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Liposuction surgically removes subcutaneous abdominal tissue (SAT) and has almost no effect on visceral abdominal tissue (VAT) depot. However, some authors suggest that deep layers of SAT are functionally similar to VAT and the amount of deep subcutaneous abdominal adipose tissue is strongly related to insulin resistance in a manner nearly identical to that of visceral adiposity. Moreover, SAT determines leptin secretion which indirectly reflects the level of insulin sensitivity in the body. Thus, the immediate removal of SAT could potentially affect metabolic profile of a patient. The current data are conflicting and cannot bring a clear evidence suggesting that liposuction itself results in important metabolic outcomes and, on the other hand, cannot exclude such a possibility. This review summarizes the liposuction-induced metabolic changes with regard to release of major adipokines and insulin sensitivity.

Methods: Thirty-six legs in 18 patients with secondary lower extremity lymphedema (LEL) and 20 legs in 10 healthy volunteers were examined using elastography. Thirty-six legs in 18 secondary LEL patients were examined using ICG lymphography. Elastography was performed on both legs at the following three sites: medial thigh (MT), medial leg (ML), and anterior ankle (AA). The area of the red region in the subcutaneous tissue demonstrated by elastography was calculated using Image software. ICG lymphography findings were classified into the following four patterns: linear (ICG1), splash (ICG2), stardust (ICG3), and diffuse (ICG4) patterns. Results: As ICG pattern progressed, the red region area was likely to increase. There was a correlation between ICG patterns and red region area according to the severity at bilateral MT (rs Z 0.665), ML (rs Z 0.623), and AA (rs Z 0.668). Significant difference was demonstrated among group means of the red region area by analysis of variance (healthy vs. ICG1 vs. ICG2 vs. ICG3 vs. ICG 4: 14.4 Æ 5.7 vs. 15.1 Æ 10.3 vs. 25.2 Æ 6.2 vs. 30.8 Æ 9.4 vs. 35.0 Æ 2.8; P < 0.001). Conclusions: The area of the red region in the subcutaneous tissue shown using elastography, which represents fluid, increases with the aggravation of lymphedema demonstrated by ICG

Background: Lipedema is a poorly known disorder of painful subcutaneous adipose tissue (SAT) likely affecting millions of women worldwide. Stage 1 lipedema has smooth skin with increased underlying fat, Stage 2 has indentations and nodules, and Stage 3 has large extrusions of skin and SAT. Women with lipedema have more SAT below the waist. As this gynoid fat is known to be cardioprotective, we aimed to determine if health declined with increasing stage and extent of lipedema SAT. Methods and Findings: Chart review from June 2012 to February 2013 at a tertiary academic center. Fifty women and one man were included in consecutive order. Fat was assessed in 29 areas for lipomas, size of the depot, and presence of lipedema fat. Pain was assessed by a numerical pain scale. Average age of patients was 50 ± 13 y; average body mass index was 38 ± 12 kg/m2. Median age of development of lipedema was 20 y. Pain occurred daily in 89.7%. None of the patients with Stage 1 lipedema had diabetes, hypertension or dyslipidemia. The amount of lipedema fat differed significantly between Stages of lipedema (p=0.003), with Stage 3 having significantly more. There was no difference in fat depot size or number of lipomas amongst Stages. Only one of 51 patients had type 2 diabetes. There was an increase in shortness of breath, palpitations, urination, and numbness in Stage 3. Conclusions: Lipedema fat can develop in any SAT location and increases in association with increasing signs and symptoms of systemic illness.

