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Disease 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).

Lipedeman 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.

Conservative Therapy

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 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.

Compression Garments for Lymphoedema and Lipoedema

Everything for successful therapy in lymphoedema With compression stockings that are effective and pleasant to wear

The fact is that only consistent compliance with therapy can prevent worsening of the disease. In the treatment of lymphoedema, Complex Physical Decongestion Therapy (CPDT) has proved successful and has now been generally adopted as the first phase of treatment. The effect is to drain away accumulations of lymph, to restructure modified and hardened connective tissue, to activate the muscle pumps etc.

In this first phase a compression dressing using a particular bandaging technique exerts pressure on the tissue and the muscles. It supports decongestion, promotes lymph drainage during exercise and prevents the reflux of lymph fluid into the affected parts of the body. This prevents further swelling.

Compression therapy using compression stockings
The second phase of therapy (CPDT Phase II) is different from Phase I particularly with respect to the compression therapy. Instead of bandages the patient is now given special compression stockings to maintain the success of decongestion. These are manufactured generally on an individual basis, using flat knit technology. Compression garments are available for arms, hands, legs and toes

Decisions concerning compression category (I to lV) and type of garment are taken by the doctor. Modern compression stockings, consist of high-tech fibres that are pleasant to wear and highly permeable to air, which is highly beneficial for the skin.

Tips for successful compression therapy
- Important factors in the success of compression therapy are the provision of comprehensive advice by the doctor and specialist retailer, and also the correct measuring technique for the stockings. Measurements must be taken at specific points.

- In order to be effective, compression stockings must fit exactly. Each patient must be shown exactly how to put these on and take them off correctly and practise this a number of times when the garments are first supplied.

- Special dressing and undressing aids are available – like the compression stockings themselves – from selected specialist retailers.

- It is important to follow the care instructions: only if the compression stockings are properly cared for will they keep their shape and ensure lasting therapeutic success.

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