American Journal Of Biomedical Science & Pharmaceutical Innovation 1 https://theusajournals.com/index.php/ajbspi VOLUME Vol.05 Issue06 2025 PAGE NO. 1-7 Challenges in Developing a Qualitative Ultrasonographic Classification for Lipedema Prof. Markus L. Schneider Institute of Diagnostic and Interventional Radiology University Hospital Heidelberg, Heidelberg, Germany Dr. Hossein R. Mirzaei Department of Medical Imaging, Tehran University of Medical Sciences, Tehran, Iran Received: 03 April 2025; Accepted: 02 May 2025; Published: 01 June 2025 Abstract: Lipedema, a chronic and progressive adipose tissue disorder, is characterized by disproportionate fat accumulation, primarily in the lower extremities, often leading to pain, bruising, and mobility impairment. Despite its significant prevalence and impact on quality of life, diagnosis remains challenging, frequently relying on clinical examination and patient history. Ultrasonography holds promise as a non-invasive diagnostic tool, offering insights into subcutaneous tissue characteristics. However, developing a standardized qualitative ultrasonographic classification for lipedema presents considerable challenges due to the heterogeneous nature of fat tissue, variability in disease presentation, and the subjective interpretation inherent in qualitative assessments. This article reviews the current diagnostic landscape of lipedema, explores the potential and limitations of ultrasonography, and critically examines the complexities involved in establishing a robust qualitative ultrasonographic classification. By outlining these challenges, we aim to guide future research towards more objective and standardized imaging criteria, ultimately improving the accuracy and consistency of lipedema diagnosis. Keywords: Lipedema, Ultrasonography, Qualitative Classification, Diagnosis, Adipose Tissue, Chronic Disease, Diagnostic Imaging. Introduction: Lipedema is a chronic, progressive disorder of adipose tissue, predominantly affecting women, characterized by a disproportionate accumulation of fat, typically in the lower extremities, from the hips to the ankles, while sparing the feet [2, 3]. This condition is often misdiagnosed as general obesity or lymphedema, leading to delayed or inappropriate treatment [2, 5]. Patients with lipedema frequently experience pain, tenderness, easy bruising, and impaired mobility, significantly impacting their quality of life [2, 8]. The prevalence of lipedema is substantial, with recent studies in Brazil indicating its significant presence and associated risk factors [1]. Despite its widespread occurrence and debilitating symptoms, lipedema remains under-recognized and under-diagnosed globally, highlighting a critical unmet need in clinical practice [7, 8]. The diagnosis of lipedema primarily relies on clinical criteria, including specific fat distribution patterns, pain upon palpation, easy bruising, and the absence of pitting edema in the affected areas [3, 8]. However, the subjective nature of these clinical assessments can lead to diagnostic inconsistencies and delays. Objective diagnostic tools are urgently needed to provide a more definitive and standardized approach to identification. Diagnostic medical imaging plays a crucial role in modern medicine, offering valuable insights into disease pathology [10]. Ultrasonography, in particular, is a non-invasive, cost-effective, and readily available imaging modality that has shown potential in differentiating lipedema from other conditions like obesity and lymphedema by visualizing subcutaneous tissue characteristics [9]. Early research suggests that specific ultrasound criteria, such as increased American Journal of Applied Science and Technology 2 https://theusajournals.com/index.php/ajast American Journal of Applied Science and Technology (ISSN: 2771-2745) subcutaneous fat thickness, altered echogenicity, and the presence of characteristic "snowstorm" or "cobblestone" patterns, may aid in lipedema diagnosis [9]. However, the development of a standardized and widely accepted qualitative ultrasonographic classification for lipedema presents significant challenges. The inherent variability in fat tissue composition, the progressive nature of lipedema with different stages, and the subjective interpretation of qualitative ultrasound features contribute to these complexities. This article aims to explore these challenges in detail, reviewing the current state of lipedema diagnosis, the promise and limitations of ultrasonography, and the specific hurdles in establishing a robust qualitative ultrasonographic classification. By dissecting these issues, we hope to contribute to a clearer understanding of the path forward for improving diagnostic accuracy in lipedema. Literature Review Lipedema is a complex and often misunderstood condition, distinct from general obesity and lymphedema, yet frequently confounded with them [2, 5]. The lack of a definitive diagnostic test contributes significantly to diagnostic delays and misdiagnosis, impacting patient care [8]. 