By Amy Compston PT,DPT, CRT, CLT-LANA

1. The Ohio State University Comprehensive Cancer Center – Arthur G. James Cancer Hospital and Richard J. Solove Research Institute
Lipedema: Clinical
Presentation and Treatment
Amy Compston PT, DPT, CRT,
CLT-LANA
April 16, 2016
Biomedical Research Tower

2.  Define Lipedema and all its stages.
 Identify the anatomy and physiology associated with
Lipedema and the effects it has on body
homeostasis.
 Learn how to identity Lipedema based on
evaluation findings.
 Identify current conservative and surgical
intervention management for Lipedema.
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Objectives

3.  First described in 1940
 Adipose tissue disorder
 “Painful fat syndrome”
 Genetic component
 Prevalence in women
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Define

4. 4
Genetic component

5. 5
 Etiology is unknown
 Hormone correlation seen with increase during puberty,
pregnancy and menopause
 Main components
 Increase number and size of adipocytes and lymphocytes
 Enlargement of subcutaneous adipose tissue (SAT)
 Increased formation of edema
 Fat tissue consists of fat cells surrounded by connective tissue
septa in which free nerve fibers, arterioles, venules and lymphatic
vessels are located.
 In a normal system, the amount of interstitial space is less than
other tissues. Lipedema, the increase intercellular pressure due to
expanding fat tissue causes mechanical obstruction of small
lymph vessels, resulting in lymphostasis and edema of SAT.
Pathophysiology

6. 6

7. 7
 Elasticity of skin and fascia is
decreased causing abnormal
clumping of elastic fibers.
 Skin loses its role causing
increased compliance of SAT
resulting in increase of capillary
compliance.
 Capillary permeability releases
excess protein rich fluid into
interstitium.
 The veno-arteriolar reflux is
absent during standing so
vasoconstriction is limited which
leads to increase net filtration
causing further edema.

8. 8
 The lymphatic transport increases to accommodate=
lymphscintography is normal.
 As it progresses micro aneurysms appear in lymph system
causing leakage which increases hypertrophy and
hyperplasia of fat to accelerate altering of the system and
venous congestion.
 Later stages of lipedema the lymph system is altered, which
can be seen by indirect lymphography. The injection
deposits look “flame-like” unlike normal round deposits.
 “Tongues of flame” represent distended lymph spaces.
Some have found enlarged lymph micro vessels and
collectors that were not directed linearly but twisting through
to navigate through fat.
Compensation and imaging

9.  Skin surface smooth (with
prominent pores), thickened fat
layer, but uniform
 Disproportionate pear shape, with
somewhat increased fat.
 Leg still has shape but may be
considered somewhat larger or
thicker than average by others.
 Some swelling during the day but
usually resolves overnight or with
rest and elevation
 May have to start wearing
significantly different size pants
than tops.
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Stage 1

10.  Skin texture change more uneven
with indentations ("orange peel" or
"mattress" skin).
 Fatty deposits grow around knees
and thighs, and some develop
larger arms.
 Legs begin to thicken more,
decrease of calf and ankle contour.
 Skin rubbery/spongy begin to feel
nodular in places.
 Edema can occur but doesn't
resolve as easily as it has in the
past.
 Heat and on feet all day or sitting
all day may exacerbate swelling.
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Stage 2

11.  Increased texture "orange peel,”
“mattress,” “cottage cheese” look,
Fat nodules easy to detect.
 Large masses of tissue form folds
and ridges (lobular deformations),
especially above and below
knees and thighs.
 Decreased muscle contour
worsens forms "overshoulder" of
the ankle= ankle cut off sign.
 Swelling more consistent and
doesn’t resolve with rest and
elevation.
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Stage 3

12.  Larger masses of skin and fat
overhang, complex folds and
ridges with consistent swelling.
 Large gains in weight occur
mobility becomes affected.
 Skin harder and/or discolored.
 In severe cases, lymph fluid can
leak from lymphatic vessels
(lymphorrhea).
 Significant increase risk of
infection-cellulitis.
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Stage 4/ Stage 3b

13. 13
Staging summary

14. 1. Pelvis, buttock and
hips (saddle bag
phenomenon)
2. Buttock to knees,
with formation of
folds of fat around
the inner side of
the knee
3. Buttocks to ankles
4. Arms
5. Lower leg
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Five types

15. 15

16. 16
 Complete Decongestive Therapy (CDT)
 Manual lymphatic drainage
 Compression
 Bandaging
 Garments
 Pneumatic pumps
 Skin care
 Nutrition
 Anti-inflammatory
 RAD diet
 Exercise
 Aquatic therapy
 Psychosocial support
Conservative Treatment

17. 17
Season 8 lost 87 lbs on show

18. 18
 Liposuction
 Tumescent Local Anesthetic Liposuction (TLA)
 Large infiltration solution amount and time
 Wet Jet Assisted Liposuction (WAL)
Surgical Treatment

