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Lipoedema is an incurable chronic disease but effective treatment can minimise the impact of the condition

Lipoedema is a chronic disease frequent in women, that causes an abnormal fat deposition in their lower limbs, with a remarkable disproportion between the upper and lower part of the body, easy bruising and pain. Despite the lack of pathognomonic tests for lipoedema, more and more patients in social networks are claiming they suffer from it, giving the disease more visibility but allowing a lot of fake information about lipoedema. Information for self-care and realistic expectations are important. Depending on the severity, the treatment includes: physical therapies, compression garments, exercise, diet, psychological support and surgical treatment.

Lymphoedema is a chronic, progressive debilitating disorder of lymphoreticular system, characterized by abnormal collection of excessive proteins, oedema, chronic inflammation and fibrosis.Primary lymphoedema, associated with underlying, but inherent malfunction of lymphatic channels, unilateral or bilateral. It can be further subdivided in to congenital lymphoedema, lymphoedema praecox and lymphoedema tarda. Depends on the age of onset or manifestation. Another genetic disorder of lymphatic dysfunction is Milroy disease. It is an autosomal dominant condition due to VEGFR3 mutation characterised by lymphatic hypoplasia. Secondary lymphoedemas are more frequent than primary to dysfunction of lymphatics. Mostly localised, follwing recurrent infections, trauma, surgery, obesity and malignancy.Inadequate drainage of lymphatics, leads to accumulation of lymph, interstitial fluid and proteins in skin and subcutaneous tissue. Elastic tissue disruption, fibroblast stimulation occurs and the resulting hypoxia causes chronic inflammation and fibrosis. Later adipocyte remodelling occurs and proinflammatory cytokines secreted.Starts as pitting non tender pedal oedema, later skin thickening and fibrosis which results in non-pitting oedema. Squared off appearance and Kaposi Stemmer sign are characteristic features. May develop lymphorrhoea and secondary infections may supervene. Chronic venous insufficiency, lipoedema, myxedema.Vicious cycle of infections and lymphedema.Lymphoscintigraphy, lymphoflouroscopy- gold standard.Depends on severity. Pneumatic compression garments, Low level light therapy (LLLT), Extracorporeal shock wave therapy (ESWT). Advanced stages may require surgical debulking, lymphatic reconstruction. But the results are mostly unsatisfactory, recurrences are inevitable. Combined multi-disciplinary approaches will be helpful and that should be continued throughout their life.

Introduction The present exploratory study is the first so far to investigate the psychological stress in the period before the development of pain symptoms typical for lipoedema. Methods 150 patients diagnosed with lipoedema syndrome were questioned in semi-structured interviews about psychological stress and were diagnosed with psychological disorders according to ICD-10 criteria. The development of the symptoms typical for lipoedema was recorded in a second interview. Both interviews were blended together in collaboration with the patients, this means Lipoedema-associated pain and psychological stress were related to time. Result Exactly 80 % of the patients diagnosed with lipedema show a high level of psychological distress immediately before the onset of lipedema-associated symptoms! In this study, mental distress was defined as the presence of a manifest mental disorder (ICD 10 F diagnosis) such as Depression, eating disorder or post-traumatic stress disorder and/or serious psychological distress such as burnout syndrome or chronic stress. Summary These results contradict a widespread statement that all psychological problems of patients with the diagnosis lipoedema syndrome are caused solely by lipoedema, that lipoedema even causes the patient’s mental disorder.Moreover, depression and posttraumatic stress disorders are significantly related to the maximum pain intensity estimated by patients in everyday life. This demonstrates that it is imperative to rethink lipoedema therapy and to implement a psychosocial pillar in an overall therapy concept.

Szypłowska Małgorzata, Gorecka Adrianna, Kuś Adrian, Zaremba Bartłomiej, Obel Michał. Diagnosis and management of lipoedema – a review paper. Journal of Education, Health and Sport. 2020;10(9):494‑499. eISSN 2391-8306. DOI http://dx.doi.org/10.12775/JEHS.2020.10.09.059 https://apcz.umk.pl/czasopisma/index.php/JEHS/article/view/JEHS.2020.10.09.059 https://zenodo.org/record/4042181 The journal has had 5 points in Ministry of Science and Higher Education parametric evaluation. § 8. 2) and § 12. 1. 2) 22.02.2019. © The Authors 2020; This article is published with open access at Licensee Open Journal Systems of Nicolaus Copernicus University in Torun, Poland Open Access. This article is distributed under the terms of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author (s) and source are credited. This is an open access article licensed under the terms of the Creative Commons Attribution Non commercial license Share alike. (http://creativecommons.org/licenses/by-nc-sa/4.0/) which permits unrestricted, non commercial use, distribution and reproduction in any medium, provided the work is properly cited. The authors declare that there is no conflict of interests regarding the publication of this paper. Received: 15.09.2020. Revised: 21.09.2020. Accepted: 22.09.2020. Diagnosis and management of lipoedema – a review paper Małgorzata Szypłowska1, Adrianna Gorecka1, Adrian Kuś1, Bartłomiej Zaremba1, Michał Obel2 1Student Research Circle at the Department of Epidemiology and Clinical Research Methodology, Medical University of Lublin 2Student Research Circle at the Department of Endocrinology, Medical University of Lublin Supervisor: PhD Halina Piecewicz-Szczęsna3 3Department of Epidemiology and Clinical Research Methodology, Medical University of Lublin Corresponding author: malgorzata.szyplowska@gmail.com Abstract Lipoedema is a chronic progressive disorder of adipose tissue leading to an enlargement of lower extremities. It is considered to be rare; however, the prevalence of the disease is underestimated because it is commonly misdiagnosed as obesity or lymphedema and the general awareness is poor. The etiology of the disorder is considered to be multifarious, including genetic inheritance, hormonal imbalance and microcirculation alterations. Diagnosis is mainly based on medical history and physical examination. Management of lipoedema is focused on reducing the symptoms, improving the quality of life and preventing further progression of the disease. The aim of this paper is to raise the awareness of the disease and provide appropriate clinical guidance for the assessment of lipoedema. We searched through the PubMed/MEDLINE database and took into consideration all of the results available as of 6 September, 2020 and outlined the current evidence regarding lipoedema epidemiology, etiology, clinical presentation, differential diagnosis, and management. Better understanding of lipoedema is crucial for establishing an early diagnosis and a proper treatment, which in turn will reduce the psychological and physical implications associated with the disease. Key words: lipoedema, lymphoedema, lipolymphoedema

