5 Treatment

General Considerations

Application of Basic MLD Techniques on Different Parts of the Body

Treatment Sequences

Elastic Taping for Lymphedema

Treatment Strategies for Common Complications of Lymphedema

CDT Treatment Protocol Variations: Primary and Secondary Lymphedema

Adapting CDT to the Palliative Patient

Lipedema Treatment: Understanding the Diagnosis and Patient Profile

Application of Compression Bandages

Bandaging Procedures Using Foam Padding

Genital Lymphedema Treatment

Truncal Lymphedema

Bandaging in Presence of Wounds

Measurements for Compression Garments

Compression Bandaging Alternatives: Guidelines to Choosing the Right Home Care Systems

Treatment Considerations in Managing the Morbidly Obese Patient

Patient Education

Surgical Treatment

General Considerations

Application of Basic MLD Techniques on Different Parts of the Body

The four basic techniques of Dr. Vodder’s manual lymph drainage (MLD)—stationary circle, pump, scoop, and rotary—their effects on the lymphatic system, and the contraindications for manual lymph drainage are discussed in Chapter 4. Additional techniques incorporated into MLD sequences are soft and rhythmic strokes known as effleurage. This method is adopted from more traditional massage techniques and is used to stimulate local sympathetic activity and to promote directional flow of lymph.

The techniques and sequences outlined in the following sections are applied in conditions where edema is present, but the lymph nodes are not removed or treated with irradiation. Examples include post-traumatic and postoperative swelling, lower extremity edema caused by pregnancy, swellings caused by partial or complete loss of mobility (pareses, paralysis), reflex sympathetic dystrophy (when swelling is present), migraine headache (swelling is present in the perivascular areas of intracranial blood vessels), cyclic idiopathic edema, and rheumatoid arthritis. Selected indications are cited in the appropriate sections.

Basic treatment sequences may also be used to accomplish a general increase in lymph circulation or to achieve a common soothing effect by decreasing sympathetic activity.

In the treatment of lymphedema, these techniques are used to improve lymph production and lymph angiomotoricity, as well as to promote the lymphatic return from the drainage areas described in Chapter 4 (Intensive Phase) to the venous system. In the lymphedematous extremity and/or body part, the treatment sequences are modified accordingly, as outlined later in this chapter.

Common denominators to all techniques and sequences are the following:

• The hand positions of all basic strokes are adapted to the anatomy and physiology of the lymphatic system.

• Central pretreatment: the areas closest to the venous angles and regional groups of lymph nodes are stimulated first. This allows for drainage of the peripheral areas. At extremities, the stimulation begins proximal and is continued toward distal, in accordance with the direction of the lymph drainage.

• Stroke intensity: the applied pressure in individual strokes should be enough to utilize full elasticity of the skin and subcutaneous tissues, and to promote lymph formation and lymph angiomotoricity. Too much pressure may cause unwanted vasodilation and lymphangiospasm.

• Stroke sequence: each technique consists of a working and resting phase, during which the manual pressure increases and decreases gradually. The goal in the working phase is to promote lymph formation, lymph angiomotoricity, and directional flow by stretching the anchoring filaments and smooth musculature located in the wall of lymph angions. The suction effect created in the resting phase results in a refilling of lymph collectors with lymph fluid from more distal areas.

• Stroke duration: the relatively high viscosity of lymph fluid requires the working phase to last ~1 second. To ensure adequate reaction of the lymph collectors to the manual stimuli, the strokes should be repeated 5 to 7 times in one area.

• Working direction of the strokes: the direction of the strokes depends on the anatomical actualities and generally follows the physiological patterns of lymphatic drainage. If surgery, radiation, or trauma results in an interruption of regular drainage pathways, it will become necessary to redirect the lymph flow around the blocked areas and toward regions with sufficient lymph flow patterns.

