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Lipedema is a little-known alteration or disorder in the distribution of body fat, which affects almost exclusively women and primarily involves the lower extremities.   Epidemiological data are currently scarce and not helpful to determine the exact incidence of lipedema in the general population; its etiology and physiopathology are not clear enough; its diagnosis is basically clinical, since there are no specific diagnostic tests or enough scientific evidence to support it. However, its clinical manifestations imply deterioration in patients’ quality of life due to the physical, psychological and social impact it entails.   Since about 70% of cases are associated with pain in extremities, these are usually referred to phlebology and lymphology specialists. Treatments to control the edema are not usually successful in reducing the volume of the extremities.   This is in addition to determinants of fashion from the 21st century that demand most women to have slender bodies, while the reality is that overweight and obesity are alarmingly increasing. About 80% of obese patients do not admit to have excess weight, complicating its early diagnosis and prevention of its evolution and, consequently, delaying treatment in patients with this disease.   Due to the clinical presentation and symptoms associated with lipedema, patients are often misdiagnosed with lymphedema, obesity, lipodystrophies or chronic venous insufficiency, and therefore they are not correctly and effectively treated; in the best case scenario, they are administered symptomatic treatments.   In the absence of unified criteria for lipedema, and given the national and international controversy surrounding the term, the Spanish Association of Lymphedema and Lipedema (AEL) has put together a multidisciplinary working group of health professionals from different fields involved in the diagnosis and treatment of this disorder to draft this Consensus Document.   The aim was to answer multiple questions using the documentary evidence and clinical experience available to date.   Is the currently described physiopathology enough to explain lipedema?   Is it a progressive alteration? Does it always get worse?   When you have lipedema, is the progressive increase in body fat percentage normal?   If the main symptom is not the edema: Is manual lymphatic drainage an essential tool for the treatment?   Is it correct to prescribe compression garments in all cases?   What are the most effective treatments?   This working group included the participation of: The Spanish Association of Lymphedema and Lipedema (AEL), the Spanish Chapter of Phlebology and Lymphology (CEFyL) from the Spanish Society of Angiology and Vascular Surgery (SEACV), the Spanish Society of Aesthetic Medicine (SEME), the Spanish Society of Plastic, Reconstructive and Aesthetic Surgery (SECPRE), the Spanish Society of Dietetics and Food Science (SEDCA), the Complutense University of Madrid, and doctors specialized in Physical Medicine and Rehabilitation from the Spanish Society of Rehabilitation and Physical Medicine (SERMEF).   This document includes several chapters on the definition and physiopathology of lipedema, its diagnostic methods, differential diagnosis, classification and treatment using physical, pharmacological and surgical means. It is hoped that it can help people with lipedema and health professionals caring for them.   However, there is still a lot to learn about the etiopathogenesis, diagnosis and treatment of lipedema, so research must continue and be completed with epidemiological studies of its incidence and prevalence, always using an interdisciplinary approach.

Background Lipedema is a chronic disorder presenting in women during puberty or other times of hormonal change such as childbirth or menopause, characterized by symmetric enlargement of nodular, painful subcutaneous adipose tissue (fat) in the limbs, sparing the hands, feet and trunk. Healthcare providers underdiagnose or misdiagnose lipedema as obesity or lymphedema. Materials and methods The benefits (friend) and negative aspects (foe) of lipedema were collected from published literature, discussions with women with lipedema, and institutional review board approved evaluation of medical charts of 46 women with lipedema. Results Lipedema is a foe because lifestyle change does not reduce lipedema fat, the fat is painful, can become obese, causes gait and joint abnormalities, fatigue, lymphedema and psychosocial distress. Hypermobility associated with lipedema can exacerbate joint disease and aortic disease. In contrast, lipedema fat can be a friend as it is associated with relative reductions in obesity-related metabolic dysfunction. In new data collected, lipedema was associated with a low risk of diabetes (2%), dyslipidemia (11.7%) and hypertension (13%) despite an obese average body mass index (BMI) of 35.3 ± 1.7 kg/m2. Conclusion Lipedema is a painful psychologically distressing fat disorder, more foe than friend especially due to associated obesity and lymphedema. More controlled studies are needed to study the mechanisms and treatments for lipedema.

