Understanding Lipedema: Stages of Lipedema, Symptoms, and Diagnosis of the Condition (Abnormal Fat Distribution in the Hips and Legs)

Lipedema is a chronic disorder of the adipose tissue. It results in abnormal fat distribution with abnormally enlarged and deformed fat cells. It most commonly affects women. Lipedema is rare in men. Most people affected are between the ages of 30 and 40.

The areas most prone to excessive fat accumulation in the tissue are

• the buttocks, 
• thighs (saddlebag syndrome), and 
• the hips. 

In severe cases, the upper arms and lower legs may even become thickened. Lipedema is incurable, but it can be effectively treated with conservative methods or surgery. If the accumulation of fat cells extends from the buttocks down to the ankles, doctors refer to this as “columnar leg.”

In the early stages, it is difficult to distinguish lipedema from obesity diagnostically. More than 50 percent of patients are also obese. Furthermore, many patients suffer from depression requiring treatment due to the disproportion between their upper and lower bodies.

People with lipedema are often assumed to lack control over their eating habits. However, an unhealthy diet and the resulting weight gain are not the cause of lipedema. Excessive body weight can, however, negatively affect the course of this fat tissue disorder.

This disorder of fat distribution is genetically determined and occurs as a result of hormonal changes in the body, such as those associated with

• puberty,
• pregnancy, or
• menopause.

The extent to which hormones influence the disease has not yet been fully clarified scientifically.

Specialists who provide expert care for lipedema include vascular specialists (angiologists, phlebologists) and plastic surgeons.

Lipedema always develops symmetrically. At first, only the outer sides of the hips, the buttocks, and the thighs are affected.

Doctors believe the condition is associated with damage to the small blood vessels in the affected areas of the body: the vessel walls become permeable, which in turn impairs the lymphatic system. It has to drain too much fluid from the tissue.

As the condition progresses, even the legs become increasingly thicker—even though many patients exercise regularly. When temperatures rise and after prolonged sitting or standing, the fat cells store even more water than usual.

Other symptoms of lipedema include:

• Cellulite (orange peel skin)
• Localized, sometimes severe pain
• Tenderness in the affected areas
• an increased tendency to bruise without significant pressure
• Swollen, “heavy” legs
• Appearance of spider veins
• Cold skin surface
• Bow legs due to bulky thighs
• Premature osteoarthritis due to leg misalignment
• Reduced mobility due to joint discomfort
• Tissue damage (wound eczema) on the inner thighs

Lipedema is diagnosed based on visual examination, palpation, and an ultrasound examination. Unlike lymphedema, lipedema does not leave indentations on the skin’s surface when pressure is applied. The specialist must also differentiate this disorder of fat distribution from other conditions with similar symptoms (lymphedema, obesity).

Due to its typical distribution pattern, the condition is clearly recognizable by the advanced stage at the latest. It originates in the hips and buttocks and spreads in large fat deposits down to the ankles and wrists. The ultrasound image shows changes in the adipose tissue that resemble a snowstorm.

Lipedema can usually be diagnosed easily based on distinct symptoms:

• Time of onset: Lipedema almost always occurs in conjunction with hormonal changes, such as the onset of puberty, pregnancy, or menopause.
• Excessive fat accumulation: The fat deposits accumulated in the subcutaneous fat tissue are distributed symmetrically, for example, on both legs or both upper arms.
• Disproportion: There is a striking difference compared to the rest of the body. The upper body and waist are often slender, while the hips and thighs increase in volume uncontrollably.
• Exercise and diets: Even with a healthy diet, strict dieting, and plenty of exercise, the excess fat tissue cannot be reduced.
• Edema and tendency to bruise: Even slight pressure causes pain in affected women; they are prone to edema and develop bruises at the slightest bump.
• Skin texture: As the disease progresses, the skin’s surface becomes noticeably less smooth and develops a “pitted” appearance with increasingly larger nodules in the subcutaneous fat tissue. This is known as the “mattress phenomenon.”

Even just one or two of these symptoms may indicate lipedema. If you are affected, you should consult a specialist, such as a phlebologist. They will assess your symptoms and recommend a treatment plan.

