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Lipedema is a disproportional obesity featuring frequent hematoma formation due to even minor traumatic injuries. On the basis of clinical observations, complete decongestive physiotherapy diminishes the incidence of hematomas due to minor injuries beyond leg volume reduction. Hematoma development may be caused by altered capillary resistance (CR) or altered capillary fragility (CF). We measured capillary fragility (CF) before and after complex decongestive physiotherapy (CDP) to examine, whether CDP could reduce CF. 38 women with lipedema were included in the study. Twenty-one (21) patients were treated with CDP and 17 using exclusively moisturizers as the control group. CDP comprised once daily manual lymph drainage, intermittent pneumatic compression and multilayered short-stretch bandaging performed throughout a 5-day-course. CF was evaluated with the vacuum suction method (VSM) using Parrot's angiosterrometer in both groups. Decongestive therapy resulted in a significant reduction of the number of petechiae while no change was detected within the control group. Complete decongestive physiotherapy significantly reduced CF in patients with lipedema and this reduction may lead to reduced hematoma formation.

Lipedema is a common but rarely diagnosed disease or frequently confused with obesity. Patients are almost exclusively women. It is characterised by symmetrical, circumscribed, in advanced form deforming fat tissue accumulation on the legs that is associated with lymphedema. Spontaneous pain, pain to pressure and tendency to hematoma are characteristic. One of the possible causes of a fat leg, that is a very common complaint, is lipedema. Main differential diagnoses are obesity, lipohypertrophy and primary and secondary lymphedema. It is often associated with chronic venous and lymphatic insufficiency, early degenerative articular disease and obesity. The disease is rarely recognized and the treatment modalities are not widely known. Therefore patients feel very frustrated that leads to psychologic disorders. Until recently only conservative treatment was possible (combination of manual or intermittent pneumatic drainage, compression bandages and garments and physiotherapy). More recently surgical intervention (liposuction) is also included in the treatment options. The significance of lipedema is due not only to the disease itself, but also to the combination of lipedema and the group of associated and secondary diseases (articular and venous diseases, lymphedema, obesity, psychologic disorders). The more diseases coexist, the worse is the prognosis of lipedema itself. To prevent and delay this disease, it is indispensable to recognise it as early as possible and to treat it expertly and follow up patients suffering from lipedema.

Lipedema is a disproportional obesity for which evidence-based treatment is not currently available. We studied whether complete decongestive physiotherapy (CDP) alone or combined with intermittent pneumatic compression (IPC) could improve the treatment outcome in women with lipedema using a prospective, randomized trial. Eleven patients received CDP (60 min) and thirteen CDP (30 min) plus IPC (30 min) once daily in a 5-day-course. Subsequent to drainage, all subjects received multilayered compression bandaging, physical exercise and skin care. Treatment efficacy was evaluated by limb volume reduction. Both groups achieved significant reductions in mean lower extremity volume (p < 0.05). The addition of IPC is safe, although it provides no synergistic benefit to CDP in leg volume reduction under these study conditions.

Lymphoedema is a clinical manifestation of an impaired lymphatic drainage with accumulation of lymphatic fluid. Lipoedema is characterized by bilateral enlargement of the legs and/or arms due to abnormal deposition of fatty tissue, which accumulates fluid. Conservative treatment including compressions garments and lymphatic drainage is suitable to prevent ongoing clinical deterioration although both diseases cannot be cured. The ability to properly diagnose lymphoedema and lipoedema is crucial to prevent the significant morbidity and loss of quality of life that is associated with this condition. It is imperative that patients with lymphoedema are referred to specially trained healthcare professionals to ensure optimal treatment. Continuous therapy with strict compliance of the patients is essential, and premature interruption is the most frequent mistake. Lipoedema is a different entity but patients are still fighting for acceptance. The mutual relation of lipoedema and obesity and the poor knowledge of the underlying mechanisms limit the acceptance of lipoedema as a relevant disease.

The population of morbidly obese patients, along with the incidence of lymphedema and massive localized lymphedema associated with this condition, is increasing. A 5-year retrospective review of data (2000-2005) shows that the percentage of patients >350 lb in the authors' clinic population increased from approximately 7% to 11% and 75% of their morbidly obese patients (body mass index >40) had or have lymphedema. After a differential diagnosis between lipedema and lymphedema (primary or secondary) has been made, lymphedema management options include compression bandaging, manual lymphatic drainage, and localized surgeries. The treatment of morbidly obese lymphedema patients requires additional staff time and specialized equipment to move or position them and may be confounded by other conditions (eg, heart failure and venous insufficiency) that contribute to edema. Lymphedema treatments have been found to be useful, providing patients are able to follow treatment guidelines, especially with regard to weight control. In the authors' experience, massive localized lymphedema will recur unless the primary issue of obesity is addressed. Establishing clear criteria and patient participation guidelines before initiating a comprehensive localized lymphedema program will improve outcomes.

Knowledge of both the morphology/ pathomorphology and physiology/pathophysiology of adipose tissue is limited and the behaviour of fat tissue has not been widely researched. Changes in adipose tissue (hyperplasia, hyper trophy and atrophy) are defined differently and, as a consequence, diagnostic failures frequently occur. Figure 1 shows the complicated regulatory mechanisms which are responsible for lipolysis and lipogenesis. Even if body weight is normal, appearance depends on the distribution of subcutaneous adipose tissue (Figure 2). The amount of fat we carry and how we look are, in part, subject to fashion. What was still sexy several decades ago, a bigger waist and more on the hips, no longer corresponds to how we see perfection today. Figure 2 shows the different ideals of beauty — ‘Wonderwoman’, for example, where you can detect as little fat as possible. Recently, there has been a mania for slimness. In order to comply with the current trend in fashion, young girls starve or undergo surgical procedures to have the typical female fatty tissue removed.

