LYMPHEDEMA or LIPODEMA ?
lipedema, lipoedema and Lymphedema
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Related Terms: Lipedema, lipedema, lipodystrophy, lipadema, lipo-lymphedema,
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What is:
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.
Etiology/ Cause:
Unknown
Complications:
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.
Treatments:
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.
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Lipedema
Lipodema Lipoedema
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.
Come join, be a part of the family!
http://health.groups.yahoo.com/group/lipedema_lipodema_lipoedema/?yguid=209645515
Subscribe: lipedema_lipodema_lipoedema-subscribe@yahoogroups.com
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Lipedema
Comprehensive blog site for brining together all information on
lipedema to go
with our Yahoo group Lipedema, Lipoedema, Lipodema.
http://www.xanga.com/lipedema
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Differential diagnosis protocol for lipoedema:
From a member post by "Itobo" of UK Lymph Forums
http://www.uklymph.com/forums/DynaLink/t/141/viewtopic.php
SECTION A
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?
SECTION B
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.
SECTION C
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.
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LYMPHOEDEMA
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.
Differential
Diagnosis
Lipodema
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
patients
have eaten low calorie diets for many years. In some cases their
stomachs have
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
problem!
Obesity, caused by overeating, does respond to a proper dietary regime;
lipodema
does not.
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.
Psychological
Problems
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.
Treatment
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.
Lymphoedema
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.
Psychological
Problems
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.
Treatment
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.
Acknowledgement
THE LYMPHOEDEMA ASSOCIATION OF AUSTRALIA, INC.
www.lymphoedema.org.au
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Lipedema - status, new perspectives current
Journal of
the German Dermatologi society
Volume 2 Issue 3 PAGE 181 -
March 2004
doi:10.1046/j.1439-0353.2004.04051.x
Summary
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.
Summary 2
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.
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CELLULITE, LINFEDEMA And LIPEDEMATranslated 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.
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Lipoedema Discussion
Broadcast
ABC online: 6.30pm on 7/5/2002
Presented by Dr Norman Swan
Australia
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.
NORMAN
SWAN: Cellulite
is a word that many women dread, something that was invented by the
cosmetic
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.
NORMAN
SWAN: A few years ago it would
have been unthinkable for Margie Broomhead to show her legs on national
television.
And although she is a keen swimmer, she was even too embarrassed to
show them at
the beach.
MARGIE
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.
NORMAN
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
It's
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.
PROFESSOR
NEIL PILLER, FLINDERS MEDICAL
CENTRE: The interesting thing with this group of people is that they
don't seem
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.
NORMAN
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.
Once
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?
by
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.
Definition
Lipedema
(painful fat syndrome) can be defined as a chronic disease that occurs
in female
patients and is characterized by bilateral, symmetrical fatty tissue
augmentation mainly in the hip region and upper and lower leg combined
with a
tendency to orthostatic edema. In male patients lipedema is extremely
rare (2).
Morphology
Fat cells have
a spherical shape and like any other cells contain fat deposits covered
by a
micro filament-reinforced cell membrane. Groups of fat cells form lobes
which
are surrounded by fibrous tissue. The septa between the lobes contain
blood and
lymph vessels and nerves. Fatty tissue has an excellent blood supply
but fat
cell-associated lymph capillaries are not present. Lipedema is likely
triggered
by a microangiopathy with an increased fragility of the blood
capillaries. The
increased capillary permeability then leads to a protein-rich
intercellular
edema. In subsequent stages, inflammation sets in leading to
perivascular
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).
Pathogenesis
Right now, the
pathogenesis of lipedema and other types of fatty tissue enlargement
(lipohypertrophy
and obesity) is still unclear. According to the literature, the
regulation of
the fat metabolism seems to be a very complex process. There might be
interaction with the nervous system, different hormones and the
microcirculation
(3). Genetic factors may play a role too. Details regarding the
connections of
the different systems and the possible influence of drugs have yet to
be
clarified. In addition, it is not known exactly if the increase of
fatty tissue
is caused by hypertrophy or hyperplasia of the fat cells (adipocytes).
An
increased blood flow and an increased angiomotoricity support fat
reduction. In
contrast a reduced blood flow seems to increase the storage of fat. The
same may
be true in cases of a reduced lymph flow.
Diagnosis
Basic
diagnostic procedures including medical history, inspection and
palpation and
additional laboratory tests provide the basis for further examinations
that
might be necessary to finally assess the disease. In most cases,
lipedema
(symmetrical, pillar like volume augmentation) develops during puberty
or some
years later. Heavy hips and thighs are obvious signs. Women with
lipedema
frequently complain about pain by compression independent of the extent
of fatty
tissue proliferation. Small injuries that cause no macroscopic lesions
in
healthy people can result in hematoma due to an increased fragility of
the blood
vessel wall. When the lymphatic system is not damaged the feet are
normal and
the Stemmer sign negative. Lipedema is frequently seen in female
relatives (e.g.
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.
Differential diagnosis
The most
common mistake in the assessment of lipedema is diagnosis as
lymphedema. The
false diagnosis is usually based on the fact that the entire set of
lipedema
symptoms are often not known and cannot be found in many textbooks.
Therefore,
massive lipedematous volume increases in the legs are commonly
diagnosed as
obesity or lymphostatic elephantiasis (7, 8). On the other hand
lipedema can be
seen quite often combined with other diseases e.g. obesity, chronic
venous
insufficiency and lymphedema. With lipo-lymphedema, the tissue is
indurated and
pretibial indentations can be made. Contrary to simple lipedema, the
regions of
the ankle and the dorsal foot are edematous. Natural skin creases are
deepened
and a positive Stemmer sign confirms damage of the lymphatic system (7,
8).