Background Lipedema is a chronic disorder presenting in women during puberty or other times of hormonal change such as childbirth or menopause, characterized by symmetric enlargement of nodular, painful subcutaneous adipose tissue (fat) in the limbs, sparing the hands, feet and trunk. Healthcare providers underdiagnose or misdiagnose lipedema as obesity or lymphedema. Materials and methods The benefits (friend) and negative aspects (foe) of lipedema were collected from published literature, discussions with women with lipedema, and institutional review board approved evaluation of medical charts of 46 women with lipedema. Results Lipedema is a foe because lifestyle change does not reduce lipedema fat, the fat is painful, can become obese, causes gait and joint abnormalities, fatigue, lymphedema and psychosocial distress. Hypermobility associated with lipedema can exacerbate joint disease and aortic disease. In contrast, lipedema fat can be a friend as it is associated with relative reductions in obesity-related metabolic dysfunction. In new data collected, lipedema was associated with a low risk of diabetes (2%), dyslipidemia (11.7%) and hypertension (13%) despite an obese average body mass index (BMI) of 35.3 ± 1.7 kg/m2. Conclusion Lipedema is a painful psychologically distressing fat disorder, more foe than friend especially due to associated obesity and lymphedema. More controlled studies are needed to study the mechanisms and treatments for lipedema.

Das Lipödem ist weit mehr als einfach nur dickere und schmerzhafte Beine! Die Erkrankung Lipödem ist mit zahlreichen Mythen behaftet. Im ersten Teil dieser Übersicht werfen wir einen kritischen Blick auf zwei populäre Statements zum Lipödem; Statements, die vor Jahrzehnten schon Eingang in wissenschaftliche Publikationen gefunden haben und seither unkritisch und stetig wiederholt werden; Statements, die inzwischen zum selbstverständlichen Wissensallgemeingut von Lipödempatientinnen und vor allem auch von Lipödem-Selbsthilfegruppen geworden sind. In unserer Darstellung über die Mythen des Lipödems fokussieren wir uns in diesem Beitrag vor allem auf zwei Aspekte, die aufs Engste mit dem Lipödem verbunden sind: auf die Adipositas sowie auf die psychische Situation von Lipödempatientinnen – die wiederum eng mit der Adipositas in Zusammenhang steht. Dabei überprüfen wir zwei häufig publizierte Statements auf wissenschaftliche Evidenz: 1. „Das Lipödem ist eine progrediente Erkrankung”, 2. „Ein Lipödem macht psychisch krank”. Beide Statements widersprechen in hohem Maße unserer seit Jahren bestehenden täglichen klinischen Erfahrung mit diesem speziellen Patientengut. Gleichzeitig haben wir im Rahmen unserer umfangreichen Literaturrecherche festgestellt, dass es auch keine Evidenz für diese in den „Lipödemsprachgebrauch” eingegangenen Behauptungen gibt. Tatsachlich ist das Lipödem in der Regel keine progrediente Erkrankung! Vielmehr liegt bei Lipödempatientinnen häufig eine Gewichtsprogredienz (meist eine Adipositasprogredienz) vor, in deren Folge sich auch das Lipödem verschlechtern kann. Unsere Pilotstudie zum 2. Statement macht deutlich, dass in der Regel nicht das Lipödem Ursache von psychischen Erkrankungen ist. Hier weisen unsere Ergebnisse in die umgekehrte Richtung: Eine – vorbestehende – psychische Vulnerabilität kann ganz wesentlich zum Krankheitsbild Lipödem beitragen. Um das Lipödem in seiner ganzen Komplexität und Vielfalt zu erfassen, braucht es mehr als nur Medizin. Psychosoziale Therapieansätze sollten integraler Bestandteil eines wirksamen multimodalen Behandlungskonzepts sein. Neben den beiden dargestellten Mythen gibt es weitere, die sich um das Lipödem ranken. Diese werden in weiteren Ausgaben dieser Zeitschrift diskutiert werden.

Lipedema, the Unknown Abstract. Lipoedema patients suffer from the widespread ignorance of their pathology. Considering its chronic, progressive and invalidating character, the early diagnosis of the disease must constitute the challenge of their caregivers in order to limit medical wanderings and the occurrence of complex clinical pictures. Treatments allow the reduction of lipedema and its long-term control. Management must be individualized according to the stage of the disease. The adherence of the patient, the supervision and the support of the practitioner are essential for obtaining the best results.

