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10.5 Obesity, Gastric Banding, and Liposuction 375
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Madelung’s disease (Benign symmetric lipomatosis/
Launois-Bensaude syndrome) is a rare condition,
characterized by massive symmetric deposits of nonencapsulated adipose tissue in the head, the neck,
and the upper trunk.
Madelung’s disease (MD) is typically seen in middleaged males of Mediterranean origin with a history of
excessive alcohol consumption (90% of cases). Patients
with MD typically consume more than 80 g of alcohol
per day for more than 10 years. MD is considered a
“sight diagnosis” because of the typical patterns of fat
distribution in the head and neck region. Lipomatosis
is typically seen accumulating in both parotid regions
(hamster cheeks appearance), cervical region (horse
collar appearance), and the posterior neck region (buffalo hump appearance) (
Fig. 10.5.5 ). The disease is
divided into two types: type 1 MD is characterized by
symmetric body lipomatosis that gives the patient a
“pseudo-athletic” appearance (Fig. 10.5.5 ). Type 2 MD
is characterized by diffuse lipomatosis that gives the
patient a generalized obese appearance.
Sensory, motor, or autonomic polyneuropathy is
seen in up to 85% of patients with MD. Rarely, the
tongue or the mediastinum is involved in lipomatosis,
resulting in dysphagia and dyspnea.
Metabolic syndrome (Syndrome X) is defi ned by the
WHO as the presence of impaired glucose regulation
or diabetes, with two of the following risk factors:
hypertension, dyslipidemia, central obesity, and
microalbuminuria. There is a strong association
between the development of metabolic syndrome
and increase in visceral adipose tissue (VAT).
Fröhlich syndrome is a rare hypothalamic disorder,
characterized by obesity, stunned growth, and genital hypoplasia.
Obesity-hypoventilation (Pickwickian) syndrome ) is
a disease characterized by the triad of morbid obesity, hypoventilation, and irresistible hypersomnolence (drowsiness). Hypoventilation in Pickwickian
syndrome is defi ned clinically by an arterial blood
gas as a PaCO 2 > 45 and/or a PO 2 < 55 in the presence of morbid obesity. This hypoventilation is
attributed to obstructive sleep apnea in these patients,
and by the ventilation/perfusion mismatch that
results from the irregular shallow breathing with or
without compression by a thick chest wall.
Fig. 10.5.5. An illustration
demonstrates the typical
clinical signs of Madelung’s
disease: ( a ) hamster cheeks
appearance, ( b ) horse collar
appearance, ( c ) buffalo
hump appearance, and
( d ) pseudo-athletic appearance
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10.5
Drug-Induced Obesity
Glucocorticoids use : glucocorticoids cause fat accu-
mulation in the body in a similar fashion to people
with Cushing’s syndrome. Glucocorticoid obesity is
seen in patients with chronic prednisolon intake
>10 mg/day or its equivalent.
Cessation of smoking : Patients who quit smoking
can gain up to 4–5 kg on average, and it is partly
mediated by nicotine withdrawal.
Evaluation of Fat within the Body
There are several techniques used to estimate body fat.
Anthropometry is a technique used to estimate BMI
by measuring waist circumference and skinfold thickness. BMI is a good indicator of obesity, but it provides
indirect measurement of body fat, and is unable to
differentiate lean body mass from body fat. The inability of BMI to discriminate lean body mass from fat
body mass leads to defi ning lean, muscular individuals
as obese.
The metabolism of adipocytes varies with fat sites.
Fat deposits in the abdomen and fl ank are more metabolically active than fat deposits in the buttocks or
thighs. Upper-body obesity is more associated with
hypertension, glucose intolerance, and serum cholesterol levels than is lower-body obesity. Recent research
emphasizes the high risks of cardiovascular diseases
and metabolic abnormalities associated with increased
intra-abdominal VAT. VAT is defi ned as the fatty tissue that accumulates beneath the abdominal muscle
wall and surrounding the abdominal viscera. VAT
mass is pathologically more important than subcutaneous fat thickness over the trunk. Also, visceral fat is
a major determinant of whole body insulin
resistance.
