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Lipedema of the legs is a symmetrical thickening of upper and lower leg and topically accentuated fat pads. The back of the foot is usually free of swelling. Pathogenetically it is a disturbance of the distribution pattern of subcutaneous fat tissue. Epidemiologically, the subjects affected are women, starting from puberty. Weight reduction programs do not influence the real deformations. If this abnormal fat tissue is infiltrated by angiological diseases, these manifest themselves in modified form. In particular, all the symptoms are more painful. In arterial ischemic syndromes that taut skin is susceptible to necrosis at atypical locations. For reconstruction of trunk arteries it is advisable to bypass larger bulges for better wound nealing. Venous strips should be peeled out away from fat pads and venous-bridges very carefully to protect the tissue. Acute and chronic phlebothrombosis lead to unusual and asymmetrical forms of swelling. The venous ulcer lies directly beneath a fat-muff in the gaiter region. Since they are hard to compress, free skin transplants should be considered early in the course of development. Surgery of varicose veins calls for most careful technique to ensure wound healing. From the lymphological viewpoint there are clinically and lymphographically mixed forms of lymphedema with lipedema.
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This condition, which has the full name of 'erythrocyanosis frigida crurum puella rum' (cold reddish blueness of the legs of girls), is extremely common. It is not always recognized, being misdiagnosed as lymphoedema, vasomotor disease, arterial insufficiency, and other things. The skin of the legs is cold to the touch and exhibits patches of bluish discoloration. There may be chilblains and small superficial ulcerated areas. There is often an abnormally large amount of fat particularly above the ankle and around the tendo Achillis. For this reason it is sometimes called ' lipoedema'. The affected patches are often hypersensitive to light touch and may irritate with changes of temperature. Deeper palpation may reveal tenderness and nodularity of the underlying fat. The condition is usually symmetrical or alsmost so. The feet often remain normal. At typical case is illustrated in Figs. 14.22 and 14.23
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Systemic causes of leg edema include idiopathic cyclic edema, heart failure, cirrhosis, nephrosis and other hypoproteinemic states. Lymphedema may be primary, or secondary to neoplasm, lymphangitis, retroperitoneal fibrosis and, rarely (in the U.S.), filariasis. Thrombophlebitis and chronic venous insufficiency are not uncommon causes. Finally, infection, ischemia, lipedema, vascular anomalies, tumors and trauma can be responsible for the swollen leg.
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1. Lipoedema is described with an illustration of a recent case. 2. This condition should be distinguished from lymphoedema of the legs. 3. The differential diagnosis is discussed. 4. Comment is made on treatment.
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