Lateral Neck and Submandibular Area

Patient in supine position, therapist on the patient’s side:

3. Manipulation of the deep lateral cervical lymph nodes (Fig. 5.1)

Stationary circles from the earlobe to the supraclavicular fossa in two hand placements, if necessary (sagittal plane)

4. Manipulation of the parotid and retroauricular lymph nodes (Fig. 5.2)

Stationary circles with fingers in front of and behind the ear, followed by reworking the deep lateral cervical lymph nodes as in step 3 (both placements in sagittal plane)

Patient in supine position, therapist at the head-end of the patient:

5. Manipulation of submandibular lymph nodes (Fig. 5.3) Stationary circles with distal phalanges (2–5) from the tip of the chin in the direction of the angle of the jaw (superior cervical lymph nodes). Two hand placements if necessary (phalanges in horizontal plane). This technique is followed by reworking the deep lateral cervical lymph nodes as in step 3.

Patient in supine position, therapist on the patient’s side:

6. Manipulation of the shoulder collectors Stationary circles in 2 hand placements, which should cover the area located cranial to the anterior and posterior upper horizontal watershed. First hand placement on the acromion, second hand placement on the medial shoulder (both placements in horizontal plane).

7. Effleurage (as in step 1)

Abbreviated Neck Sequence

Review Fig. 5.4 for drainage areas on the lateral neck.

1. Effleurage, 2 or 3 times from the sternum to the acromion

2. Manipulation of the inferior cervical lymph nodes Stationary circles in the supraclavicular fossa (horizontal plane)

3. Manipulation of the deep lateral cervical lymph nodes (Fig. 5.1)

Stationary circles from the earlobe to the supraclavicular fossa in 2 hand placements, if necessary (sagittal plane)

Posterior Neck and Occipital Area

Selected indications: postsurgical (oral, dental, plastic surgery, etc.) and post-traumatic swellings (whiplash injury, others); migraine headache; partial treatment for primary head and neck lymphedema; general increase in lymph circulation, or to achieve a common soothing effect by decreasing sympathetic activity (Fig. 5.5)

Pretreatment: lateral neck

Patient in prone position, therapist at the head-end of the patient:

1. Effleurage, 2 or 3 three times starting at the back of the head and following the descending trapezius muscle to the acromion

2. Manipulation of the deep lateral cervical lymph nodes Stationary circles starting at the angle of the jaw in the direction of the supraclavicular fossa (sagittal plane). Two hand placements if necessary.

3. Manipulation of the occipital and parietal region Alternating stationary circles in several tracks, starting on the posterior head toward the parietal area (frontal plane). Working phase in the direction of the occipital and retroauricular lymph nodes.

4. Manipulation of the parotid and retroauricular lymph nodes Stationary circles with fingers in front of and behind the ear, followed by reworking the deep lateral cervical lymph nodes as in step 2 (both placements in sagittal plane)

5. Manipulation of the shoulder collectors Alternating pump techniques on both shoulders, starting at the acromion, following the upper trapezius muscle in the direction of the supraclavicular fossa Both hands in horizontal plane

6. Manipulation of the inferior cervical lymph nodes Bimanual thumb circles in the supraclavicular fossa (horizontal plane)

Patient in prone position, therapist on the patient’s side:

7. Manipulation of the paravertebral lymph nodes and vessels Stationary circles paravertebrally with the finger pads (working deep)

8. Effleurage (as in step 1)

Face

Selected indications: postsurgical (oral, dental, plastic surgery, etc.) and post-traumatic swellings (whiplash injury, etc.); migraine headache; partial treatment for primary head and neck lymphedema; general increase in lymph circulation, or to achieve a common soothing effect by decreasing sympathetic activity (Fig. 5.6)

Pretreatment: lateral neck (posterior neck if necessary)

Patient in supine position, therapist at the head-end of the patient:

1. Effleurage, 2 or 3 times along lower jaw, upper jaw, the cheek, and the forehead in the direction of the angle of the jaw (following the pathway of the collectors)

2. Manipulation of the submental and submandibular lymph nodes (Fig. 5.3) Stationary circles with distal phalanges (2–5) from the tip of the chin in the direction of the angle of the jaw (superior cervical lymph nodes). Two hand placements if necessary (phalanges in horizontal plane). This technique is followed by stationary circles along the deep lateral cervical lymph nodes (sagittal plane).

Posterior Thorax

The treatment area is outlined by the lower horizontal watershed (caudal limitation), the upper horizontal watershed (cranial limitation), and the sagittal watershed (medial limitation) (Fig. 5.7).