Treatment
Up
till now lipedema could only be treated using conservative methods with
complex
physical therapy and exercises. By this, a reduction of edema and a
decrease or
elimination of tension and pain could be reached. Nowadays the
increased fat
volume can be removed by surgical therapy with liposuction in tumescent
local
anesthesia. However, an existing lymphangiopathy must be considered as
a
contraindication. Liposuction is the most frequently used cosmetic
procedure not
only in the United States but also in Germany. Cosmetic surgery is
lucrative and
is increasingly being performed by non-plastic surgeons and
non-physicians, some
of whom have little more experience than a weekend seminar. The public
perception of this cosmetic procedure as minor cosmetic surgery fails
to
consider the possibility that major complications may result from this
which
could cause fatal outcome according to recent publications. Therefore
it is
strongly recommended that liposuction in lipedema be performed only in
specialized centers using modern techniques (5, 6). Finally, it should
be
mentioned that lipedema is not caused by excessive consumption of
calories;
hence calorie reduction will not be beneficial. Dietary measures are
advised
only with obesity.
References
Allen
E V, Hines E A, Lipoedema of the legs. A syndrome characterized by fat
legs and
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]
-------------------------------------------------------------
TITLE: The Role of the Interstitial Matrix in the Treatment of Lipo-lymphedema
Lipedema, Lipedema, Lipoedema
Author(s):
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
http://www.lymphedema-therapy.com/Lipedema.htm
-------------------------------------------------------------
WEIGHT AND SECONDARY LYMPHEDEMA
http://www.lymphnet.org/question1096.html
-------------------------------------------------------------
Lipoedema
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
bilateral enlargement
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
'painful fat
syndrome'. It was not until 1949 that Wold et al would define
diagnostic
criteria for lipoedema that included bilateral, symmetrical leg
swelling
excluding the feet, which remain normal in size; minimal pitting
oedema; pain
and bruising in the swollen areas and large legs, thighs and buttocks
despite
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
from the
tissues. Fluid accumulation can be due to the absence, damage to, or
obstruction
of lymphatic vessels affecting the transporting capacity of the
system.When the
fluid formation is increased to a point that it overwhelms the capacity
of the
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.
| Characteristic | Lipoedema | Lymphoedema |
| Sex
|
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) | |
| Obesity | yes | variable |
| Symmetry | usually symmetrical | always symmetrical |
| Swollen feet | never | usually |
| Skin consistency | normal or thinner | thicker & firmer |
| Pitting of skin | usually absent | always pits |
| Easy bruising | often | no increase |
| Pain & discomfort | often | infrequent |
| Tenderness | 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.
Treatment
Dieting and
Exercise
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.
Diuretics
Alternatively, diuretics are prescribed, in the belief that the
swelling is
caused by fluid retention, but very little, if any, benefit will be
gained.
Hosiery
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.
Diagnostic Tests
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
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.
Current Research
Treatment is still largely unavailable to many individuals
with lipoedema,
through a lack of understanding as to the causes of the condition.
Research
continues to play an important part in helping to find a cause. The
Lipoedema
Study Group is undertaking one such study at St George's Hospital
Medical School
in London. Through the use of blood samples given by individuals with
lipoedema,
this study aims to identify genes that can predispose an individual to
develop
lipoedema within their lifetime. Currently this study is in the early
stages,
but it is anticipated over the next few years enough families with one
or more
affected relatives will be located to provide the necessary blood
samples for
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.
Conclusion
In conclusion, it has been shown how hard it is to make an
accurate diagnosis
of lipoedema. Often, individuals will present with a combination of
signs and
symptoms, which may overlap with lymphoedema, making a straightforward
diagnosis
very difficult. The key factor to come out of the research so far has
been that
individuals with a diagnosis of lipoedema need to have both physical
and
psychological support to help them overcome the mental anguish, which
accompanies the abnormally large limbs. These individuals need to know
that they
are not 'going mad' and that they are not primarily obese, which is
very often
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
Cranmer Terrace,
London SW17 0RE
Or email psharpe@sghms.ac.uk
http://www.lymphoedema.org/lsn/lsn070.htm
-------------------------------------------------------------
Lipodema - Lipedema
Dr. Reid's Corner
http://www.lymphedema.com/lipedema.htm
-------------------------------------------------------------
Lipodema
http://www.juzo.de/en/pub/health/lipoedema/lipoedema.htm
-------------------------------------------------------------
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 PROBEBreu FX, Marshall M. Phlebologie.
2000;29:124-128.
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.
COMMENTARY:
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
http://www.servier.com/pro/phlebologie/pdfs/01Breu.asp
-------------------------------------------------------------
Pub Med Related Links Page
-------------------------------------------------------------
Case report of swollen legs-- An uncommon cause for a common problem Swollen legs
http://www.medicalandvein.com.au/Lipoedema%20%20%20a%20distinct%20clinical%20entity.htm
================================================
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Lymphedema People / Advocates for Lymphedema
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Support Groups
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The time has come for families, parents, caregivers to have a support
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Lipedema
Lipodema Lipoedema
No matter how you spell it, this is another very little understood and
totally
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All
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Support group for parents, patients, children who suffer from all forms
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Lymphatic
Disorders Support Group @ Yahoo Groups
While we have a number of support groups for lymphedema... there is
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comprehensive information sites on all lymphatic disorders, I thought
perhaps,
it is time that one be offered.
DISCRIPTION
Information and support for rare and unusual disorders affecting the
lymph
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hennekam's syndrome, distichiasis, Figueroa
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