
are not 'going mad' and that they are not primarily obese, which is
definitely not the case.
If you would like further advice about this condition, a leaflet has been produced. Please contact:
Miss Pip Sharpe, Research Nurse
Dept of Cardiological Sciences
St George's Hospital Medical School
London SW17 0RE
Lipodema - Lipedema
Dr. Reid's Corner
-------------------------------------------------------------Painful fat syndrome in a male patient.
PMID: 15006533 [PubMed - indexed for MEDLINE]
-------------------------------------------------------------Tumefactive lipedema with pseudoxanthoma elasticum-like microscopic changes.
PMID: 14690469 [PubMed - indexed for MEDLINE]
................................COMPRESSION DUPLEX-SONOGRAPHY OF LIPEDEMA AND LYMPHEDEMA OF LOWER LIMBS USING A NEW 3 MHZ LINEAR PROBE
Breu FX, Marshall M. Phlebologie.
Differentiation of lower-limb lymphedema from lipedema and simple swelling of venous insufficiency is a difficult problem for most practitioners. Even experienced angiologists may have difficulties in establishing a proper diagnosis, especially in the advanced stages of the diseases. The present authors present their experience in compression-sonography, which facilitated discrimination between lymphedema and lipedema. They used a new 13-MHz linear probe that allowed demarcation of skin from subcutaneous tissues, facilitated subcutis thickness measurement, and demonstrated changes in echogenicity produced by tissue compression.
Painful lipedema showed increased echogenicity and could be compressed only 10% to 20%, while the nonpainful lipedema was compressible up to 50%. There was a direct relationship between pain produced by the probe and compressibility of tissue. Skin and muscles were not compressible. Lymphedematous tissues were nonechogenic, noncompressible, and not painful. Echolucent confluent gaps without color coding were characteristic of dilated lymphatics. All venous structures were compressible, even by slightly pressing the sonographic probe.
Duplex sonography has always been an extremely useful diagnostic tool for differentiation between lymphedema and simple edema of venous insufficiency, especially in the early stages of both conditions. Now, it appears that it will be of value in differentiation of lymphedema from so-called lipedema. Diagnosis of lipedema is important not only for the angiologist therapeutic decision-making, but also for the patient. Ultrasound examination may convince the patient that the lymphatics are not damaged, and prognosis with respect to increases in limb volume and developing inflammatory complications is good. It may also show that pharmacological treatment is not necessary and that elastic compression may be prescribed.
However, some patients will ask for lymphoscintigraphy, to be absolutely sure that lymph vessels have not been affected. I usually combine both diagnostic methods and do it routinely in advanced stages of swelling in obese patients.
The story becomes more complicated when excessive fatty tissue is found in lymphedematous legs. The pathologic mechanisms of adipose tissue formation in limbs with lymphedema has not been clarified to date. Adipocytes accumulate water, but not much protein. What other factors are involved remains unknown.
Normal fat tissue composed of large adipocyte lobules bathing in tissue fluid is evidenced during debulking surgery of lymphedematous limbs, especially in young patients. This fluid may be mistaken on duplex sonography for dilated lymphatics.
Although ultrasonography of tissues remains an invaluable diagnostic tool, it should be combined with lymphoscintigraphy and physical examination of the limb to define the topography of edema. To take one example, in lipedema, the foot is usually free of swelling.
Prof Waldemar L. Olszewski, Warsaw, Poland
Pub Med Related Links Page
Case report of swollen legs-- An uncommon cause for a common problem Swollen legs
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