The Lipoedema
General
Lipedema is a chronic, progressive disease involving abnormal deposition of adipose tissue under the skin, resulting in disproportionate and progressive enlargement of the lower limbs and, in some cases, the upper limbs as well. Lipedema is a relatively common disease, but its exact prevalence is not known. Despite significant advances and intensive research, lipedema remains an under-diagnosed condition whose mechanisms are not fully understood. Many sufferers are only diagnosed after years of medical wandering and false diagnoses (obesity, lymphedema, etc.).
Nevertheless, the available literature on this disease has grown considerably in recent years. Our knowledge of the disease is constantly increasing and treatment in Switzerland is significantly improving, as is awareness among both the general population and the medical profession.
This pathological entity deserves to be more widely known, to enable earlier and more appropriate diagnosis and treatment.
Definition
Lipoedema is not a constitutional variant and is now recognised as a genuine pathology. Essentially female, chronic, progressive, painful and disabling, it is characterised by a disproportionate accumulation of subcutaneous adipose tissue and intercellular fluid, most often localised from the waist to the ankles. In around a third of cases, the upper limbs are also affected.
Etiology
The causes of lipoedema appear to be multifactorial, with genetic, lymphatic vascular and hormonal involvement. A family history is noted in 15 to 64% of cases. Various investigations carried out on patients with lipoedema have revealed a slowing of lymphatic flow and the presence of small-calibre tortuous collectors.
Types and stages of lipoedema
The chronic and progressive nature of this pathology has led to a distinction being made between the four stages mentioned above.
Different types of this pathology have been described depending on the accumulation of adipose tissue in different locations:
Type I | Pelvis, buttocks, hips |
Type II | From the buttocks to the knees with formation of folds on the inner side of the knees |
Type III | From the buttocks to the knees with the formation of folds on the inner side of the knees From the buttocks to the ankles |
Type IV | Arms |
Type V | Calves alone |
The chronic and progressive nature of this condition has led to a distinction being made between four different stages of lipoedema:
Stage I | Macroscopically smooth skin, supple on palpation with increased thickness of the hypodermis. |
Stage II | Scalloped appearance of the skin (orange peel), palpation of fatty nodules. |
Stage III | Deformed appearance of the limbs with bulky accumulations of adipose tissue responsible for functional discomfort. |
Stage IV | Irreversible secondary lipo-lymphoedema or lipo-phlebo-lymphoedema infiltrating the feet accompanied by a positive Stemmer's sign. |
Diagnosis and examination
Diagnosis is usually clinical.
In the vast majority of cases, the cardinal clinical signs of lipoedema can be identified by careful inspection and palpation of the patient, such as :
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Bilateral and symmetrical damage
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Pain on pressure or spontaneously
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Hands and feet spared
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Frequent haematomas following minor or spontaneous trauma
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Absence of the buckeye sign (or a slight buckeye sign after a prolonged period of orthostatism or during the warmer seasons)
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Absence of Stemmer's sign (except in stage IV)
Imaging or invasive investigations are generally not necessary.
Treatements
There is currently no cure for lipoedema. Treatment is symptom-based, multi-disciplinary and tailored to the different types and stages of the disease. Early treatment is essential to slow the progression of the disease and maintain it at stages free of functional discomfort and disability (stages I and II).
Management is based on two pillars:
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Conservative decongestant treatment
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Surgery
Whatever the stage of the disease, conservative treatment must precede the surgical option.
It helps to reduce oedema, maintain venous and lymphatic vascular function, improve skin elasticity and reduce pain.
Conservative decongestant treatment
The treatment is divided into two phases. A short reduction phase is followed by a long stabilisation and optimisation phase. The first, intensive phase combines MLD, reducing bandages, physical exercise and skin care.
As soon as the oedema is reduced, after one to three sessions in the initial stage and sometimes more than ten sessions for combined forms (lipo-phleboedemas, lipo-lymphoedemas and lipo-phlebo-lymphoedemas), the second phase begins. This is characterised by the replacement of bandages with elastic support in the form of flat-knit, made-to-measure compression class II tights.
Surgery
When the benefits of conservative treatment are deemed insufficient, the surgical option may be evaluated. Tumescent liposuction and lipectomy are currently the two appropriate surgical techniques for reducing adipose tissue volumes in the context of lipoedema.
It is recommended that an intensive reduction phase of conservative treatment precedes surgery and is resumed for a few weeks as soon as possible after surgery in order to optimise volume reduction.
Conclusion
Although not curative, these treatments enable patients to benefit from a significant improvement in their quality of life.
Whatever the treatment, conservative or surgical, regular physical activity and a healthy, balanced diet are required to achieve optimal therapeutic benefit.
I suffer from lipoedema. What should I do?
Contact your general practitioner.
A consultation with an angiologist may be useful in order to carry out a more complete vascular assessment. This information will help refine your diagnosis and plan your treatment.