2.1. Clinical Diagnosis and Differential Diagnosis: The current standard of care for lipedema in the United States and other regions relies heavily on clinical examination [3, 8]. Key diagnostic features include: • Symmetrical, disproportionate fat accumulation: Primarily affecting the legs (from hips to ankles) and sometimes the arms, with a sharp demarcation at the wrists and ankles, sparing the hands and feet [2, 3]. • Pain and Tenderness: Affected adipose tissue is often painful to touch and can bruise easily [2, 8]. • Negative Stemmer's Sign: The skin at the base of the toes cannot be pinched and lifted, which is typically positive in lymphedema [3]. • Absence of Pitting Edema: In the early stages, although secondary lymphedema can develop in later stages [6]. Differentiating lipedema from obesity is crucial, as lipedema fat is resistant to diet and exercise [2]. While obesity can affect lymphatic function [4], lipedema is a distinct pathological entity. Distinguishing it from lymphedema, which involves lymphatic fluid accumulation, is also vital for appropriate management [6]. 2.2. Role of Medical Imaging in Lipedema: Given the diagnostic challenges, medical imaging has been explored as a potential objective tool. Various imaging modalities have been investigated: • Magnetic Resonance Imaging (MRI): Can provide detailed anatomical information about fat distribution and may show characteristic patterns in lipedema fat, but it is expensive and not always readily available [2]. • Computed Tomography (CT): Also provides detailed cross-sectional images but involves radiation exposure, making it less suitable for routine diagnosis [10, 11]. • Lymphoscintigraphy: Useful for assessing lymphatic function and differentiating lipedema from primary or secondary lymphedema, but it is an invasive procedure [4]. • Dual-energy X-ray Absorptiometry (DXA): Can quantify body composition and fat distribution but does not provide detailed tissue characteristics. 2.3. Ultrasonography in Lipedema Diagnosis: Ultrasonography is a non-invasive, radiation-free [FDA, Cleveland Clinic, American Cancer Society], and relatively inexpensive imaging technique that has emerged as a promising tool for visualizing subcutaneous tissue in lipedema [9]. Amato et al. (2021) specifically proposed ultrasound criteria for lipedema diagnosis, highlighting several key features [9]: • Increased Subcutaneous Fat Thickness: Particularly in affected areas compared to unaffected areas or control subjects. • Altered Echogenicity: Lipedema fat may exhibit a more heterogeneous or "snowstorm" appearance compared to normal fat, due to underlying fibrosis or edema [9]. • "Cobblestone" Pattern: Some studies describe a characteristic "cobblestone" pattern, possibly related to septal thickening or nodular fat lobules [9]. • Dilated Blood Vessels/Lymphatics: Though less consistently reported, some observations suggest dilated vessels within the lipedema fat. • Absence of Dermal Thickening: Helping to differentiate from lymphedema. 2.4. Challenges in Qualitative Ultrasonographic Classification: Despite these promising features, developing a standardized qualitative ultrasonographic classification for lipedema faces significant hurdles: • Subjectivity of Qualitative Descriptors: Terms like "snowstorm" or "cobblestone" are subjective and American Journal of Applied Science and Technology 3 https://theusajournals.com/index.php/ajast American Journal of Applied Science and Technology (ISSN: 2771-2745) can be open to varied interpretation among different sonographers or clinicians [9]. This inter-observer variability can reduce diagnostic consistency. • Heterogeneity of Lipedema Fat: Lipedema is a progressive disease, and the structural characteristics of the adipose tissue can vary depending on the stage and individual patient. Early-stage lipedema might show subtle changes, while later stages might exhibit more pronounced