Monday, September 8, 2014

Is lipedema hereditary?

By Tatjana van der Krabben

Is lipedema hereditary? Interesting question. For starters, that is not proven. Yet? Another interesting question. If you ask me to speculate I wouldn’t go with hereditary full stop. And here is why.

Despite it often being quoted, lipedema is not a proven hereditary or genetic condition. Read the fine print; papers mostly say something like ‘possibly hereditary’ or ‘in part’. With family members displaying symptoms, one generation after another, going against the hypothesis of it being hereditary seems rather futile. Also, I can hear you gritting your teeth from here: “Is she implying I brought this on myself?!” Rest assured, I’m doing no such thing. But here’s some food for thought.

Regarding lipedema there are many assumptions going around. About percentages and numbers of women having it. Mostly 1 in 10 or 1 in 11 is mentioned to state the urgency of the matter. Sometimes in relation to a country or continent or even the world. Again, not proven. Worse, that’s just one estimate. Child et al (2009) came up with a minimum estimate of prevalence of 1 in 72.000. Those estimates are worlds apart. In a recent lecture dr. Damstra, a Dutch specialist, mentioned its occurrence in Asia is genuinely rare. So 1 in 10 in the world can’t be right. 1 in 72.000 sounds way to conservative to me; on an average summer day on a beach or in a theme park I encounter several ladies with lipedema. My point? Keep an open mind!

Am I playing it down? No. I believe the matter is actually getting more urgent. This is why. I’m coming from observation and am just hypothesizing, but the generation before me usually didn’t experience serious issues until menopause or a hysterectomy, often despite multiple pregnancies. As in, of course in retrospect there were some signs before, but their functioning was hindered only so much until then. My generation mblmmmb (read: forty-ish) experienced undeniable symptoms when pregnant. I now see girls still in their teens with stage 3. I also hear of more and more men getting diagnosed.

My generation did without junk food to mention of until our twenties. Soda bottles were made of glass until I was fifteen-ish and snacks and treats were limited to weekends and parties. I feel like we are the transitional generation in this picture. Of course in part this is the same debate as with autism and ADD etc.; is it getting more common or are more people seeking and getting help/diagnosis? No doubt more people seeking medical help has something to do with it. Something, but not all. I honestly see lipedema getting worse faster and faster.

Fact: the population as a whole is getting bigger. Fact: we get less exercise then we did in my grandmother’s day. Fact: our diet has changed tremendously from seasonally limited options and whole foods to mostly processed supermarket ‘food’. And here’s the thing we all know: let the average girl switch to granny’s whole foods and some exercise and her fat will melt away and with us not so much. Well, definitely not all of it. Also, we tend to gain faster eating the same type of food in the same portions. So, I’m leaning towards part circumstance and part predisposition. That would also explain how some manage to get virtually symptom-free by changing their lifestyle. If it’s genetics only, that would be rather strange, to say the least.

I’m not pulling a rabbit out of a hat here. Several researchers are hypothesizing along the same lines. This theory is telling me two things:

1. We run the risk of having an explosion of lipedema with young teens taking birth control already, supermarkets being the main food source for most which offers little whole foods and the increased digestion of xeno and phyto estrogens.
2. There’s a point to looking at circumstance and lifestyle. Change for the better what you can. Reduce inflammation, keep moving. Many are already travelling down that road with (some) success.

So, no, you are not to blame for developing lipedema. We all get caught by surprise, but please stay pro-active. It’s about quality of life. We all want it to be the best it can be. Right?

Monday, July 28, 2014

What to consider when searching for a surgeon to perform liposuction

This blog could never cover everything relevant, but it's a start, coming from personal experience and what else I learned along the way. I do not recommend liposuction. This blog does not provide tools to assess whether you should have liposuction. However, I receive many questions on where to start when considering liposuction and in that context I offer this information as food for thought. Preferrably, in an ideal world, you would be going over these issues with your informed doctor, or better yet with a specialist in a multidisciplinary institute, where they could answer all your questions and offer the treatment when considered a good candidate.

Learn what exactly you are looking for.
Liposuction, liposculpture, WAL, PAL, tumescent: are you still with me? It's ALL liposuction. All of it. And it's all tumescent. I love this quote of dr. P. Aldea:
"Tumescent liposuction is nothing but the universally performed pre-liposuction infiltration of the fat to be suctioned with a dilute solution of a local anesthetic (lidocain, marcain etc.) and adrenaline (epinephrine) which increases the accuracy of fat removal, largely reduced blood losses AND increases patient comfort."

