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15% of the patients of a special clinic for lymphological diseases had a lipedema. In 97% it was located in the legs and in 31% also in the arms. In 66% it was located only in the legs and in 3% only in the arms. Combinations of lipedema of the leg with phlebedemas have been seen in 2% and with a lymphedema in 1%. The differential diagnosis to lipohypertrophy, adiposis and lymphedema is given. The therapy with liposuction and physical therapy of edema, combination of manual lymphatic drainage and compression, will be discussed.
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Early terms of lymphostasis in lipedema can be detected with lymphoscintigraphy. A normal examination almost certainly excludes a lymphatic component. Indirect lymphography is only used to rule out morphological abnormalities of lymph vessels. If a lymphoscintigraphic study is normal indirect lymphography is not indicated.
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The "Lipedema" or "Fatedema" is conditioned by a slight mechanical obstruction of the small lymphatic vessels by the increasing pressure of the growing fat tissue. This lymphostasis in a normal lymphatic vessel system arises only with women and always symmetrically and conducts to typical complaints. Therapeutically, apart from loss in weight, only lymph drainage therapy is in a position to remove the complaints of edema.
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In a review of 250 cases of lymphedema of the lower extremity, 9 patients were noted to share unique similarities in their history and physical findings. Although these patients had mild swelling in their pretibial areas and were all referred with a diagnosis of lymphedema of the legs, their findings differed significantly from the usual patient with either congenital or acquired lymphedema. Notably, the lower extremity swelling was always bilateral and symmetrical in nature and never involved the feet. Skin changes characteristic of lymphedema were not found, and consistent fat pads were present anterior to the lateral malleoli in each patient. These findings are representative of a clinical entity known as lipedema, which is distinct from lymphedema and for which treatment may be different.
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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 txochanteric 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. Nearly all patients have severe feelings of inferiority because people mock and laugh at them; thus, the alimentary component of the obesity is a form of compensation for lack of love. By dieting, the adiposity disappears only partly because the typical deformity of lipodystrophy remains. I believe that in the lipodystrophy patient a lipedema may develop resulting from lymphatic and venous disease, which may arise later in life. Younger patients' complaints are mainly psychological and result from a disturbed body image, whereas older patients are troubled by pain and leg weariness. Treatment consists of dieting, subcutaneous lipectomy by liposuction, and prescription of elastic stockings.
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An elderly patient with a swollen leg or legs can present a challenging problem in differential diagnosis. Although most swollen legs are the result of congestive heart failure, thrombophlebitis, cellulitis, or lymphedema, many other conditions should also be considered.
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Lipedema is a common disease in the usual clinical practice. None organic description about the clinical symptoms and signs associated to this condition has been published. Fifty women with lipedema have been examined by the authors, and incidence rates of symptoms and signs have been emphasized. The following signs and symptoms were constantly reported: "Egyptian column", elastic edema, negative Stemmer's sign, alterated plantar support, cutaneous hypothermia. Some others were frequently found: ecchymosis, spontaneous pain, liposclerosis on the thigh, hypodermic hyperalgesia and pain on the internal face of the knee. Moreover, the two most relevant differential diagnosis as well as their two variant's clinical features (mixed lipedema and "thin women" lipedema) have been described.
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