Lipedema: Fatty pillows at the legs

Short informations for those in hurry

[Translate to English:] Lipédem - Dr. med. Daniel Münch

For many years, lipoedema, a symmetrical increase in fat that occurs mainly on the legs and is associated with water retention, tension and pressure pain and an increased tendency to bruises, was considered untreatable. The only measures were consistent decongestion therapy using lymphatic drainage, compression and medication. Because many doctors do not recognize the fat distribution disorder, it sometimes takes a long time before those affected get the right diagnosis and therapy. Because the gentle method of water-jet-assisted liposuction does not cause any damage to the lymphatic system when carried out correctly, this technique offers a treatment option for lipoedema. By reducing the subcutaneous fatty tissue, a significant reduction in the tendency to swell and a lasting improvement in the quality of life can be achieved. In certain cases, health insurance will cover the costs of liposuction if lipoedema is present. Here you will find the requirements that must be met.

Water-Jet assisted liposuction to treat the lipedema

I have published our experiences and results with water-jet-assisted liposuction for the treatment of lipedema in the renowned journal "Journal for Aesthetic Surgery" (II/2017). The study analyzes the safety and efficiency of WAL and compares it to conventional tumescent liposuction. In each case, a significant reduction in the subcutaneous fat layer and an improvement in proportions could be achieved. Liposuction of lipoedema using WAL promises long-lasting and good results because this surgical technique is focused on protecting the lymphatic system. Impressive results can often be achieved in terms of reducing pain, reducing the tendency to edema, improving body contours and increasing the quality of life.

Already known in ancient times

Statue of the great goddess, Hal Tarxien, Malta
Relief King Point, Hatshepsut Tempel, Ägypten

Lipoedema is a clinical picture that is still unknown to many laypeople - but often also to doctors. Artistic representations that can be interpreted today as eyelid edema already exist from the early days of mankind. There is a stone statue of the Great Goddess in the Hal Tarxien temple in Malta (3000 BC) and a relief of the Queen of Bunt in the Egyptian temple of Hatshepsut in Deir el Bahar from 1500 BC. However, the clinical picture was not scientifically described until 1940 by the American doctors Allen and Hines. The existing literature on lipedema is still rather sparse overall.


Cause unknown

[Translate to English:] Lipödem - Dr. med. Daniel Münch

Lipoedema is a chronic, symmetrical fat distribution disorder that mostly occurs on the thighs and lower legs, sometimes also on the arms, and practically only occurs in women. A genetic predisposition and hormonal influences are assumed to be the causes - factors that cannot be influenced. A lack of exercise and too many calories are not the real reasons for lipoedema, lipoedema does not arise as a result of increased calorie intake. During puberty or during pregnancy, the thickening occurs on the outside of the thighs (saddlebags) and on the inside of the knees. Over the years, the fat reaches the ankles, giving the legs a columnar shape. The cause of lipedema is unknown. There is a massive disproportion between the upper body and the legs, these patients are mostly very slim on the upper body, the increase in fat can only affect the thighs or lower legs in isolation, but can also be distributed homogeneously over the entire leg ("pillared leg"). The feet are usually free. In addition to the optics, those affected develop a feeling of tension and heaviness on the thighs and lower legs as well as a pronounced tenderness to touch and pressure. The pain is mainly described as dull, pressing and heavy. Lipoedema is not an aesthetic treatment, it is a disease. The psychological strain of these patients, who often suffer from the pathologically increased fat tissue at a young age, is enormous.

Great suffering

[Translate to English:] Lipödem - Dr. med. Daniel Münch

The patients not only suffer from the appearance, but also from the symptoms such as swelling, tenderness and bruises after even the slightest pressure. However, lipoedema often also has an effect on personality: a lack of acceptance of lipoedema as an illness, discomfort in one’s own body, injured femininity. The feeling that those around you think you don't do enough exercise or that you can't stick to a diet. This self-doubt has a negative impact on building healthy self-esteem. However, a lack of self-confidence has a negative impact on many areas of life: partnership, friendships, professional advancement.