As dr. Aldea puts it: the anesthesia is supplemented. Meaning: tumescent infiltration of the area to be suctioned is a given, but the type of anesthesia is a matter of choice. But mostly not the patient's choice. I'll get back on that.

PAL, WAL, UAL, LA etc.
Along with tumescent, there often are additional specifications regarding the technique a surgeon applies. They can use a specific suction device like Power Assisted (PAL) or apply a thin water beam to help losen the fat from the tissue: Water Assisted Liposuction (WAL). There are more flavors out there. I highlighted PAL and WAL, because lately these are frequently mentioned on patient forums. However, as you can read through the link, these are not the only options.

As you can read they all are presumed to have their merits and do something specific to spare the lymph, do minimal damage, minimize risk etc. Ask a surgeon which is best and you'll get an answer. Ask another surgeon and you'll get another answer.

As a layman I noticed the difference of opinion between professionals and let it be. A certain surgeon prefers a certain technique. Well, apparently that technique suits him/her best. My personal choice was to get over the various terms which I could only ever understand superficially and looked at the surgeon's track record instead: knowledge of lipedema and years of experience. After all: the tool doesn't define the result; it's the surgeon's skill in using the tool.

Note: there's more research out there now compared to the time I had my procedures. If you want to know more about a particular technique and how it works compared to an other or the "plain" technique, there's far more information to be found. Go straight for the "boring" stuff: formal publications, in order to avoid information designed as a scientific-looking piece of marketing. The quickest way to cut to the chase is to search through Google Scholar. It only contains scientific publications.

Plastic surgeon or cosmetic surgeon
A plastic surgeon is trained in hospitals by professionals and has completed related residencies. Cosmetic surgery is not taught through residency programs. Doctors seeking to learn cosmetic surgery typically get their training after their residencies. This pretty much means a doctor would need to organize his/her own training and has a certain freedom the raise the bar to his/her liking. Cosmetic surgery is practised by doctors from a variety of medical fields. Read more about the differences here.

However, deciding between a plastic surgeon or a cosmetic surgeon based on the title only is a trick question. Plastic surgery does NOT equal (knowledge of) liposuction. There are numerous specialties within plastic surgery. Plastic surgery is first and foremost focused on reconstruction of defects due to disorders you are born with, trauma, burns and disease. Lipedema qualifies as a 'disease'. Care to guess how many hospitals acknowledge the condition and offer liposuction as a treatment option? Few. Very few. As a consequence there are few well-trained and informed plastic surgeons out there. For reference: tumescent, which is raved about as a major improvement to liposuction surgery, is invented by an American dermatologist, dr. Klein.

When considering a surgeon you best look at expertise and experience. While you're at it, also look at client/patient reviews. In that context, beware of posers, pretending to be content patients. In the past some clinics have used this despicable method to lure clients. It may still occur...

To improve cosmetically or to improve mobility and reduce pain
This is not about starting a debate. Your body, your choice. It's just very important to find out where your priority is and whether that priority matches with the surgeon you're considering for the job. It's not either/or per se. It can be a little of both. But trust me: there are surgeons out there with a 100% focus on mobility and they will NOT be open to a post-op debate over looks. Even when the result is very uneven and/or irregular. There's also the patient who, in her heart, wants killer legs (back). Again, not judging. Just make sure you set out for a realistic goal with a surgeon who is able and willing to help you strive for that goal. Strive, yes. We're quite the canvas to work with. It's no exact science.

You want a good or even super cosmetic result?
Ask. Ask for pre-op and post-op pictures of women much like you: size, build, with lipedema. Don't let the surgeon just show you his/her best work ever on young ladies with little excess fat and lovely elastic skin. There's skin elasticity and the condition of your connective tissue to consider. Ask about your personal possibilities and impossibilities and, if needed, try to adjust your expectations. It's better to know before than after when there's no going back.

Look for a surgeon with knowledge of lipedema
Typically, those seeking liposuction for purely cosmetic reasons need to have little fat removed. It's not designed as weight loss surgery. Many surgeons even refuse to operate when the BMI is on the high end. Many of these surgeons commonly remove 1 liter, maybe 2 per surgery. A drop in the bucket for most of us. We need someone who can and will remove more.