fibrosis or nodularity, making a single, fixed qualitative classification difficult [2, 3]. • Overlap with Other Conditions: While ultrasound can help differentiate, there can still be some overlap in qualitative appearances between lipedema, obesity (especially morbid obesity [4]), and secondary lymphedema, particularly in advanced stages [6]. • Dependence on Equipment and Operator Skill: The quality of ultrasound images and their interpretation depend heavily on the ultrasound machine's resolution and the sonographer's experience and skill [10]. • Lack of Standardized Protocols: There is currently no widely accepted standardized protocol for performing ultrasound examinations specifically for lipedema, including parameters like probe frequency, depth settings, or measurement points [9]. This lack of standardization makes comparative studies and universal classification difficult. These challenges underscore the complexity of moving from promising observations to a reliable, universally accepted qualitative ultrasonographic classification for lipedema. METHODOLOGY (This section will outline a hypothetical methodological approach that researchers might undertake to address the challenges of developing a qualitative ultrasonographic classification for lipedema. It will not describe an actual experiment, but rather propose a robust study design.) To address the challenges in developing a qualitative ultrasonographic classification for lipedema, a multi- center, prospective, observational study with a focus on inter-rater reliability and correlation with clinical staging would be crucial. 3.1. Study Design and Participants: • Design: A prospective, observational study with a cross-sectional component for initial classification and a longitudinal component for tracking disease progression and classification stability. • Participants: A large cohort of female patients (N=500-1000) diagnosed with lipedema based on established clinical criteria (e.g., S2K Guideline Lipedema [3], Standard of Care for Lipedema in the United States [8]). A control group of age- and BMI- matched healthy women, and groups with general obesity and secondary lymphedema, would also be included for differential diagnosis comparison. Participants would be recruited from multiple specialized lipedema clinics to ensure diverse disease presentations. 3.2. Data Collection: • Clinical Data: Comprehensive clinical data would be collected for all participants, including: o Detailed medical history and physical examination findings specific to lipedema (pain, bruising, fat distribution, Stemmer's sign). o Clinical staging of lipedema (e.g., Stages I- III/IV). o Anthropometric measurements (BMI, limb circumferences, volume measurements). o Quality of life assessments. • Ultrasonography Data: o Standardized Protocol Development: A rigorous, standardized ultrasound protocol would be developed collaboratively by expert sonographers and lipedema specialists. This protocol would specify: o Ultrasound machine settings (e.g., probe frequency (e.g., 7-15 MHz linear array), depth, gain). o Specific anatomical landmarks and measurement points (e.g., thigh, calf, arm at defined intervals). o Standardized image acquisition techniques (e.g., consistent pressure, perpendicular probe orientation). o Image Acquisition: Two independent, experienced sonographers, blinded to clinical diagnosis, would perform ultrasound examinations on each participant using the standardized protocol. o Image Parameters for Qualitative Classification: Images would be acquired to evaluate: • Subcutaneous Fat Thickness: Objective measurement at standardized points. • Echogenicity Patterns: Qualitative descriptions of fat echogenicity (e.g., homogeneous, heterogeneous, "snowstorm," "cobblestone," presence of fluid pockets, fibrosis). High-resolution images of various tissue layers would be captured. • Presence and Characteristics of Septa/Nodules: Qualitative description of fibrous septa, fat lobules, and nodular formations. • Vascularity/Lymphatics: Presence of dilated vessels American Journal of Applied Science and Technology 4 https://theusajournals.com/index.php/ajast American Journal of Applied Science and Technology (ISSN: 2771-2745) or lymphatics within the fat layer. • Digital Image Archiving: All ultrasound images and clips would be digitally archived for subsequent independent qualitative analysis. 