Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Article
  • Published:

Clinical Research

Lower extremity lymphatic function predicted by body mass index: a lymphoscintigraphic study of obesity and lipedema

International Journal of Obesity volume 45, pages 369–373 (2021)Cite this article

Subjects

Abstract

Background/objectives

Patients with obesity and lipedema commonly are misdiagnosed as having lymphedema. The conditions share phenotypic overlap and can influence each other. The purpose of this study was to delineate obesity-induced lymphedema, obesity without lymphedema, and lipedema in order to improve their diagnosis and treatment.

Subjects/methods

Our Lymphedema Center database of 700 patients was searched for patients with obesity-induced lymphedema (OIL), obesity without lymphedema (OWL), and lipedema. Patient age, sex, diagnosis, cellulitis history, body mass index (BMI), and treatment were recorded. Only subjects with lymphoscintigraphic documentation of their lymphatic function were included.

Results

Ninety-eight patients met inclusion criteria. Subjects with abnormal lymphatic function (n = 46) had a greater BMI (65 ± 12) and cellulitis history (n = 30, 65%) compared to individuals with normal lymphatic function [(BMI 42 ± 10); (cellulitis n = 8, 15%)] (p < 0.001). Seventeen patients had a history of lipedema and two exhibited abnormal lymphatic function (BMI 45, 54). The risk of having lower extremity lymphedema was predicted by BMI: BMI < 40 (0%), 40–49 (17%), 50–59 (63%), 60–69 (86%), 70–79 (91%), ≥80 (100%). Five patients with OIL (11%) underwent resection of massive localized lymphedema (MLL) or suction-assisted lipectomy. Three individuals (18%) with lipedema were treated with suction-assisted lipectomy.

Conclusions

The risk of lymphedema in patients with obesity and lipedema can be predicted by BMI; confirmation requires lymphoscintigraphy. Individuals with OIL are at risk for cellulitis and MLL. Patients with a BMI > 40 are first managed with weight loss. Excisional procedures can further reduce extremity size once BMI has been lowered.

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Fig. 1: Increasing BMI predicts the risk of lower extremity lymphatic dysfunction.
Fig. 2: Diagnosis of lymphedema in obese patients requires lymphoscintigraphy.
Fig. 3: Elevated BMI negatively affects lymphatic function in patients with lipedema.

Similar content being viewed by others

References

  1. Schook CC, Mulliken JB, Fishman SJ, Alomari AI, Grant FD, Greene AK. Differential diagnosis of lower extremity enlargement in pediatric patients referred with a diagnosis of lymphedema. Plast Reconstr Surg. 2011;127:1571–81.

    Article  CAS  Google Scholar 

  2. Maclellan RA, Couto RA, Sullivan JE, Grant FD, Slavin SA, Greene AK. Management of primary and secondary lymphedema: analysis of 225 referrals to a center. Ann Plast Surg. 2015;75:197–200.

    Article  CAS  Google Scholar 

  3. Greene AK, Grant FD, Slavin SA. Lower-extremity lymphedema and elevated body-mass index. N Engl J Med. 2012;366:2136–7.

    Article  CAS  Google Scholar 

  4. Executive Committee. The diagnosis and treatment of peripheral lymphedema: 2016 consensus document of the international society of lymphology. Lymphology. 2016;49:170–84.

    Google Scholar 

  5. Rudkin GH, Miller TA. Lipedema: a clinical entity distinct from lymphedema. Plast Reconstr Surg. 1994;94:841–7.

    Article  CAS  Google Scholar 

  6. Child AH, Gordon KD, Sharpe P, Brice G, Ostergaard P, Jeffery S, et al. Lipedema: an inherited condition. Am J Med Genet Part A. 2010;152:970–6.

    Article  Google Scholar 

  7. Halk AB, Damstra RJ. First Dutch guidelines on lipedema using the international classification of functioning, disability and health. Phlebology. 2017;32:152–9.

    Article  Google Scholar 

  8. Bauer AT, von Lukowicz D, Lossagk K, Aitzetmueller M, Moog P, Cerny M, et al. New insights on lipedema: the enigmatic disease of the peripheral fat. Plast Reconstr Surg. 2019;144:1475–84.

    Article  CAS  Google Scholar 

  9. Greene AK, Grant FD, Slavin SA, Maclellan RA. Obesity-induced lymphedema: clinical and lymphoscintigraphic features. Plast Reconstr Surg. 2015;135:1715–9.

    Article  CAS  Google Scholar 

  10. Hassanein AH, Maclellan RA, Grant FD, Greene AK. Diagnostic accuracy of lymphoscintigraphy for lymphedema and analysis of false-negative tests. Plast Reconstr Surg - Glob Open. 2017;5:e1396.

    Article  Google Scholar 

  11. Szuba A, Shin WS, Strauss HW, Rockson S. The third circulation: radionuclide lymphoscintigraphy in the evaluation of lymphedema. J Nucl Med. 2003;44:43–57.

    PubMed  Google Scholar 

  12. Maclellan RA, Zurakowski D, Voss S, Greene AK. Correlation between lymphedema disease severity and lymphoscintigraphic findings: a clinical-radiologic study. J Am Coll Surg. 2017;225:366–70.

    Article  Google Scholar 

  13. Lowry R. VassarStats: website for statistical computation. 2019. http://vassarstats.net/.

  14. Maclellan RA, Zurakowski D, Grant FD, Greene AK. Massive localized lymphedema: a case-control study. J Am Coll Surg. 2017;224:212–6.

    Article  Google Scholar 

  15. Greene AK, Grant FD, Maclellan RA. Obesity-induced lymphedema nonreversible following massive weight loss. Plast Reconstr Surg Glob Open. 2015;3:e426.

    Article  Google Scholar 

  16. Greene AK, Maclellan RA. Operative treatment of lymphedema using suction-assisted lipectomy. Ann Plast Surg. 2016;77:337–40.

    Article  CAS  Google Scholar 

  17. Greene AK, Voss SD, Maclellan RA. Liposuction for swelling in patients with lymphedema. N Engl J Med. 2017;377:1788–9.

    Article  Google Scholar 

  18. Peled AW, Slavin SA, Brorson H. Long-term outcome after surgical treatment of lipedema. Ann Plast Surg. 2012;68:303–7.

    Article  Google Scholar 

  19. Couto JA, Maclellan RA, Greene AK. Management of vascular anomalies and related conditions using suction-assisted tissue removal. Plast Reconstr Surg. 2015;136:511e–4e.

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Plastic and Oral Surgery, Lymphedema Program, Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA

    Arin K. Greene & Christopher L. Sudduth

Authors
  1. Arin K. Greene
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Christopher L. Sudduth
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Arin K. Greene.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Greene, A.K., Sudduth, C.L. Lower extremity lymphatic function predicted by body mass index: a lymphoscintigraphic study of obesity and lipedema. Int J Obes 45, 369–373 (2021). https://doi.org/10.1038/s41366-020-00681-6

Download citation

  • Received:

  • Revised:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/s41366-020-00681-6

Search

Advanced search

Quick links