Lipoedema is associated with widespread adipose tissue expansion, particularly in the proximal extremities. The mechanisms that drive the development of lipoedema are unclear. In this Perspective article, we propose a new model for the pathophysiology of lipoedema. We suggest that lipoedema is an oestrogen-dependent disorder of adipose tissue, which is triggered by a dysfunction of caveolin 1 (CAV1) and subsequent uncoupling of feedback mechanisms between CAV1, the matrix metalloproteinase MMP14 and oestrogen receptors. In addition, reduced CAV1 activity also leads to the activation of ERα and impaired regulation of the lymphatic system through the transcription factor prospero homeobox 1 (PROX1). The resulting upregulation of these factors could effectively explain the main known features of lipoedema, such as adipose hypertrophy, dysfunction of blood and lymphatic vessels, the overall oestrogen dependence and the associated sexual dimorphism, and the mechanical compliance of adipose tissue.

Lipoedema is an incurable chronic disease causing limb deformity, painful skin and excessive ecchymosis. Compression garments are frequently recommended to manage symptoms, but the existing products are not designed specifically for lipoedema, and are for other medical conditions. A structured questionnaire was prepared in Online Surveys in October 2018 to investigate lipoedema symptoms and the use of compression garments to manage them. Some 279 people with lipoedema completed the survey; 70% wore compression garments in all four compression classes, of which class 2 was most common (58% of wearers). The top three reasons for wearing compression garments were to feel supported (73%), reduce lipoedema pain (67%) and improve mobility (54%). Most people with lipoedema who wore compression garments found compression helpful in managing their symptoms, but overall satisfaction was low. Problems with existing compression garments were so severe in some cases that the garments were not worn at all or used less often. The information collected in this survey might be useful for the design and development of compression garments specifically for lipoedema.

Background: Lipedema and Dercum's disease (DD) are incompletely characterized adipose tissue diseases, and objective measures of disease profiles are needed to aid in differential diagnosis. We hypothesized that fluid properties, quantified as tissue water bioimpedance in the upper and lower extremities, differ regionally between these conditions. Methods and Results: Women (cumulative n = 156) with lipedema (n = 110), DD (n = 25), or without an adipose disease matched for age and body mass index to early stage lipedema patients (i.e., controls n = 21) were enrolled. Bioimpedance spectroscopy (BIS) was applied to measure impedance values in the arms and legs, indicative of extracellular water levels. Impedance values were recorded for each limb, as well as the leg-to-arm impedance ratio. Regression models were applied to evaluate hypothesized relationships between impedance and clinical indicators of disease (significance criteria: two-sided p

ZusammenfassungDas Lipödem war bis vor einigen Jahren ein eher unbekanntes Erkrankungsbild. In den letzten 5 Jahren gewann die Lipödemerkrankung immer mehr Bekanntheit, insbesondere durch die mediale Aufmerksamkeit. Neben der konservativen Behandlung durch eine komplex-konservative Entstauungstherapie gibt es immer mehr Studien, die das Potenzial eines Liposuktionsverfahrens zur erfolgreichen Therapie des Lipödems nahelegen. Infolgedessen werden Betroffene dieser Erkrankung zunehmend bei Plastischen Chirurgen vorstellig mit dem Wunsch nach Korrektur und Schmerzlinderung. Da die Liposuktion in Deutschland allerdings seitens des gemeinsamen Bundesausschusses (G-BA) noch nicht als Behandlungsalternative zur Therapie von Lipödemerkrankten positiv bewertet worden ist, ist eine Leistungserbringung zu Lasten der GKV immer noch eine Einzelfallentscheidung, welche gesondert von den Patientinnen in Zusammenarbeit mit dem behandelnden Plastischen Chirurgen beantragt werden muss. Im vorliegenden Übersichtsartikel legen wir die aktuelle Rechtslage dar und geben Hilfestellung bei der Beantragung von Kostenübernahmen.

