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Lymphoedema is a debilitating, progressive and incurable pathological condition caused by a chronic imbalance between the production and transport of lymph within the lymphatic system. There are many reasons for this damage or disruption to the lymphatic system. Lymphoedema results in significant physical and psychological morbidity. Approximately 140–250 million people worldwide are affected by this condition, mostly in developing countries as a result of lymphatic filariasis, a parasitic infection transmitted by mosquitoes. In the majority of cases, treatment is non-curative, complex and requires a multidisciplinary clinical approach. Surgery takes place as a last resort when conservative treatment has proven ineffective to restore function, reduce comorbidity or the frequency of erysipelas attacks.

Lipoedema: a new therapy regimen b Lipoedema, a disease in women, is characterised by circumscribed accumulation of subcutaneous fat, mainly in the legs, with oedema, tension pain, tenderness and haematomas.

Only a limited number of studies on cellulite have been published in the international literature and many of them reach somewhat antithetical conclusions. Consequently, it is not yet possible to reconcile the extreme differences of opinion which have lingered on for years concerning the nature of this disorder, as well as its origin and even the most basic aspects of its histopathological classification. It does not even have a recognized name: in fact, the term 'cellulitis' is used in scientific English to indicate a spreading gangrenous infection of the subcutaneous cellular tissue. The other terms used from time to time [panniculitis, lipodystrophy, edematofibrosclerotic panniculitis (EFP), liposclerosis, lipoedema, etc.] have quite different morphological and pathogenetic connotations in general. Over the last few decades, three major conflicting theories have emerged in relation to the ethiopathogenesis of cellulite. These indicate, respectively, the following causes: 1. Oedema caused by excessive hydrophilia of the intercellular matrix. 2. A homeostatic alteration on a regional microcirculatory level; this pathogenetic theory is summarized in a synthetic and self-explanatory denomination: EFP. 3. A peculiar anatomical conformation of the subcutaneous tissue of women, different from male morphology. These theories must all now be updated in the light of recent advances on the sophisticated and composite physiopathology of the adipose organ - which acts not only as a control device which regulates the systematic equilibrium of energy and modulates the food intake and the metabolism of other tissue substrate through a multiple glandular secretion of hormones and parahormones.

OBJECTIVE: Many investigations and treatments exist for lower limb lymphoedema. We undertook a survey on the management of this condition by vascular surgeons and the resources available for its treatment in the UK. DESIGN: A questionnaire was designed to assess the management of lymphoedema. MATERIALS AND METHOD: A postal questionnaire was sent to all members of the The Vascular Society of Great Britain and Ireland. RESULTS: 251/440 (57%) consultant surgeons returned a completed questionnaire comprising 45.3% teaching hospital and 54.7% district general hospital (DGH) consultants. 77.9% of the consultants saw less than 10 patients annually with lymphoedema. The commonest causes of lymphoedema were primary lymphoedema (99.3%) and malignancy (37.1%). Lipoedema, a cause of limb swelling was only seen or recognised by 46.2% of the consultants. The commonest investigations performed were a duplex scan, lymphoscintigram, full blood count and urea and electrolytes. The common methods of confirming lymphoedema were either by lymphoscintigram (54.5%) or from a diagnosis of exclusion (33.7%). Lymphoedema physiotherapy was available only to 53.8% of the consultants. Surgery was performed by 10.5% of consultants. 73.4% of the consultants believed that lymphoedema is managed inadequately and 72.9% believed that resources are insufficient in the UK for this condition. CONCLUSION: In the UK the majority of vascular consultants see less than 10 patients annually with lymphoedema. Very few patients undergo confirmation of this diagnosis with non-invasive investigation and very few consultants perform surgery. Management of this condition is perceived by the consultants to be poor, with a lack of resources and particular shortage of lymphoedema physiotherapists. Centralisation of these services may be a way of improving this condition.

