Lipedema, Lymphedema, and Lipo-Lymphedema
What is Lipedema?
 
Lipedema, which is also known as painful fat syndrome, is abnormal symmetrical swelling due to accumulations of fat and fluid located in the tissues just under the skin of the hips and legs, down to the ankles but not extending to the feet. Also there are fatty bulges on the outer surfaces of the thighs. [1]
This inherited condition occurs almost exclusively in women and usually develops during puberty. Additional causes of this consition include a hormone component, microcirculation disorders, and inflammation.
Lipedema and Lymphedema Confused
While lipedema is not a disorder of the lymphatic system, lipedema and lymphedema are often confused because both conditions involve enlargement of the legs. Although distinctly different conditions, lipedema can cause lower extremity lymphedema to be present as a comorbidity.
There are several features about lipedema that distinguish it from bilateral lower extremity lymphedema.
Lipedema is symmetrical because the excess fat involves both legs equally. 
Lymphedema is not symmetrical and often occurs in only one leg. 
Lipedema swelling creates a characteristic ring at the base of the ankle. The swelling stops here and does not affect the feet.  
Lymphedema swelling, due to primary lymphedema, often begins at the foot and progresses up the leg. Secondary lymphedema most commonly begins near the trunk and progresses down the leg and includes the foot. 
Lipedema does not include swelling of the foot.
Lymphedema swelling affects the leg and the foot. 
Lipedema causes severe pain paticularl when the patient is touched.
Lymphedema does cause pain; however, it is rarely this severe. 
Lipedema often causes bruising and subcutaneous bleeding.
Lymphedema symptoms do not include bruising and subcutaneous bleeding. 
Lipedema does not have Stemmer’s sign as a diagnostic indicator
Lymphedema has Stemmer’s sign as a diagnostic indicator. 
The Symptoms of Lipedema
In the early stages of lipedema, the upper part of the body may be slim. Despite a slender upper body, fat accumulates from the tops of the hips to the ankles. 
As weight is gained, it accumulates in the areas of the hips and legs. 
When weight is lost, the fat decrease occurs in areas other than those affected by lipedema. Weight loss does not occur in the area between the waist and ankles. 
Fat extends down the legs and creates a ring of fatty tissue that overlaps the tops of the feet. 
Swelling develops in the legs during the second half of the day; however, this swelling decreases during sleep. 
Pain is present, particularly along the shin. 
In the early stages nodules develop. 
In the later stages lobules develop.
Diagnostic Errors
Diet is not the answer to the problem! Often patients are told that they are fat and weight loss is recommended. However the fatty tissue accompanying lipedema cannot be significantly decreased by diet. Obesity, caused by overeating, responds to a proper dietary regime: lipedema does not. 
This is not primary lymphedema. Another common diagnostic error is that the condition is primary lymphedema. A misdiagnosis of primary lymphedema results in frustration for the person seeks out lymphedema therapy with poor results. Differential diagnostic keys include: 
In lymphedma, Stemmer’s sign is positive. 
In lymphdema, the swelling affects both the feet and legs (but not the hips). 
In lymphedema, pain is not usually present along the shinbone. 
Complications of Lipedema
Obesity due to gaining excess weight is a common complication of lipedema. As more weight is gained, additional stresses are placed on all of the body systems. 
As lipedema progresses into the later stages, secondary lymphedema affecting the legs often develops as a complication. Swelling of the feet, and a positive Stemmer’s sign, are indications that lymphedema is present. 
Lipo-lymphedema is the combination of lipedema, obesity, and lymphedema. Lipo-lymphedema can also develop in combination with chronic venous insufficiency, idiopathic edema, or other vascular disorders. 
The Treatment of Lipedema 
At this time there is no effective treatment for lipedema. Evaluation by an endocrinologist, and the treatment of endocrine imbalances, may help. When lymphedema is also present, treating that condition can also help; however, the lymphedema treatment must be modified to accommodate the pain and other needs due to the lipedema. 
Weight control, without drastic dieting, can help to prevent other conditions associated with obesity. 
Water exercises are helpful. The support of the water eases the strain on the joints. It is also relaxing and makes movements easier. 
What about Liposuction?
Liposuction is a surgical procedure to remove excessive fat from under the skin. Liposuction has been studied as a potential treatment of lipedema; however, it is not accepted for this purpose because of the risk that such surgery can make the condition worse. [2]
Although often perceived as being minor cosmetic surgery, this is not true of liposuction. Instead it is an invasive procedure that cannot be performed without causing additional damage to the lymphatic system that can make the condition worse. When lymphedema is already present, there is also the increased risk of infection or poor healing after this surgery. 
What about Gastric Bypass?
Gastric bypass surgery is performed to bring about the loss of body weight; however, in those with lipedema this weight will not be lost in the areas affected by that condition. When gross obesity is present, such surgery may be necessary; however, it is unrealistic to expect a reduction in the fatty areas of the hips and legs.
Treating Lipedema and Lymphedema
When lipedema and lymphedema are present concurrently, the lymphedema therapist must balance the needs of both conditions.
Manual lymph drainage with only light strokes is used initially, because of the pain associated with lipedema. These gentle strokes open the superficial lymphatics (located just under the skin) and decrease the pain by clearing blocked draining areas and clogged lymph nodes. After several sessions, when the pain is less, the therapist can start working on the affected limbs. 
Bandaging and compression garments are not applied until the patient is able to tolerate this compression without pain. Some researchers believe that once the patient can tolerate compression, this may help to reduce the amount of fat that is present.
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