3.3. Data Analysis: • Qualitative Classification Development: o A panel of expert sonographers and lipedema specialists (blinded to patient clinical details) would independently review a large, diverse set of ultrasound images. o They would use a consensus-building process to develop a preliminary qualitative classification system based on reproducible visual patterns. This might involve iterative discussions and refinement based on initial inter-rater agreement assessments. o The classification would aim to describe distinct patterns (e.g., "fine granular," "coarse granular," "nodular," "fibrotic") and their potential correlation with disease stage. • Inter-Rater Reliability: The developed qualitative classification system would be applied by multiple independent, blinded expert raters to a subset of the archived ultrasound images. Kappa statistics and intraclass correlation coefficients (ICCs) would be used to assess inter-rater agreement on the qualitative descriptors and proposed classification categories. • Correlation with Clinical Staging: The finalized qualitative ultrasonographic classifications would be correlated with the established clinical stages of lipedema using appropriate statistical methods (e.g., Chi-square, regression analysis). The aim is to determine if specific qualitative ultrasound patterns are consistently associated with particular clinical stages. • Differential Diagnosis Efficacy: Ultrasound findings from lipedema patients would be compared with those from obesity and lymphedema control groups to identify unique qualitative features that aid in differential diagnosis. 3.4. Ethical Considerations: Ethical approval would be obtained from all participating institutional review boards. Informed consent would be secured from all participants, ensuring confidentiality and voluntary participation. Given that ultrasound imaging does not involve ionizing radiation, the risks associated with the imaging procedure itself are minimal [FDA, Cleveland Clinic, American Cancer Society]. However, the ethical implications of using imaging for non-medical reasons or by untrained users would be considered in the broader context [Cleveland Clinic]. RESULTS (This section presents hypothetical results based on the common findings and challenges encountered in developing qualitative classifications for complex medical conditions, particularly in imaging.) The hypothetical study designed to develop and validate a qualitative ultrasonographic classification for lipedema would likely yield the following results, highlighting both potential and persistent challenges: Stages and features of lipedema. (a) to (f): Front and back pictures of women with lipedema Stages 1 to 3. Staging references the legs, however women pictured also have arm involvement. Stage 1 skin has a smooth texture with subdermal pebblelike feel due to underlying loose connective tissue fibrosis. Lipedema Stage 2 women have more lipedema tissue than women with Stage 1 and skin dimpling due to progressed fibrotic changes and excess tissue. Palpable nodules may be more numerous and larger. Note the full Achilles sulci in pictures (d) to (f). In Lipedema Stage 2 arms, the tissue begins to hang off the arm and full arm involvement shows a more pronounced wrist cuff. Lipedema Stage 3 features increased lipedema tissue more fibrotic in texture with numerous large subdermal nodules and overhanding lobules of tissue. Patient (e) and (f) has lipedema, non-lipedema obesity and lipolymphedema. Types I to V describe the locations of lipedema tissue. Type I, lipedema tissue is present under the umbilicus and over hips and buttocks, Type II, under the umbilicus to knees (a, b), Type III, under the umbilicus to ankles (c to f), Type IV, arms (a to f) and Type V, lower legs (not shown). A tissue cuff at the ankle or wrist may be present in all stages. (g): Lipedema tissue overhangs the elbow. (h): Lipedema tissue often hangs well below the arm due to loss of elasticity and heaviness of the tissue. (i): Livedo reticularis is often a feature of lipedema. (j): Close view of tissue filling the Achilles sulci. (k): Close view of a column type lipedema leg with an obvious ankle cuff. (l): An ankle of a woman with lipedema without an ankle cuff (compare to (k)). (m): Pronation of the ankle commonly found in women with lipedema. Consent was obtained for use of all photos. LCT: loose connective tissue. American Journal of Applied Science and Technology 5 https://theusajournals.com/index.php/ajast American Journal of Applied Science and Technology (ISSN: 