Only women are affected

Lipoedema occurs exclusively in women. In men, lipoedema can occur very rarely only after pronounced hormonal disorders, in the case of liver cirrhosis or tumor diseases.

The evelopment of the lipedema

[Translate to English:] Lipödem - Dr. med. Daniel Münch
Normal condition: Tissue fluid from the blood vessels is absorbed and transported away by the lymphatic vessels
[Translate to English:] Lipödem - Dr. med. Daniel Münch
Lipoedema: The defective blood vessel wall causes increased leakage of fluid, which cannot be fully absorbed by the lymphatic vessels. The excess fluid accumulates in the tissues and especially in the fat cells
[Translate to English:] Lipödem - Dr. med. Daniel Münch
Final stage: The enlarged fat cells press on the lymphatic vessels, which also impedes the removal and further increases the swelling of the fat cells

Lipoedema is a disease in its own right. Unlike obesity, it is not about stored reserve fat: lipoedema fat has a completely different structure and cannot be broken down through exercise or diet. On the one hand, there is a hereditary, circumscribed proliferation of subcutaneous fatty tissue in the form of enlarged fat cells (hypertrophy) in lipoedema, but also as a result of an increased number of fat cells (hyperplasia). In addition to this increase in fat volume, there is a disturbance in the fluid permeability of the small blood vessels (this explains the tendency to bruise spontaneously). As a result, more fluid from the blood vessel system gets into the tissue. Due to the increased supply of liquid, the initially intact lymphatic system reacts with increased evacuation of the accumulated lymphatic fluid. The permanent strain on the lymphatic vessels ultimately also leads to damage to the walls of the lymphatic vessels, with a resulting reduction in transport capacity. If the accumulated tissue fluid can no longer be transported away sufficiently, fluid builds up in the interstitial spaces between the tissues, but above all in the fat cells. Over the years, there is a further increase in subcutaneous fat and protein-rich edema. This leads to hardening of the tissue and the walls of the lymphatic vessels. This leads to a further reduction in lymph transport with the possible development of lymphedema.

Complex clinical picture

There are still many unanswered questions regarding the cause and the underlying disease processes and functional disorders of eyelid edema.

Why does the subcutaneous fat layer increase?

Lipedema: the fat cells are hypertroph and hyperplastic (more and greater cells)

"Normal" fat cells (storage fat) change their size by absorbing or releasing fat. If fat cells increase in volume (overweight), this is referred to as hypertrophy. If the volume of the fat cells remains constant, but their number increases, there is hyperplasia (excessive formation of fat cells). Lipoedema often involves enlarged fat cells, but there is always an increase in these fat cells. The fact that there is effectively an increase in fat cells explains the fact that fat volume cannot be influenced by diet.


The cause of the pain

The volume-plus of the fat cells will lead to pain

Lipoedema patients suffer from spontaneous ("causeless") pain in the form of a dull feeling of tension in the legs. There is also tenderness to touch and pressure. This pain is caused by the increased number and additionally enlarged fat cells, which cause pressure against the skin. A feeling of tension is also caused by the fluid retention typical of lipoedema. Studies show that due to this increased tissue water, sensory nerves react with signals to the brain, which interprets these signals as pain.


How do we can explain the pain?

Compression of the lymphatic- and bloodvessels by the increased fat cells

A typical feature of lipedema is fluid retention (edema) in fatty tissue, especially in warm weather and after standing or sitting for a long time. Due to the increased permeability of the small blood vessels, a lot of tissue water accumulates. This fluid cannot be transported away in sufficient quantity by the lymphatics because the walls of the lymphatic vessels are damaged by the large amount of fluid and because the paths are compressed by the enlarged fat cells.


Why more haematoms?

The fragil capillars will lead to haematoms

In the case of lipoedema, there is a pronounced tendency to bruises (haematomas) even with minor impacts or pressure loads. The reason for this is increased fragility and permeability of the capillary vessels (capillary fragility).In the case of lipoedema, there is a pronounced tendency to bruises (haematomas) even with minor impacts or pressure loads. The reason for this is increased fragility and permeability of the capillary vessels (capillary fragility).