Medical professionals distinguish three stages of this progressive condition:

• Stage 1: Development of “orange peel” skin (small dimples) — In the initial stage, the skin’s surface is still relatively smooth, with soft subcutaneous tissue containing fine nodules. The body’s overall appearance is barely affected.
• Stage 2: Development of larger dimples (mattress skin)—As the disease progresses, nodules increasingly form in the fatty tissue. The skin’s surface becomes more uneven, and the fat deposits grow larger and more asymmetrical. The difference from the rest of the body is clearly visible.
• Stage 3: Large, harder skin flaps and skin ridges that even cover the backs of the hands and feet—The subcutaneous fatty tissue is severely thickened and hardened, with large nodules and a pitted skin surface. Affected patients are severely swollen. The disproportion compared to the other half of the body is very pronounced, especially on the thighs and hips, where there are sometimes large fat flaps.

In addition—depending on the severity—five types are distinguished:

• Type I: limited to the buttocks and hip region
• Type II: extending down to the knees, with fat folds on the inner side of the knees
• Type III: extending down to the ankles
• Type IV: only the hands and feet are unaffected
• Type V: Fluid retention (edema) even on the backs of the hands and feet, fingers, and toes (lipolymphedema). Damage to the larger lymphatic vessels

There are several treatment options for this hereditary fat tissue disorder:

• manual (by hand) lymphatic drainage performed by a physical therapist (usually a lifelong conservative therapy)
• compression therapy (compression bandages, compression stockings)
• Exercise
• Liposuction performed by a cosmetic and plastic surgeon (usually a procedure performed multiple times)

Regular lymphatic drainage

Lymphatic drainage is often used in the later stages of lipedema. It is intended to reduce the swelling (edema) caused by the excess fluid accumulation in the tissue.

The lymph trapped between fat cells is drained using specific manual techniques: pressure and traction activate the lymphatic vessels, allowing lymph fluid to drain from the affected area. The mechanical stimulation also has a pain-relieving effect.

During decongestive therapy at the start of treatment, lymphatic drainage is recommended 5 to 7 times per week. In the subsequent maintenance phase, sessions are reduced to just 1 to 2 times per week. The affected areas of the body are additionally wrapped with compression bandages.

Compression stockings

Thanks to their special manufacturing process and firm material, compression stockings exert increased pressure on the leg veins. They are used in maintenance therapy.

Compression stockings are available in three levels of compression—depending on how intense the pressure should be. Since people with lipedema often have a larger leg circumference, the doctor prescribes flat-knit support stockings. They must be worn daily—even during physical activity, if possible—and prevent venous blood from pooling in the legs. Fluid retention in the fatty tissue decreases. The legs become slimmer.

Exercise

Patients with lipedema who also suffer from obesity should lose excess weight if possible. This alleviates their pain and helps them regain mobility. Not only does a moderate and healthy diet (not a weight-loss diet!) contribute to this, but so does exercise.

All water sports are well-suited, including

• aqua aerobics,
• swimming, and
• aqua-jogging.

These sports are particularly gentle on the joints and enhance the effects of manual lymphatic drainage. In addition, vascular specialists recommend 

• cross-country skiing,
• walking, and
• walking.

Liposuction

The removal of fat cells and lymph fluid (liposuction) is the only method that provides long-term relief for those affected. It not only removes excess interstitial fluid but also reduces fatty tissue. Furthermore, the treatment is permanent: fat can no longer accumulate in the treated areas.

The surgical procedure can reduce thigh circumference by up to 3 pant sizes. The treatment also reduces edema in the legs, so that the patient will experience virtually no pain in the future.

The cosmetic surgeon first marks the surgical area and makes several incisions there, each about 4 millimeters long. He then injects a saline solution into these incisions. The solution also contains adrenaline and a local anesthetic.

The solution

• stops the bleeding that occurs during liposuction,
• alleviates the patient’s pain, and
• causes the fat cells stored there to swell, making them easier to remove.

Using a narrow cannula, the doctor then suctions out up to 9 liters of fat cells, lymph, and blood from the subcutaneous fat tissue. After liposuction, the patient must wear a special compression garment for about 4 weeks. It contours the treated areas of the body and helps the skin heal properly. If the surgery goes well, the patient may be able to avoid lymphatic drainage in the future.

Preparation and Type of Anesthesia for Liposuction

In most cases of lipedema, large amounts of fat are removed. Tumescent fluid continues to drain even hours after the surgery. For this reason, virtually every liposuction procedure is performed under general anesthesia.

To prepare for the procedure, the team conducts standard preoperative anesthetic evaluations. In cases of lipedema, a lymphatic drainage session shortly before the procedure is also helpful and improves the outcome.

