Lipedema is a chronic condition consisting of a pathological increase in subcutaneous fat and edema in the lower limb. It is caused by impairment of symmetrical fatty tissue distribution and storage, combined with hyperplasia of the individual fat cells. It is a common but underdiagnosed syndrome of unclear etiology.
Lipedema is characterized by enlargement in the lower extremities and is rarely accompanied by edema of the upper extremities. This enlargement is caused by an abnormal deposition of adipose tissue. The area of diffuse fatty hypertrophy typically starts at the hips and extends throughout the legs bilaterally and symmetrically. One of the major distinguishing features of lipedema is the sparing of the feet, which can create a distinct step-off at the ankle. Patients with lipedema may have a history of easy bruising on their lower extremities from a minor shock or slight touch, due to the increased fragility of the microvessels. It is also commonly associated with tenderness in response to small stimuli and palpations.
Lipedema almost exclusively occurs in women (11% of adult women worldwide), with the onset typically by the third decade of life. 15% of patients have a family history of lipedema, as it is a disease that occurs due to an abnormal distribution of fat because of genetic or hormonal abnormalities.
Lipedema progresses gradually and is divided into 3 major types, based on morphological appearance. But individual patients can present with a mixture of types. In the first stage of lipedema, there occurs a soft skin and small, evenly distributed nodes can be observed in thick subcutaneous tissues. The second stage shows larger, unevenly distributed nodes of subcutaneous tissue. Subcutaneous fat tissue projects outside the skin of the knees or thighs, which hinder mobility which is characteristic for stage 3. In the later stage, it involves the presence of lipo-lymphedema.
Often women with lipedema are told that their leg growth and swelling is a result of their inability to control their diet or of their sedentary lifestyles. One of the most common misconceptions about patients with lipedema is that they suffer from lifestyle- or diet-induced obesity. But unlike obesity, most patients with lipedema will have involvement of the extremities exclusively. This significant discrepancy in adiposity of the extremities, compared with the trunk is often a hallmark of lipedema, whereas the adiposity associated with lifestyle-induced obesity is generally global and proportionate. Also, the adipocyte hypertrophy and swelling associated with lipedema are resistant to change with diet and exercise or bariatric surgery and caloric restriction. But as a result of a fixation on their increasing weight and growing body, coupled with the “fat-shaming” which runs in society today, women with lipedema frequently suffer from significant psychosocial distress, including anxiety, depression, eating disorders and isolation.
Although lipedema fat is resistant to lifestyle modifications, there is evidence to support the positive effects of exercise, particularly aquatic therapy, and lifestyle change on lymphedema, lymph flow and overall health. Patients with late-stage lipedema are often sedentary because of immobility and also subsequently develop lifestyle-induced obesity. Lifestyle modifications in these patients will, therefore, treat their obesity, however, the lipedema fat will remain.
Another misconception is that patients with lipedema are often diagnosed as having lymphedema. But in contrary to lymphedema, a family history of lipedema is common. Also, the Stemmer sign is absent and the typical relative sparing of the feet is noticed. Whereas lymphedema is most likely to be unilateral, lipedema occurs to be bilaterally and symmetrically.
Where lipedema occurs due to the accumulation and impaired distribution of fat tissue, lymphedema occurs due to the accumulation of lymph because of abnormalities in lymph circulation. In the early stages of lipedema, the lymphatic system seems to be functioning normally. The “edema” at this stage is likely secondary to overwhelming the lymphatic pimp, rather than a true dysfunction within the lymphatic system. Due to the development of this secondary lymphedema and their irreversible damage to the lymphatic system that occurs, lipedema progresses to lipo-lymphedema in later stages of the disease.
Management of Lipedema
Lipedema can be seriously damaging the quality of life due to a reduction in the patient’s mobility and aesthetic issues and is a major psychosocial burden for most patients. Active treatment for lipedema is required because early diagnosis and treatment can determine the patient long-term prognosis.
The most widely applied therapy for lipedema is combined decongestive therapy, which consists of manual lymphatic drainage and wearing compression garments. Compression therapy does not result in a decrease of fat deposition, but can help to prevent further edema formation, stimulate the arterial, venous and lymphatic flow and limit recurrence. After this compression stockings can be considered.
Besides that, the goal of therapeutic interventions is improving strength and fitness to enable an active lifestyle. Low levels of physical exercise are a risk factor for further deterioration of lipedema, especially in combination with an increase in body weight. So, although lipedema fat is resistant to lifestyle modifications and dietary changes, it is still important for the overall health and quality of life of the patient.
For patients with minimal or no improvement with conservative treatment, surgical options should be evaluated. Classic dry liposuction cannot be applied to lipedema patients due to the potential injury to lymphatic vessels, which can cause secondary lymphedema. However, the introduction of the tumescent technique has made the application of liposuction possible. Liposuction using super tumescent local anaesthesia and vibrating cannulas is now considered an effective treatment for lipedema with good long-term outcomes. It shows a reduction in the volume of fatty tissue in the affected limbs and the disproportionality of these limbs to the rest of the body and there is seen an improvement of the quality of life.
Lipedema is a common underdiagnosed disease with a lot of misconceptions. It is often misdiagnosed as lymphedema or obesity.
Exercise, weight-loss programs, reconditioning and physiotherapy form important pillars of conservative lipedema treatment.
Lipedema: diagnostic and management challenges (Anna Warren Peled, Elisabeth A kappos) (3-10-17)
Lipedema with multiple lipomas(Annabella Pascucci, Peter J Lynch) (2010)
Lipedema, a Rare Disease (Bea Wook Shin, Young-Joo Sim, Ho Joong Jeong, Ghi Chan Kim) (2011)
Lipedema: A relatively common disease with extremely common misconceptions (Donald W. Buck II, Karen L Herbst) (june 2016)
Lipostuction in the treatment of lipedema: a longitudinal study (Mehran Dadras, Peter Joachim Mallinger, Cord Christian Corterier, Sotiria Theodosiadi, Mojtaba Ghods) (10 may 2017)