Selected indications: Pretreatment for unilateral secondary upper extremity lymphedema (this sequence is applied on the healthy quadrant); postsurgical and post-traumatic swellings; general increase in lymph circulation, or to achieve a common soothing effect by decreasing sympathetic activity

Pretreatment: lateral neck (abbreviated; see lateral neck sequence, steps 1–3)

Patient in prone position, therapist contralateral to the healthy quadrant:

1. Manipulation of the axillary lymph nodes Stationary circles bimanually with flat hands between the latissimus dorsi and pectoral muscles (sagittal plane), with the working direction toward the apex of the axilla (subclavian trunk)

2. Effleurage, 2 or 3 times in several pathways, starting at the posterior sagittal watershed in the direction of the axillary lymph nodes (following the pathway of the collectors)

3. Manipulation of the lateral thorax Stationary circles alternating and dynamic from the horizontal watershed toward the axillary lymph nodes (sagittal plane). This sequence follows the thoracic portion of the inguinal axillary (IA) anastomosis.

4. Manipulation of the posterior thorax (Fig. 5.8) Rotary techniques in several tracks starting at the sagittal watershed in the direction of the axillary lymph nodes (following the pathway of the collectors). This technique should cover the entire treatment area as outlined previously (Fig. 5.7).

Lumbar Area

The treatment area is outlined by the lower horizontal watershed (cranial limitation), the horizontal gluteal fold (caudal limitation), and the sagittal watershed (medial limitation) (Fig. 5.9).

Selected indications: Pretreatment for unilateral secondary and primary lower extremity lymphedema (this sequence is applied on the healthy quadrant); phlebolymphostatic edema; lipedema and lipolymphedema; postsurgical and post-traumatic swellings; general increase in lymph circulation, or to achieve a common soothing effect by decreasing sympathetic activity

Anterior Thorax

The treatment area is outlined by the lower horizontal watershed (caudal limitation), the upper horizontal watershed (cranial limitation), and the sagittal watershed (medial limitation) (Fig. 5.10).

Selected indications: Pretreatment for unilateral secondary and primary upper extremity lymphedema (this sequence is applied on the healthy quadrant); postsurgical and post-traumatic swellings; general increase in lymph circulation, or to achieve a common soothing effect by decreasing sympathetic activity

Pretreatment: lateral neck (abbreviated; see lateral neck sequence, steps 1–3)

8. Manipulation of intercostal lymph vessels (Fig. 5.11) Stationary circles with 3 or 4 finger pads working from lateral placements to medial placements, using wavelike movements with pressure working deep (perforating precollectors)

9. Effleurage (as in step 2)

Abdomen (Superficial and Deep Manipulations)

Refer to the list of local contraindications for the abdominal area in Chapter 4, Contraindications for Manual Lymph Drainage. Abdominal techniques should not be applied if they cause pain or discomfort, or directly following meals. Patients should empty their bladder before treatment starts.

Abdominal sequences can be separated into superficial and deep techniques. The skillful manipulation of the intra-abdominal areas, especially when combined with diaphragmatic breathing, results in increased lymph transport within the thoracic duct and larger lymphatic trunks. A decongestive effect on organ structures located within the abdominal and pelvic cavities, as well as on lymphatic drainage areas located more distally (the lower extremities), is additionally realized when performing abdominal techniques.

Selected indications: part of the treatment sequence for lower extremity lymphedema (primary and secondary) as well as lymphedema involving the external genitalia; chronic venous insufficiency stages II and III (phlebo-lymphostatic edema); lipedema and lipolymphedema; part of the treatment sequence for primary lymphedema of the genitalia; part of the treatment sequence for upper extremity lymphedema (particularly with removal or irradiation of both axillary lymph node groups); part of the treatment for cyclic idiopathic edema; general increase in lymph circulation

