Lipedema

What is lipedema?

This illness was described for the first time in the 1940s in the US.

Lipedema is a rare, chronic and painful illness in which the subcutaneous fat tissue grows disproportionately in the lower limbs (70%) and in some cases in the upper limbs (30% in the arms). Water also builds up in this tissue causing pain.

The hands and feet are free from illness and the torso also remains unaffected.

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The illness affects almost exclusively women, therefore it is suspected there is an originally hormonal cause. It can begin post-puberty or following a pregnancy and it is slow developing, meaning it is often confused with "normal" weight gain but does not respond to dieting or exercise.

The disproportion becomes more evident the more a patient tries to lose weight, as the weight loss is only noticeable in the torso,while the limbs remain asymmetrically large.

Patients describe feelings of internal tension and noticeable nodules in their skin, which slowly deforms. Edema causes pain upon pressure, and later on even without pressure, but paradoxically does not leave pitting edema. These causes of discomfort often worsen with heat, long periods standing up or sat down, as well as at night. Localised cases of blood clotting with spider veins and proclivity to hematomas also appear.

Over the years, the build-up of local fat can go from being an aspect commonly known as "love handles" to creating symmetrical deformities all over the legs, causing legs known as "column legs" or, with regards to the ankles, as "fat cuffs", or even swollen fat lobules around the knees and ankles, as the joints in them are not affected.

In most cases an incorrect diagnosis of excess weight, obesity or cellulite prevents adequate treatment of lipedema and this prolongs the suffering of the patients who, also due to the extreme, uncontrollable aesthetic and functional change to their figure, tend to isolate themselves socially and/or become depressed.


Epidemiology:

Lipedema affects, in general, between 10% and 20% of adult women.

The real figure is probably higher as in many cases the diagnosis is misinterpreted or confused with lymphedema. There is probably a hereditary element in 20% of cases.


Causes:

Unfortunately, as with many rare illnesses, we still do not have a definite answer to this question.

Hormonal changes that occur in puberty, pregnancy and even pre-/menopause can be the beginning of this illness although in most cases, the illness develops in women between 30 and 40 years old. This makes sense if we bear in mind that fat tissue is especially receptive to female hormones (oestrogen and progesterone) due to their receptors.


Classification:

According to Schmeller &Meier-Vollearth (Schmeller W, 2004; Meier-Vollrath I, 2004), lipedema can be cateogrised in three stages of development:

  • lipedema-estadios-teknonlipedema-estadios-teknonStage I: The placement of subcutaneous fat is still balanced, the skin remaining relatively smooth. In the connective tissue, extracellular fluid builds up In this stage, it is difficult to distinguish the illness from a simple gain in weight or build-up of fat.
  • Stage II: Painful subdermal nodules form and the skin becomes deformed with a cellulite-like or "cushioned" appearance due to the lipodystrophy.
  • Stage III: The proportion of connective tissue increases and the area hardens. The painful sensation without pressure worsens. The skin becomes deformed with fat lobules.

Diagnosis:

The illness lipedema has a fundamentally medical diagnosis.

There are no specific diagnostic tests that confirm it. Medical records, family history and physical examinations of the deformed, painful limbs can allow us to be surer.

Other methods that can help are ultrasound, lymphograms or magnetic resonance imaging. Whilst they are still not specific, these methods allow other illnesses with similar symptoms to be ruled out.

Specialists in phlebology, angiology and vascular surgeons will be the ones in charge of evaluating these diagnostic tests.


Differential diagnosis:

Lipedema must be properly differentiated from other illnesses of fat or conjunctive tissue with which they can often be confused. For example, fat hypertrophy, lymphedema, vein insufficiency, Madelung disease or obesity.


Treatment

The treatment of this illness is always interdisciplinary.

If the diagnosis is made early on, treatment can positively influence its development. The problem is that the initial stages are slow and deceptive and confuse the patient at first.

Compression methods in the initial stages can prevent the build-up of fluid in the affected limbs and control the pain, although they do not manage to reduce the volume of the limbs nor stop the development as they do not work on the fat tissue itself.

Conservative is basically decongestive:

The terms used internationally to refer the conservative treatment we use for lipedema are: "Complex physical therapy" (CPT) or "Complex Decongestive Therapy" (CDT).

Decongestive treatment can be carried out in different ways and combine different techniques; manual lymphatic drainage (MLD) once or several times a week, compression bandages, intermittent pneumatic compression or flat knit compression garments (available in 3 different strength levels).

Nutrition should not include calorie restriction, as this does not imply a decrease in the volume of the affected limbs but rather in the healthy parts of the body. In any case, if the patient is overweight, they will have to be nutritionally re-educated and adapt their diet (diet being understood as the amount of food we consume daily) to their current state or guide them towards maintaining a healthy weight.

Exercise:

Although there is no special type of sport which helps to reduce lipedema, some exercises can be done more easily in water, as the joints do not suffer so much and weight feels lightened. Furthermore, the pressure of the surrounding water performs a certain "lymphatic drainage" on the tissue. Swimming, aqua-jogging, aqua-aerobic etc. are recommend… as well as sports such as nordic-walking, cross-country skiing and long walks.