Lymphatic disease is quite prevalent, and often not well clinically characterized. Beyond lymphedema, there is a broad array of human disease that directly or indirectly alters lymphatic structure and function. The symptomatic and objective presentation of these patients can be quite diverse. In this review, we have attempted to provide a systematic overview of the subjective and objective spectrum of lymphatic disease, with consideration of all of the categories of disease that primarily or secondarily impair the functional integrity of the lymphatic system. Lymphedema is discussed, along with chromosomal disorders, lymphangioma, infectious diseases, lymphangioleiomyomatosis, lipedema, heritable genetic disorders, complex vascular malformations, protein-losing enteropathy, and intestinal lymphangiectasia.

ipoedema is a disease characterised by an abnormal, circumscribed accumulation of subcutaneous fat, mainly in the lower extremities, in combination with oedema. This results in an obvious disproportion between the upper and lower half of the body, as well as pain (Figure 1). Although lipoedema was first described in 1940 by Allen and Hines in the United States of America, the discussion still continues today as to whether this disease really is an entity, with some clinicians even doubting that it exists. In the 1940s it was described as a symmetrical subcutaneous deposition of fat in the buttocks and lower legs, together with an accumulation of fluid that begins almost imperceptibly, progressing gradually. Lipoedema was often associated with weight gain and accentuated by orthostatic activity. There are still aspects of lipoedema that are poorly understood. However, what we do know is that lipocytes, capillaries and venules are involved. An increased number and/or size of lipocytes results in increased fat volume, increased permeability of the capillaries causes oedema, and increased fragility of venules leads to haematoma (Table 1). Oedema is the main and most obvious cause of pain in people with lipoedema, so conservative therapy which reduces oedema can lessen the pain suffered. There are probably other factors causing pain, but oedema seems to be the most obvious. Lipoedema only develops in adult females. Figures 2a and 2b show the same patient at different ages. In most cases, lipoedema starts after puberty, a time when women want to look slim and beautiful. Figures 3a and 3b show the legs of a girl at the age of 17 and then 10 years later. The increase in volume can be seen mainly in the thighs. For some people lipoedema continues to progress until the end of life and is accentuated by pregnancy, birth and other hormonal changes, such as the menopause. In others, it remains at a steady level without progressing. The disease can also develop later in life. Figures 4a and 4b show a patient’s arm at the age of 51 and 10 years later. The forearms have stayed the same, while the upper arms have dramatically increased. It is not known why only the upper part of the arm is affected and the lower part remains unchanged.

Lipedemawas first described by Allen and Hines in 1940 (1).Today, however, a large number of physicians remain unaware of the disease and its symptoms. Many lipedema patients are not correctly diagnosed or effectively treated until after they have endured decades of suffering (2). Epidemiological statistics on the incidence of lipedema are not available. An investigation of patients treated at one lymphedema clinic from 1995 to 1996 revealed lipedema in approximately 15% of the patients treated on an inpatient basis (3). A similar number (8% to 17%) was reported in surveys carried out in 2003 in four lymphedema clinics in Germany (4). In contrast to lymphedema, literature on lipedema is extremely sparse. Lipedema findings in the Anglo-American literature in particular often report only isolated case studies (5-8). Many more publications, including a monograph, are available in German literature (9). Table 7-1 lists synonyms for lipedema.

Introduction: Complaints of lipoedema are mainly referred to as pressure pain or tension in the scientific literature. Objective: The objective was to enable a further differentiation of the quality of the perceived discomfort and provide a preliminary quantification of pain severity. Methods: 50 patients with Stage II lipoedema were asked to complete a questionnaire containing 30 items corresponding to sensory and affective pain sensations. For these items, they could choose between “completely applicable”, “largely applicable”, “somewhat applicable”, or “not applicable”. The patients were also asked to describe their complaints in their own words. Results: The items pressing and dull were specified most frequently. The following were indicated to a lesser extent: severe, tearing, nagging, unnerving, fierce, unbearable, exhausting, and sharp. Compared to patients with chronic pain, the mean values of all the patients’ sensory and affective scores yielded an average pain severity. However, when the patients used their own formulations, the complaints were often described as being very pronounced. Conclusion: Only a small portion of the adjectives offered was suitable for characterising the sensations of lipoedema. There were considerable inter-individual variations in how the pain was perceived. The severe symptoms, which are partially subjective, should be considered when characterising lipoedema.

Introduction: In the scientific literature complaints in patients with lipoedema are described as pain due to pressure or as tenderness. Objective: To better classify the quality of pain in lipoedema and to find out about the extent of complaints. Methods: 50 patients with lipoedema stage II received a questionnaire with 30 items containing adjectives of sensory and affective pain qualities. For these items they could choose between »fits exactly«, »fits fairly well«, »fits little« or »does not fit«. In addition, patients were asked to describe their complaints with their own words. Results: In most cases the items pressing and lumpish were chosen. Many patients used the characterizations heavy, tearing, distressing, enervating, fierce, unbearable, exhausting, and pinching. The median values of all the patients´ sensory and affective scores showed – compared to people with chronic pain – »average« values. However, by using their own words, the complaints were often described as extremely burdensome. Conclusion: For describing pain in lipoedema only few items were used by the patients. There were great interindividual variations. Aspects of pain can be quite burdensome; they should be used in the characterization and the grading of lipoedema. Key words: lipedema, pain assessment, pain experience scale