ZusammenfassungObwohl die Liposuktion des Lipödems eine etablierte Therapieoption in der Behandlung des Lipödems darstellt, variieren die dargebotenen Behandlungskonzepte zwischen den Kliniken stark untereinander. Eine dezidierte Zusammenfassung aller beschriebenen Protokolle sowie deren kritische Evaluierung blieben bislang unveröffentlicht. Als Primärziel der vorgestellten Übersichtsarbeit soll eine Basisstruktur zur geplanten konsensuellen Standard Operative Procedure (SOP) der Fachgesellschaft DGPRÄC in der operativen Behandlung des Lipödems geschaffen werden. Hierfür wurden insgesamt 140 Publikationen bezüglich des Lipödems systematisch aufgearbeitet und katalogisiert. Es werden sowohl grundsätzliche Unterschiede in den Behandlungsstrategien, als auch kleinere Differenzen im organisatorischen Management aufgezeigt und zur Diskussion gestellt.

This study examined the disease‐specific quality of life (QoL) in lipoedema patients undergoing treatment for the condition with liposuction. We conducted a retrospective analysis of all patients (n = 69) who underwent liposuction for treatment of lipoedema between 2004 and 2019, and gathered data on patient age, body mass index, the number of liposuction sessions, and the amount of fat removed per side. The study also prospectively evaluated the QoL in 20 lipoedema patients before and after liposuction using the Freiburg Life Quality Assessment for lymphatic diseases questionnaire. The mean age was 50.6 ± 12.8 years, and the average number of liposuction sessions performed was 2.9 ± 1.9, with a mean volume of 1868 ± 885.5 mL of fat removed per side. Before treatment with liposuction, disease‐specific QoL in patients with lipoedema was low on every single subscale as well as on the global score and showed a significant improvement in all aspects after liposuction. There was a significant correlation between a higher number of liposuction treatment sessions and general health status in lipoedema patients (P = .007). Liposuction greatly improves the QoL in lipoedema patients. A higher number of liposuction treatment sessions seem to have a positive effect on general health status in these patients.

Introduction: Lipoedema is characterized as subcutaneous lipohypertrophy in association with soft-tissue pain affecting female patients. Recently, the disease has undergone a paradigm shift departing from historic reiterations of defining lipoedema in terms of classic edema paired with the notion of weight loss-resistant leg volume towards an evidence-based, patient-centered approach. Although lipoedema is strongly associated with obesity, the effect of bariatric surgery on thigh volume and weight loss has not been explored. Material and Methods: In a retrospective cohort study, thigh volume and weight loss of 31 patients with lipoedema were analyzed before and 10–18 and ≥19 months after sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB). Fourteen patients, with distal leg lymphoedema (i.e., with healthy thighs), who had undergone bariatric surgery served as controls. Statistical analysis was performed using a linear mixed-effects model adjusted for patient age and initial BMI. Results: Adjusted initial thigh volume in patients with lipoedema was 23,785.4 mL (95% confidence interval [CI] 22,316.6–25,254.1). Thigh volumes decreased significantly in lipoedema and control patients (baseline vs. 1st follow-up, p < 0.0001 and p = 0.0001; baseline vs. 2nd follow-up, p < 0.0001 and p = 0.0013). Adjusted thigh volume reduction amounted to 33.4 and 37.0% in the lipoedema and control groups at the 1st follow-up, and 30.4 and 34.7% at the 2nd follow-up, respectively (lipoedema vs. control p > 0.999 for both). SG and RYGB led to an equal reduction in leg volume (operation type × time, p = 0.83). Volume reduction was equally effective in obese and superobese patients (weight category × time, p = 0.43). Conclusion: SG and RYGB lead to a significant thigh volume reduction in patients with lipoedema.

Multiple associated comorbidities have been described for lipedema patients. Disease diagnosis still remains challenging in many cases and is frequently delayed. The purpose of this study was to determine the most common comorbidities in lipedema patients and the impact of surgical treatment onto disease progression. A retrospective assessment of disease-related epidemiologic data was performed for patients who underwent liposuction between July 2009 and July 2019 in a specialized clinic for lipedema surgery. All patients received a standardized questionnaire regarding the clinical history and changes of lipedema-associated symptoms and comorbidities after surgery. 106 patients who underwent a total of 298 liposuction procedures were included in this study after returning the questionnaire fully filled-in. Multiple comorbidities were observed in the assessed collective. The prevalence for obesity, hypothyroidism, migraine, and depression were markedly increased in relation to comparable nonlipedema populations. Despite a median body mass index (BMI) of 31.6 kg/m2 (IQR 26.4-38.8), unexpected low prevalence of diabetes (5%) and dyslipidemia (7%) was found. Diagnosis and initiation of guideline-appropriate treatment were delayed by years in many patients. After surgical treatment (medium follow-up 20 months, IQR 11-42), a significant reduction of lipedema-associated symptoms was demonstrated. Lipedema occurs with a diversity of associated comorbidities. Therefore, on the basis of available data, the authors suggest the necessity of a multimodal therapy concept for a comprehensive and holistic treatment. Despite a commonly increased BMI, lipedema patients appear to have an advantageous metabolic risk profile.

Patients with obesity-associated lipoedema minimize by diet only the regular fat especially in the lower leg area. The pathological lipoedema with a possible secondary lymphodynamic oedema remains and causes skin irritation, discomfort and pain wearing the compression elements. The dorsal lower leg lift with previous liposuction is a useful therapeutic strategy to overcome these difficulties. A 37-year-old female patient after post-bariatric surgery and massive weight loss (MWL) presented with a lower leg lipoedema and lymphodynamic oedema. She underwent a liposuction removing lipoedema of the lower leg followed by a calf lift procedure on both sides. With sufficient surgical experience in skin tightening surgery after MWL, a significant improvement in day-to-day problems in patients with lipoedema can be achieved by dorsal lift of the lower leg after liposuction.