When liposuction is performed under general anesthesia, the local anesthetic in the tumescent solution is not required. As a result, patients recover more quickly after surgery and their circulation stabilizes sooner.

Complications and Risks of Liposuction

Every surgical procedure carries potential risks, regardless of the specific condition. However, these risks can be significantly reduced through thorough preparation.

The patient should therefore inform her doctor in detail about any possible

• allergies,
• intolerances, and
• other health issues

. This allows the necessary precautions to be taken to ensure the procedure goes smoothly.

In the case of lipedema, venous disorders are a very real possibility. In this case, a vascular specialist must be involved in the treatment.

Compression garments are put on while you are still under anesthesia and should be worn for 6 weeks. The garment can be removed for a few hours for washing.

A one- to two-day hospital stay is recommended.

The first lymphatic drainage session is scheduled for the day after surgery. Initially, two to three lymphatic drainage sessions per week should be scheduled. After two weeks, this can be reduced to one to two sessions per week.

You will notice significant pain relief shortly after the procedure. Once the swelling subsides after a few weeks, you can resume your normal life, exercise, and enjoy new clothes.

Effective January 1, 2020, and initially through December 31, 2024, statutory health insurance may cover liposuction under certain circumstances. 

The requirements are

• the presence of lipedema at stage 3 or higher,
• prior conservative treatment lasting at least six months that was unsuccessful, and
• a maximum BMI of 35

Before deciding to undergo liposuction, please be sure to consult with your health insurance provider in detail to ensure coverage.

Billing private health insurance companies is sometimes easier, but even in these cases, costs are often not covered. Please clarify this directly with your private health insurer. In any case, the treatment costs can be claimed as a special expense for tax reduction.

General practitioners and family doctors are often the first point of contact for symptoms that can be explained by lipedema. However, the initial signs and symptoms of this condition are usually very nonspecific, so the family doctor or general practitioner will then refer the patient to a specialist. These include phlebologists, lymphologists, and plastic and cosmetic surgeons.

The best results in lipedema treatment are achieved through an interdisciplinary approach. This means that various treatment methods from different medical specialties are combined in the treatment plan.

Lipedema is a chronic condition that occurs almost exclusively in women and is characterized by a painful accumulation of fatty tissue. Women with lipedema often suffer from typical symptoms such as pain, tenderness, and bruising, especially on the inner thighs and both legs. Lipedema can also occur in the arms, while the feet and hands are usually spared. The symptoms of lipedema include both visible changes and subjective symptoms that significantly impact quality of life.

Lipedema is diagnosed through a thorough physical examination, including visual inspection and palpation. The classification into stages and the distinction between obesity and lipedema play an important role in this process. Lipedema is classified into three stages, with symptoms becoming more severe, particularly in advanced stages. The causes of lipedema are not yet fully understood, but it is believed that hormonal factors play a central role.

The diagnosis and treatment of lipedema are guided by current recommendations, such as the Lipedema Guidelines, which are published by the German Society for Phlebology and the Society for Phlebology and Lymphology, among others. The goal of any lipedema treatment is to alleviate symptoms and slow the progression of the disease. Complex physical decongestive therapy forms an important foundation for this, supplemented by nutrition and weight management.

In many cases, surgical treatment of lipedema—particularly liposuction for lipedema—can significantly improve symptoms. Nevertheless, lipedema remains a chronic condition. Treatment for lipedema should be tailored to the individual and take into account both conservative and surgical approaches.

In summary, it is clear that lipedema must be regarded as a distinct condition in its own right. The importance of a healthy diet and early diagnosis are crucial for the course of the disease. Even though lipedema cannot be completely cured, targeted measures can ensure that it is well-managed and provide long-term relief for those affected.

How is lipedema diagnosed?
Lipedema is usually diagnosed through a physical examination, visual inspection, and palpation. Key criteria include symmetrical distribution, differentiation from obesity, and typical symptoms of lipedema.

What are the stages of lipedema?
Lipedema is classified into three stages. This staging system describes the severity of the fatty tissue and changes in skin structure, ranging from mild to severe.

What treatment options are available for lipedema?
Treatment for lipedema includes conservative measures such as compression therapy, manual lymphatic drainage, and exercise. In advanced stages, surgical treatment of lipedema may be performed via fat removal or liposuction.

Does liposuction provide long-term relief for lipedema?
Liposuction for lipedema can provide long-term relief from symptoms and improve quality of life. However, it should always be part of a holistic treatment plan that also includes diet and exercise.