Objectives: The aim of this study was to determine the ability of the central sensitization inventory (CSI), a new screening instrument, to assist clinicians in identifying patients with central sensitivity syndromes (CSSs). Methods: Patients from a psychiatric medical practice (N = 161), which specialized in the assessment and treatment of complex pain and psychophysiological disorders, were assessed for the presence of a CSS. CSI scores, using a previously determined cutoff of “40” of “100,” were compared between the CSS patient group (n = 99) and the non-CSS patient group (n = 62). Information on false positives, false negatives, true positives, and true negatives were analyzed, and sensitivity and specificity analyses were conducted. In addition, CSS-relevant variables such as depression, abuse, and substance abuse were examined. Results: A large percentage of CSS patients had comorbid major depressive disorder (80%) and abuse history (43%), which was higher than rates for the patients without a CSS (55% and 24%, respectively). The CSI correctly identified 82.8% (n = 82) of CSS patients as having a CSS (ie, sensitivity) and 54.8% (n = 28) of non-CSS patients as not having a CSS (ie, specificity). False-positive patients (not diagnosed with a CSS, but scoring >40 on the CSI) reported more severe pain, interference in daily functioning, and abuse history, compared with the non-CSS patients who scored below 40 (ie, true negatives). Conclusions: The CSI is a useful and valid instrument for screening patients for the possibility of a CSS, although the chances of false positives are relatively high when evaluating patients with complex pain and psychophysiological disorders.

Background: Lipedema is a painful, genetically induced, abnormal deposition of subcutaneous fat in the extremities of women. The pathogenesis is unknown. Also unknown is the number of women affected in Germany. This study presents the epidemiology of the disease. There are currently two treatment options available: Complex physical decongestive therapy and liposuction. Liposuction is the only method that removes fat permanently. An additional study proves its effectiveness and highlights its vital role as part of a comprehensive treatment concept.

AIM: Application of microcurrents of bioresonance may allow protein aggregates lysis and a related enhancement of lymphatic drainage. Combining bioresonance with transcutaneous passage of active principles, by means of skin electroporation, microcirculation and clearance of connective tissues may be theoretically activated. A pilot study on an electro-medical device which includes these two technologies (Transponder(®)), has been performed on patients affected by lymphedema (LYM) and/or lipedema (LIP) of the lower limbs. METHODS: Eight patients affected by primary or secondary unilateral LYM or LIP were submitted to six consecutive daily sessions with the medical device; the first two sessions were performed by a trained physiotherapist, whilst the following four sessions were self-administered by the patients themselves at home (who were educated about the technique). Magnesium silicate was delivered transcutaneously by means of the device at each session. Pre-post-treatment assessment included: 1) limb volumetry by means of tape measurement; 2) segmental multifrequency bioimpedance spectroscopy for fluid changes, with L-DEX measurement; 3) visual analogue scale (VAS) (0-10 score) questionnaire for related symptoms. RESULTS: All the patients completed the scheduled treatment. After the treatment the mean volume of the whole limb decreased from 9462.85 (±3407.02) to 9297.37 cc (±3393.20), which accounts for a 165.48 cc (2%) reduction after six days of treatment. The pre/post-treatment VAS mean score changes were: heaviness from 4.57±3.46 to 2.43±2.57 (-47%), dysesthesias from 1.71±2.63 to 0.71±1.50 (-58%), pain from 1.57±2.57 to 0.57±0.79 (-64%). Diuresis VAS measurement passed from 7.43±1.81 to 8.57±0.98 (15% increase). The average L-DEX percentage reduction was 21%. No side effects were reported and a good patients' compliance was recorded. CONCLUSIONS: The preliminary data of this pilot study show that the combination of microcurrents of bioresonance with transdermal delivery of active principles indicate that it could result in edema decrease and symptom improvement in patients affected by LYM and/or LIP of the lower limbs. Self-administered modality of the electrical device is possible and effective; no side effects have been reported.

