Lipedema surgery / Lipedema vs. lymphedema
Lipedema vs. Lymphedema: How to Tell the Difference
They are often confused, and they can occur together, but they are different conditions with different treatments. This page goes over how lipedema and lymphedema differ on examination, what lipo-lymphedema is, the conditions that look like both, the tests that help, and how each is treated.
Overview
Two conditions that get mixed up
Lipedema and lymphedema both enlarge the legs, both are chronic, and both are regularly mislabeled as weight gain. That is where the similarity ends. Lipedema is a disorder of the fat tissue. Lymphedema is a build-up of lymph fluid. Each has its own signs, its own course, and its own treatment, and telling them apart is the first step in treating either one well.
The confusion has real consequences. A patient with lipedema who is treated only for lymphedema wears firm compression for years without the tenderness or the disproportion improving, because the fat tissue is still there. A patient with lymphedema who is treated as though she has lipedema misses the skin care and decongestive therapy that prevent infections and keep the swelling from hardening. And a patient who has both needs a plan for both.
The difference
Fat tissue, or fluid
Lipedema is a condition of the fat
In lipedema, fat tissue under the skin builds up in the legs, hips, and buttocks, and often the arms, on both sides of the body in the same pattern. The tissue itself is abnormal: it is tender, it bruises easily, and it does not shrink with dieting the way the rest of the body does. It almost always affects women and usually begins or worsens at puberty, pregnancy, or menopause.
The feet are usually spared, so the leg widens down to the ankle and then stops, sometimes with a visible cuff or step at the ankle. Pressing a thumb into the tissue does not leave a dent.
Lymphedema is swelling from fluid
In lymphedema, the lymphatic system cannot drain fluid from a limb fast enough, and the fluid collects. It can affect one arm or leg, or both unevenly, and it usually includes the foot or hand. Early on, pressing a thumb into the swelling leaves a dent (pitting). Over years the fluid causes the tissue to thicken and harden, the swelling stops pitting, and infections of the skin (cellulitis) become more likely.
Lymphedema can be present from birth or develop later for no clear reason (primary), or it can follow treatment for cancer, surgery, radiation, infection, or injury to the lymphatic system (secondary).
Side by side
How they differ on examination
Most of the difference can be seen and felt in the examining room. These are the findings Dr. Ovadia looks for.
| Lipedema | Lymphedema | |
|---|---|---|
| What it is | Abnormal fat tissue under the skin | Fluid the lymphatic system cannot drain |
| Where | Legs, hips, and buttocks; often the arms | An arm or a leg, sometimes both |
| Pattern | Both sides, in the same pattern | Often one side, or uneven |
| Feet and hands | Usually spared, with a cuff at the ankle or wrist | Usually swollen, including the toes or fingers |
| Pressing on it | Does not leave a dent | Leaves a dent early on; firm and non-pitting later |
| Pinching the skin on top of the foot | A fold can be lifted (Stemmer sign negative) | The skin is too thick to lift (Stemmer sign positive) |
| Tenderness | Common; the tissue hurts when pressed | Heaviness and tightness more than tenderness |
| Bruising | Bruises easily, often without an injury | Not typical |
| Skin infections | Not typical | Cellulitis is common and can be serious |
| Who | Almost always women; often runs in families | Anyone; often after cancer treatment or surgery |
| Elevating the legs | Little change | Helps, especially early on |
| Weight loss | The affected areas change little | Does not remove the swelling, though it can help |
No single row decides it. The pattern across the whole table, together with your history, is what makes the diagnosis.
When both occur
Lipo-lymphedema
Lipedema and lymphedema are not either-or. Long-standing lipedema can lead to lymphedema, and the combination has its own name.
Lipo-lymphedema
Over years, the weight of lipedema tissue and the pressure it puts on the lymphatic vessels can wear the lymphatic system down. When it can no longer keep up, lymphedema develops on top of the lipedema. This is called lipo-lymphedema, and it is sometimes described as stage 4 lipedema.
What changes
The clearest sign is the feet. In lipedema alone the feet are spared. When lymphedema joins it, the swelling spreads onto the top of the foot and the toes, the skin there thickens, and the Stemmer sign becomes positive. The legs may start to pit when pressed, feel heavier, and be more prone to skin infections.
Why it matters for treatment
Lipo-lymphedema needs both conditions managed. The lymphedema is treated with compression and lymphatic therapy, which usually continue after surgery. The lipedema tissue can still be reduced with lymph-sparing liposuction, which some studies suggest can take load off the lymphatic system. Dr. Ovadia plans the two together.
Look-alikes
Other conditions that are confused with lipedema
Lymphedema is the most common mix-up, but it is not the only one. These conditions can look like lipedema, and several of them can occur alongside it.
Weight gain and obesity
Weight gain affects the whole body, including the trunk, hands, and feet, and it responds to diet and exercise. Lipedema is disproportionate: the legs and arms are out of proportion to the upper body, and dieting changes the upper body while the legs change much less. The two can exist together, and added weight makes lipedema symptoms worse, so weight is still worth managing. It is not the cause.
Vein disease
Chronic venous insufficiency causes swelling in the lower legs that is worse at the end of the day and better in the morning, often with varicose veins, skin discoloration around the ankles, and sometimes ulcers. The swelling pits. It can coexist with lipedema, and a vein ultrasound sorts it out.
Dercum's disease
Dercum's disease causes multiple painful fatty lumps (lipomas) that can appear anywhere on the body, including the trunk. Lipedema is a diffuse, symmetric enlargement of the legs and arms rather than separate lumps. Dercum's is rare, and it is more often confused with lipedema in reading than in the examining room.