Background Lymphatic insufficiency might play a significant role in the pathophysiology of lipoedema. Liposuction is up to now the best treatment. As liposuction is invasive, the technique could destruct parts of the lymphatic system and by this aggravate the lymphatic component and/or induce lymphoedema. We investigated the function of the lymphatic system in lipoedema patients before and after tumescent liposuction and thus whether tumescent liposuction can be regarded as a safe treatment. Methods Lymphoscintigraphy was performed to quantify the lymph outflow of 117 lipoedema patients. Mean clearance percentages of radioactive protein loaded after 1 min with respect to the total injected dose and corrected for decay of the radiopharmaceutical in the subcutaneous lymphatics were used as functional quantitative parameters as well as the clearance percentages and inguinal uptake 2 h post injection. The results of lymphatic function in lipoedema patients were compared with values obtained from normal healthy volunteers. We also compared 50 lymphoscintigraphies out of the previous 117 lipoedema patients before and six months after tumescent liposuction. Results In 117 lipoedema patients clearance 2 h post injection in the right and left foot was disturbed in 79.5 and 87.2% respectively. The inguinal uptake 2 h post injection in the right and left groin was disturbed in 60.3 and 64.7% respectively. In 50 lipoedema patients mean clearance and inguinal uptake after tumescent liposuction were slightly improved, 0.01 (p = 0.37) versus 0.02 (p = 0.02), respectively. This is statistically not relevant in clearance. Conclusion Lipoedema legs have a delayed lymph transport. Tumescent liposuction does not diminish the lymphatic function in lipoedema patients, thus tumescent liposuction can be regarded as a safe treatment.

BACKGROUND Chronic lymphoedema (CLE) is a burdensome disease of multiple causes leading to significant reductions in health-related quality of life (HRQoL). A specific method to assess HRQoL is the Freiburg Life Quality Assessment for lymphoedema (FLQA-L), which consists of 92 items. OBJECTIVES To develop and validate a short form of the FLQA-L with improved psychometric properties and feasibility. METHODS The FLQA-L validation data were reanalysed by patients and experts. The application of factor analysis enabled the exclusion of lower-load items. An optimized short version of the questionnaire (FLQA-LS) with 33 items was generated and tested in a validation study on patients with different forms of CLE. RESULTS In total, 348 patients with CLE of the upper or lower extremities were included (mean age 57.3 years, range 24-89; 90.8% female), and data from 301 patients could be analysed. Overall, 42.8% of the patients had secondary lymphoedema, 23.6% had primary lymphoedema, 9.5% had lipoedema and 24.1% had lipolymphoedema. The lower extremities were mostly affected (64.4% of the patients presented with leg involvement and 17.5% with both arm and leg impairment). The FLQA-LS showed good internal consistency, with high Cronbach's alpha in the subscales and in the global scale ranging between 0.79 and 0.94. Regarding convergent validity, a good correlation was found with the general HRQoL questionnaire EQ-5D (r = 0.72, P < 0.001). CONCLUSIONS FLQA-LS is an improved version of the FLQA-L questionnaire for chronic lymphoedema. It demonstrated validity and feasibility and can be easily used in clinical practice and research studies.

Zusammenfassung. Lipödem-Patienten leiden an der weit verbreiteten Unkenntnis ihrer Pathologie. Angesichts ihres chronischen, fortschreitenden und invalidierenden Charakters muss die frühe Diagnose der Krankheit ZIel der Bezugspersonen sein, um medizinische Wanderungen und das Auftreten komplexer Krankheitsbilder zu begrenzen. Behandlungen ermöglichen die Reduzierung von Lipödemen und deren Langzeitkontrolle. Das Management muss entsprechend dem Krankheitsstadium individualisiert werden. Die Compliance des Patienten, die Überwachung und die Unterstützung durch den Arzt sind für das Erreichen der besten Ergebnisse unerlässlich.

Lipoedema is a rare painful disorder of the adipose tissue. It essentially affects females and is often misdiagnosed as lymphoedema or obesity. It is globally misdiagnosed or underdiagnosed, and the literature is lacking appropriate guidance to assist clinicians towards this diagnosis. However, the need to recognise this disorder as a unique entity has important implications to establish proper treatment and, therefore, its tremendous effect on patients. Early diagnosis and treatment can turn these patients' lives upside down. The aim of this review is to focus on the clinical guidance, differential diagnosis, and management strategies. In addition, other aspects of lipoedema, including epidemiology and pathogenesis, are also being discussed here. Lipoedema is distinct from obesity and distinct from lymphoedema, although it might progress to involve the venous and lymphatic system (venolipedema or lympholipedema or both). Late diagnosis can leave the patient debilitated. Management of lipoedema includes weight loss, control of oedema, complex decongestive physiotherapy, liposuction, and laser-assisted lipolysis. However; there are increasing reports on tumescent liposuction as the preferred surgical option with long-lasting results. The role of more randomised controlled studies to further explore the management of this clinical entity remains promising.

