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Ketterings, C. (1988). Lipodystrophy and its treatment. Annals of Plastic Surgery, 21(6), 536–543. https://doi.org/10.1097/00000637-198812000-00008

Lipodystrophy, almost exclusively seen in female patients, causes psychological problems at an early age. In later life, additional complaints are heavy painful legs, edema, and varicose veins. Nearly all patients suffer from alimentary adiposity. Dermolipectomies in general are not advisable because of the resulting large scars and the risk of damaging the lymphatic system. Subcutaneous lipectomy according to the Illouz method can provide good results. Weight loss is a good alternative to liposuction of the upper legs. After sufficient weight loss, only additional liposuction of the trochanteric area and the medial side of the knee is needed. No unpleasant scarring of the leg results. Unfortunately, older patients often require a skin reduction. The results of surgery in the lower legs were, except in 2 patients, good to excellent. The results in the upper legs were disappointing because 9 of 11 patients gained weight again after surgery. Considering this, the preferable treatment now is liposuction of the lower legs, medial side of the knee, and the trochanteric area. Only in cases of ptotic skin on the medial side of the upper legs is skin reduction without lipectomy indicated. Lipodystrophy suggests a disappearance of the subcutaneous fat. When this occurs in the upper part of the body, it is called progressive lipodystrophy. Lipodystrophy is known as an abnormality of the lower half of the female body, swollen by deposition of subcutaneous fat and determined by heredity. It occurs more frequently in the lower social classes and is often accompanied by an alimentary obesity which is a psychological reaction to the disturbed body image.(ABSTRACT TRUNCATED AT 250 WORDS)
Partsch, H., Stöberl, C., Urbanek, A., & Wenzel-Hora, B. I. (1988). Clinical use of indirect lymphography in different forms of leg edema. Lymphology, 21(3), 152–160.

Indirect lymphography by subepidermal infusion of newly developed nonionic, dimeric contrast media (e.g., Iotrolan) opacifies peripheral lymphatics of the skin. Using this method we examined 159 patients with primary and secondary lymphedema, chronic venous insufficiency, and lipedema and compared the findings to normal individuals. A variety of characteristic patterns were uncovered. The technique causes little patient discomfort and takes on the average only 30 minutes.
Stöberl, C., Partsch, H., Urbanek, A., Földi, E., & Mannheimer, E. (1986). Indirekte Lymphographie bei Lipödem. In : (pp. 129–132). Perimed.
Hadjis, N. S., Carr, D. H., Banks, L., & Pflug, J. J. (1985). The role of CT in the diagnosis of primary lymphedema of the lower limb. AJR. American Journal of Roentgenology, 144(2), 361–364. https://doi.org/10.2214/ajr.144.2.361

Twelve patients with primary lymphedema of the lower limb were examined with computed tomography (CT). A characteristic "honeycomb" pattern of the subcutaneous compartment was seen in 10 of these patients. CT scans in nine other patients with swollen leg secondary to chronic venous disease or lipedema did not show this characteristic pattern. CT may be helpful in the differential diagnosis of a swollen leg, thus obviating venography or lymphangiography.

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Tiedjen, K., & Schulz-Ehrenburg, U. (1985). Isotope lymphographic findings in lipedema. In H. Holzmann, P. Altmeyer, G. Hör, & K. Hahn (Eds.), Dermatologie und Nuklearmedizin (pp. 432–438). Springer.

Lipedema of the lower extremities are diagnosed on the basis of clinical findings . An exact differentiation is necessary since therapeutical considerations are depending on the pathophysiology of the diseases. In lipedema (Allen and Hines) as weil as in erythrocyanosis cruris puellarum (Klingmüller) an examination of the state of the lymphatic vessels is justified. Using isotope lymphography the lymphatic capacitY, of the lower extremities can be assessed without problem. As demonstrated a disturbance of lymphatic transport is not regularly present in these two syndroms. Therefore we can not consider them as lymphedema. The frequent appearance of unilateral lymphostasis with definite clinical differenccs of both extremities indicate on the other band that lipedema is not seldom superimposed by the lymphedema .
Jagtman, B. A., Kuiper, J. P., & Brakkee, A. J. (1984). [Measurements of skin elasticity in patients with lipedema of the Moncorps “rusticanus” type]. Phlebologie, 37(3), 315–319.

Patients with lipoedema of the typus rusticanus Moncorps show a skin elasticity deficit of the skin of the calf. This is partly due to the derma oedema in the skin of these patients and seems partly to be due to an intrinsic connective tissue defect in the skin of such patients. The auteurs put forward the hypothesis that also present calf muscle pump dysfunction in these patients is the result of a connective tissue defect of the fascia of the muscular compartment, as an expression of a more generalized connective tissue defect.
Földi, E., & Földi, M. (1984). Die Therapiemöglichkeiten des Lipödems, dessen mit verschiedenen Ergebnissen kombinierten Formen sowie der benignen symmetrischen Lipomatose. Swiss Med, 6, 19–24.
Stallworth, J. M. (1974). The chronically swollen painful extremity. A detailed study for possible etiological factors. JAMA: The Journal of the American Medical Association, 228(13), 1656–1659. https://doi.org/10.1001/jama.228.13.1656

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Wold, L. E., Hines, E. A. J., & Allen, E. V. (1951). Lipedema of the legs; a syndrome characterized by fat legs and edema. Annals of Internal Medicine, 34(5), 1243–1250. https://doi.org/10.7326/0003-4819-34-5-1243
Moncorps, C., Brinkhaus, G., Herteld, F., & others. (1940). Experimentelle untersuchungen zur frage akrozyanotischer zustandsbilder. Arch Derm Syph, 186, 209–215.
Alshomer, F., Lee, S. J., Kim, Y., Hong, D. W., Pak, C. J., Suh, H. P., & Hong, J. P. (n.d.). LIPEDEMA ASSOCIATED WITH SKIN HYPOPERFUSION AND ULCERATION: SOFT TISSUE DEBULKING IMPROVING SKIN PERFUSION. Archives of Plastic Surgery, 0. https://doi.org/10.1055/a-2181-8469

<p>INTRODUCTION: Lipedema is a progressive connective tissue disease with enlargement of adipose tissue, fibrosis, fluid collection and dermal thickening. Herein, we present a case of lipedema associated with skin hypoperfusion and ulceration in which soft tissue debulking with liposuction improved patients’ symptoms. CASE PRESENTATION: A 39-year-old female presented with asymmetric progressive initially unilateral lower limb swelling with severe pain with subsequent skin ulceration. Conservative management have failed to improve her condition. After excluding other causes and detailed radiologic investigation, lipedema was diagnosed with an associated impaired skin perfusion. Trial of local wound care and compression therapy failed to improve the condition. Subsequent soft tissue debulking with circumferential liposuction and ulcer debridement and immediate compression showed dramatic improvement of the symptoms and skin perfusion. DISCUSSION: The unique nature of this case shed light on lipedema as a loose connective tissue disease. Inflammation and microangiopathies explains the associated pain with hypoperfusion and ulceration being quite atypical and in part might be related to the large buildups of matrix proteins and sodium contents leading to micro-vessels fragility with frequent petechiae and hematoma and subsequent tissue ischemia. Conservative measures like compression therapy plays a significant role in disease course. Surgical debulking with liposuction was shown to be efficacious in reducing the soft tissue load with improvement in limb pain, edema, circumference and skin perfusion that was seen in our patient. CONCLUSION: Lipedema is a frequently misdiagnosed condition with disabling features. Skin involvement in lipedema with potential hypoperfusion was shown and it requires further investigation</p>

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