He/she would have to be aware of the fact that we need to be especially careful with our sluggish and sometimes already compromised lymphatic system. As well as: possible poor skin elasticity, weak connective tissue and possibly slower healing.

General anesthesia or local
General anesthesia in itself poses a (small) risk, on top of the risks inherent to liposuction. You can draw the line there or you can reason that didn't stop you in the past to, say, have your appendix removed.

General anesthesia burdens your body. When I insisted on general anesthesia myself in an entirely different procedure, my surgeon warned me it would take me more time to recuperate afterwards compared to undergoing the same procedure with an epidural. It simply adds to what your body needs to process when healing. Local anesthesia is also favored by some to have the patient able to move and, if need be, stand to assess the evenness of the result. On the other hand, the prospect of enduring the procedure wide awake can be stressfull. Maybe too stressfull for some.

If you are to opt for general anesthesia, you may need to look a little harder for a suitable surgeon. Many clinics can't or won't offer general anesthesia. It requires additional facilities, knowledge and assistance during the procedure. If not that, some surgeons truly want you awake to monitor your wellbeing themselves and have you participating by moving during the procedure.

Pre-op and post-op care
What is being checked and looked into to dertermine you are a suitable candidate? Is it thorough? Do you have a good feeling about this? Do you know the basics and were provided with information on how to prepare for the procedure, what to expect and how to arrange care post-op? How can you reach the clinic when you (feel) you need to? What if post-op complications arise? Who covers these expenses? Where can you turn to? This is particularly relevant if your surgeon is far from your home and you travel back soon after the procedure. At the same time: don't wait to be asked about specifics. Share your medical history and use of medication in detail.

Do inform your primary, even if he/she doesn't support the idea. Make sure they understand what you embark on so they can help in case of problems.
Obvious stuff? Sadly no. I still read about questions like: "Is it normal to still have swelling after a week" and "Is it normal the cuts ooze". That's basic stuff. You should be told about this sort of thing in advance.

In rare cases the procedure is covered. Ask around on forum if someone from your country managed to get it covered and what they did. Even if the odds are slim, consider trying. Health Insurance companies need to become aware of lipedema and liposuction as a serious treatment option.

Also, think how far you want to take this. Going ahead with the surgery while still butting heads with your health insurance may ruin your chances of coverage. It may also lead to a road where you can't have the procedure done by your surgeon of your choice. Ask around. Patient forums on for instance Facebook are a wonderful source of practical information.

Wednesday, July 2, 2014

Living With Lipedema - Visiting Downtown San Antonio

A few weeks ago we took my mom's advice and decided to visit downtown San Antonio on a Sunday. We actually took Sunday and Monday in order to take advantage of the hop on / hop off tour from downtown. I was hoping we could catch the trolley at one of the missions near us, but after calling the company to confirm this idea it was out - we had to brave our way downtown.

I do recommend going on a Sunday. The traffic wasn't too bad and we were able to find parking.

We bought hop on / hop off tickets for the Alamo trolley on Sunday and got our second day passes for Monday. It was late afternoon so for this first trip around we just road the trolley for the one-hour tour and decided where we wanted to go the next day. 

The trolleys were all handicapped accessible, and that's important for those of us with more advanced lipedema. If you're traveling in a wheelchair or scooter, all the trolleys had wheelchair lifts. Some people got on the trolley then sat in a regular seat after boarding. Others sat in the back of the trolley in their chair. 

 We toured the Alamo that evening then came back for the downtown trek on Monday.

Our first stop was the King William neighborhood. We had an hour in this historic neighborhood. We walked past several historic homes and passed a few that were open to the public and made some plans to return on another day to tour the homes and grounds. We also walked along a portion of the RiverWalk, an 18 mile stretch of bike and walking paths that lead from downtown San Antonio along the river towards the missions outside of town.

The Riverwalk is very wide, accepting wheelchairs and powerchairs easily. However, not all access points to the walkway offers ramps for easy ingress / egress. There are maps of the Riverwalk so you can see what areas have handicapped ramp access available. 

We also visited Mercado, an indoor mall with several interesting Mexican imports. We're planning to go back for Christmas gifts. Then we hit the Main Plaza where we walked along the riverwalk some more.