Introduction Lipoedema is a chronic disorder in which excessive fat distribution occurs predominantly from the waist down, resulting in a disproportion between the lower extremities and upper torso. Lipoedema is often not recognized, while patients experience pain and easy bruising. As a long-term condition, lipoedema has a massive effect on patients’ lives and mental health. The aim of this study is to explore patient characteristics, quality of life, physical complaints and comorbidities in patients with lipoedema. Methods A survey was conducted by email amongst lipoedema patients, consisting of informed consent and multiple questionnaires. The questionnaires included general patient characteristics, physical complaints, comorbidities, RAND-36 and EQ-5D-3L. Participants who responded to a message on the Dutch Lipoedema Association website were recruited. Results All lipoedema patients experience physical complaints, with pain (88.3 %) and easy bruising (85.9 %) as primary complaints. The diagnosis was mostly made by a dermatologist after visiting a mean of 2.8 doctors. Furthermore, mean time from onset until diagnosis was 18 years. Quality of life (59.3) was significantly lower than the Dutch female average (74.9; p

Lipoedema is a disorder of adipose tissue that is characterized by abnormal subcutaneous fat deposition, leading to swelling and enlargement of the lower limbs as well as the trunk. This entity is often misdiagnosed as lymphoedema or obesity and, therefore, may be overlooked and missed in patients scheduled for bariatric surgery. Patients with lipoedema who undergo bariatric surgery may have to continue to have extensive lower extremity and trunk adiposity despite adequate weight loss. In this report, we present two patients who had extensive trunk and lower extremity adiposity, one of them before and the other after the bariatric surgery.

(1) Background: Lipoedema is a disease characterized by excessive bilateral and symmetrical accumulation of subcutaneous tissue in the lower extremities. It is a poorly understood condition, and low awareness of its existence often leads to incorrect diagnosis Initially, lipoedema was considered to be completely independent of lifestyle Currently, however, more and more cases of the coexistence of lipoedema and obesity are described in the literature as additionally affecting the severity of the disease The aim of the review is to present lipoedema as a social problem. (2) Methods: Materials on lipoedema in the social context were selected from 2018–2021. The PRISMA-Scr checklist was used in the review. (3) Results: Research has shown that more than 3/4 of patients with lipoedema are also overweight or obese. Patients with lipoedema have many comorbidities, and their presence negatively affects the quality of life. The quality of life in patients with lipoedema is lower than in healthy patients. (4) Conclusions: The number of studies available on lipoedema is low. Obesity is common in patients with lipoedema. Mental disorders increase the level of experienced pain. Lipoedema significantly reduces quality of life. A healthy lifestyle in patients with lipoedema could be helpful for prevention of complications and disability.

Lymphoedema results from a failure of the lymphatic system. The consequences are swelling, skin and tissue changes and predisposition to infection. Lipoedema, however, results from the predisposition of an excessive number of fat cells in the lower limbs, typically from the ankle to the waist. Management for lymphoedema consists of volume reduction, reduction in shape distortion and improvement of skin condition. Treatment consists of a two-phase approach including an intensive and maintenance phase. The maintenance stage of treatment or self-care consists of skin care, exercise and compression garments. Case studies are presented featuring lower limb lymphoedema and upper limb lymphoedema and a patient affected by lipoedema. The case studies demonstrate how JOBST Elvarex custom-fit, flat-knit compression garments with knee and elbow functional zones enhances patient choice, garment suitability and potential for improved quality of life.

Compression therapy is a key component in the effective management of people with lower limb problems associated with venous, lymphatic and fat disorders such as lipoedema. Individuals with lymphoedema, venous ulceration and lipoedema often require long-term compression therapy to prevent and manage problems such as chronic ulceration and skin changes, persistent swelling and shape distortion. There are challenges in achieving acceptable, safe, effective and cost-efficient compression therapy choices. Adjustable, compression-wrap devices incorporating hook-and-loop systems present new opportunities for improving treatment outcomes, supporting patient independence and self-management in the use of compression therapy.

Anne Williams and Isobel MacEwan of Talk Lipoedema supply an overview of an often misunderstood disorder and the effects of additional complications – and provide guidance for supporting self-management in patients This article explores the pathophysiology of lipoedema, and the changes to the lymphatic system in someone with lipoedema. It aims to identify some of the challenges for individuals who live with lipoedema complicated by secondary lymphoedema, and provides information for health professionals in managing associated problems such as cellulitis.

Background Lipedema is a condition consisting of painful bilateral increases in subcutaneous fat and interstitial fluid in the limbs with secondary lymphedema and fibrosis during later stages. Combined decongestive therapy (CDT) is the standard of care in most countries. Since the introduction of tumescent technique, liposuction has been used as a surgical treatment option. The aim of this study was to determine the outcome of liposuction used as treatment for lipedema. Methods Twenty-five patients who received 72 liposuction procedures for the treatment of lipedema completed a standardized questionnaire. Lipedema-associated complaints and the need for CDT were assessed for the preoperative period and during 2 separate postoperative follow-ups using a visual analog scale and a composite CDT score. The mean follow-up times for the first postoperative follow-up and the second postoperative follow-up were 16 months and 37 months, respectively. Results Patients showed significant reductions in spontaneous pain, sensitivity to pressure, feeling of tension, bruising, cosmetic impairment, and general impairment to quality of life from the preoperative period to the first postoperative follow-up, and these results remained consistent until the second postoperative follow-up. A comparison of the preoperative period to the last postoperative follow-up, after 4 patients without full preoperative CDT were excluded from the analysis, indicated that the need for CDT was reduced significantly. An analysis of the different stages of the disease also indicated that better and more sustainable results could be achieved if patients were treated in earlier stages. Conclusions Liposuction is effective in the treatment of lipedema and leads to an improvement in quality of life and a decrease in the need for conservative therapy.