Juvenile dermatomyositis (JDM) is a rare but complex and potentially life-threatening autoimmune disease of childhood. Significant proportions of patients have residual weakness, muscle atrophy, joint contractures, and calcinosis. Recently, new clinical findings, such as lipodystrophy accompanied with increased fat deposition in certain areas, have been reported. So far, it is not known whether the redistribution of body fat may be the type of lipedema of lower extremity. We describe a 39-year-old woman who was diagnosed with JDM at the age of 7. Later she developed symmetrical lipodystrophy of upper extremities and symmetrical lipedema of lower extremities (making 2 and 58.3 % of total body fat mass, respectively), with multiple calcified nodules in the subcutaneous tissues. These nodules gradually increased in size despite therapy. Capillaroscopy findings showed scleroderma-like abnormalities. ANA and anti-U1RNP antibodies were positive. Similar cases with simultaneous occurrence of the lipedema of lower extremities, lipodystrophy of upper extremities, and severe calcinosis complicating JDM have not been published so far. We showed that the calcinosis and lipodystrophy were associated with short duration of active disease. Also, we display case that raises the question whether it is possible overlapping autoimmune diseases revealed during follow-up.

Upper- and lower-body fat depots exhibit opposing associations with obesity-related metabolic disease. We defined the relationship between DEXA-quantified fat depots and diabetes/cardiovascular risk factors in a healthy population-based cohort (n = 3,399). Gynoid fat mass correlated negatively with insulin resistance after total fat mass adjustment, whereas the opposite was seen for abdominal fat. Paired transcriptomic analysis of gluteal subcutaneous adipose tissue (GSAT) and abdominal subcutaneous adipose tissue (ASAT) was performed across the BMI spectrum (n = 49; 21.4-45.5 kg/m(2)). In both depots, energy-generating metabolic genes were negatively associated and inflammatory genes were positively associated with obesity. However, associations were significantly weaker in GSAT. At the systemic level, arteriovenous release of the proinflammatory cytokine interleukin-6 (n = 34) was lower from GSAT than ASAT. Isolated preadipocytes retained a depot-specific transcriptional "memory" of embryonic developmental genes and exhibited differential promoter DNA methylation of selected genes (HOTAIR, TBX5) between GSAT and ASAT. Short hairpin RNA-mediated silencing identified TBX5 as a regulator of preadipocyte proliferation and adipogenic differentiation in ASAT. In conclusion, intrinsic differences in the expression of developmental genes in regional adipocytes provide a mechanistic basis for diversity in adipose tissue (AT) function. The less inflammatory nature of lower-body AT offers insight into the opposing metabolic disease risk associations between upper- and lower-body obesity.

Lipedema is a common, but often underdiagnosed masquerading disease of obesity, which almost exclusively affects females. There are many debates regarding the diagnosis as well as the treatment strategies of the disease. The clinical diagnosis is relatively simple, however, knowledge regarding the pathomechanism is less than limited and curative therapy does not exist at all demanding an urgent need for extensive research. According to our hypothesis, lipedema is an estrogen-regulated polygenetic disease, which manifests in parallel with feminine hormonal changes and leads to vasculo- and lymphangiopathy. Inflammation of the peripheral nerves and sympathetic innervation abnormalities of the subcutaneous adipose tissue also involving estrogen may be responsible for neuropathy. Adipocyte hyperproliferation is likely to be a secondary phenomenon maintaining a vicious cycle. Herein, the relevant articles are reviewed from 1913 until now and discussed in context of the most likely mechanisms leading to the disease, which could serve as a starting point for further research.

Lipedema is a common, but often underdiagnosed masquerading disease of obesity, which almost exclusively affects females. There are many debates regarding the diagnosis as well as the treatment strategies of the disease. The clinical diagnosis is relatively simple, however, knowledge regarding the pathomechanism is less than limited and curative therapy does not exist at all demanding an urgent need for extensive research. According to our hypothesis, lipedema is an estrogen-regulated polygenetic disease, which manifests in parallel with feminine hormonal changes and leads to vasculo- and lymphangiopathy. Inflammation of the peripheral nerves and sympathetic innervation abnormalities of the subcutaneous adipose tissue also involving estrogen may be responsible for neuropathy. Adipocyte hyperproliferation is likely to be a secondary phenomenon maintaining a vicious cycle. Herein, the relevant articles are reviewed from 1913 until now and discussed in context of the most likely mechanisms leading to the disease, which could serve as a starting point for further research.