Adipose tissue is a specialized loose connective tissue that is laden with adipocytes. It works as a source
of energy, thermal insulation (e.g., brown fat), and as a
mechanical cushion in mammals. A 70-kg man normally has 15 kg of adipose tissue, representing 21% of
body mass. In contrast, fat is a term used to describe
the chemical lipid component in the form of triglycerides. It can be found within adipocytes, or in
pathological conditions like fatty liver. Modern methods use ultrasound, CT, and MRI as useful and accurate tools for VAT quantifi cation.
Quantitative Assessment of Visceral Fat by US
Ultrasound can be used as a fast and easy method to
quantify visceral and subcutaneous fat. Although it is
not as standard as CT quantifi cation, it is reported by
many investigators to be an accurate method to quantify the abdominal wall fat thickness and preperitoneal
fat thickness.
Quantitative Assessment of Visceral
Fat by CT and MRI
An axial body section is taken at the level of the navel
or (L4/L5), and assessment is done via a computer
software program to calculate the percentage of visceral fat distribution (Figs. 10.5.6 and 10.5.7 ). Excess
visceral fat typically separates the intra-abdominal
structures. The drawbacks of the CT method are the
use of radiation and the limited gantry diameter to
patients less than 70 cm wide (the standard CT gantry
diameter). MRI, on the other hand, is radiation-free,
but more expensive in its use as a regular monitoring
method. The MRI method uses the same procedures as
the CT method of quantifi cation.
Gastric Banding
Gastric banding is a widely performed surgical procedure as a surgical therapy for morbid obesity. The procedure consists of placing a silicon band around the
upper part of the stomach to create a small gastric
pouch that works as a stomach (neostomach). The
pouch is connected to the rest of the stomach via a narrow stoma. The silicon band contains an adjustable
inner balloon that can be infl ated with air or fl uid up to
3
5 cm
, and it is connected to a reservoir that is typically
sutures to the anterior rectus sheath. The stoma width
normally should be within 3–4 mm.
10.5 Obesity, Gastric Banding, and Liposuction 377
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complications may arise later in up to 35% of cases.
Additional surgery may be required in up to 11% of
cases.
Early complications of gastric banding include
esophageal perforation (0.5% of cases), dysphagia
(14% of cases), gastroesophageal refl ux disease, and
early slippage of the band (1% of cases). Late complications include eccentric pouch dilatation (25%), slippage
of the band (24%), intra-gastric band migration, and
gastric necrosis (<0.3%). Patients with diabetes show
early gastric dilatation due to diabetic gastroparesis.
Fluoroscopic barium meal examination is performed to detect abnormalities and complications of
gastric banding. Initially, a scout supine abdominal
Fig. 10.5.6. An axial CT section obtained at the level of L4/L5
vertebra
image is taken to identify the place of the band and
the reservoir. Water-soluble contrast media is initially
administered in the early stages to confi rm the
absence of leakage. The normal images should reveal
The gastric banding procedure controls obesity by
restricting food administration to the stomach into a
small gastric pouch and narrow stoma, which creates
early satiety when the pouch is full. Although gastric
banding is a relatively safe procedure, several
a small upper gastric pouch, a narrow stoma extending through the gastric band, and opacifi cation of the
rest of the stomach (
Fig. 10.5.8 ). CT can be per-
formed after the fl uoroscopic examination to detect
other abnormalities.
Fig. 10.5.7. Computergenerated histogram
segmentation of the same CT
section as (Fig. 10.5.6 ) done by
using image analysis software
(Image J ). The image in ( a )
refl ects fat density (represented in white ) and the other
nonfatty tissues are removed
(represented in black ). Image
( b ) represents total body
volume, image ( c ) represents
subcutaneous tissue volume
(in back after inversion of the
original white color ), and
image ( d ) represents VAT
volume (in black ). The volume
of VAT or subcutaneous tissue
in this image is gained in cm
The volume must be
multiplied by the slice
thickness of the original image
to get the fat volume in cm
2
3
.
378 Chapter 10 Diabetology
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10.5
Fig. 10.5.8. Barium meal illustration shows the normal radiographic fi ndings in gastric banding: the gastric pouch ( solid
arrowhead ), the stoma ( solid arrow ), the gastric band ( hollow
arrowhead ), and the gastric fundus ( hollow arrow )
Fig. 10.5.9. Barium meal illustration shows eccentric pouch
dilatation
Signs on Barium Meal
Eccentric pouch dilatation is seen as an abnormally dilated
gastric pouch. It is usually seen in patients with dietary
noncompliance (Fig. 10.5.9 ). The gastric pouch is dilated due to
chronic overfi lling. The stoma is usually in its normal position.