An audit of 100 new patients attending a specialist lymphoedema clinic revealed 52% presented with chronic oedema. More than half (58%) of the chronic oedema group presented with skin changes whereas 14% of those with lipoedema, 4% with lymphoedema of the arm, and 8% with lymphoedema of the leg developed skin changes. None of the primary lymphoedema group developed skin changes. Chronic venous disease (CVD) was significantly more prevalent in the chronic oedema group. More patients with bilateral chronic oedema suffered from cellulitis (41%) compared to unilateral (27%). Skin changes, CVD and red leg syndrome (RLS) also occur more often in bilateral leg swelling. Incidence of cellulitis is highest in the chronic oedema group (36.5%), closely followed by the primary lymphoedema group (33.3%). 85% of the patients who were weighed (n=93) were overweight, 39% obese, and 29% morbidly obese. The findings from this audit highlight the importance of skin care training for community nurses managing chronic oedema patients.

Lymphedema is a complex and burdensome medical problem and requires continuous specific therapy. The aim of this cross-sectional study of community lymphedema care in the metropolitan area of Hamburg, Germany, was to evaluate health-related quality of life (QoL) in lymphedema patients. Generic as well as disease-specific health-related QoL was assessed using EQ-5D and FLQA-LK, respectively. Pain was assessed using a visual analogue scale (VAS). About 301 patients (median age of 60.5 years, 90.8% female) with lymphedema of any origin were included. About 66.4% had lymphedema, 24.1% combined lipolymphedema, and 9.5% lipoedema. Mean disease-specific QoL (FLQA-LK) was 2.4 (range 0 = no to 4 = maximum burden). The highest impairment values were observed in subscales for physical complaints, everyday life, and emotional well-being. Mean EQ-5D VAS was 70.4, mean EQ-5D score 63.3. Lymphedema was associated with major impairments in QoL, which differed for subgroups of pain, clinical severity, and comorbidity. Pain as a common problem for lymphedema patients seemed to be underestimated and undertreated. Early diagnosis and structured treatment strategies are urgently needed.

Compression hosiery is commonly used for the management of lymphoedema as well as lipoedema, but it is more commonly indicated for the lower limbs than for the upper limbs. The effects of compression hosiery on upper-limb lipoedema are poorly understood and researched. It is known that compression hosiery works in conjunction with activity or movement when standing or walking, which produces anti-inflammatory and oxygenating effects in the tissues. This effect is naturally difficult to realise in the upper limbs. Lymphoedema practitioners who treat those with lipoedema should bear in mind that compression treatment might not produce the same effects in upper-limb lipoedema as it does in lower-limb lipoedema. In these times of an overstretched health service, pragmatic resource use is essential.

Liposuction is one of the most common procedures undertaken in plastic surgery with a steadily increasing trend over the years. Although usually performed as an aesthetic procedure for body contouring, it can also be utilized in specific patient groups for disease symptom reduction. One such disease entity is lipedema. The goal of this video to present the authors’ technique in the surgical treatment of lipedema, and to offer the viewer a better understanding of the differences between an aesthetic liposuction and a functional liposuction as performed on a lipedema patient. Between July 2009 and July 2019, 106 lipedema patients have been treated in the authors’ specialized lipedema clinic, with a total of 298 liposuction procedures and a median follow-up of 20 months. The mean amount of lipoaspirate was 6354.73 ml (± 2796.72 ml). The patients reported a significant reduction in lipedema-associated complaints and improvement in quality of life. The need for conservative therapy was significantly reduced. No serious complications were reported. The authors also present before and after photographs of three patients. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Lipoedema is a progressive disorder that is characterized by an abnormal distribution of subcutaneous adipose tissue, which results in a disproportion between the extremities and the trunk. This vascular/dermatological disease might have a detrimental impact on psychosocial wellbeing and quality of life. In this article, we report on a patient with morbid obesity that had a Roux en-Y Gastric bypass with sufficient weight loss. However, due to this weight loss, an abnormal disproportion came to light. A dermatologist diagnosed lipoedema five years after the surgery. Eventually, she had a dermolipectomy of the upper arms, of which reimbursement was initially rejected by her insurance.

Lipoedema is a chronic progressive adipose disorder that affects mainly women and presents as symmetrical enlargement of the buttocks and legs. It is commonly misdiagnosed as obesity or lymphoedema, but careful assessment will reveal a disproportionate enlargement below the waist which is resistant to dieting, sparing of the feet, legs are tender or painful to touch and bruise easily, there is occasional orthostatic oedema, and there is often significant psychological morbidity. Lipoedema is a oestrogen-regulated condition with onset around puberty in 78% of women, and there is often a strong family history. The condition is exacerbated by weight gain and there is increasing anecdotal evidence that women who are obese are seeking a diagnosis of lipoedema, either to procure NHS funded manual lymphatic drainage, or to medicalise their obesity and avoid acknowledging that the responsibility for their weight gain is lifestyle orientated. Management of lipoedema consists of accurate diagnosis, psychological care, management of orthostatic oedema, and prevention of progression through skin care and weight management.