Compression therapy is the mainstay of treatment in the management of lymphoedema and lipoedema. However, due to variance in the location, severity and type of the condition, patients often have to compromise on garments to ensure that the affected area of oedema is controlled. This article discusses the use of Veni compression shorts (Haddenham Healthcare) and Capri garments as an alternative treatment option to full-leg compression garments. The article explains treatment areas and conditions where the application of these garments will enhance care-for example, for trunkal swelling-and where compression may not generally be required-for example, in the feet.

BACKGROUND: Distinguishing lymphoedema from lipoedema in women with swollen legs can be difficult. Local tissue water content can be quantified using tissue dielectric constant (TDC) measurements. OBJECTIVES: To examine whether TDC measurements can differentiate untreated lower extremity lymphoedema from lipoedema, and to test interobserver agreement. METHODS: Thirty-nine women participated in the study; 10 patients with lipoedema (LipP), nine patients with untreated lymphoedema (U-LP), 10 patients with lymphoedema treated with compression bandaging for ≥ 4 weeks (T-LP) and 10 healthy controls. All subjects were measured at three predefined sites (foot, ankle and lower leg). All groups except U-LP were measured by three blinded investigators. Using a handheld device, a 300-MHz electromagnetic wave is transmitted into the skin via a 2.5-mm depth probe. TDC calculated from the reflected wave is directly proportional to tissue water content ranging from 1 (vacuum) to 78.5 (pure water). RESULTS: Mean ± SD TDC values for U-LP were 48.8 ± 5.2. TDC values of T-LP, LipP and controls were 34.0 ± 6.6, 29.5 ± 6.2 and 32.3 ± 5.7, respectively. U-LP had significantly higher TDC values in all measurement sites compared with all other groups (P < 0.001). A cut-off value of 40 for ankle and lower-leg measurements correctly differentiated all U-LP from LipP and controls. Intraclass correlation coefficients were 0.94 for the ankle and the lower leg and 0.63 for the foot. CONCLUSIONS: TDC values of U-LP were significantly higher than those of T-LP, LipP and controls and may aid in differentiating lymphoedema from lipoedema. Interobserver agreement was high in ankle and lower-leg measurements but low in foot measurements.

OBJECTIVES: Patient-relevant treatment benefit is traditionally measured with health-related quality of life (HRQoL) instruments. The Patient Benefit Index (PBI) methodology allows for a more direct measurement, with the patients rating both importance and achievement of treatment goals. Here, we developed and validated a PBI version specific for the assessment of benefit in lymphedema and lipedema treatment (PBI-L). METHODS: The development included five steps: (1) open item collection; (2) consensus of items in a multidisciplinary expert panel; (3) application of the German PBI-L in a cross-sectional study (n = 301); (4) translation into English; (5) application of the English PBI-L in a randomized clinical trial (n = 82). Subscales were developed using factor analysis. Construct validity was analyzed by correlating PBI-L and convergent criteria such as HRQoL and quality of care. To test for responsiveness, the association to change in HRQoL measures was computed. RESULTS: Floor and ceiling effects were low. There were few missing values. Two well-interpretable subscales were found with Cronbach's alpha >0.8 each. Global and subscale scores correlated with convergent criteria and with change in disease-specific HRQoL, but not with change in generic HRQoL. CONCLUSIONS: The PBI-L is an internally consistent, valid, and responsive instrument for the assessment of patient-relevant benefit of edema treatment.