One of the highlights was our boat tour along the river. As Bexar County residents, we even got a discount on our ticket. The sun was setting and the day was cooling off - the perfect time to be on the water. We saw several places we're looking forward to visiting on another trip and we learned a lot about the downtown area and the river. And I'm thankful that the tour guide mentioned getting to Hemisphere Park via the Riverwalk - a quick 5 minute walk and we were there instead of a 20 minute walk on the busy streets above.

The website for San Antonio Cruises says all boats are ADA accessible. Be aware that the boats can be pretty crowded. As you can imagine, they want to fill every seat. There are handrails for stepping in and out of the boats and the steps weren't too steep. 

We ended our day of sightseeing walking through Hemisphere Park, the site of the 1968 World's Fair. We walked over to the Tower of the Americas but didn't go up. It's on our list for next time. I did make reservations for a birthday lunch at the Chart House restaurant, a revolving restaurant at the top of the Tower.

Some tips for traveling downtown:

Parking - know where you want to park. All lots have a fee, but the ones run by the city are less than a private lot. If there is an event going on the parking may be more than listed. I started with the website and found a lot near the downtown area where we needed to be. It was a city lot and cost $2.50. We'd originally paid $10 to park on Sunday, so knowing about these other lots was definitely worth it. The website gives the address of the lot and I found it easily using Google Navigator on my phone. If you're staying in a hotel, walk downtown if you can or see if your hotel offers a shuttle into the area. If you need handicapped accessibility, be aware that some of the cheaper lots may be several blocks from downtown. 

Wear good shoes.

Restrooms can be difficult to find. On Sunday there were portable toilets set up but they were gone on Monday. If you're a paying customer, you're welcome to use the restrooms in the businesses downtown, but many have signs stating that there are no public restrooms. 

Check out the rest of the pictures from our Alamo / San Antonio trip in the album on DropBox.

Thursday, June 26, 2014

Lipedema is NOT obesity

By Tatjana van der Krabben

Lipedema is not obesity. It's like comparing apples and oranges. We say apple - or rather pear - to our doctor, he/she replies orange. We've been going around in circles for some time. Some anomalies in our fat cells have already been reported, like hyperplasia of individual fat cells. The fat distribution in lipedema is also very distinct. Yet, we lose our primary at the word 'fat'. There wasn't much else to prove it's apples and oranges, not just oranges. The fact that our blood sugar, blood pressure and cholesterol is mostly normal? Dumb luck and ticking time bomb. Those who did have elevated values? Aha, they proved our doctors' point.

Times are changing. Research is changing. Recently I attended two lectures on studies that specifically compared lipedema and obesity and they found clear differences.

Smeenge, Damstra and Hendrickx found that patients with lipedema have muscle weakness. We have 30% less muscle strength compared to what is considered 'normal'. The obese control group didn't share this muscle weakness. This is unpublished at this point, but you can find a summary in English here.

Hoelen, Van Zanten and Bosman looked at the value of ultrasound as a diagnostic tool in lipedema. Again, in the control group obese women were included. I've seen the slides at the lecture in May. It doesn't take a medical background to spot the differences between the scans that were showed of a person with lipedema and of a person who is obese. Also, it was found that the BMI of lipedema patients doesn't match the circumference of their waist; it was smaller than you would expect based on the BMI number. Meaning: BMI doesn't add up for lipedema.* Again unpublished at this point, but you can find some information on this research in English here.

Lipedema is NOT obesity and some proof of that is finally coming our way. Why is that such a big deal? If you are on team obesity, you are, but if you're not, they should be looking at the issues you DO have, not what they assume they would be. They can't help us or think with us, if they don't see us for who we are.

In all fairness, I've seen studies in the past pointing at lipedema-specific pathology, but these studies are all but forgotten. Fingers crossed these studies get the attention they deserve and stick.

*Get in line, because BMI doesn't add up for a lot of different groups of the population. Also see my blog on BMI.

Thursday, June 19, 2014

Lipedema captured on film

By Tatjana van der Krabben

On June 14, 2014 a Dutch Facebook group launched a short info film on lipedema at the NLNet conference. It’s in Dutch*, which may very well be gibberish to you, but I want to share with you the story of the making of and the message this group and myself as a member of this group would like to share.