This study aimed to explore patients' perceptions regarding the impact that lower limb chronic oedema has on their quality of life (QoL). A quantitative descriptive design was used to collect data from patients with lower limb chronic oedema. A condition-specific validated questionnaire was distributed to a purposive sample (n = 122) through manual lymphatic drainage/vascular/health clinics in Ireland. Results indicated that patients with lower limb chronic oedema experience a wide range of physical problems such as limb heaviness (74%, n = 66), weakness (44%, n = 40) and pain (38%, n = 34). Additionally, difficulties with walking (53%, n = 48), standing (51%, n = 46) and bending (45%, n = 40) were reported. Concerns regarding poor body image were strongly evident (76%, n = 68). Difficulties finding clothing/footwear to fit oedematous limb(s) were reported (59%, n = 53), in addition to finding clothes that participants would like to wear (64%, n = 58). Emotional symptoms of irritability (42%, n = 38), anxiety (41%, n = 37) and tension (40%, n = 36) were reported. Over half of the participants (55%, n = 49) stated that their chronic swelling affected their social functioning and their ability to engage in leisure activities. This study has identified that lower limb chronic oedema has significant psychological, social and physical implications for persons' QoL.

Lipoedema is a long-term, progressive condition, usually presenting as symmetrical enlargement of the legs and buttocks, and mainly affecting women. Distinct from obesity or lymphoedema, lipoedema is associated with an unusual distribution and proliferation of diet-resistant inflammatory fat tissue. This article provides background to lipoedema diagnosis and discusses self-care support for women with lipoedema.

SummaryThe following article is a summary of important benchmarks of the new guideline for diagnostics and treatment of the lipoedema, whish was updated October 2015.

While there is no proven cure for lipoedema, early detection is key as specialist treatments, complemented by self-management techniques, can improve symptoms and prevent progression. There is no universal approach as the correct treatment or treatments will depend on each patient's particular circumstances; however, when chosen early and appropriately, interventions can provide huge benefits. The most common treatments in the management of lipoedema include compression, manual lymphatic drainage (MLD), tumescent liposuction, intermittent pneumatic compression therapy (IPC), kinesio taping, deep oscillation therapy, and cognitive behavioural therapy (CBT).

Background Long-term results following liposuction in patients with lipoedema are available only for an average period of 4 years. Objective To find out whether the improvement of complaints persists for a further 4 years. Methods In a single-centre study, 85 patients with lipoedema had already been examined after 4 years. A mail questionnaire ‐ often in combination with clinical controls ‐ was repeated after another 4 years (8 years after liposuction). Results Compared with the results after 4 years, the improvement in spontaneous pain, sensitivity to pressure, oedema, bruising and restriction of movement persisted. The same held true for patient self-assessment of cosmetic appearance, quality of life and overall impairment. Eight years after surgery, the reduction in the amount of conservative treatment (combined decongestive therapy, compression garments) was similar to that observed 4 years earlier. Conclusion These results demonstrate for the first time the long-lasting positive effects of liposuction in patients with lipoedema. What’s already known about this topic? • The longest follow-up studies after liposuction performed in patients with lipoedema were performed over an average period of 4 years.

This painful condition is one all practice nurses should understand, writes Dirk Pilat

Introduction: Lipedema is a syndrome that is characterised by edema, an accumulation of fat, pain and haematomas in the lower limbs that principally affects women. Diagnosis is currently based on clinical criteria, since there is no accurate diagnostic imaging for the condition. The aim of our study was to describe the lymphoscintigraphic findings in patients with lipedema. Material and method: A prospective cohort study of women with clinical criteria of lipedema who underwent lymphoscintigraphy. Two independent nuclear physicians described and classified the lymphoscintigraphy findings in different grades of severity, according to the migration and distribution of the radiopharmaceutical. Eighty three patients were included with a median age of 49.7 years (range: 18-80) and a mean body mass index (BMI) of 29.9 kg/m(2) (95% CI: 28.4-31.3) Results: Lymphoscintigraphy showed alterations in 47% of the patients, most were low (35.9%) or low-moderate grade (48.7%). None of the patients were severely affected (no migration of the radiopharmaceutical). The degree of lymphoscintigraphic involvement bore no relation to age (P= .674), Stemmer's sign (P= .506), or BMI (P= .832). We found lymphoscintigraphy findings in all the clinical stages of lipedema, with no significant differences between the grade of lymphoscintigraphic involvement and the clinical stage of lipedema (P= .142). Conclusion: Although lymphoscintigraphy has been used to differentiate lipedema from lymphedema, we found frequent alterations in the patients with lipedema, therefore the presence of findings dues not discount a diagnosis of lip 1 aedema. (C) 2018 Sociedad Espanola de Medicina Nuclear e Imagen Molecular. Published by Elsevier Espana, S.L.U. All rights reserved.

