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Purpose: Assessment of the relation between age and lymph transport in lipedema patients using lymphoscintigraphic function test. Material and methods: 99mTc human serum nanocolloid (37 MBq) was injected subcutaneously into the dorsum of foot (n = 290 feet) in female patients suffering of lipedema, lipolipedema or patients with normal lymph transport. Patients were enrolled in standardized exercise tasks. For the radioisotope uptake calculation regional lymph nodes depth was determined by SPECT (single photon computed tomography). Results: The lymph node uptake of young patients (until 35 years) reaches higher values than the normal collective and decreases significantly with age until it drop's below the normal collective. Conclusions: The lymphoscintigraphic function test of the legs showed an increased transport function of the epifascial lymphatic system by younger and a decreased transport function by elder patients with lipedema compared to the normal population, the high transport values suggest a high lymphatic volume with compensatory capacity increase of the lymphatic system in young patients. According to these results of the lymphatic transport function the age of the patients has to be regarded.

Modern aspects of pathophysiology, epidemiology, symptoms, diagnosis and therapy in lipedema are presented. Within recent years the development of new techniques in local anaesthesia and surgery has revolutionized therapy. By using surgical and conservative methods (tumescent liposuction and combined decongestive therapy) a normalization of body proportions and a reduction of subjective and objective symptoms with a distinct improvement in the quality of life can be achieved.

In vivo measurements in 26 female patients with lipedema and cellulite parameters were carried out before and after therapy by means of complex physical decongestive therapy (CPDT) including manual lymph drainage and compression as main components and/or shock wave therapy (SWT). Oxidative stress parameters of blood serum and biomechanic skin properties/smoothening of dermis and hypodermis surface were evaluated. Oxidative stress in lipedema and cellulite was demonstrated by increased serum concentrations of malondialdehyde (MDA) and plasma protein carbonyls compared with healthy control persons. Both MDA and protein carbonyls in blood plasma decreased after serial shock wave application and CPDT. The SWT itself and CPDT itself lead to MDA release from edematous tissue into the plasma. Obviously both therapy types, SWT and CPDT, mitigate oxidative stress in lipedema and cellulite. In parallel SWT improved significantly the biomechanic skin properties leading to smoothening of dermis and hypodermis surface. Significant correlation between MDA depletion of edematous and lipid enriched dermis and improvement of mechanic skin properties was demonstrated. From these findings it is concluded, that a release of lipid peroxidation (LPO) products from edematous dermis is an important sclerosis-preventing effect of SWT and/or CPDT in lipedema and cellulite. Expression of factors stimulating angiogenesis and lymphangiogenesis such as VEGF was not induced by SWT and/or CPDT and, therefore, not involved in beneficial effects by SWT and/or CPDT.

Lipedema is characterized by bilateral enlargement of the legs due to abnormal deposition of fat tissue from pelvis to ankles. It is seen most frequently in obese women. Lipedema appears to be a distinct clinical entity but may be confounded with lymphedema. AIM OF THE STUDY: To analyze and to compare between lipedema and lymphedema the qualitative and quantitative aspects of lymphoscintigraphy. METHODS: Fifteen women with lipedema were recruited. Mean age of onset of lipedema was 31.5 +/- 15 years. Body mass index was 35.1 +/- 7.9 kg/m2, 13 women were obese. Lipedema was compared to 15 cases of primary lymphedema (women: 13, men: 2) of the lower limbs (unilateral: 13, bilateral: 2), with a mean age at onset of 28.7 +/- 12.6 years. Lymphoscintigraphy of the lower limbs with morphologic (visualization of inguinal lymph nodes) and kinetic (half-life, lymphatic speed of the colloid) studies was performed in all cases. RESULTS: Absence of visualization of inguinal lymph nodes was observed in 14/15 cases of lymphedema and in 1/15 cases of lipedema (p<0.001). In the 13 cases of unilateral lymphedema, colloid half-life was higher in the pathologic limb than in the controlateral limb (230 +/- 92 vs 121 +/- 36 minutes, p<0.01) and lymphatic speed of the colloid was slower (6.91 +/- 0.86 vs 8.16 +/- 1.02 cm/min, p<0.001). The two patients with bilateral lymphedema had an increased half-life and decreased lymphatic speed of the colloid. Colloid half-life was significantly higher in lipedema than in controlateral limbs of lymphedema (154 +/- 23 vs 121 +/- 36 minutes, p<0.01) with no difference in lymphatic speed of the colloid. Colloid half-life was significantly higher in lymphedema than in lipedema (230 +/- 92 vs 154 +/- 23 minutes, p<0.01) and the lymphatic speed of the colloid was slower (6.91 +/- 0.86 vs 8.10 +/- 0.45 cm/min, p<0.001). CONCLUSION: Lower limb lymphoscintigraphy showed lymphatic insufficiency in lipedema without morphologic abnormality as seen in lymphedema. Lymphoscintigraphy is not indispensable but is a useful tool when diagnosis is doubtful. Treatment is difficult and may include weight loss and possible surgery.

