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Diagnosis & treatment

Lipoedema – abnormal fat distribution

Lipoedema is not a build-up of fat caused by being overweight; it is an abnormal distribution of fat over the thighs, lower legs and hips. It is associated with an increased number of pathologically modified fat cells. Since it is almost exclusively women who suffer from lipoedema, experts suspect that the causes are hormonal. Amongst the few men with lipoedema, the liver is often damaged.

Symptoms of leg lipoedema

  • Negative Stemmer's sign
  • Tendency to spider veins
  • Tendency to bruise easily
  • Increased swelling of the lower legs later in the day
  • Symmetrical swelling
  • Pain on contact or pressure
  • Family history
  • Soft, knotty skin with typical pitting

In some cases, the arms are also affected. Lipoedema is always symmetrical. There are "pillar-like" changes and deformations of the legs, with "saddlebags" around the hips and bottom. If the disorder spreads down the legs, we talk about the "baggy trouser" effect, since the deformed swelling generally ends at the ankle but the fat overlaps onto the feet.

Lipoedema is sensitive to pressure and touch. In the advanced stage, even close-fitting clothing can be painful.

What are "saddlebags"?

The term "saddlebags" is used colloquially to describe the build-up of fat on the bottom, hips and insides of the knees which occurs almost exclusively in women.

 Diet-resistant accumulations of fat

Often, it is actually women with slim upper bodies who are affected. If the accumulation of fat persists despite dieting and exercise, these "saddlebags" can be a sign of lipoedema. Another indication of lipoedema is a tendency to suffer from spider veins, to bruise easily and to feel pain on contact or pressure.

Unlike lymphoedema, it is always both legs that are affected – and sometimes the arms too.

Differences between lipoedema and lymphoedema

There are several ways to distinguish lipoedema from lymphoedema


  • Stemmer's sign is negative – that means that you can lift up a fold of skin over the second or third toe or on a finger
  • Tendency to spider veins
  • Tendency to bruising
  • Increased swelling of the lower leg later in the day
  • Lipoedema is always symmetrical, that means it affects both legs
  • Sensitive to pressure and touch
  • In the advanced stage, even close-fitting clothing can be painful


Stemmer's sign is positive – that means that you can't lift up a fold of skin at the second or third toe

Risk factors and causes

diagnosisLipoedema almost only affects women and girls. Experts think that the causes are hormonal. Lipoedema generally first appears towards the end of puberty, during pregnancy or during the menopause. In addition, a tendency to develop lipoedema seems to be hereditary.

How to prevent it

During the early stages of lipoedema, exercise and a healthy diet can help. You should exercise around three times a week, but for at least 45 minutes. Compression stockings must be worn any time you exercise, as this will prevent any further swelling.

Tips for living with lipoedema

Lipoedema is a chronic disorder. Alongside the medical treatment provided, your personal behaviour will also determine how well you can live with oedema.

  • Exercises

Exercises are a good idea, but only if you wear compression stockings or bandages. Without compression, your legs would swell up even more because of the movement. The following types of exercise are most suitable:

  • Power walking
  • Walking
  • Hiking
  • Aerobics
  • Aqua jogging
  • Swimming
  • Comfortable clothing

Make sure that you wear loose clothing and comfortable, flat shoes. Do not wear tight belts or bras.

  • A balanced diet

Lipoedema is not a build-up of fat caused by being overweight. It therefore cannot be treated by weight loss diets. However, losing weight combined with exercise (wearing compression stockings) can have a positive effect. You should avoid putting on weight in any case. If you are overweight, you should try to keep your body mass index (BMI) between 19 and 25.

  • Medication

Medications and creams unfortunately have absolutely no effect on lipoedema.

  • Skin care

Hygiene is particularly important for oedema patients. You should always use cleansing and skincare products that have a neutral pH. Deodorants should not be used in the areas where you have oedema.

How is lipoedema treated?

Lipoedema occurs almost exclusively in women and girls. Diet and exercise cannot treat it successfully, but compression therapy achieves very good results. It prevents the oedema from developing any further. So rest assured, you can do something to tackle your oedema.

Compression garments will reduce lipoedema or make sure it doesn't get any worse. In Stage 1 often just seamless, round knit compression stockings in compression class 2 (CCL 2) or 3 (CCL 3) are worn. In most cases, however, experts recommend flat-knit compression garments.

The stockings should be worn every day if possible and on at least three days a week (and also when you do excercises). Your doctor or medical supply will be happy to advise you. Patients in Stage 2 should only wear flat-knit compression stockings (with seam).

In Stage 3, complex physical decongestion therapy (CPD) is used, as it is for lymphoedema. It starts in Phase 1 with manual lymph drainage followed by application of a compression bandage. This phase is followed by the maintenance phase, when compression garments are worn. Once again, flat-knit products are used, because the material is less elastic and offers the best pressure stability.