Pouch dilatation may also occur due to narrow stoma
(Fig. 10.5.10 ). The scan shows pouch dilatation, with narrow
stoma (2–3 mm). Patients with this kind of obstruction often
present with esophageal dysmotility, vomiting, and pseudoachalasia.
Band slippage is seen as stomach herniation above the band,
resulting in pouch dilatation (Fig. 10.5.11 ). Patients may be
asymptomatic (20%), or may present with epigastric pain,
vomiting, and progressive gastroesophageal refl ux disease. If
not corrected, band slippage can lead to gastric volvulus and
gastric necrosis.
Intragastric migration of the band is a serious complication, in
which the band gradually erodes into the gastric wall until it
perforates the stomach. It is a rare complication, seen in 0.2–2%
of cases. Patients present with nonspecifi c gastric pain,
gastrointestinal bleeding, and perotinitis when perforation
occurs. The herniated band edge is seen as a barium fi lling defec t
within the stomach on barium examination (pathognomonic).
Fig. 10.5.10. Barium meal illustration shows pouch dilatation
due to narrow stoma ( arrowhead )
10.5 Obesity, Gastric Banding, and Liposuction 379
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equals the amount of fat to be removed (Illouz technique). The dissecting fl uid is composed of isotonic
saline, hyaluronidase, and perhaps lidocain, epinephrine, and sodium bicarbonate.
Liposuction is a relatively safe procedure, with overall complications occurring in approximately 5–10% of
patients. Most of these complications include the formation of hematoma, seroma, edema, and skin pigmentation problems. Removal of more 3,000 mL of fat may
carry the risk of severe systemic complications that
require resuscitation and blood transfusion. The amount
of fat removed should not exceed 6–8% of the patient’s
body weight and 30% of patient’s body surface area.
Also, blood loss should not exceed 1–1.5 units.
Causes of severe complications and death in liposuction include the development of crush syndrome
and fat embolism syndrome (FES). Crush syndrome is
a pathological condition characterized by severe shock
and hypotension, anuria, coma, and death. Classically,
the disease is caused by muscle disintegration that
Fig. 10.5.11. Barium meal illustration shows band slippage into
the dilated gastric pouch ( arrowhead )
releases myoglobin into the circulation, which has toxic
effect over the renal glomerule. During liposuction, the
numerous tunnels created through the fat create a
mechanism of subcutaneous injury similar to crush
syndrome. Also, uncontrolled cannula movements may
Liposuction
cause muscle injury, creating crisscrossed tunnels that
may produce large cavities. These large cavities result
Liposuction is a procedure that allows surgical removal
of excess adipose fat in healthy individuals. It is a very
common and popular aesthetic surgical procedure that
is performed in many countries around the world.
The main complications in fat removal procedures
lies in the degree of hemostasis achieved after detachment of the subcutaneous fat layer from the skin in the
area of desired fat removal. Poor hemostasis results in
the formation of hematoma, seroma, infection, necrosis, and even shock and death, which was commonly
seen in the old fat removal techniques that used cutting
instruments. In modern liposuction techniques, the
detachment of subcutaneous fat is accomplished by
injecting fl uid under the skin in the desired region
through a blunt-edged cannula (hydrodissection). The
cannula is used to create multiple tunnels within the
subcutaneous fat, inject the dissecting fl uid, and then
pulled (rather than cut) from the neighboring structures. The liquefi ed dissected fat is then sucked into a
container via the same cannula that injects the dissecting fl uid. Classically, the amount of injected fl uid
in third space fl uid loss, which produces severe symptoms. FES is a pathological situation characterized by
the development of metastatic fat emboli in multiple
body organs, resulting in a triad of pulmonary insuffi ciency, cerebral involvement, and petechial rashes. FES
can result due to fat droplets leaking into the systemic
circulation via ruptured veins at the site of cannula tunneling (mechanical theory), or due to the liberation of
free fatty acids such as “chylomicrons” from the
detached adipocytes. These free fatty acids are toxic to
the pneumocytes and the capillary epithelium, producing chemical pneumonitis. FES typically manifests
within 24–72 h after trauma or liposuction procedure.