Lipedema refers to the abnormal deposition of subcutaneous fat causing a striking enlargement of the lower extremities that is out of proportion to the upper body. Most clinicians are unaware of this disease and thus it is seldom diagnosed correctly. Cutaneous myiasis is the infestation of skin by fly larvae. We describe an unusual case of a woman with lipedema who developed cutaneous myiasis.

Painful fat syndrome or lipoedema is a distinct clinical condition, characterised by bilateral and symmetrical enlargement of the upper and lower leg with tenderness, but excluding the feet. Lipoedema occurs almost exclusively in females, and no male patient has been reported in the literature published in English. We report on an extremely rare presentation of lipoedema in a male patient. A thorough study based on the case history, physical manifestations, and magnetic resonance imaging (MRI) provided valuable clues for a differential diagnosis. Conservative treatment using weight reduction, compression-stocking application, and diuretic therapy was not effective. Tumescent liposuction with postoperative pressure garments provided a satisfactory treatment.

Because of the lifelong and often progressive course and the mental trauma to the patients, lipoedema is an important dermatologic disorder. Complex physical therapy programs were introduced as a standard therapy years ago and can achieve an impressive oedema reduction. Liposuction in tumescent local anesthesia with vibrating microcannulas has proved to be a new effective treatment. A targeted and permanent reduction of the fat tissue leads to an increased quality of life due to an improved appearance, reduced tendency to swelling and less pain.

Up until recently, complex physical therapy has been the mainstay in treatment of lipedema. This generally improved edema and reduced pain and tension in affected patients. More recently, surgical approaches such as liposuction have been used to reduce the fat volume under tumescent local anesthesia. Combining both methods, dramatic improvements can be achieved in treating the disease and in improving the quality of life. However liposuction in lipedema should only be performed in specialized medical centers.

HYPOTHESIS: The causes and management of lower limb lymphedema in the Western population are different from those in the developing world. OBJECTIVE: To look at the differential diagnosis, methods of investigation, and available treatments for lower limb lymphedema in the West. DATA SOURCE: A PubMed search was conducted for the years 1980-2002 with the keyword "lymphedema." English language and human subject abstracts only were analyzed, and only those articles dealing with lower limb lymphedema were further reviewed. Other articles were extracted from cross-referencing. RESULTS: Four hundred twenty-five review articles pertaining to lymphedema were initially examined. This review summarizes the findings of relevant articles along with our own practice regarding the management of lymphedema. CONCLUSIONS: The common differential diagnosis in Western patients with lower limb swelling is secondary lymphedema, venous disease, lipedema, and adverse reaction to ipsilateral limb surgery. Lymphedema can be confirmed by a lymphoscintigram, computed tomography, magnetic resonance imaging, or ultrasound. The lymphatic anatomy is demonstrated with lymphoscintigraphy, which is particularly indicated if surgical intervention is being considered. The treatment of choice for lymphedema is multidisciplinary. In the first instance, combined physical therapy should be commenced (complete decongestive therapy), with surgery reserved for a small number of cases.

Aim: In pathophysiology of lipoedema, almost exclusively seen in women, lymphatic insufficiency might play a significant role. However, little is known about the pathophysiology of these abnormal localized depositions of body fat. We studied the involvement of the lymphatic system in lipoedema of the type Allen-Hines as well as of Typus Rusticanus Moncorps. Patients, methods: The standard (epifascial pathway) and a modified method (subcutaneous pathway) of lymphoscintigraphy was carried out with 28 patients suffering from lipoedema. Uptake percentages normalized to the injected dose were used as functional quantitative parameters. Visual assessment of both studies were done and scored. Patients with oedema of the legs because of venous insufficiency (Widmer stage II) served as a control group. Results: All patients of the control group and all patients with lipoedema of Typus Rusticanus Moncorps showed a normal standard lymphoscintigraphic study by visual scoring as well as by quantitative outcome. Lymph transport from the subcutaneous fat tissue was significant higher (p <0.012) in the group of patients with lipoedema diagnosed as type Allen-Hines than in Typus Rusticanus Moncorps. Conclusion: Epifascial lymph drainage in patients with lipoedema is not significantly disturbed. However, subcutaneous lymphatic drainage significantly differed in patients with lipoedema of type Rusticanus Moncorps in comparison with type AllenHines hinting at a differing lymphatic pathophysiology.

