Introduction: Nosological Definition and Clinical Pictures of Lipedema

Nosological Definition and Clinical Pictures of Lipedema is typically defined as a volumetric increase localized mainly in the lower limbs, being bilateral, symmetrical, and of a soft consistency. It develops with the accumulation of adipose tissue in a pattern similar to “riding breeches,” extending from the hips to the ankles. Lipedema is a nosological entity of unknown etiology, predominantly affecting females. According to recent epidemiological studies, it manifests in about 11% of the female population, often beginning during menarche, menopause, or pregnancy. 

Although less common in males, cases have been described with significant alterations in male sexual hormones and/or liver function disorders. Some authors highlight an increased incidence following cranial traumas and surgeries for pituitary adenomas. 

Nosological Definition and Clinical Pictures of Lipedema can develop in an ascending or descending manner. The phenomenon begins at the hips and thighs, progressively worsening in the lower limbs. The typical sign of edemato-fibrosclerotic panniculitis, however, appears late. In advanced cases, particularly in untreated elderly subjects, subcutaneous nodular formations, a result of sclerotic processes affecting the subcutaneous connective tissue, can be observed. In severe cases, immobility is a direct consequence of elephantiasis in the lower limbs. Nosological Definition and Clinical Pictures of Lipedema The skin color is usually normal, except in cases where lipedema is associated with a particular form of erythrocyanosis (erythrocyanosis crurum puellarum). In some cases, hemispherical adipose cushions are evident medially at the knee joint. Occasionally, lipedema of the lower limbs is accompanied by lipedema of the upper limbs, typically developing from the shoulder and ending near the wrist. In rare cases, lipedema exclusively affects the upper limbs. 

Other significant aspects defining lipedema include: Nosological Definition and Clinical Pictures of Lipedema

Physiopathological Aspects Nosological Definition and Clinical Pictures of Lipedema Adipose tissue is a particular type of connective tissue consisting of adipose cells (adipocytes), forming lobules separated by fibrous septa of connective tissue. Each adipocyte is supported by its own blood supply through a capillary system and innervated by adrenergic nerve fibers. It’s also believed that adipose tissue has sensory innervation. Lymphatic capillaries can be identified at the levels of the fibrous septa but not among the adipocytes. Few reticular fibers among the adipocytes constitute the initial (or prelymphatic) lymphatic drainage system. 

Microangiopathy, which develops in the adipose tissue area causing increased protein permeability and capillary fragility, is one of the initial mechanisms distinguishing lipedema. As a consequence of increased permeability, high-protein fluid accumulates in the surrounding cellular area, while increased capillary fragility results in typical ecchymosis. 

Nosological Definition and Clinical Pictures of Lipedema The soft consistency of adipose tissue may be associated with a neurogenic inflammatory state, further complicating the condition of microangiopathy. Some scholars believe this extremely soft consistency is linked to damage to the autonomic nervous system. This alteration could lead to erroneous interpretation of protopathic sensory inputs (related to pressure, temperature, or posture), as known, for example, in Sudeck-Leriche syndrome. 

The pericellular fluid accumulation is associated with dilation of the prelymphatic drainage system, resulting in very slow lymphatic fluid drainage through the initial lymphatic vessels. 

Typical pathological alterations in cutaneous lymphatic capillaries include very high capillary wall permeability. Studies using fluorescent microlinfangiography have shown aneurysm-like formations in association with numerous capillary segments of extremely reduced caliber. 

Nosological Definition and Clinical Pictures of Lipedema: This explains how the dilation of prelymphatic channels, along with morphological and functional alterations of the lymphatic capillaries, suggests progressive damage to lymphatic drainage capacity. 

Additionally, a disorder in the motor activity of the lymphangion (the anatomical-functional unit of the lymphatic collector, i.e., the segment between one valve apparatus and another) has been observed. Early stages, evidenced through oily contrast lymphangiographic examination, have shown the presence of wavy superficial lymphatic collectors, described as “corkscrew-shaped.” In cases associated with elephantiasis, the condition of progressive immobility exerts a detrimental effect on lymph formation and the motor activity of the lymphangion. Moreover, isotopic lymphography has shown an accelerated aging of the lymphatic pump. 

In lipedema, skin elasticity is greatly reduced, while skin “compliance” (hardness index, measured in mmHg using a tonometer) is increased. This leads to severe consequences: 

Complications and Association with Other Pathologies Complications related to the patient: 

Complications related to doctors: Nosological Definition and Clinical Pictures of Lipedema

Natural complicationsNosological Definition and Clinical Pictures of Lipedema : Nosological Definition and Clinical Pictures of Lipedema

FIG.1, A-F: CLINICAL, RADIOLOGICAL Nosological Definition and Clinical Pictures of Lipedema (LYMPHANGIO-CT, RETROGRADE DUCTOGRAPHY), SURGICAL (NEEDLE CANNULA INSERTED INTO THE ORIFICE CORRESPONDING TO THE CHYLOUS FISTULA AND CHYLOCELE CAPSULE), AND LONG-TERM RESULTS RELATING TO A TRAUMATIC LESION OF THE THORACIC DUCT. 

Therapy It’s important to emphasize that lipedema is not merely a “subjective problem” of the patient, nor just a matter of excessively adipose lower limbs, nor a simple constitutional variation, as sometimes claimed, but a pathology that requires appropriate treatment to avoid possible complications. 

Nosological Definition and Clinical Pictures of Lipedema Complete decongestive therapy (CDT), characterized by manual lymphatic drainage, the use of suitable graduated compression supports and/or functional bandages, therapeutic exercises, and meticulous skin hygiene, is initially contraindicated in cases where obesity, generally associated with significant anatomical-functional alterations of the cardiovascular, pulmonary, and musculoskeletal systems, is present as a comorbidity. This includes, in particular, arterial hypertension, congestive heart failure, diabetes mellitus, hyperlipidemia, Pickwick syndrome, osteoarthritis of the hips, knees, or feet. In these cases, where a combined form of lipedema and obesity exists, it is advisable to begin complete decongestive therapy after carefully correcting the disorders related to obesity, not only with medical-conservative aids, through a suitable body weight reduction program, but also, and above all, surgically. Obesity treatment is, in fact, essential so that complex decongestive therapy, associated with microsurgical treatment, is successful. 

Nosological Definition and Clinical Pictures of Lipedema Nosological Definition and Clinical Pictures of Lipedema, The surgical treatment of obesity experienced a groundbreaking shift with the conception and introduction of biliopancreatic diversion (Biliopancreatic Diversion, BPD) by Prof. Nicola Scopinaro and his collaborators at the Surgical Clinic of the University of Genoa. This marked a fundamental qualitative shift in the surgical treatment of obesity, as it guarantees a true resolution of the pathological condition through a functional regulation of energy intake and absorption, resulting in significant weight loss associated with a permanent normalization of blood glucose and cholesterol levels in all cases. 

Conclusion and Key Points: Nosological Definition and Clinical Pictures of Lipedema  

Effective management of Nosological Definition and Clinical Pictures of Lipedema , addressing both the physical symptoms and the psychological impact of the condition. Early recognition and proper treatment are key to improving quality of life and preventing complications. 

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