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Dr. Ayush PandeyMBBS,PG Diploma

December 13, 2019

July 02, 2020


Painful Fat Syndrome or Lipedema is a chronic condition in which abnormal build-up of fats causes “symmetric enlargement” of both the legs and the lower body. This condition should not be confused with obesity: though it is often seen in overweight or obese people, it does not go away even when they lose weight.

Lipedema literally means fluid in fat. Symptoms include fat accumulation in the thighs, legs and hips; sometimes to the extent that it makes the skin tender and painful. The condition is more common in women than in men. Some patients with this condition can have a thin upper body but fat accumulation on their thighs and buttocks.

Often, women with this condition have big arms and thighs, but their hands and feet don’t have fat accumulation. The result: thinner bands where their legs meet the feet and just above the wrist.

Though doctors don’t yet know the exact cause of lipedema, patients have been known to pass it on to future generations. Hormonal changes in the body, like at the onset of puberty, during pregnancy or during menopause, have also been associated with this condition.

Diagnosis is hard because the condition often looks a lot like ordinary fat gain. There are some telltale signs, though. For example, unlike many other edemas (build-up of fluid under the skin), lipedema gives rise to non-pitting swelling: the flesh doesn’t dimple when you poke the swollen area but bounces right back. The swelling also doesn’t go down by elevating or resting the legs. People with lipedema bruise easily.

Though there are therapies available to improve the flow of lymph in the body, the most successful treatment for lipedema so far has been weight-loss surgeries like tumescent liposuction. Using compression stockings and massages may also help some patients get relief from the pain.

Changes in the skin during Lipedema (Painful Fat Syndrome)

Normal fat cells of the body are called fat lobules. When you press the skin down in a healthy person, these fat lobules slide over one another under the skin along thin fibrils, making the skin feel soft and smooth.

Lipedema occurs when the fat cells increase in size (hypertrophy) and get accumulated under the skin. These super-sized (hypertrophied) fat cells stimulate the production of hyaluronic acid in the skin tissues.

Increase in hyaluronic acid makes the fat stiff like gelatin, thus the person starts feeling heaviness in the legs.

This gel-like environment makes it difficult for the fat cells to slide past each other when the skin is pressed down. 

Hyaluronic acid further attracts inflammatory white blood cells, like neutrophils, to the fat cells which damage the fat lobules, as well as the surrounding blood and lymphatic vessels. This leads to breaking up of the blood vessels, leading to visible bruising.

The lymphatic vessels start to fail. (The lymphatic system normally helps to remove excess fluid from the tissues and also helps in fat absorption.) Eventually, the lymphatic vessels start leaking, which allows more water to collect around the fat cells, causing the fat tissues to become heavier.

When the body’s immune system tries to repair the damage, it creates scar around the fat lobules, making them feel like small beads through the skin.

Stages of Lipedema (Painful Fat Syndrome) in the legs

Stage 1: At this stage, the patient's skin is still smooth but they can feel enlarged fat tissues underneath. The swelling may increase during the daytime.

Stage 2: The skin is now uneven, with indentations and underlying fat that may make it feel like a lumpy mattress. The fat contains larger mounds of fat that can be lipomas. In some cases, the lipomas could be filled with blood vessels which are medically known as angiolipomas.

Stage 3: The skin has an irregular surface with more nodular fat depositions. The fat creates overhanging folds of skin. Since the fat deposition is more on the thighs and around the knees, the patient may experience pain and difficulty in moving.

Stage 4: The patient may develop Lipolymphedema, a condition where both lipedema and lymphedema are present in the body, with large overhangs of tissue on the legs and/or arms.

Types of Lipedema (Painful Fat Syndrome)

Lipedema can be of five types, depending on the distribution of fat in the body:

  • Type 1: the fat deposition is only on the buttocks
  • Type 2: the fat deposition is seen on the buttocks, hips and thighs, basically up to the knees.
  • Type 3: the fat deposition is seen on the buttocks, hips and thighs till the calves (backside of the legs) up to the ankles. Typically, when patients stand with their legs together, their thighs touch but there is a separation between their feet.
  • Type 4: the fat deposition is seen on the buttocks, hips and thighs till the calves, along with fat deposition in the upper arms.
  • Type 5: fat deposition can be seen on the lower leg, starting from the knees till the ankle and on the calves.