Combined decongestive therapy (CDT) in lipedema can only reduce edema, not the fat components; therefore only a portion of the symptoms can be treated. In contrast liposuction is able to reduce the increased volume of fatty tissue; it also decreases the tendency to develop edema. Only by combining conservative and surgical therapy regimens optimal results can be achieved. From the theoretical and practical point of view nowadays in lipedema grade I, II and partially grade III conservative treatment alone can be considered as an insufficient therapy.

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.

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.

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.

"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.

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.

PURPOSE: Lymphoscintigraphy has emerged as the diagnostic test of choice in patients with suspected lymphedema. To assess the lymphatic circulation of 386 extremities in 188 patients, we prospectively recorded a semiquantitative index of lymphatic transport in addition to visual evaluation of lymphoscintigraphy image patterns. METHODS: Sixty-one male and 127 female patients were studied (mean age 48 years, range 13 to 87 years). Twenty had upper extremity swelling, and 168 had lower extremity swelling. The disease was bilateral in 60 patients. Lymphoscintigraphy was performed by injecting a mean of 503 microCi of technetium 99m-antimony trisulfide colloid subcutaneously into the second interdigital space of the extremity. Time for transport to regional lymph nodes, appearance of lymph vessels and nodes and distribution pattern were scored. These scores were compiled into a modified Kleinhans transport index (TI). To assess the venous circulation, 155 patients underwent evaluation of the venous system by impedance plethysmography, ultrasonography, or contrast venography. RESULTS: The mean TI (+/- SEM) in 79 asymptomatic extremities was 2.6 +/- 0.5, with 66 (83.5%) demonstrating normal lymphoscintigraphy pattern (TI < 5). Patients with clinical diagnosis of lymphedema (n = 124) had a mean TI of 23.8 +/- 1.5; 81.5% of these were greater than 5. Fifty-six patients (30%) had primary and 68 (36%) had secondary lymphedema. (TI of 26 +/- 3.5 and 22.1 +/- 1.9, respectively, p = NS). Patients without any lymphatic transport (TI of 45) were more likely to have cellulitis in their history (p < 0.05). Contrast lymphangiography in six patients correlated with lymphoscintigraphy. Sixty-four patients (34%) had swelling without lymphedema (venous edema, cardiac edema, lipedema, etc.; TI of 1.9 +/- 0.4, p < 0.001). Of the 41 patients with abnormal venous studies, 18 (44%) had an elevated TI. CONCLUSIONS: Semiquantitative evaluation of the lymphatic transport with lymphoscintigraphy reliably depicts abnormalities in the lymphatic circulation. Lymphoscintigraphy excluded lymphedema as a cause of leg swelling in one third of our patients.

Twelve patients with primary lymphedema of the lower limb were examined with computed tomography (CT). A characteristic "honeycomb" pattern of the subcutaneous compartment was seen in 10 of these patients. CT scans in nine other patients with swollen leg secondary to chronic venous disease or lipedema did not show this characteristic pattern. CT may be helpful in the differential diagnosis of a swollen leg, thus obviating venography or lymphangiography.

« La parenté de l'ædeme chronique avec la lipomatose a depuis long lemps frappé les auteurs » ( 1 ) . Le cas actuel que nous publions aujourd'hui, après l'avoir présenté en quelques mots à la Société de Neurologie ( 2) , vient à l'appui de celle rollesion Ichard et L. Lévi. OBSERVATION ( PI. LXV ). Il s'agit d'une brodeuse de 39 ans, Mlle Eugénie B ... 1, venue à notre consul tation de l'hôpital Laënnec pour grosseur anormale des membres inférieurs . Antécédenis héréditaires -- La mère est morte à 25 ans, de tuberculose aiguë (alcoolisme possible). Son père est mort à 56 ans, très probablement d'un cancer du pylore. Eugénie B ... a une scur âgée de 41 ans, bien portante. Une de ses tantes aurait eu , pendant longtemps, de la difficulté à marcher . Antécédents personnels. -- Mile B ... n'a jamais été malade. Elle se souvient que, vers l'âge de 8 ans, elle avait déjà de gros mollets qui faisaient l'admira tion de ses camarades ; néanmoins, en promenade, elle se fatiguait plus vite que ses compagnes. Elle n'a jamais ressenti de douleurs vives dans les mem bres inférieurs. A 14 ans ses règles apparaissent régulières, avec un peu de dysmenorrhée. A 22 ans,, elle s'aperçoit que, sans aucun doute, ses jambes grossissent et non le reste du corps . L'ordème aurait envahi, par étapes, les jambes, les cuisses et les fesses . Elle est examinée et traitée à Lille , à Amiens et à Paris. A Lille elle prend de la tyroïdine ( 2 pilules par jour) , et de l'iode , pendant 15 jours . Elle maigrit sous l'influence de ce traitement.