Neurological manifestations due to fat emboli to the
brain include seizures, altered level of consciousness,
focal neurological defi cits, and even coma. Patients
develop petechial skin rash on the head and neck
region and on the upper body, which is believed to be
the only pathognomonic feature (seen in 50% of
cases). Laboratory fi ndings show decreased hematocrit level, increased serum lipase level, hypoxemia,
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and hypokalemia. These fi ndings are observed during
the fi rst 24–72 h. Fluminant FES is a term reserved for
severe manifestations of cardio-pulmonary obstruction
by fat produced by a sudden intravascular liberation of
a large amount of fat. Severe heart failure, shock and
10.5
Signs on Radiographs
Pulmonary edema may be seen on chest radiograph if a large
amount of fl uid is injected subcutaneously or intravenously, or if
the patient develops ARDS due to multiple pulmonary fat
emboli. When pulmonary manifestations develop, the
radiological signs may remain for up to 3 weeks.
Signs on US
Seromas are detected as localized fl uid (anechoic) collections
below the skin, whereas hematoma is seen as hypoechoic to
hyperechoic masses, depending on the age of the hematoma.
Fig. 10.5.12. Axial brain DW-illustration of a patient with fat
embolism syndrome shows the starfi eld pattern
Signs on MRI
When FES aff ects the brain, it usually results in multiple diff use
foci of hyperintensity located in the white matter of the
subcortical, periventricular, and centrum semiovale regions.
Characteristic multiple hyperintense foci lesions in the centrum
semiovale may be seen in DWI, resulting in a “starfi eld pattern”
(Fig. 10.5.12 ).
For Further Reading
1 . Bray GA. Obesity. Dis. Mon. 1979;26(1):1–85
2 . Buckley O et al European obesity and radiology depart-
ment. What can we do to help? Eur Radiol (2009);19:
298–309
3 . Koda M et al Sonographic subcutaneous and visceral fat
indices represent in the distribution of body fat volume.
Abdom Imaging. 2007;32:387–92
4 . Valchos IS et al Sonographic assessment of regional adi-
posity. AJR Am J Roentgenol. 2007;189:1545–53
5 . Bulum T et al Madelung’s disease: case report and review of
the literature. Diabetologia Croatica. 2007;36-2, 25–30
10.5 Obesity, Gastric Banding, and Liposuction 381
https://t.me/medicina_free
6 . Lange U et al Dercum’s disease (lipomatosis dolorosa): suc-
cessful therapy with pregabalin and manual lymphatic drainage and a current overview. Rheumatol Int. 2008;29:17–22
7 . Yoshida T et al Weber-Christian disease presenting with
ocular manifestations. Clin Rheumatol. 2003;22:339–42
8 . Nakai M et al Weber-Christian disease presenting with ret-
roperitoneal panniculitis. Eur J Radiol Extra. 2006;60:
89–92
9 . Raguse JD et al Benign symmetric lipomatosis (Madelung’s
disease) complicated by involvement of the facial nerve.
Eur J Plast Surg. 2004;27:306–308
10 . Verna G et al Launois-Bensaude syndrome: an unusual
localization of obesity disease. Obes Surg. 2008;18:1313–17
11 . Adami GF et al Metabolic syndrome in severely obese
patients. Obes Surg. 2001;11:543–45
12 . Shen W et al Adipose tissue quantifi cation by imaging meth-
ods: a proposed classifi cation. Obes Res. 2003;11(1): 5–16
13 . Carucci LR et al Adjustable laparoscopic gastric banding
for morbid obesity: imaging assessment and complications. Radiol Clin N Am. 2007;45:261–74
14 . Landen S et al Complications of gastric banding presenting
to the ED. Am J Emerg Med. 2005;23:368–70
15 . Wiesner W et al Adjustable laparoscopic gastric banding in
patients with morbid obesity: radiographic management,
results, and post-operative complications. Radiology. 2000;
216:389–94
16 . Trekner SW et al Imaging of morbid obesity procedures
and their complications. Abdom Imaging. 2008. doi:
10.1007/s00261–008–9389–3
17 . Pomerri F et al Radiological assessment of complications after
laparoscopic suprabursal adjustable gastric banding for morbid obesity. Obes Surg (2009);19: 146–152
18 . Illouz YG. Complications of liposuction. Clin Plast Surg.
