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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.

Lipedema is characterized by symmetric lower extremity enlargement secondary to the deposition of fat. Lipedema is not rare, but it is commonly misdiagnosed as lymphedema. We describe a 20-year-old woman with massive lower extremity enlargement that did not respond to compression therapy. Magnetic resonance imaging of the lower extremities helped to confirm the diagnosis.

Fluorescence microlymphography (FML) is an almost atraumatic technique used to visualize the superficial skin network of initial lymphatics through the intact skin of man. Visualization was performed with an incident light fluorescence microscope following subepidermal injection of minute amounts of FITC-dextran 150,000 using microneedles. Emanating from the bright dye depot, the surrounding network of microvessels is filled, documentation performed by photography or video film. In congenital Milroy lymphedema, a lack of microlymphatics (aplasia) is typical while in other primary lymphedemas and in secondary lymphedema after mastectomy or irradiation of proximal lymph nodes, the network remains intact but the depicted area is enlarged. Lymphatic microangiopathy characterized by obliterations of capillary meshes or mesh segments develops in phleboedema with trophic skin changes, progressive systemic sclerosis and Fabry's disease. In lipedema, lymphatic microaneurysms are stained. Microlymphatic pressure may also be measured using FML. For this purpose, glass micropipettes are inserted into the capillaries by means of a micromanipulator and pressure is determined by the servo-nulling technique. Normal subjects produced significantly lower pressure (7.9 +/- 3.4 mmHg) compared to patients with primary lymphedema (15.0 +/- 5.1 mmHg, p<0.001). This characteristic lymphatic hypertension may be improved by complex physiotherapy or local application of prostaglandins. Additionally, a modification of the FML procedure can be used to measure lymphatic capillary flow velocity in controls and patients. FML is suited to confirm the clinical diagnosis of lymphedema, contributes to distinguish among various forms of edema, and is useful in clinical research. In addition, FML has also become a tool for experimental animal studies including the depiction of gastric microlymphatics, the measurement of flow velocity in the naked mouse tail, and in evaluation of lymphangiogenesis in a model of Milroy disease.

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.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Discuss the initial evaluation of a patient presenting with lower extremity enlargement. 2. Distinguish underlying medical conditions causing lower extremity enlargement, including lymphedema and lipedema. 3. Discuss appropriate management and treatment for patients presenting with these conditions. BACKGROUND: Given the epidemic of obesity in the United States, many patients will consult the plastic surgeon with complaints of lower extremity enlargement secondary to "fat legs." In addition to cosmetic disfigurement, some patients may suffer from underlying medical conditions that are responsible for their symptoms. Knowledge of these other causes, including lymphedema and a disorder of abnormal fat deposition known as lipedema, ensures appropriate management and/or surgical treatment for affected patients. METHODS: Initial evaluation for lower extremity enlargement should include a discussion of pertinent medical history and a focused physical examination for findings that might indicate a pathologic underlying cause. When indicated, patients should undergo additional testing, including radiologic studies, to confirm their diagnoses. RESULTS: For those patients found to have lymphatic dysfunction, conservative management, such as massage therapy, use of compression garments, and limb elevation, should be initially recommended. Excisional or suction-assisted lipectomy may be considered in patients who fail conservative therapy. More extensive consultation with the plastic surgeon is recommended for patients seeking aesthetic improvement in contour and shape of large legs without a specified underlying abnormality. CONCLUSIONS: Patients with lower extremity enlargement may present to the plastic surgeon unsure of the specific cause of their deformity. A broad differential diagnosis exists for their presentation, which can be narrowed by using the common features and unique manifestations of the conditions.

In 10 patients, lymphatic drainage was studied before and after liposuction of the legs, employing dynamic lymph scintigraphy. The data (comparison of right/left, stress/rest, before/after liposuction) were well reproducible. Lymphatic drainage was not altered significantly after liposuction as compared to the pretherapeutic status. Particularly, no relevant disturbance of lymphatic drainage became evident. Our limited data indicate that liposuction does not cause relevant damage to lymph vessels.

Surgical approaches are usually not part of the strand rad approach in lymphologic therapy. Classic therapy is conservative and controls symptoms rather than seeking cures. Plastic surgical tissue reduction results in impaired lymph flow in many cases. Improving the lymphologic disease while reducing the need for complex compression therapy are major therapeutic goals. Lymphologic liposculpture offers a successful way to treat lipohyperplasia dolorosa and offers a new concept in the treatment of secondary lymphedema.

he term “lipedema“ was first used in 1974 by ALLEN and HINES. Their publication is regarded as “the classical description“ of the syndrome5; p. 184: “We wish to describe a clinical syndrome, lipedema of the legs, which is frequently very distressing. In our experience it affects solely women. The chief complaint is of swelling of the legs and feet...On questioning, the physician may elicit that enlargement of the limbs has always been generalized and symmetrical. The swelling below the knees is accentuated when patients are on their feet much and in warm weather. Aching distress in the legs is common... Occasionally, a patient feels, that her large legs have ‘ruined her life.’ Many are ‘ashamed’ of their legs.” This describes the patient’s problems very well, but it is difficult to define lipedema precisely because the definition depends mainly on subjective findings. There are no medical or laboratory tests to distinguish local lipohypertrophy (local fat tissue increase) of the legs or hips from lipedema or general obesity. Consequently, lipedema is not generally accepted as a real disease. We will attempt to describe the current knowledge on the pathophysiology and treatment of lipedema. Lipedema is a metabolic disorder of the adipose (fat) tissue with unknown etiology, affecting almost exclusively females. The following clinical and pathophysiological findings are of importance for differential diagnosis.

This case presentation illustrates the tremendous functional gains that individuals with lipo-lymphedema can achieve with proper diagnosis, education and treatment.

After successful completion of a conservative initial treatment consisting of manual lymph drainage and bandaging a lipedema must be fitted with an adequate compression garment made of flat-knitted material.The type of the compression supply and its duration following liposuction depends on the result obtained after the removal of fatty tissue. Due to liposuction alone, an improvement of the quality of life can be already achieved. An additional treatment using compression garments may have a positive effect, too.