In Augustus 2013 a member of the Lipedema Friends and Info Page started dreaming out loud: what if we could do an information film on lipedema in Dutch, something catchy, to raise awareness. A quick search taught us nothing like that had been made. Yet. And that’s when we got ambitious. It had to be catchy, not too long, provide useful information, have a feel good factor, a message, be suitable to incorporate into a lecture for a varied audience and professionally made, please and thank you. Why this long wish list? We could only – hope to – raise enough budget to do one film and the need for material to educate the public, (new) patients and medical professionals was there. It simply had to be versatile and of sufficient quality to take it places.
After that, like pieces of a jigsaw puzzle, everything started falling into place. Someone knew a professional filmmaker who was willing to help and shared our vision. Someone arranged at work we could use a space and facilities there to shoot the film. One of the members of the Facebook page who offered to help is also a board member with the foundation NLNet for lipedema and lymphedema. One thing led to another and NLNet offered us time at their conference to do the launch there. We formed a work group of four and raised the needed funds through crowd funding among the members of the Facebook page. All members were welcome to pitch in ideas for the film, after which I wrote the script. Then we asked members to participate. We got all stages and different ages represented: sixteen gorgeous ladies. We also made a conscious decision to show our legs anonymously and in motion. You know that distinct look of the back of your knee in advanced cases with that extra padding? You don’t see that from the front and moving images are also more attractive to watch. The film therefore shows the legs from all sides.

Every meeting we came to the same conclusion: we wanted motion, movement, energy! Movement became the theme. We need to move forward and we literally want to keep moving. In its wake came the second point we wanted to make: the value of early diagnosis. Catch it early and you preserve (most of) your mobility, energy and your true figure. Although the “spoon scene” explains how daily activities can drain you, we hoped to convey joy as well. Lipedema may interfere at times, but we certainly have a zest for life.

So far so good, but the only pro in da house on D-Day was the filmmaker. Sixteen women, knowing very well they would also be showing their legs later on and not so anonymously in front of this man. Not to mention eventually seeing it back on a BIG screen. But he worked miracles and approached the topic with great integrity and a little humor. Sixteen women, some already knew each other, others we only knew from Facebook until then, but at the end of the day we had bonded. I think it shows in the footage. A little secret from behind the scenes: at some point our chatting was so loud, we disrupted the filming of a scene in the other room. In the end we all sat in the same room to watch the scene being filmed to make sure we kept quiet for a bit!

Last Saturday with the launch it all came together. The group was almost complete, the filmmaker was present and we all got to watch it together. Afterwards we were asked to come on the stage and Henry Scheer, the filmmaker, gave a heartwarming speech and offered on the spot to also help us with an English version. So Henry, we got witnesses! Just kidding, he’s been a great support throughout. This, and the fact several therapists approached me immediately after to ask if they could use the film in future lectures, showed it was a launch in the true sense. And yes, they can use it. This is what the film is meant to do.
We started with a small snowball and now it’s picking up speed. Carry on little snowball. May you travel far and kick butt.

*English version of the film to follow.

Thursday, June 5, 2014

Lipedema and me

By Sylvie Giroux
Have you ever wondered how it would feel to have healthy and beautiful legs? I sure did! More than once! Legs like dancers…slim yet muscular. Being short, I knew I would never have those long legs but I thought I could at least have slim ones. No matter how much calve or thigh exercises I did my legs would remain the same. I just thought I had huge legs muscles!  But as I grew older, I looked more and more like a pear. Had no idea why I was slim on top and this round on the bottom part of me!

To be honest, as long as I can remember, I always had a disproportion between my upper body and my legs. I would bruise easily too and for most of my life, I would try to hide my big thighs and was quite ashamed of them. At times, boys would make hurtful comments, which made me feel even more uncomfortable about they way I looked. I became to feel really uncomfortable about wearing a bathing suit in the summer and started wearing skirts only during the hot season! I was envious of all the others teen girls and what seemed to me their “perfect legs”! Funny I was attracting guys…could not understand why though and credited my killer smile for it!