2771-2745) 4.1. Identification of Common Ultrasonographic Features in Lipedema: The initial image review by expert sonographers would confirm the presence of several recurring qualitative features in lipedema adipose tissue, consistent with previous observations: • Increased Subcutaneous Fat Thickness: Quantifiable measurements would show significantly greater fat thickness in affected limbs of lipedema patients compared to control groups, particularly at specific anatomical sites (e.g., inner thigh, medial calf). • Heterogeneous Echogenicity: A highly prevalent finding would be the heterogeneous appearance of subcutaneous fat, varying from a "snowstorm" or "ground glass" texture in some areas, potentially indicative of edema within the fat, to more areas of increased echogenicity suggesting fibrosis. • "Cobblestone" Pattern: This characteristic pattern, representing enlarged fat lobules separated by thickened septa, would be identifiable in a considerable subset of lipedema patients, particularly in more advanced stages. • Presence of Nodules: Palpable nodules would correlate with distinct hyperechoic structures within the fat layer, often with irregular shapes. • Dilated Lymphatics/Vessels: While less consistently visualized, some images would show evidence of dilated lymphatic vessels or small blood vessels within the subcutaneous fat, possibly due to underlying inflammation or lymphatic dysfunction. 4.2. Challenges in Qualitative Classification Development: Despite identifying common features, the process of developing a qualitative classification based on these features would face significant hurdles: • Inter-Rater Variability in Qualitative Descriptors: When multiple independent raters apply subjective terms like "snowstorm" or "cobblestone" to the same images, inter-rater reliability (Kappa coefficients) would be only moderate (e.g., Kappa = 0.4- 0.6), indicating a lack of strong consensus in subjective interpretation. This highlights the inherent ambiguity of purely qualitative descriptions. • Continuum vs. Discrete Categories: The observed ultrasonographic changes often exist along a continuum rather than falling into clear, discrete categories. Early-stage lipedema might show subtle heterogeneity, gradually progressing to more pronounced fibrosis and nodularity. Attempting to force these continuous changes into a few distinct qualitative stages would prove challenging, leading to boundary disputes among raters. • Overlap with Other Conditions: While quantitative fat thickness might differ, the qualitative appearance of fat in some lipedema patients (especially those with secondary lymphedema or severe obesity) could still overlap with the appearance of fat in control groups or those with other conditions, making definitive qualitative differentiation difficult. For instance, severe obesity can also present with heterogeneous fat patterns. American Journal of Applied Science and Technology 6 https://theusajournals.com/index.php/ajast American Journal of Applied Science and Technology (ISSN: 2771-2745) • Influence of Probe Pressure and Technique: Despite a standardized protocol, subtle variations in probe pressure during image acquisition could affect the perceived echogenicity and compressibility of the fat, influencing qualitative interpretation. 4.3. Limited Correlation with Clinical Staging: The attempt to correlate proposed qualitative ultrasonographic categories with established clinical stages of lipedema would yield only moderate or weak associations. While patients with clinically advanced lipedema (Stage III/IV) might consistently exhibit more fibrotic or nodular patterns, and early-stage patients (Stage I) might show more subtle heterogeneity or "snowstorm" patterns, a clear, one-to-one correspondence for all stages would not be consistently evident. This indicates that a purely qualitative ultrasonographic classification might not fully capture the clinical heterogeneity of lipedema or may be too broad to accurately reflect subtle stage differences. In summary, while ultrasonography can identify several characteristic features of lipedema, the results suggest significant challenges in creating a robust and reliable qualitative ultrasonographic classification due to the subjective nature of visual interpretation and the heterogeneous presentation of the disease. DISCUSSION The findings from this hypothetical study highlight the persistent difficulties in developing a robust qualitative ultrasonographic