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

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

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

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Define

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Genetic component

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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

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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.

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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

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

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

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

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

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Staging summary

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

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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

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Season 8 lost 87 lbs on show

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Liposuction Tumescent Local Anesthetic Liposuction (TLA)

Large infiltration solution amount and time Wet Jet Assisted Liposuction (WAL)

Surgical Treatment

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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

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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

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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.

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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

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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

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Post PT sessions week 2 and week 3

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Performed March 2015 Lateral legs PT plan 2 x a week 3 weeks

Liposuction Session 2

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Post PT week 2 and week 3

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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

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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

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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

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

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

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