<p>INTRODUCTION: Lipedema is a progressive connective tissue disease with enlargement of adipose tissue, fibrosis, fluid collection and dermal thickening. Herein, we present a case of lipedema associated with skin hypoperfusion and ulceration in which soft tissue debulking with liposuction improved patients’ symptoms. CASE PRESENTATION: A 39-year-old female presented with asymmetric progressive initially unilateral lower limb swelling with severe pain with subsequent skin ulceration. Conservative management have failed to improve her condition. After excluding other causes and detailed radiologic investigation, lipedema was diagnosed with an associated impaired skin perfusion. Trial of local wound care and compression therapy failed to improve the condition. Subsequent soft tissue debulking with circumferential liposuction and ulcer debridement and immediate compression showed dramatic improvement of the symptoms and skin perfusion. DISCUSSION: The unique nature of this case shed light on lipedema as a loose connective tissue disease. Inflammation and microangiopathies explains the associated pain with hypoperfusion and ulceration being quite atypical and in part might be related to the large buildups of matrix proteins and sodium contents leading to micro-vessels fragility with frequent petechiae and hematoma and subsequent tissue ischemia. Conservative measures like compression therapy plays a significant role in disease course. Surgical debulking with liposuction was shown to be efficacious in reducing the soft tissue load with improvement in limb pain, edema, circumference and skin perfusion that was seen in our patient. CONCLUSION: Lipedema is a frequently misdiagnosed condition with disabling features. Skin involvement in lipedema with potential hypoperfusion was shown and it requires further investigation</p>

Background: Lipedema is a chronic disorder characterized by symmetrical and disproportionate fat accumulation, pain, and easy bruising, often resistant to conventional treatments. Functional dysmetria (FD), a maladaptive neuromotor response linked to epigenetic stress, has been proposed as a relevant contributor to pain in lipedema., Objective: This retrospective observational study aimed to evaluate whether correcting FD through the radioelectric asymmetric conveyer (REAC) technology Neuropostural Optimization (NPO) protocol can reduce pain in patients with lipedema, using a sham-controlled design., Methods: In this retrospective observational study, 83 consecutive women with stage 2-5 lipedema underwent both sham and real NPO procedures during a single session. Pain intensity was measured using the visual analog scale (VAS) immediately after each procedure. Statistical analyses were performed using paired t-tests with effect sizes (Cohen’s dz) and 95% confidence intervals., Results: Baseline pain was uniformly high (mean 7.41 ± 0.53), with some pre-sham values reaching 10/10. Pain reduction was observed exclusively after real NPO and not after sham. Sham NPO induced no significant changes, whereas real NPO yielded a mean pain reduction exceeding 3.5 VAS points across all stages (mean change -3.65 ± 0.62; 95% CI: -3.79 to -3.51; Cohen’s dz = 5.88, 95% CI: 4.85-6.92; p < 0.0001)., Conclusions: These findings suggest that correction of FD by REAC NPO provides rapid and clinically meaningful analgesic effects in lipedema patients, addressing an upstream neuropsychomotor dysfunction that may contribute to disease progression. However, given the retrospective single-center design and absence of long-term follow-up, these conclusions are limited to the short-term effects observed. Further multicenter and longitudinal studies are warranted to confirm these results and evaluate long-term outcomes.