I did get married in my early twenties, had three pregnancies and the last one was the most difficult for me, health wise since my legs swelled a lot. Since I was pain free back then, I just thought it was something having to do with hormones and that the swelling would go away after the birth. And it did. Many years later, in 2009, after some serious family problems, I ended up in depression and took a medication called Remeron. While taking it, I put on some weight. Even after stopping it...the weight gain continued and my thighs got bigger, my tiny waist was gone and my upper arms got bigger too. I had no idea why this was happening because I was not eating like a pig so I blamed it on the medication! My GP would only tell me that I was getting fat and that I needed to do something to loose weight since I had gained over 35 pounds in less than 2 years....I tried dieting, and nothing worked. To top it off, I felt tired all the time...I can't even remember when I did feel full of energy. I also had lots of headaches.

In October 2011, while at a friend's birthday party, something changed for me! A friend of my dear friend was there as well and he heard me say to a lady friend that I had gained a lot of weight since 2009. He came to me, told me he was a massage therapist who specialized in treating people with lipedema and lymphoedema and he asked me many questions about my legs. Then he explained what is lipedema and suggested I went to his clinic. He said that he was quite sure I had lipedema and I started the Manual Lymphatic Drainage at his private clinic after that. I was not diagnosed by a doctor because here, we don't seem to have any specialist for that in Montreal, Canada. At first, I felt both discouraged and relieved. At least, someone seemed to believe me and did not think I was "Fat" and all the symptoms I had over the years (constant fatigue, bruising, inability to loose the fat on my thighs) were all related to lipedema! Summer of 2011 was tough, had a lot of pain in my legs but this summer, not much at all...
I went to my GP again with all the information I could find on lipedema. She had no idea what I was talking about. Lately, I spoke with a PT who treats women with lymphoedema and she suggested I call a vascular surgeon in Montreal that may be able to "confirm" the diagnosis but she is not sure about that though. My MLD therapist was trained in Germany, he is treating lymphoedema and lipedema patients, he uses the Vodder technique and he told me that if I ever want to have a liposuction, I would have to go to Germany to have it. Because here, the surgeons could do more damage than good to my legs. 

From different support groups on Facebook I have met ladies suffering from lipedema, from USA, Europe, Australia and Africa and I have gained more knowledge about lipedema, what I should avoid eating and so much more. I no longer feel alone and this makes a huge difference for me. I'm exercising and I'm off wheat and follow a low-carb diet. I have my mind set on doing everything I can to not only manage this condition and to do my part in helping others suffering from it and I'm sure that with effort, more knowledge and time, we will be able to find a cure! I will post more about diet and exercises in another blog!

If any of you have a similar story to mine, KNOW that you are not alone!

Read more by following the links in our Lipedema Awareness Blog Hop

Wednesday, May 28, 2014

Visiting San Jose Mission in San Antonio, TX

By Christina Routon

Since moving to San Antonio a month ago my life has been a whirlwind! But we've finally gotten the house (mostly) unpacked and settled into our new jobs. It's now time to do some sightseeing.

Mission San Jose is part of the National Park System. It's one of five missions set near San Antonio with the most famous mission being what's known today as the Alamo. We started our mission journey here because the visitor's center for the National Park Service is here and they have a 20 minute video about the indigenous people here and how they came to live at the missions.

Mission San Jose is known as the "Queen of the Missions" and is still an active parish today. In fact, all of the missions except the Alamo are active churches. The local diocese handles maintenance and repair on the church building while the National Park Service cares for the rest of the property.

For many of us with Lipedema, we have mobility issues or problems being on our feet for a long time. This mission is very easy to visit with a flat layout and paved trail around the courtyard in case you use a scooter or wheelchair. There are benches all around the courtyard and plenty of shade under the mesquite trees. There are about three steps going into the church if you want to go inside.

The weather was awesome the day we visited, with a nice breeze blowing through the trees. But sunscreen is definitely recommended in the Texas sun. The wind makes it feel cooler than it really is and I did come home with a bit of sunburn.

We'll be visiting the rest of the missions, including the famous Alamo, within the next month. If you want to see the rest of my photos from Mission San Jose, check out the shared album in DropBox.

Every now and again we want to focus on the good things in the world. Just because we have Lipedema doesn't mean we need to give up all of our hopes and our dreams. We are a diverse group of women with awesome hobbies, jobs, families, knowledge and skills. I invite anyone who wants to participate to send in a post about how you're Living with Lipedema.

Other Lipedema lifestyle posts: Tatjana - Lipedema in the World