2006;33:129–63
19 . Wang HD et al Fat embolism syndromes following liposuc-
tion. Aesth Plast Surg. 2008;32:731–36
20 . Chen JJS et al MR imaging of the brain in fat embolism syn-
drome. Emerg Radiol. 2008;15:187–92
21 . Reddix RN Jr. et al Crush syndrome presenting three days
after injury. Injury Extra. 2004;35:73–75
382 Chapter 10 Diabetology
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10.6
10.6
Lipoatrophic–Lipodystrophic
Syndromes
Lipoatrophy syndromes are a wide group of disorders,
characterized by diffuse or focal paucity of fatty tissue
within the body.
Loss of fat is known as “ lipoatrophy ,” whereas
abnormal fat distribution is known as “ lipodystrophy .”
When diabetes mellitus occurs with lipoatrophy, it is
called “ lipoatrophic diabetes .”
Patients with lipoatrophy syndromes are clinically
characterized by focal or diffuse loss of fatty tissue,
diabetes mellitus, acanthosis nigricans, hyperandrogenism and amenorrhea in females, cardiomyopathy
and muscular hypertrophy, increased appetite and high
basal metabolic rate, and nonalcoholic liver steatosis
or cirrhosis.
Focal lipoatrophy refers to a condition where the loss
of fat involves a single region in the body. An example
of focal lipoatrophy is loss of fat in the gluteal area, usually following intramuscular injection (Fig. 10.6.1 ).
Laboratory investigations in lipoatrophy syndromes
typically show hyperinsulinemia, hyperglycemia, hypertriglyceridemia, abnormal cholesterol profi le, elevated
free fatty acids, and low leptin and other adipocytes
hormones.
In general, radiological features show normal bone
mineral density on DEXA scan and hepatic steatosis
on ultrasound. However, the conventional radiographic
and MRI features depend on the syndrome. Different
lipoatrophy syndromes and their characteristic radiological features are discussed below.
Congenital Generalized Lipodystrophy
(Seip-Berardinelli Syndrome)
Seip-Berardinelli syndrome (SBS) is a disease characterized by generalized absence of fat within the fi rst
year of life (primarily affects neonates).
As neonates grow up, they develop diabetes mellitus type 2 before the teenage years. Acanthosis nigricans, hypertriglyceridemia, and frequent bouts of
pancreatitis are other common features.
The syndrome has an autosomal recessive mode of
inheritance; with females showing more severe lipid
profi le abnormalities than males. Features of gigantism
are often found in patients with SBS.
Talon cusp has been reported in cases with SBS.
Talon cusp , also known as “eagle cusp,” is an extra
cusp of an anterior tooth. In the premolar teeth, an
extra tooth-cusp is referred to as “ dens envaginatus .”
When dens envaginatus occurs in an anterior tooth
such as an incisor or a canine, it is referred to as a talon
cusp (
Fig. 10.6.2 ).
Fig. 10.6.2. An illustration demonstrates talon cusp
Fig. 10.6.1. Axial T1W ( a )
and T1W postcontrast
fat-saturation ( b ) images
show focal fatty necrosis with
enhancement due to previous
intramuscular injection
( arrowhead )
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Signs on Plain Radiographs
Skeletal radiographs usually show advanced bone age plus
loss of subcutaneous fat.
Craniosynostosis may be seen in some patients
(e.g., dolichocephaly).
Signs on CT and MRI
Transverse sections of the torso at the level of the fi fth lumbar
vertebra often show markedly defi cient subcutaneous fat and
loss of the visceral fat.
Liver cirrhosis or steatosis is a common feature of SBS.
Fig. 10.6.3. Axial abdominal CT illustration demonstrates profound proliferation of the visceral fat in the retroperitonium
( arrow ), with almost complete absence of subcutaneous fatty
tissue ( arrowheads ), which is a typical fi nding in a patient with
familial partial lipoatrophy
Familial Partial Lipodystrophy
(Dunnigan-Kobberling Syndrome)
Dunnigan-Kobberling syndrome (DKS) is a rare autosomal dominant disease, characterized by normal fat
distribution at birth, with progressive loss of subcutaneous fat, mainly that located in the extremities and
the trunk, as the patient reaches puberty. The loss of
subcutaneous fat from the extremities and the trunk is
associated with increased fat deposition in the face and
the neck as puberty is complete.