With this technique, the caudal part of the thoracic duct, the cisterna chyli, the larger lymphatic trunks, the pelvic and lumbar lymph nodes, and the organ structures with their lymphatic system are stimulated. Deep abdominal sequences are applied on 5 different hand placements on the abdominal area and are combined with the patient’s diaphragmatic breathing (Fig. 5.12). To avoid hyperventilation, the therapist performs only one sequence per placement. Ideally, the placements on the thoracic cage and in the center of the abdomen are repeated during the full sequence, resulting in a total of 9 manipulations (depending on the patient’s reaction). During each manipulation, the therapist’s hand follows the patient’s exhalation into the abdominal area and offers moderate (but soft) resistance to the initial subsequent inhalation phase. The therapist then releases the resistance and stays in skin contact until the end of the inhalation phase. The hand is moved to the next placement on the abdomen during the pause between inhalation and the next exhalation phase. To avoid discomfort, the hand, which is in contact with the patient’s skin, remains soft and passive. Pressure is applied with the top hand, which rests on top of the working hand.

Pretreatment: lateral neck (abbreviated; see lateral neck sequence, steps 1–3)

Patient in supine position, with the legs and the head elevated and the arms resting on the patient’s side; therapist on the patient’s side, with the hand placements as follows:

Upper Extremity

4. Manipulation of the tissues covering the anterior and posterior portion of the deltoid muscle Stationary circles bimanually and alternating on the anterior and posterior portion of the deltoid muscle; the working phase is directed toward the axillary lymph nodes Note: In the treatment of upper extremity lymphedema, the working phase of this sequence is directed toward the AAA and PAA anastomoses (Fig. 5.13)

5. Manipulation of the lateral aspect of the upper arm Pump technique, with the hand closer to the patient’s head on the lateral upper arm in several placements from the lateral epicondyle toward the acromion. The other hand holds the patient’s arm in a comfortable and elevated position.

Combination of pump technique and stationary circle (alternating hands) on the lateral aspect of the upper arm, beginning at the lateral epicondyle in several hand placements toward the olecranon

Combination of pump technique and stationary circles between the wrist and the elbow to cover the patient’s anterior and posterior aspects of the forearm. The patient’s forearm is rotated in pronation and supination, respectively, to cover both surfaces.

9. Manipulation of the palmar aspect of the hand and the anterior wrist (Fig. 5.14)

Thumb circles (one thumb or alternating) in the palm, following the ulnar and radial bundle from the center of the palm toward the ulnar and radial edges of the hand (following the path of the collectors)

10. Manipulation of the fingers Combination of thumb/finger circles on each individual finger from the distal to the proximal ends

11. Rework

Appropriate techniques are used (depending on the patient’s condition) covering specific parts of the limb or the entire extremity to increase lymph angiomotoricity

12. Final effleurage (as in 2)

Lower Extremity

1. Manipulation of the inguinal lymph nodes Stationary circles with both hands at the same time, with the working phase directed toward the inguinal ligament; 3 hand placements in the medial femoral triangle (Fig. 5.15)

First hand placement: the upper hand lies parallel to the inguinal ligament (the fifth metacarpophalangeal joint is aligned with the patient’s ASIS), the lower hand is positioned diagonally to the upper hand (with the fingertips touching the inguinal ligament) Second hand placement: the same hand positions are applied on the medial thigh (medial aspect of the femoral triangle)

Third hand placement: both hands lie parallel on the medial aspect of the thigh (sagittal plane) to address the lymph nodes located in the distal apex of the medial femoral triangle

2. Effleurage, 2 or 3 times covering the entire leg

3. Manipulation of the anterior thigh Alternating pump techniques following the rectus femoris muscle between the base of the patella and the ASIS

4. Manipulation of the anterior and lateral thigh Combinations of pump techniques and stationary circles with alternating hands, beginning at the knee to proximal. The lateral pathway follows the iliotibial tract; the anterior pathway follows the rectus femoris muscle.

The treatment of the posterior leg with the patient in the prone position is recommended in those cases where the decongestion of the limb does not advance as expected (“stubborn legs”) with the treatment in supine, or if the swelling is more distally emphasized (e.g., larger swelling on the lower leg). The techniques on the posterior leg are similar to the sequences for the anterior leg (Figs. 5.16 and 5.17). Manipulation of the inguinal lymph nodes in the supine position precedes the treatment of the posterior leg (Fig. 5.15).