Liopedema and adipositas

Lipedema and obesity are two different things. However, they often occur together: around 50% of lipoedema patients suffer from obesity at the same time.

The lipedema patient: not fat but ill

[Translate to English:] Lipödem - Dr. med. Daniel Münch

Lipedema is often overlooked even by doctors or confused with obesity or lymphedema. As a result, those affected often have a long ordeal behind them before the correct diagnosis and treatment option is recommended. The symptoms caused by the edema, i.e. by "water in the legs", are particularly stressful for the patients. During the day, these swellings appear in the subcutaneous tissue of the lower legs, but not in the feet. They are caused by an increased permeability of the capillaries for fluid and an obstruction of the lymphatic drainage. At the onset of the disease, there is little or no edema in the morning, but it is clearly visible in the evening. This is intensified by standing or sitting for a long time, especially in the hot season. Over the years, the finding intensified: the lower legs and thighs are swollen all day long and no longer get slim overnight. This accumulation of water causes feelings of heaviness and tension as well as pain when touched and pressured. This congestion pain forces you to reduce sporting activities and, if necessary, to do aqua gymnastics with the brief feeling of weightlessness. The gait pattern can also change as a result of lipoedema: It becomes knock-kneed and overloads the lower back as well as the hip and knee joints.

Psychological distress

[Translate to English:] Lipödem - Dr. med. Daniel Münch

The affected women suffer psychologically from their disproportionate, columnar legs and strong arms. Many sufferers wrongly blame themselves for their figure. Despite all measures such as diets or exercise, the fatty tissue on the legs and arms continues to increase, at most the trunk becomes slimmer, which further worsens the existing disproportion. This disease can only be treated in a trend-setting and sustainable manner by means of a water-jet-assisted liposuction.

Varicose veins

If varicose veins are present in addition to eyelid edema, the varicose veins should be operated on as a first step.

Diagnose of a lipedema

[Translate to English:] Lipödem - Dr. med. Daniel Münch

The diagnosis "lipoedema" can be made from the history, the typical symptoms and the observation. Lipedema is still little known even among doctors and is often confused with obesity or lymphedema. Lipoedema is a chronic disease that only affects women. The thick legs or upper arms are often noticed in childhood, and the mother or aunts may also be affected. Initially, only individual parts of the body are affected (thighs or calves). The findings can increase after puberty, sometimes relapses with rapid increases in size occur later or after pregnancy. The typical pattern of fat distribution indicates lipoedema: below the hips, on the outside, inside and front of the thighs. Unsightly cushions form on the inside of the knee, the calves become columnar, and boots no longer fit. Water can accumulate in the calves, and there is a kind of sleeve on the ankles with a transition to the rather slender feet. A specialist in angiology or phlebology should use ultrasound to rule out the presence of varicose veins that require surgery (if they exist, varicose veins should be operated on as a first step). Further examinations are not necessary, in particular no contrast medium examination of the lymphatic vessels, because this can damage them and this examination is also uncomfortable.

Staging of the desease

Lipedema - Dr. med. Daniel Münch
The 3 stages of the lipedema

Lipoedema can be divided into 3 stages: In stage 1, the skin is smooth and the subcutaneous fatty tissue is thicker but without knots. In stage 2, the skin surface is uneven, the subcutaneous tissue is thickened and interspersed with small knots. In stage 3, the skin surface is very uneven, the subcutaneous tissue thickens and hardens, and there are large bulges of fat under the skin. A distinction must be made between lipedema and lymphedema. Lipoedema always occurs on both sides, causes pain, the feet or hands are not affected and there is a tendency to bruise spontaneously. The cause is an increased storage of lymph in the fatty tissue. Lymphedema usually occurs on one side, causes less pain and the feet or hands are involved. The cause is damage to the lymphatic drainage system.

Only women are affected

Lipoedema occurs exclusively in women. In men, lipoedema can occur very rarely only after pronounced hormonal disorders, in the case of liver cirrhosis or tumor diseases. (0)32 636 25 25