Zusammenfassung Die Prävalenz der Adipositas ist in den letzten 15 Jahren weiter stark angestiegen. Dabei fällt besonders die deutliche Zunahme der morbiden Adipositas auf, die wiederum bei den Älteren besonders ausgeprägt ist. Da mit dem Alter auch venöse Thromboembolien, chronisch venöse Insuffizienz und sekundäre Lymphödeme zunehmen, steigt die Zahl der Patienten mit venösen oder lymphatischen Erkrankungen, die gleichzeitig schwer adipös und häufig multimorbide sind, überproportional an. Die Adipositas, vor allem die viszerale, verschlechtert alle Ödemerkrankungen, erhöht das Risiko für thromboembolische Erkrankungen und postthrombotisches Syndrom und kann alleinige Ursache sein für die Adipositas-assoziierte funktionelle Veneninsuffizienz ohne Nachweis von Obstruktion oder Reflux. Das Adipositasassoziierte Lymphödem stellt inzwischen den größten Anteil unter den sekundären Lymphödemen. Mehr als 50 Prozent der Lipödempatientinnen sind adipös, die bei ihnen im Verlauf zu beobachtenden sekundären Lymphödeme in der Regel Folge der Adipositas, nicht des Lipödems. Die Symptomatik wird bei allen Krankheitsbildern durch Gewichtsreduktion gebessert. Neben mechanischen Faktoren wie der Erhöhung des intraabdominalen und intertriginösen Drucks, der wiederum zu einer venösen Drucksteigerung in den Beingefäßen führt, sind es vor allem die durch die Zunahme des viszeralen Fettgewebes verursachten metabolischen, chronisch inflammatorischen und prothrombotischen Prozesse, die für diese Zusammenhänge verantwortlich sind, erkennbar an niedrigen Spiegeln von Adiponektin und hohen von Leptin, Insulin, intaktem Proinsulin, PAI-1 sowie proinflammatorischen Zytokinen (Il-6, Il-8, TNF-α). Therapeutische Maßnahmen müssen also in erster Linie auf die Reduktion der viszeralen Adipositas und damit der Hyperinsulinämie bzw. der Insulinresistenz sowie auf die Bekämpfung der chronischen Entzündung abzielen. , Summary The prevalence of obesity has continued to rise considerably during the last 15 years. There is a striking increase of cases with morbid obesity (BMI over 40 Kg/m2), especially among the elderly. Since venous thromboembolic events, chronic venous insufficiency and secondary lymphoedema also increase with age, the number of patients who suffer from these conditions and, at the same time, are obese and often multimorbid, rises disproportionately. Obesity, especially if it is visceral, causes all sorts of oedema to deteriorate, increases the risk of thromboembolic events and postthrombotic syndrome and can be the sole cause of the so called obesity-associated dependency- syndrome, or rather the obesity-associated functional venous insufficiency without obstruction or reflux, as it ought to be called, with its skin lesions characteristic of CEAP stages C4 to C6. Among the various causes of secondary lymphoedema obesity is by now the most common. Of patients suffering from lipoedema more than 50 percent are obese, with the secondary lymphoedema often to be seen in those cases being the direct consequence of obesity, not the lipoedema itself. In all the conditions mentioned above symptoms can be ameliorated by weight loss. Aside from mechanical factors like intraabdominal and intertriginous pressure which in turn raise the intravenous pressure in the legs, it is foremost the metabolic, proinflammatory and procoagulatory effects of the augmented visceral fat tissue which can explain the correlation between obesity and thrombosis, oedema and, probably, the skin changes, too. These effects can be identified by low levels of adiponectin, which has antiinflammatory and vasoprotective qualities, and high levels of leptin, characteristic of leptin resistance, inflammation and insulin resistance, insulin and intact proinsulin (precursor of insulin, indicating β-cell insufficiency). Plasminogen Activator Inhibitor-1 (PAI-1), preventing fibrinolysis, and proinflammatory cytokines like Interleukin-6 (Il-6), Interleukin-8 (Il-8) and Tumour Necrosis Factor-α (TNF-α) are also found to be raised. In addition to treating the acute or chronic symptoms by anticoagulation, compression, manual lymphdrainage and wound care, therapeutic measures must endeavour to sustainably reduce visceral fat tissue, and thus hyperinsulinaemia, insulin resistance and inflammation. English version available at: www.phlebologieonline.de

Lipedema: Which Etiological Pathways? Abstract. The pathogenesis and epidemiology of lipedema are uncertain, and its diagnosis often delayed. Lipedema almost exclusively affects women, and a link to sex hormones is likely. The metabolic risk of this accumulation of fat in the lower limbs is not known, and weight loss has no impact on the morphology of the lower limbs. Due to the aesthetic discomfort and frequent initial misdiagnosis which results in inappropriate treatment, this condition can lead to significant psychological suffering for the patient. A better understanding of this disease is essential to the proper diagnosis and support for these patients, as well as guiding them in the effective care.