"Lipedema," a special form of obesity syndrome, represents swelling of the legs due to an increase of subcutaneous adipose tissue. In 12 patients with lipedema of the legs and in 12 healthy subjects (controls), fluorescence microlymphography was performed to visualize the lymphatic capillary network at the dorsum of the foot, at the medial ankle, and at the thigh. Microaneurysm of a lymphatic capillary was defined as a segment exceeding at least twice the minimal individual diameter of the lymphatic vessel. In patients with lipedema, the propagation of the fluorescent dye into the superficial lymphatic network of the skin was not different from the control group (p > 0.05). In all 8 patients with lipedema of the thigh, microaneurysms were found at this site (7.9 +/- 4.7 aneurysms per depicted network) and in 10 of the 11 patients with excessive fat involvement of the lower leg, multiple microlymphatic aneurysms were found at the ankle region. Two obese patients showed lymphatic microaneurysms in the unaffected thigh and in only 4 patients were microaneurysms found at the foot. None of the healthy controls exhibited microlymphatic aneurysms at the foot and ankle, but in one control subject a single microaneurysm was detected in the thigh. Multiple microlymphatic aneurysms of lymphatic capillaries are a consistent finding in the affected skin regions of patients with lipedema. Its significance remains to be elucidated although its occurrence appears to be unique to these patients.

Venous oedema, which occurs almost exclusively in the legs, develops due to increased venous pressure following valvular insufficiency, and is marked by blue discolouration, varicosities and, in chronic forms, by brown discolouration of the skin resulting from the deposition of haemosiderin. It is possible to confirm the condition by phlebological instrumental diagnosis. Primary lymphoedema also almost always occurs in the legs. It is caused by underdevelopment of lymphatic vessels, but the skin colour remains normal. It is recognisable by Stemmer’s sign and characteristic thickening of the skin over the toes resulting from subcutaneous protein fibrosis. Lymphoscintigraphy may be required for diagnosis in rare cases. Venous oedema and lymphoedema are found in both sexes, uni- or bilaterally. If bilaterally then usually asymmetrical. In contrast, lipoedema occurs in women only, thickening is always symmetrical, and the skin has a normal colour as in lymphoedema. The predisposing condition for lipoedema is lipohypertrophy of the extremities, a congenital accumulation of adipose tissue in the extremities that results in a disproportionate physical form with a relatively slim trunk. In one third of cases lipoedema is also observed in the arms. In contrast to lymphoedema, the hands and feet characteristically remain free of thickening and oedema.

Lipedema never reveals clinical picture of extreme lymphedema-elephantiasis, and skin signs and complications have not been observed. Aim of this paper is to present a case of lipedema with the initial lymphedema in which, after one episode of lymphangiitis and cellulitis, came to the rapid development of lymphedema followed by chyloderma. During the local treatment of extreme chyloderma with excessive exudation, semiocclusive synthetic dressings have been used for moist wound healing. The treatment was completed after 20 weeks with total epithelizsation, without maceration and irritation, without additional spreading of the chyloderma field, without wound infections, with fast and full relief of the pain. Lipedem with extreme lymphedema can be followed by skin complications of lymphedema like chylodermia.

We describe a 52 year-old woman in whom lymphedema primarily of the abdominal wall was superimposed on lipedema resulting in an abdomen of enormous dimensions with marked impairment of ambulation. Treatment consisted of preoperative compression of the legs by an external pneumatic device (Lympha-Press) followed by excision of the lymphedematous abdominal fat pad in conjunction with "debulking" of the right leg. The patient illustrates the extremes of lipedema complicated by lymphedema and the technical difficulties associated with its management.

In order to develop further the criterias of the ultrasonographic diagnosis of the lip- and lymphedema, also in the demarcation of the phlebedema, we examined 100 patients in our practice. In addition to the specific “sonomorphology”of the lip- and lymphedema we found a different reaction of the subcutaneous tissue of the lower leg in painful and not painful lipedemas examined with compression-sonography. A more precise demarcation of the cutis from the subcutis was made possible with a new 13 MHz linear probe. The spontaneous painful lipedema shows a thickened subcutis with increased echogenity and is only compressible at 10 to 20 percent, while the not painful lipedema is compressible at about 50 percent. In patients with lymphedema the typical echoless gaps showed no colour coding and were also not compressible. Especially because of the low time needed, the non-invasive method and the lack of radiation the ultrasonographic description, measurement and compression of the subcutaneous tissue of the lower leg is useful for diagnosis, the objective control of therapeutic strategies and the estimation of the clinical symptoms – especially in cases of lipedema – and also for the etiology – especially in cases of lymphedema. The sonography is superior to the clinical examination and should be the second step in diagnosis of all nonsystemic forms of edemas of the legs.