Cankles refer to the area where the calf and ankle meet. Unaesthetic fat cankles, where definition between the calf and ankle is impossible, are a frustrating aesthetic deformity, which are exacerbated by their genetic conditioning and special resistance to diet. This article reports our experience with laser-assisted lipolysis (LAL) in cankle remodelling. A total of 30 patients were treated for unaesthetic fat cankles with LAL. The 924/975-nm diode laser used in this study consisted of two lasers, one emitting at 924 nm, and the other at 975 nm. According to our mathematical models, we assumed that to destroy 1 ml of fat, 0.1 kJ was required in dual emission mode at 924/975 nm. Patients were asked to file a satisfaction questionnaire. Ultrasound was used to measure the fat thickness pre- and postoperatively. Oedema in both lateral sulcus of the Achilles tendon was seen in all patients. It subsided after 4 weeks in nine cases and 6 weeks in 21 cases. Only two patients developed mild hyperpigmentation that disappeared, respectively, after 4 and 10 weeks. Pain during the anaesthesia and discomfort after the procedure were low with this technique. Mean down time was 1.0 day. Of the 30 patients, 29 would recommend this treatment. Overall, high patient and investigator satisfaction was confirmed by the sonography used to measure decrease in fat thickness. LAL in cankle remodelling is a safe and reproducible technique that is particularly appreciated by the patient. The procedure allows homogenous reduction of fatty tissue together with skin tightening.

In many respects, lipedema of the arms and legs is still an underresearched disease within the lymphatic spectrum. It is clear that clinical symptoms frequently include symmetrical fat distribution in the arms and legs and pathognomonic tenderness in female family members. However, 75 years after the first descriptions provided by Allen and Hines, we still lack pathological evidence that would provide more insight than that offered by the theses proposed by Marsch and Brauer. We also lack information about hormonal influence on hyperplastic fatty tissue and the causes of obviously increased lymph formation in the fatty tissue in patients with lipohyperplasia dolorosa. Much more is known about the effects of combined decongestive therapy, which has been used since the 1960s. Moreover, since 1997, surgery has been used to successfully treat this disease presentation. The success rate in long-term observation (15 years) is 97%.

Lipedema is a chronic, incurable, often progressive affliction that occasionally causes significant morbidity. Initially, patients develop a disproportionate increase of body fat in the legs, buttocks and/or arms. Dieting and physical exercise have only limited effect on this disproportionate body fat distribution. The legs may be sensitive and are prone to bruising after only mild trauma. This can deteriorate into severe pain and reduced mobility, ultimately leading to a limitation of activity and social participation. As a result, lipedema patients may often be diagnosed with obesity. Dietary measures generally affect the obesity component but have little effect on the disproportionate body fat distribution. Because lipedema contributes to an increased BMI, even in non-­‐obese patients, a connection between lipedema and excessive calorie-­‐intake or obesity is often incorrectly assumed. In addition to physical problems, lipedema can also lead to psychoso-­‐ cial problems. These are often caused by the failure of consulting professionals to recognize or acknowledge the condition, or because (incorrect) recommendations for weight loss and physical exercise do not contribute to improvements in the complaints. Therefore, it is important to recognize lipedema early so that its accompanying symptoms can be acknowl-­‐ edged at an early stage and be incorporated into an integrated treatment. Little consistent information regarding the diagnosis or treatment of lipedema is found in the literature. Therefore, the goal of this directive is to attempt to establish a consensus for the diagnosis of lipedema and to discuss its symptoms and influencing factors, as well as its effects on activity and social limitations, as these negatively influence the life of the patient.

In 2014 250 women with Lipoedema took part in our survey about their experiences with Lipoedema. The results give a clear picture of what living with Lipoedema is like and reveal that along with the pain and discomfort caused by Lipoedema, many simple tasks that other people regard as straightforward become extremely challenging for people with Lipoedema. Lipoedema UK’s Big Survey 2014 led to the development of the Royal College of GPs’ e-learning course, a half hour course, which enables GPs to recognise Lipoedema and diagnose patients Our survey was created by Lipoedema UK, the Lymphoedema Department at St George’s Hospital, London, and the support of the Lymphoedema Support Network.