classification for lipedema. While ultrasonography undeniably offers valuable insights into the subcutaneous adipose tissue characteristics in lipedema, and can distinguish it from normal fat and even obesity [9], translating these observations into universally reproducible qualitative categories remains a significant hurdle. The observed "inter-rater variability in qualitative descriptors" is a central challenge. Terms like "snowstorm" or "cobblestone" [9], while evocative, are inherently subjective. What one sonographer perceives as a distinct "cobblestone" pattern, another might interpret as generalized heterogeneity. This lack of precise, objective definitions leads to inconsistencies in diagnosis and hinders the standardization needed for widespread clinical application and research. It reinforces the difficulty of achieving high reliability with purely qualitative assessments in medical imaging [10]. To mitigate this, future efforts must move towards more objective, quantifiable parameters, possibly incorporating texture analysis algorithms or advanced imaging techniques to characterize fat tissue. The "continuum vs. discrete categories" issue further complicates classification. Lipedema is a progressive disorder [2, 3], meaning its ultrasonographic appearance likely changes subtly over time and across different stages. Attempting to fit this dynamic spectrum into a limited number of static qualitative categories may oversimplify the disease's complexity and lead to misclassification. A more effective classification might require a continuous scoring system or a multi-parametric approach that considers not just the "pattern" but also the severity of changes and the presence of associated features (e.g., septal thickness, vascularity). The "overlap with other conditions," particularly severe obesity and secondary lymphedema, is another critical point. While ultrasound can help differentiate, the qualitative appearance of fat in these conditions might, at times, mimic certain lipedema features [4, 6]. This necessitates careful correlation with clinical examination and patient history, emphasizing that ultrasound is an adjunctive tool rather than a standalone diagnostic arbiter for lipedema. Future research should focus on identifying highly specific ultrasonographic "signatures" for lipedema that are truly unique to the condition and resistant to confounders. The "influence of probe pressure and technique" highlights the operator-dependent nature of ultrasound. Even with standardized protocols, subtle variations can affect image quality and interpretation. This underscores the need for extensive training and certification for sonographers involved in lipedema assessment to ensure consistency and accuracy. Efforts to reduce low-value imaging [11] also implicitly highlight the need for clear diagnostic utility and standardization. Ultimately, while qualitative ultrasonography offers promising avenues for lipedema diagnosis, its current limitations prevent the establishment of a robust, universally accepted classification. Moving forward, research should focus on: 1. Developing Quantitative Ultrasound Parameters: Moving beyond subjective descriptors to measure specific parameters like fat lobule size, septal thickness, and tissue compressibility using advanced ultrasound modalities (e.g., elastography). 2. Integrating Multi-parametric Analysis: Combining multiple qualitative and quantitative ultrasound features into a comprehensive scoring system rather than relying on a single qualitative pattern. 3. Artificial Intelligence/Machine Learning: Utilizing AI algorithms to analyze ultrasound images for subtle patterns not easily discernible by the human eye, potentially leading to more objective and American Journal of Applied Science and Technology 7 https://theusajournals.com/index.php/ajast American Journal of Applied Science and Technology (ISSN: 2771-2745) consistent classifications. 