Other forms of treatment: liposuction

Another form of treatment is liposuction, where the fat is actually sucked out. Pitting of the skin may occur after this intervention. However, this can be largely avoided by wearing special compression garments. Before undergoing liposuction, you should talk to your doctor to see whether this is the best option for you.

To summarise: If your legs, hips or bottom are getting bigger, don't just think about dieting. Ask your GP (or a phlebologist) whether you might have lipoedema. If you do, take the advice you're given as in regard to your treatment and make sure you get plenty of exercise – but always wearing compression garments. Eat a healthy, balanced diet. In this way, you'll stay fit and mobile – even if you do have lipoedema.

Lipedema – signs and symptoms

Lipedema, first described in the 1940s in the United States, is a rare disease of unknown origin. It occurs almost exclusively in women and is characterized by bilateral symmetric enlargement of the legs as a result of abnormal depositions of subcutaneous fat and orthostatic edema. In most cases, the hips, buttocks, thighs, knees, and calves are affected, sometimes with an abrupt cut off at the ankles. Arms are rarely involved, and hands and feet are never afflicted. The accumulation of fluid results in pain, tenderness and sensitivity to pressure; together with easy bruising it causes significant physical morbidity. Abnormal body proportions in association with edema often result in considerable psychological problems. Although patients may appear with generalized obesity and increased weight, trunk and face are normal in size and contour in most of them. So lipedema may appear in women with normal weight (causing obvious disproportion between upper half of the body and lower extremities) and in women with obesity (showing no obvious body disproportions).

ILipedeman the majority of patients the disease starts almost imperceptibly after puberty, persists lifelong, and progresses gradually. At the beginning, the skin is smooth, and the subcutaneous tissue is soft (stage I); later, the surface of the skin becomes uneven, and nodules can be felt underneath
(stage II). After several decades, patients may present with huge amounts of subcutaneous tissue, legs that have become more tender, and bulging protrusions of fat at the inner side of the thighs or knees (stage III). The etiology and epidemiology of this distinct clinical entity are unknown. While in Germany the number of textbooks and publications dealing with lipedema is quite extensive, this is not the case in most English speaking countries; many clinicians are unaware of this disease, and lipedema is often under-recognized or mis-diagnosed as lymphedema, phlebedema, lipohypertrophy, or obesity


Differential diagnosis

Lymphedema of the legs can be differentiated clinically by Stemmer´s sign (edema of forefoot and toes) and by lymphoscintigraphy demonstrating a reduced lymphatic flow. Phlebedema shows pathological vein function tests. Lipohypertrophy may look similar to lipedema; it also has a circumscribed increase of fat volume but no edema; therefore these women are without pain. Obesity is characterized by an increased body mass index also without edema and without pain. So the entity of lipedema is clearly specified and descriptive terms like adiposis dolorosa or stove pipe leg should be avoided.

In lipedema conservative treatment with manual lymphatic drainage, physiotherapy, and compression hoisery (combined physical therapy) is used as standard régime worldwide. It was introduced by the Dane E. Vodder in the thirties and the German J. Asdonk in the 1960s. Decreases in tenderness and of aching distress in the affected extremities can be achieved by reducing edema. Although improving these symptoms, conservative therapy cannot reduce the amount of fat. In spite of life-long conservative treatment, the disease persists and often progresses. Diet, physical activities like sport, restriction of fluid, and diuretics are all without benefit.


Surgical therapy

In July 2002, preliminary results concerning effective surgical therapy of lipedema by tumescent liposuction were reported during the 20th World Congress of Dermatology in Paris. In the same year, this method of treatment was initiated at the Hanse-Clinic in Luebeck (Germany), a clinic specialized in liposuction for cosmetic and medical reasons.

Since then, more than 70 patients from 22-63 years with lipedema stages I, II and III, who had undergone conservative therapy for many years, were treated by liposuction. Depending on the size and the number of areas affected, operations were performed in one, two, three or four sessions. So up till now more than 200 liposuctions were performed in the deep subcutaneous fat on the inner side, outer side and front side of the thighs and circumferentially in the deep and superficial fat of the calves under tumescent local anesthesia with vibrating microcannulas of 3 and 4 mm diameter (power-assisted liposuction).

The average amount of fat removed per session was 3017 ml with a range of 1060-5500 ml depending on the size and number of operated areas. All patients experienced an often dramatic improvement of body proportions and symptoms. There was a reduction or disappearance of spontaneous pain, sensitivity to pressure, swelling and bruising. Some of these results have been published in many German speaking journals and previously in an English speaking journal.

Wilfried Schmeller, MD
Ilka Meier-Vollrath, MD


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