Like SBS, DKS shows a more severe course in
females than in males. Diabetes and dyslipidemia are
seen in much earlier ages in females compared to
males. Polycystic ovary disease is often seen in females
with DKS.
The presentation of DKS may be clinically mistaken for Cushing’s syndrome. The absence of fat and
the well-reserved muscles in the extremities enable
establishing the correct diagnosis.
Signs on CT and MRI
The patient’s body shows loss of the subcutaneous fat in the
extremities and increased subcutaneous fat in the head and
neck region.
Transverse sections of the torso at the level of the fi fth lumbar
vertebra often show markedly reduced subcutaneous fat and
increased visceral fat (Fig. 10.6.3 ).
Mandibuloacral Dysplasia
Mandibuloacral dysplasia (MAD) is a very rare, multisystemic, autosomal recessive disease, characterized
by mandibular and clavicular hypoplasia (Fig. 10.6.4 ),
joint contractures, acro-osteolysis, joint and skin problems, and lipodystrophy.
Patients with MAD present with loss of the subcutaneous fat of the extremities with increased visceral
fat deposition.
Fig. 10.6.4. An
illustration
demonstrates the
clinical fi ndings in
a patient with
mandibuloacral
dysplasia. Notice
the hypoplastic
mandible
(micrognathia)
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Signs on Plain Radiographs
Hypoplastic clavicle and mandible (micrognathia).
Loss of the terminal phalangeal tufts (acro-osteolysis).
10.6
Widened skull sutures.
Acquired Generalized Lipoatrophy
(Lawrence-Seip Syndrome)
Lawrence-Seip syndrome (LSS) is an acquired generalized lipodystrophy disorder. Its clinical features are
similar to SBS (congenital form), but it often arises
after a triggering event (e.g., infection). The key diagnosis between the two conditions is the age of presentation. SBS typically starts in neonates, while LSS
starts in much older patients after a triggering event.
Fat loss in LSS is usually severe, and may lead to a
dramatic change in the physical appearance. Patients
often develop diabetes mellitus within 4 years from the
time they starting losing fat. The fat loss is profound,
and it may affect the retro-orbital fat, hands, feet, the
genital area, and the bone marrow. Nephrotic syndrome is often seen in patients with LSS.
Signs on Plain Radiographs
Skeletal radiographs usually show advanced bone age plus loss
of subcutaneous fat.
Signs on CT and MRI
Almost the same radiological features as SBS.
Acquired Partial Lipoatrophy (BarraquerSimon Syndrome)
Barraquer-Simon syndrome (BSS) is a disease with a
wide-range of variations, with a few shared features.
Patients with BSS are typically women in their second or
third decade of life, who also have autoimmune disorder
(e.g., scleroderma), presenting with partial loss of fat.
Fig. 10.6.5 . Axial abdominal CT illustration demonstrates profound proliferation of the subcutaneous fat in the buttocks
( arrow ) compared to the visceral fat and the anterior abdominal
wall subcutaneous fat ( arrowheads ), which is a characteristic
fi nding in acquired partial lipoatrophy
The loss of fat in BSS typically starts from the face
and descends downward until the gluteal line, with
increased fat deposition in the lower extremities. Not
all patients with BSS develop diabetes mellitus and
dyslipidemia (only 50%).
Signs on CT and MRI
A body section of the upper abdomen shows marked reduced
subcutaneous fat compared to the lower pelvis and the lower
extremities (Fig. 10.6.5 ).
Parry-Romberg Syndrome
(Progressive Facial Hemiatrophy)
Parry-Romberg syndrome (PRS) is a sporadic disease
of unknown origin, characterized by slow, progressive
atrophy of the face with all its components, involving
the skin, subcutaneous tissues, muscles, cartilage, and
bones (Fig. 10.6.6 ). Some authors consider PRS a focal
form of lipoatrophy affecting the face, while other
authors consider it a form of phakomatosis.
PRS starts at a young age, and slowly progresses as
the patient gets older. Patients commonly present with
epilepsy and brain abnormalities ipsilateral to the
facial atrophy. Bilateral facial atrophy is seen in 5–10%
of cases, and atrophy of the ipsilateral eye or enopthalmus is seen in 10–35% of cases.
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