Surgical:

Water-jet assisted liposuction (WAL) is the surgery of choice. This technique allows the fat tissue to be aspirated whilst amounts of the solution to infiltrate and separate the cells are injected. This way, with a lower amount of infiltration and less trauma to the tissue, equal or better results are achieved. What is more, surgery time is reduced because there is no need to wait for the infiltration to have an effect.

The aspiration technique is also different to a cosmetic liposuction; thinner cannulas are used and an axial, longitudinal pattern is followed so as not to damage the superficial lymphatic system.

Following a period of conservative treatment in order to reduce the build-up of fluid, an "offloading" liposuction is recommended; the only method through which excess panniculus adiposus can be reduced.

In each procedure, up to 6 litres of fat tissue, water and blood can be aspirated. Following surgery, compression garments are prescribed, which must be worn 24 hours a day for 4 weeks. This helps to eliminate the rest of the infiltrated liquid solution, "mould" the tissue and smooth the skin.

Normally, more than one procedure is necessary, which must be spread out over time, at least two months.

Treatment is long-lasting in the long-term, as fat cells that have been aspirated do not return.

Before performing surgery, all the patient’s tests will be evaluated; physical examination, waist-hip ratio (WHR), BMI, records of daily activity and pain, questionnaire on quality of life – ultrasound, lymphogram etc.

Prongnosis:

Decongestive therapy improves the symptoms and pain, and slows down the progression of the illness in its initial stages, but should always be accompanied by weight control, moderate and regular exercise and a healthy lifestyle. Hormonal fluctuation (contraceptives, menopause), changes in weight or discontinuity in maintenance treatment can cause a new build-up of fat.

Other types of therapy that help treat localised fat and that have proven effective are, for example, mesotherapy, carboxytherapy and cryotherapy, and they can be applied and used in the initial stages or on occasion in order to locally improve fat lobules, nodules and pain.

We are SPECIALISTS in LIPEDEMA; we know the illness and we can offer you a solution for it.

Book an appointment with no obligation at the clinic and get answers to any questions you may have on the subject.

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LIPEDEMA treatment protocol

1. TREATAMENT PROTOCOL for LEGS

  • REQUIREMENTS for SURGERY
    • The patient must have worn flat knit pressure socks for at least 6 weeks. The tissue must be decongested. Only in cases of very congested tissue is previous lymphatic drainage recommended.
  • SURGERY
    • Intraoperative antibiotic dosage (standard: Cefazolin: 2g). Analgo-sedation by the department of anaesthesia. Local anaesthesia / infiltration of tumescent solution. Water-jet assisted liposuction of all the surgical area (circular). Surgery by regions: legs-thighs (including buttocks) each of them in a circular manner. Closing of cutaneous incisions (except the most distal ones which are used for drainage). Wearing of compression garments and elastic bandage.
  • POSTOPERATIVE
    • Hospitalisation for one night.
    • Beginning of antithrombotic prophylaxis.
  • HOMECARE GUIDE
    • Removal of elastic bandages on day 2 post-operation and change for: Flat knit compression socks from day 2 post-operation for 8 weeks or until the following surgery (during the day). Compression socks for 6 weeks (at night). Antithrombotic therapy with low molecular weight herapin once a day (x7 days).
      Manual lymphatic drainage for 8 weeks (or until next surgery) twice a week. Removal of stitches day 7 post-operation. As of day 10 post-operation exercise is not restricted (including swimming or sauna)

2. TREATMENT PROTOCOL for ARMS

  • REQUIREMENTS for SURGERY
    • It is not often necessary to wear decongestive garments prior to surgery. The tissue must be decongested. Only in cases of very congested tissue is previous lymphatic drainage recommended.
  • SURGERY
    • Intraoperative antibiotic dosage (standard: Cefazolin: 2g). Analgo-sedation by the department of anaesthesia. Local anaesthesia / infiltration of tumescent solution. Water-jet assisted liposuction of all the surgical area (circular) arms and forearms up to the shoulder area Closing of cutaneous incisions (except the most distal ones which are used for drainage). Wearing of compression garments (bolero arm bandage) and elastic bandage.
  • POSTOPERATIVE
    • Hospitalisation for one night.
    • Beginning of antithrombotic prophylaxis..
  • HOMECARE GUIDE

    • Removal of elastic bandages on day 2 post-operation and change for:


    • Flat knit compression garments from day 2 post-operation for 8 weeks or until the following surgery (during the day) Compression socks for 6 weeks (at night. Antithrombotic therapy with low molecular weight herapin once a day (x 7 days). Manual lymphatic drainage for 8 weeks (or until next surgery) twice a week. Removal of stitches day 7 post-operation. As of day 10 post-operation exercise is not restricted (including swimming or sauna).


If you need any more details or have any specific questions on the subject do not hesitate to send us an email or book an appointment with no obligation at our surgery.