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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%.

BACKGROUND: Lipedema is a rare female disorder with a characteristic distribution of adipose tissue hypertrophy on the extremities, with pain and bruising. In advanced stages, reduction of adipose tissue is the only available effective treatment. In elderly patients with advanced lipedema, correction of increased skin laxity has to be considered for an optimal outcome. METHODS: We report on a tailored combined approach to improve advanced lipedema in elderly females with multiple comorbidities. Microcannular laser-assisted liposuction of the upper legs and knees is performed under tumescent anesthesia. Medial thigh lift and partial lower abdominoplasty with minimal undermining are used to correct skin laxity and prevent intertrigo. Postsurgical care with nonelastic flat knitted compression garments and manual lymph drainage are used. RESULTS: We report on three women aged 55-77 years with advanced lipedema of the legs and multiple comorbidities. Using this step-by-step approach, a short operation time and early mobilization were possible. Minor adverse effects were temporary methemoglobinemia after tumescent anesthesia and postsurgical pain. No severe adverse effects were seen. Patient satisfaction was high. CONCLUSION: A tailored approach may be useful in advanced lipedema and is applicable even in elderly patients with multiple comorbidities.

OBJECTIVE: Elephantiasis nostras is a rare complication in advanced lipo-lymphedema. While lipedema can be treated by liposuction and lymphedema by decongestive lymphatic therapy, elephantiasis nostras may need debulking surgery. METHODS: We present 2 cases of advanced lipo-lymphedema complicated by elephantiasis nostras. After tumescent microcannular laser-assisted liposuction both patients underwent a debulking surgery with a modification of Auchincloss-Kim's technique. Histologic examination of the tissue specimen was performed. RESULTS: The surgical treatment was well tolerated and primary healing was uneventful. After primary wound healing and ambulation of the patients, a delayed ulceration with lymphorrhea developed. It was treated by surgical necrectomy and vacuum-assisted closure leading to complete healing. Mobility of the leg was much improved. Histologic examination revealed massive ectatic lymphatic vessels nonreactive for podoplanin. CONCLUSIONS: Debulking surgery can be an adjuvant technique for elephantiasis nostras in advanced lipo-lymphedema. Although delayed postoperative wound healing problems were observed, necrectomy and vacuum-assisted closure achieved a complete healing. Histologic data suggest that the ectatic lymphatic vessels in these patients resemble finding in podoplanin knockout mice. The findings would explain the limitations of decongestive lymphatic therapy and tumescent liposuction in such patients and their predisposition to relapsing erysipelas.

Leg swelling is an extremely frequent symptom with a broad variety of largely differing causes. The most important mechanisms behind the symptom include venous and lymphatic pathology, volume overload, increased capillary permeability, and lowered oncotic pressure. Therefore, the most frequent diseases associated with leg swelling are deep vein thrombosis and chronic venous insufficiency, primary or secondary lymphedema, cardiac failure, hypoproteinemia due to liver or renal failure, idiopathic cyclic edema, and drug-induced edema. Lipedema as a misnomer represents an important differential diagnosis. History and physical examination, when based on a sound knowledge of the diseases of interest, enable a conclusive diagnosis in most cases. Additional test are required in only a minority of patients. The present review discusses pathophysiology and clinical features of the most prevalent types of leg swelling. Finally, a brief guide to differential diagnosis is given.

The International Compression Club (ICC) is a partnership between academics, clinicians and industry focused upon understanding the role of compression in the management of different clinical conditions. The ICC meet regularly and from these meetings have produced a series of eight consensus publications upon topics ranging from evidence-based compression to compression trials for arm lymphoedema. All of the current consensus documents can be accessed on the ICC website (http://www.icc-compressionclub.com/index.php). In May 2011, the ICC met in Brussels during the European Wound Management Association (EWMA) annual conference. With almost 50 members in attendance, the day-long ICC meeting challenged a series of dogmas and myths that exist when considering compression therapies. In preparation for a discussion on beliefs surrounding compression, a forum was established on the ICC website where presenters were able to display a summary of their thoughts upon each dogma to be discussed during the meeting. Members of the ICC could then provide comments on each topic thereby widening the discussion to the entire membership of the ICC rather than simply those who were attending the EWMA conference. This article presents an extended report of the issues that were discussed, with each dogma covered in a separate section. The ICC discussed 12 'dogmas' with areas 1 through 7 dedicated to materials and application techniques used to apply compression with the remaining topics (8 through 12) related to the indications for using compression.

A grossly obese woman was wrongly diagnosed throughout her adult life of having lymphoedema. Her condition was subsequently confirmed as lipoedema, an entirely different condition, which is noted in medical text books but is seldom taught to medical students or to general practitioners. The condition is caused by abnormal deposition of adipose tissue in the extremities (usually the lower limbs) and almost exclusively affects women. It often starts at puberty or may occur after pregnancy. The exact aetiology is not yet understood but genetic and hormonal factors may be implicated. The problem is that misdiagnosis leads to inappropriate tests and improper treatment to the patient. When recognised it is often too late to do anything for the patient and they become highly dependent on social care. This case describes how the diagnosis can be confirmed through an ultrasound image and illustrates the need for early recognition to facilitate specialist care.

Lipoedema UK was founded in 2012 by women with lipoedema and clinicians working in the Lymphoedema Service at St George's Hospital in London. Its patron is Professor Peter Mortimer, the UK's leading Lipoedema expert, and its nurse consultant is Sandy Ellis, who diagnoses and treats many women with Lipoedema in the UK and is also the nurse consultant in the St George's team. The charity's objectives are to educate doctors, health professionals and the public about lipoedema and its symptoms, so it may be diagnosed and treated earlier.

BACKGROUND: Functional pelvic disorders in patients undergoing conservative surgical approach for rectal cancer are considered a major public health issue and represent one third of cost of colorectal cancer. We investigated the hypothesis that lymphadenectomy, involves the pelvic floor results in a localized hides or silent pelvic lymphedema characterized by symptoms without signs. PATIENTS AND METHODS: We examined 13 colo-rectal cancer patients: five intra-peritoneal adenocarcinoma: 1 sigmoid and 4 upper third rectal cancer (1 male and 3 female) and 9 extra-peritoneal adenocarcinoma: 3 middle and 5 lower third rectal cancer (4 male and 5 female) using 1.5-T magnetic resonance, one week before and twelve months after discharged from hospital. RESULTS: Lymphedema was discovered on post-operative magnetic resonance imaging of all 9 patients with extra-pertitoneal cancer, whereas preoperative magnetic resonance imaging as well as a post-operative examination of 4 intra-peritoneal adenocarcinoma, revealed no evidence of lymphedema. Unlike the common clinical skin signs that typify all other sites of lymphedema, pelvic lymphedema is hides or silent, with no skin changes or any single symptom manifested. Magnetic resonance imaging showed that pelvic illness alone is accompanied by lymphedema related exclusively to venous congestion, and accumulation of liquid in adipose tissue or lipedema. CONCLUSIONS: Alteration of the pelvic lymphatic network during pelvic surgery can lead to lymphedema and, pelvic floor disease. Patients should be routinely examined for the possibility of developing this post-surgical syndrome and further studies are needed to establish diagnosis and to evaluate treatment preferences.