4. Longitudinal Studies: Tracking ultrasonographic changes over time in lipedema patients to better understand disease progression and refine stage-specific imaging criteria. By addressing these challenges, the field can progress towards a more objective, reliable, and clinically useful ultrasonographic classification for lipedema, ultimately facilitating earlier and more accurate diagnosis for millions of affected individuals. CONCLUSION The development of a standardized qualitative ultrasonographic classification for lipedema presents significant challenges stemming from the subjective nature of visual interpretation, the inherent heterogeneity and progressive nature of the disease, and potential overlaps with other conditions. While ultrasonography offers valuable, non-invasive insights into subcutaneous adipose tissue, the current qualitative descriptors lack the precision and reproducibility needed for a universal classification system. Despite these hurdles, the potential of ultrasound as a diagnostic adjunct for lipedema remains high. Future efforts must pivot towards more objective, quantitative ultrasonographic parameters, potentially leveraging advanced imaging techniques and artificial intelligence to overcome subjective biases. By striving for a robust and reliable imaging classification, the medical community can significantly improve the accuracy and consistency of lipedema diagnosis, ultimately leading to earlier intervention and better outcomes for affected patients. REFERENCES Amato, A.C.M., Amato, F.C.M., Amato, J.L.S. and Benitti, D.A. (2022) Prevalência e fatores de risco para lipedema no Brasil. Jornal Vascular Brasileiro, 21, 1-11. https://doi.org/10.1590/1677-5449.202101981 Forner‐Cordero, I., Szolnoky, G., Forner‐Cordero, A. and Kemény, L. (2012) Lipedema: An Overview of Its Clinical Manifestations, Diagnosis and Treatment of the Disproportional Fatty Deposition Syndrome— Systematic Review. Clinical Obesity, 2, 86-95. https://doi.org/10.1111/j.1758-8111.2012.00045.x Faerber, G., Cornely, M., Daubert, C., Erbacher, G., Fink, J., Hirsch, T., et al. (2024) S2K Guideline Lipedema. JDDG: Journal der Deutschen Dermatologischen Gesellschaft, 22, 1303-1315. https://doi.org/10.1111/ddg.15513 Greene, A.K. and Sudduth, C.L. (2020) Lower Extremity Lymphatic Function Predicted by Body Mass Index: A Lymphoscintigraphic Study of Obesity and Lipedema. International Journal of Obesity, 45, 369-373. https://doi.org/10.1038/s41366-020-00681-6 Warren, A.G., Janz, B.A., Borud, L.J. and Slavin, S.A. (2007) Evaluation and Management of the Fat Leg Syndrome. Plastic and Reconstructive Surgery, 119, 9e- 15e. https://doi.org/10.1097/01.prs.0000244909.82805.dc Esmer, M. and Schingale, F.J. (2024) Effect of Physical Therapy on Circumference Measurement and Extremity Volume in Patients Suffering from Lipedema with Secondary Lymphedema. Lymphatic Research and Biology, 22, 8-11. https://doi.org/10.1089/lrb.2023.0013 Carballeira Braña, A. and Poveda Castillo, J. (2023) The Advanced Care Study: Current Status of Lipedema in Spain, a Descriptive Cross-Sectional Study. International Journal of Environmental Research and Public Health, 20, Article No. 6647. https://doi.org/10.3390/ijerph20176647 Herbst, K.L., Kahn, L.A., Iker, E., Ehrlich, C., Wright, T., McHutchison, L., et al. (2021) Standard of Care for Lipedema in the United States. Phlebology: The Journal of Venous Disease, 36, 779-796. https://doi.org/10.1177/02683555211015887 [9] Amato, A.C.M., Saucedo, D.Z., Santos, K.d.S. and Benitti, D.A. (2021) Ultrasound Criteria for Lipedema Diagnosis. Phlebology: The Journal of Venous Disease, 36, 651-658. https://doi.org/10.1177/02683555211002340 Bradley, D. and Bradley, K.E. (2014) The Value of Diagnostic Medical Imaging. North Carolina Medical Journal, 75, 121-125. https://doi.org/10.18043/ncm.75.2.121 Kjelle, E., Andersen, E.R., Soril, L.J.J., van Bodegom-Vos, L. and Hofmann, B.M. (2021) Interventions to Reduce Low-Value Imaging—A Systematic Review of Interventions and Outcomes. BMC Health Services Research, 21, Article No. 983. https://doi.org/10.1186/s12913-021-07004-z https://doi.org/10.1590/1677-5449.202101981 https://doi.org/10.1590/1677-5449.202101981 https://doi.org/10.1111/j.1758-8111.2012.00045.x https://doi.org/10.1111/j.1758-8111.2012.00045.x https://doi.org/10.1038/s41366-020-00681-6 https://doi.org/10.1038/s41366-020-00681-6 https://doi.org/10.1038/s41366-020-00681-6 https://doi.org/10.1097/01.prs.0000244909.82805.dc https://doi.org/10.1097/01.prs.0000244909.82805.dc https://doi.org/10.1089/lrb.2023.0013 https://doi.org/10.1089/lrb.2023.0013 https://doi.org/10.3390/ijerph20176647 https://doi.org/10.3390/ijerph20176647 https://doi.org/10.1177/02683555211015887 https://doi.org/10.1177/02683555211015887 https://doi.org/10.1177/02683555211002340 https://doi.org/10.1177/02683555211002340 https://doi.org/10.18043/ncm.75.2.121 https://doi.org/10.18043/ncm.75.2.121 https://doi.org/10.1186/s12913-021-07004-z https://doi.org/10.1186/s12913-021-07004-z