Summary Introduction Liposuction for lymphoedematous limbs is an effective treatment for chronic lymphoedema, with excellent long-term results in well-selected patients. In 2008 NICE produced guidelines ‘Liposuction for Chronic lymphoedema', acknowledging this treatment modality. However, there remain very few centers that provide this service in the United Kingdom. We aim to share our experience of our referral system at Ninewells Hospital, Dundee, Scotland. Methods A 10 year prospective database from 2005 to 2014 was analysed. Referral sources, patient demographics, diagnosis and treatment offered were examined. Results There were 221 referrals in total, 190 (86%) female and 31 (14%) male. The mean age was 51 (range 7–86 years). 127 (58%) were referred via their general practitioners, 72 (33%) from a hospital consultant and 22 (10%) from a lymphoedema nurse specialist. 153 (69%) referrals were from Scotland, 61 (28%) from England and 7 (3%) from Northern Ireland. The majority of patients 165 (75%) were referred with lower limb swelling. Following assessment in clinic, 146 (66%) were found to have lymphoedema whilst the rest were deemed to have other non-lymphoedematous diagnoses which include lipoedema (47, 21%), dependent oedema (8, 4%) and obesity (5, 2%). 131 (59%) were offered liposuction- 74 (34%) have received liposuction, 18 (8%) are awaiting their procedure, 3 (1%) have declined surgery, 27 (12%) are awaiting funding approval and 9 (4%) have been declined funding by their primary care trust/clinical commissioning group (PCT/CCG). 4 (2%) are awaiting investigations to further evaluate the cause of their swelling, whilst the remaining 86 (39%) were felt unsuitable for surgery and were treated conservatively. Conclusion Chronic lymphoedema is a challenging condition to treat, with few specialist centers offering surgical treatment. We hereby share our referral process, diagnosis and management.

ZusammenfassungHintergrund: Beim Lipödem handelt es sich um eine schmerzhafte, anlagebedingt übermäßige Fettgewebsvermehrung der Extremitäten bei Frauen. Die Ursache ist unbekannt. Ebenso unbekannt ist die Zahl der betroffenen Frauen in Deutschland. Eine eigene Untersuchung zur Epidemiologie wird vorgestellt. Als Therapiemöglichkeit stehen die Komplexe Physikalische Entstauungstherapie und die Liposuktion zur Verfügung. Nur durch die Liposuktion ist eine dauerhafte Entfernung des Fettgewebes möglich. Ihre Wirksamkeit wird in einer weiteren Untersuchung aufgezeigt und die Bedeutung als Teil eines umfassenden Behandlungskonzeptes dargelegt.Patienten und Methodik: Für die epidemiologische Untersuchung wurden in einer ländli-chen Hausarztpraxis sämtliche Patientinnen bezüglich Beinleiden untersucht. Die Studie zur Liposuktion umfasste die prä- und postoperative Untersuchung von 85 Patientinnen mittels Beschwerdefragebogen.Ergebnisse: Bei 5 % aller Patientinnen einer Hausarztpraxis wurde ein Lipödem festgestellt. Mittels Liposuktion konnten bei 85 Patientinnen Schmerzen, Druckschmerz, Hämatomneigung und Schwellungsneigung signifi-kant vermindert und die Lebensqualität verbessert werden.Schlussfolgerung: Das Lipödem ist eine relativ häufige Erkrankung der weiblichen Bevölkerung. Die Liposuktion stellt zusammen mit der prä- und postoperativen komplexen physikalischen Entstauungstherapie, einem Sportprogramm und der Behandlung einer begleitenden Adipositas sowie bedarfsweise einer psychologischen Unterstützung ein wirksames Behandlungskonzept dar.Sie kann nur im Zusammenwirken mit diesen anderen Therapien erfolgreich sein und daher ist ein umfassender Therapieplan anzustreben.

Self-management and the use of adjustable velcro compression wraps are not new concepts and quite often both can form part of the maintenance phase of treatment in those with lymphoedema or lipoedema, as well as those diseases in which compression therapy is advised as long-term management. The aim of this article is to identify some aspects that contribute to effective self-management and how the use of easywrap adjustable velcro compression wraps have improved quality of life for those with lymphoedema, chronic oedema and lipoedema. Case studies are given from patients to demonstrate the individual experience of living with lymphoedema or lipoedema, how this has impacted on daily life, and how using easywrap has helped as part of self-management.

Liposuction is a procedure commonly performed in the UK usually with a low incidence of serious sequelae; however with larger patients and increased volumes of lipoaspirate, complications have been reported more frequently. One of the rare but very serious complications postliposuction is fat embolism syndrome (FES), a life-threatening condition difficult to diagnose and limited in treatment. The authors present the case of a 45-year-old woman who was admitted to the intensive care unit postelective liposuction for bilateral leg lipoedema. She presented with the triad of respiratory failure, cerebral dysfunction and petechial rash requiring a brief period of organ support. This case highlights that with the recent increase in liposuction procedures worldwide, FES is a differential to always consider. Although still a rare condition this article emphasises the importance of thinking outside the box and how to identify and manage such a life-threatening complication.

A 42-year-old Japanese woman with a body mass index of 42, presented with a long history of bilateral swelling of buttocks and lower extremities. The upper trunk, upper extremities and feet were spared of excessive fat deposition without a complete loss of adipose tissues (figure 1), lowering the likelihood of partial lipodystrophy. Physical examination revealed that the edema was dry, hard and non-pitting. Stemmer’s sign was …

The use of velcro compression wrapping devices in the management of lymphoedema and chronic oedema is not a new concept. Wraps have been available for many years and are being used widely in clinic and community settings where bandaging or traditional compression garments are not suitable. Furthermore, they are becoming more common when treating venous disease, patients with wounds and lipoedema. The aim of this article is to introduce the reader and clinician to the new Haddenham easywrap and to demonstrate why it is different to any other velcro wrapping device available. Case studies will be utilised from clinicians currently using easywrap in clinical practice, with both therapist and patient feedback given to demonstrate the efficacy of this new velcro compression wrapping device.