Swelling from other causes
Heart, kidney, liver, and thyroid conditions and some medications cause swelling that usually affects both legs, includes the feet, and pits. These are ruled out from your history and, when needed, blood tests. Lipedema does not cause this kind of swelling by itself.
Tests
How the diagnosis is made
There is no blood test or scan that diagnoses lipedema. The diagnosis is clinical, and tests are used to confirm or rule out the other conditions.
The examination comes first
Both lipedema and lymphedema are diagnosed from your history and a physical examination. The pattern, whether the feet are involved, whether the swelling pits, whether a skin fold can be lifted at the base of the second toe (the Stemmer sign), tenderness, and bruising usually give the answer. There is no blood test for lipedema.
Vein ultrasound
A duplex ultrasound of the leg veins is a painless test that shows whether the veins are working properly. It is used when vein disease could be adding to the swelling, or before surgery on the legs.
Lymphatic imaging
When lymphedema is suspected and needs to be confirmed, the lymphatic system can be imaged with lymphoscintigraphy: a small amount of tracer injected into the foot or hand shows how well lymph drains. It is not needed to diagnose lipedema.
Other tests
Blood tests are sometimes used to rule out the other causes of swelling listed above. Imaging such as MRI is not needed to diagnose lipedema and is not routinely used for it.
Treatment
How the treatments differ
The two conditions share some tools, especially compression and lymphatic therapy, but they are used differently, and surgery means something different in each.
| Lipedema | Lymphedema | |
|---|---|---|
| Compression | Supports the tissue and limits heaviness; strength chosen for comfort | Central to treatment; firmer, graduated compression and bandaging |
| Lymphatic therapy | Manual lymphatic drainage helps symptoms for many patients | Complete decongestive therapy: drainage, bandaging, skin care, exercise |
| Movement | Low-impact exercise for circulation, strength, and mobility | Exercise in compression; elevation helps |
| Skin care | Not a major focus | Essential, to prevent cellulitis |
| Surgery | Lymph-sparing liposuction to remove the abnormal tissue; staged by area | Liposuction to remove thickened tissue once the swelling has become firm, in selected patients |
| What surgery can do | Reduce pain, heaviness, and size; improve mobility | Reduce the size and heaviness of the limb; compression and therapy continue |
Not sure which one you have, or whether you have both? Call or email us, or book a consultation, and Dr. Ovadia will examine you and go over it with you.
Your surgeon
A surgeon who knows the difference
Dr. Steven Ovadia is a board-certified plastic and reconstructive surgeon, fellowship-trained in microsurgery, who treats lipedema with lymph-sparing reduction surgery, including patients whose lipedema has progressed to lipo-lymphedema.
A consultation starts with sorting out which condition you have, or how much of each, before any treatment is discussed. He sees patients in New York City and in Jersey City and Millburn, New Jersey, and by phone or video.
Questions
Common questions about lipedema and lymphedema
How can I tell if I have lipedema or lymphedema?
The pattern is the biggest clue. Lipedema affects both legs (and often both arms) in the same way, stops at the ankles so the feet look normal, is tender when pressed, and bruises easily. Lymphedema often affects one limb more than the other, includes the foot or hand, pits when pressed early on, and is more heavy than tender. Many patients have features of both, which is why an examination by someone who treats both conditions matters.
What is the Stemmer sign?
It is a simple test done during the examination. The examiner tries to pinch and lift a fold of skin at the base of the second toe (or finger). If the skin is too thick to lift, the Stemmer sign is positive, which points to lymphedema. In lipedema alone the skin on the foot is normal and a fold lifts easily, so the sign is negative.
Does lipedema turn into lymphedema?
It can. Over many years the lipedema tissue can overload the lymphatic system, and lymphedema develops on top of it. This is called lipo-lymphedema. It does not happen to everyone, and keeping the lipedema managed with compression, movement, and a stable weight is thought to lower the chance of it.
Can I have lipedema and lymphedema at the same time?
Yes. Lipo-lymphedema is lipedema with lymphedema added. Patients can also have lipedema and a separate lymphedema from another cause, such as cancer treatment. Each part is treated on its own terms, and the plan is made for both together.
Why does my swelling pit when I press it?
Pitting means fluid. Lipedema alone does not pit. If your legs pit, there may be lymphedema, vein disease, or another cause of fluid along with the lipedema, or instead of it. That is one of the things the examination sorts out.
Do I need lymphatic imaging before lipedema surgery?
No. Lymphatic imaging is used when lymphedema is suspected and needs to be confirmed. It is not part of diagnosing or planning surgery for lipedema. Dr. Ovadia goes over whether any test is needed in your case.
What if I have lipedema and lymphedema together?
Lipo-lymphedema is common in long-standing lipedema, and Dr. Ovadia sees many patients who have it. The lymphedema is managed with compression and lymphatic therapy, which continue after surgery, and the lipedema tissue is reduced with lymph-sparing liposuction. In selected patients with lymphedema that has become firm and thickened, liposuction can also reduce that tissue.
Which one is covered by insurance?
Compression and lymphatic therapy are often covered for both. Lymphedema surgery and lipedema surgery each have their own coverage rules, and they vary by plan. The insurance page for lipedema surgery goes over what plans generally look for.
Next step
Start with a consultation
Dr. Ovadia examines you, goes over your symptoms and what you have tried so far, and tells you whether your findings fit lipedema and what treatment would look like. Phone and video consultations are available.
225 Broadway, Suite 3100, New York, NY
377 Jersey Ave, Suite 440, Jersey City, NJ · 90 Millburn Ave, Suite 206, Millburn, NJ
Phone and video consultations available · info@ovadiaps.com