In this mini-review pathology, diagnosis, signs and symptoms, as well as treatment of lipedema are discussed. As the cause of lipedema is unknown for nearly 80 years, therapy is supportive and aimed at prevention of progression of the disease. Symptoms, signs and phenotypes of these patients are well defined. Guidelines for treatment are clear. When supportive therapy is inadequate surgical tumescent liposuction is the treatment of first choice. Surprisingly, the unproven compression and manual lymphatic drainage therapies of lipedma patients are covered by insurance, while the rational tumescent liposuction is not covered. Quality of life, mobility, lipedema pain, altered gait all improved by tumescent liposuction and disease progression is slowed. Insurance coverage of this procedure will help lipedema patients greatly. Cost-benefit analyses should be made. Research in pharmacotherapy of lipedema that makes sense should be stimulated

Surgical Treatment for Lipedema Abstract. Lipedema is a progressive disease that occurs in adolescence and affects one in nine women. The signs are limited to the lower limbs. Early signs are nonspecific, which is why the diagnosis is often ignored. Later, pain and heaviness of lower limbs become predominant. Finally, at an advanced stage, tissue fibrosis is associated with significant edema. At this stage, patients become severely disabled and bedridden. At the early stage, the treatment is conservative. Liposuction is indicated at the onset of pain. Its effectiveness pain and long-term control has been demonstrated on. Finally, late stages require heavy and complex surgeries combining dermolipectomy and liposuction.

Lipedema is a chronic disorder of subcutaneous adipose tissue of unknown etiology not uncommon among post-puberty women. The disease has a negative impact on selfesteem, mobility, and quality of life. Lipedema is characterized by symmetrical, disfiguring hyperplastic adipose tissue combined with bruising and pain. Untreated lipedema fosters osteoarthritis, secondary lymphedema, limitedmobility, and psychosocial stigmatization. Treatment consists of conservative complex decongestive therapy and surgery by microcannular tumescent liposuction. Liposuction is the only available treatment capable to reduce the pathological adipose tissue durable and to prevent complications.

INTRODUCTION: Nowadays, liposuction is the most frequently performed aesthetic surgery procedure in Western Countries. This technique has had rapid development since the 1970s, when it was experimented for the first time by A. and G. Fischer. It is currently widely used in clinical practice for many different situations in aesthetic, reconstructive and functional fields. MATERIALS AND METHODS: This review aims to describe the historical evolution of liposuction by analyzing the transformation of the method in function of the introduction of innovative ideas or instruments. We have also focused on reporting the major clinical applications of this surgical technique, applicable to almost the entire body surface. We finally analyzed the complications, both major and minor, associated with this surgical technique. RESULTS: Liposuction is mainly used to correct deep and superficial fat accumulations and remodel the body contour. It has become an essential complementary technique to enhance the aesthetic result of many other aesthetic procedures such as reduction mammoplasty, abdominoplasty, brachioplasty, thigh lift and post bariatric body contouring. However, it can be largely used for the treatment of innumerable pathologies in reconstructive surgery such as lipomas, lipedema, lipodystrophies, pneudogynecomastia and gynecomastia, macromastia e gigantomastia, lymphedema and many others. The complication rate is very low, especially when compared with conventional excisional surgery and the major, complications are generally associated with improper performance of the technique and poor patient management before and after surgery. CONCLUSION: Liposuction is a safe, simple and effective method of body contouring. It has enormous potential for its application in ablative and reconstructive surgery, far from the most common aesthetic processes with a very low complication rate.

Lipedema an often overlooked but treatable disease Lipedema is a painful disease that affects some women between puberty and menopause through a subcutaneous fat accumulation especially in the lower extremities. Patients suffer from pain and pressure tenderness. The larger fat accumulation, especially on the inside of the thighs and knees, causes walking difficulties. This can successfully be treated by liposuction with good long-term results in terms of pain reduction and prevention of osteoarthritis development in the knee and ankle joints.

Lipedema is a chronic disorder of subcutaneous adipose tissue of unknown etiology not uncommon among post-puberty women. The disease has a negative impact on self-esteem, mobility, and quality of life. Lipedema is characterized by symmetrical, disfiguring hyperplastic adipose tissue combined with bruising and pain. Untreated lipedema fosters osteoarthritis, secondary lymphedema, limited mobility, and psychosocial stigmatization. Treatment consists of conservative complex decongestive therapy and surgery by microcannular tumescent liposuction. Liposuction is the only available treatment capable to reduce the pathological adipose tissue durable and to prevent complications.