19. 19
 Completed conservative therapy
course
 No pitting
 Compliance with compression in
the past
 No active cancer
 No more effect of conservative
therapy
 No wounds
 Performed in segments depending
on areas affected.
Criteria

20. 20
 Performing each with 4-6 weeks of heal time in between
each procedure
 Wearing garments 23-24 hours a day and performing
manual lymphatic drainage once a day.
 Compression garments are pre-measured 2 weeks in
advance quantity of 2 ordered
 Limb remains elevated during hospital stay.
 Garments are donned in OR and removed 2 days postop
Postoperative Care

21. 21
 New clean set of garments then donned this continues
for another 2 days in hospital and then after discharge.
 Patient is to receive manual lymphatic drainage weekly in
between liposuction sessions.
 Garments will then be taken in via sewing machine in
order to compensate for the reduction in limb volume.
 This is most important during the first 3 months
 Garments are then re-measured at 3, 6, 9 and 12
months.
Post op care cont.

22. 22
 37 y.o female married with 3 children
 Presented December 2013 with complaints of leg swelling for 10-15
years.
 Diuretics, exercise 3 x a week consisting of weights, elliptical,
insanity exercise tapes, dieting and 15 mmHG knee high stockings
were used in the past.
 Reported family trait
 Swelling worsened with every pregnancy which consisted each
delivered by cesarean section.
 She had tenderness upon palpation in thighs
 Discomfort with increased activity.
 Unable to get on floor and play with children.
 CDT initiated 2-3 x a week for 6 weeks consisting of: MLD,
bandaging, drainage exercises (HEP of elliptical and light weights),
garments were velcro lower extremity garments and soft leggings
Patient Case Study

23. 23
 First liposuction
session performed Feb.
2015 on medial lower
extremities.
 PT plan 2 x a week for
3 weeks
 KT tape and MLD
 Post PT session 1
 Patient’s mother in law
seamstress adapted
garments throughout
Post WAL liposuction

24. 24
Post PT sessions week 2 and week 3

25. 25
 Performed March 2015
 Lateral legs
 PT plan 2 x a week 3 weeks
Liposuction Session 2

26. 26
Post PT week 2 and week 3

27. 27
 Performed April 2015
 Abdomen
 Minimal bruising
 Patient had increased suprapubic swelling post op
 PT plan 1 x a week
 Consisting of MLD only
 Compression garments consisted of pantyhose bilateral
lower extremity with trunk.
Liposuction Session 3

28. 28
 Performed May 2015
 On bilateral arms
 Post op garments ill-fitting
 Increased bruising
 Made 6 inches short
 Gave her short stretch bandage post op
 PT plan 2 x a week for 4 weeks
 MLD and compression bandaging until new compression
garments were delivered.
Liposuction Session 4

29. 29
 June 2015
 Patient wearing
compression garments
 During day only
 Limb girth stable
 Function: Patient able to
play with kids, leg
discomfort zero, able to
get up and down off floor
with no problem.
PT Discharge

30.  Allen EV, Hines EA. Lipedema of the legs. Proc Mayo Clinic 1940; 15: 184-7.
 Brorson, J., Foldi, E., Freccero, C., Schmeller, W., & Voesten, H. (2009).
Lymph/Lipoedema Treatment in its Different Approaches (pp. 1-51).
Upperkirkgate, Aberdeen: Wounds UK, a subsidiary of HealthComm UK Limited.
 Child AH, Gordon KD, Sharpe P, Brice G, Ostergaard P, Jeffery S, et al.
Lipedema: in inherited condition. Am J Med Genet A 2010; 152AL:970-6
 Harvey, N. L., Srinivasan, S. R., Dillard, M. E., Johnson, N. C., Witte, M. H.,
Boyd, K., & Sleeman, M. W. (2005, October). Lymphatic vascular defects
promoted by Prox1 haploinsufficiency cause adult-onset obesity. Nature
Genetics, 37(10), 1072-1081.
 Herbst, K. (2011, August 31). Rare Adipose Disorders (RADS) Masquerading as
Obesity. Acta Pharmacologica Sinica, 155-172.
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References

31.  Langendoen, S., Habbema, L., Nijsten, T., & Neumann, H. (2009, July 9).
Lipoedema: From Clinical Presentation to Therapy. A review of the literature
[Electronic version]. British Journal of Dermatology, 980-986.
 Rapprich, S., Dingler, A., & Podda, M. (2011). Liposuction is an effective
treatment for lipedema-results of a study with 25 patients. Journal of German
Society of Dermatology, 33-40.
 Schmeller, W., Hueppe, M., & Meier-Vollrath, I. (2011, July 29). Tumescent
Liposuction in Lipoedema Yields Good Long-Term Results [Electronic version].
British Journal of Dermatology, 161-168
 Stutz, J. J., & Krahl, D. (2008, March 13). Water Jet-Assisted Liposuction for
Patients with Lipoedema: Histologic and Immunhistologic Analysis of the
Aspirates of 30 Lipoedema Patients [Electronic version]. International Society of
Aesthetic Plastic Surgery, 153-162.
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References Continued

32. Thank You
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