(Read more: How to lose hip fat)

Symptoms of Lipedema (Painful Fat Syndrome)

The symptoms can vary from person to person, but they usually include abnormal deposits of gynoid fat - there is enlargement of the lower body, involving the thighs, buttocks and lower legs. Lipedema could make your body pear-shaped.

Fat deposition may be seen in the arms as well. They may become enlarged at the same time and to the same extent as the legs. 

The other symptoms may involve:

  • "Bracelet" effect or "band-like" appearance of arms and legs, which tend to be much thinner just above the ankles and wrists.
  • Pain that usually worsens gradually with the increase in fat deposition.
  • Loose elastic skin.
  • Nodules on the skin that can be felt on touching.
  • Skin gets bruised easily.
  • Fatty swelling in the affected region.
  • Depression due to the social stigma attached to increased body size, and anxiety about going to new places or on meeting new people.

Diagnosis of Lipedema (Painful Fat Syndrome)

It is very difficult to diagnose lipedema. It can only be done by a medical professional who has expertise in this disorder. 

The diagnosis is mainly done on the basis of the classic clinical symptom of persistent swelling in both the legs despite elevation or weight loss.

Additional MRI, ultrasound and lymphangiogram may be useful in diagnosing lipedema.

Lymphangiogram is an imaging technique that uses a contrast dye and an X-ray machine to look into the lymph vessels and lymph nodes. Apart from lipedema, this scanning technique may also be used to diagnose some types of cancer as well as filariasis.

Treatment of Lipedema (Painful Fat Syndrome)

There is no effective treatment for lipedema, as the cause has not been found yet.

The treatment focuses on alleviating the symptoms and preventing the progression of the disease with exercises, diet and emotional support.

Diet modification

It is difficult to lose the lipedema fat. The size of the fat cells, the gel layer of hyaluronic acid and water move the fat cells farther away from the blood vessels, therefore there is a constant slow release of fat.

People living with lipedema should avoid dairy products, animal proteins and fats, simple sugars, carbohydrates, salt and wheat or processed flour products.

Their diet must include organic fruits, vegetables, whole grains and healthy proteins.

Complex decongestive therapy

After confirming the diagnosis, a medical professional may suggest complex decongestive therapy which includes different treatment approaches like:

  • Manual lymph drainage: The therapist will gently open your lymphatic channels and help move the lymphatic fluid using hands-on techniques like stretching the skin lightly.
  • Aquatic exercises like swimming can help improve the movement of lymphatic fluid, as the water acts as natural compression on the skin. High-impact exercises, such as running, are not recommended because they aggravate the disease.
  • The doctor may prescribe some supplements and medications that help with lymphatic pumping.
  • Layered bandaging with foam or specially fitted compression stockings that support the swollen area to control swelling.
  • Taking care of the affected area, by cleaning and moisturising it.

Emotional support

People living with lipedema often suffer from psychosocial disorders, including depression, anxiety, and eating disorders due to social stigma attached to bigger body size and physical restrictions. Emotional support should be given by family and friends.

Invasive approach

The invasive approach would involve surgeries like weight loss surgeries (WLS) for abdominal fat removal and liposuction or lipectomy where the doctor helps loosen the fat cells from connective tissue and then gently removes them using a suction tube. Tumescent liposuction or water-assisted liposuction could be used by your doctor.

Doctors for Lipedema

Dr. Tanmay Bharani Dr. Tanmay Bharani Endocrinology
15 Years of Experience
Dr. Sunil Kumar Mishra Dr. Sunil Kumar Mishra Endocrinology
23 Years of Experience
Dr. Parjeet Kaur Dr. Parjeet Kaur Endocrinology
19 Years of Experience
Dr. M Shafi Kuchay Dr. M Shafi Kuchay Endocrinology
13 Years of Experience
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