b'The following subsections will elaborate on howclinically diagnosed with lipedema 126 . 85% of the ultrasound, MRI, and ICG lymphography imagingpatients did not have any evidence of any dermal techniques are being utilized to better diagnose andbackflow, and 2 patients were diagnosed with characterize lipedema, lymphedema based on the results of the lympho-Ultrasound graphy. The authors suggest that ICG lymphography Ultrasound was first studied by Marshall et al in 2011can be used to differentiate lipedema from for assessing the severity of lipedema 123 . Theylymphedema as well as help guide therapeutic measured thickness of the dermal and cutaneousmanagement in patients who are found to have both tissue in 38 patients with lipedema 6-8 cm above thelipedema and lymphedema.medial malleolus. They classified combined cutaneousTREATMENT OF LIPEDEMAand subcutaneous thickness of 1215 mm as mildConservative Managementlipedema, 1520 mm as moderate lipedema, andConservative therapy, also called complex greater than 30 mm as severe lipedema. A group of decongestive physiotherapy (CDP), for lipedema 38 health controls had a combined thickness of 11.2consists of compression garments and bandages, mm. Furthermore, ultrasound has also been studied manual lymph drainage (MLD), physical exercise, and by Amato et al as a diagnostic imaging method for lipedema 124 . In their study of 62 lipedema patients andskin care. However, because of the painful nature of 27 healthy controls, they found that measurements oflipedema, some patients cannot tolerate compression dermal and subcutaneous thickness at three lowerstockings 127 . In some cases, this therapy can also be extremity anatomical regions were significantly largercombined with intermittent pneumatic compression than controls. The area of measurement at the anterior(IPC) 116,128 . In a study of 38 women with bilateral leg thigh region was defined as the midpoint between thelipedema, CDP, along with specialized skin care, has iliac crest and the lower patellar border. The area ofbeen shown to decrease limb volume and capillary measurement of the pre-tibial region was defined asfragility and is the most successful conservative the midpoint between the anterior tibial tuberositytherapy 128 . However, conservative therapy does not and the medial malleolus. The lateral leg region wasaddress fat accumulation and only treats the edema defined as the midpoint between the lateral malleolusand does not have reliable long-term success 129 . and the fibular head. Upon receiver operating Because the conservative therapy used for lipedema curve (ROC) analysis, the best-performing area ofwas designed for lymphedema patients, the best measurement, based on the area under the curve, effects that are documented for lipedema patients are was found to be the pre-tibial region with an optimaltemporary reduction of leg volume, and CDP shows cutoff value of 11.6 mm on the right (with a sensitivitybetter results when patients also have secondary of 79% and a specificity of 96%) and 11.8 mm on thelymphedema as a complication 127 . left (with a sensitivity of 77% and a specificity of 92%).SURGICAL MANAGEMENT OF LIPEDEMAThe authors recommend that measurements from theLiposuction as a Treatment for Lipedemapre-tibial region are to be considered first followed by measurements of the thigh and the lateral leg regions. Liposuction using the tumescent anesthesia technique Magnetic Resonance Imaging (MRI) has been shown to be a safe and successful therapyfor people with lipedema. A study done in 2003 by Crescenzi et al established an elevated level of Hoffmann studied the dry liposuction technique with sodium content and higher fat/water volume ratio the tumescent liposuction technique in 9 cadaversas biomarkers of lipedema in a study of 10 lipedemaand 18 legs to determine whether the tumescent patients and 11 healthy controls 125 . Using MRI,liposuction technique is safer and causes less damage biomarkers were measured in both cutaneous tissueto the lymph vessels. They found that tumescent and subcutaneous adipose tissue (SAT) using the liposuction caused significantly fewer lymph vessel Dixon post-processing technique. Both sodiumlesions than the dry technique and is much safer content and fat/water volume ratio were significantlyoverall 13 0. Furthermore, Schmeller reported that ingreater in lipedema patients when compared to21 patients who followed up after having received controls. The authors suggested that their findings ofbetween 1 and 4 liposuction treatments, all significantly increased intramuscular sodium andexperienced a satisfactory, often dramatic, adipose content explains the symptoms of myopathyimprovement in body proportions. Out of 18 patients commonly reported amongst lipedema patients. who reported spontaneous pain before surgery,ICG Lymphography 6 patients reported a complete disappearance of spontaneous pain, and 10 reported an improvement.Mackie et al used indocyanine green lymphography 2 patients reported no change. Out of all the patients to study the presence of lymphedema in 40 patientswho reported pressure sensitivity, 13 reported | Standardized Approach for the Diagnosis and Management of Lymphedema (LE) and Lymphatic Diseases (LD)|32'