Patient in prone position, with the leg slightly abducted; therapist on the patient’s same side:

1. Effleurage, 2 or 3 times covering the entire leg

2. Manipulation of the posterior thigh Alternating pump techniques between the popliteal fossa and the horizontal gluteal fold (frontal plane)

3. Manipulation of the medial thigh

Stationary circles alternating and dynamic at the medial thigh, beginning at the medial aspect of the knee to the groin (sagittal plane)

4. Manipulation of the posterior and lateral thigh Combinations of pump techniques and stationary circles with alternating hands, beginning at the popliteal fossa to proximal. The lateral pathway follows the iliotibial tract; the posterior pathway follows the posterior thigh musculature in a frontal plane.

Treatment Sequences

Truncal Lymphedema

Given the fact that the breast, anterior and posterior thorax, and the upper extremity share the axillary nodes as regional lymph nodes (see Figs. 1.7, 1.8, and 1.17), it is predictable that disruption of lymphatic drainage pathways by partial or complete removal of axillary lymph nodes, with or without radiation therapy, can cause the onset of swelling in the chest wall and breast on the same side. The swelling can either be subtle or quite obvious in presentation and may be present with or without swelling in the arm.

The disruption of the natural lymphatic drainage pattern is further complicated by scars on the upper trunk wall following lumpectomy, mastectomy, and reconstructive breast surgery, biopsies or drain sites. Fibrotic tissues in the chest wall or armpit following radiation treatments may further inhibit sufficient lymphatic drainage.

Certain breast reconstructive procedures, such as the TRAM-flap reconstruction also disrupt lymphatic drainage in the abdominal area, which may cause the onset of additional swelling in the lower truncal (abdominal) area.

Like lymphedema in the extremities, swelling affecting the breast, chest and posterior thorax is typically asymmetrical in appearance if compared with the other side (Fig. 5.18). However, there are often other symptoms present prior to the onset of visible swelling, which can include altered sensation (numbness, tingling, diffuse fullness and pressure, heat), pain, and decreased shoulder mobility. Once lymphedema is visibly present, the swelling can include the entire thorax wall, or it can be localized to the armpit, the scapula, the area over the clavicle or around mastectomy or lumpectomy scar lines, around the reconstructed breast or implants, or it may be limited to the breast tissue only.

The breast in patients who have undergone lumpectomy or reconstructive surgery may be larger and heavier, or the shape and height of the breast tissue may change due to fibrotic tissue, resulting in added psychological distress due to problems involving clothing, bra fitting, and body image issues.

Postoperative swelling following breast cancer surgery is to be expected and generally lasts up to about 3 months; it appears almost immediately following surgery and places additional stress on the lymphatic system by contributing to the lymphatic workload. The difference between “normal” postoperative edema and lymphedema is its perseverance following the completion of treatment, and the presence of changes in tissue texture, such as lymphostatic fibrosis.

During the initial stages of the treatment, patients should be instructed in self-MLD (see page 320) and encouraged to perform self-treatment for at least 20–30 minutes daily.

Skin care: Areas between skinfolds on the trunk or the underside of the breast are particularly prone to skin damage and infections. Edematous areas should be kept clean and dry and suitable ointments or lotions formulated for sensitive skin, radiation dermatitis, and lymphedema should be applied (refer to Chapter 4, Skin and Nail Care, for more information on skin care).

Custom-cut or commercially manufactured foam pads (Fig. 5.19) or foam chips may be inserted underneath the bandages or compression bra or vest to increase localized pressure in areas of excess fluid pooling, or to soften localized fibrotic tissue. Flat foam pieces can be used to shape and stabilize the compression bandages and to distribute the pressure evenly over a greater surface area.

The patient should be fitted with a specially designed lymphedema bra (see Fig. 5.197) or compression vest following decongestion of the trunk to assist with maintaining the positive results of CDT. Compression bras and vests have minimal seams and wide straps, are available as off-the-shelf or custom-made garments, and ensure that the trunk and breast tissues are properly supported. Compression bras and vests should fit comfortably, provide sufficient support around the trunk and not squeeze breast tissue; pockets to accommodate a prosthesis can be sewn into these garments.

Patients using regular bras or sports bras should make sure to avoid narrow bra straps and obtain bra strap pads or wideners, if necessary, to avoid restriction of lymphatic pathways on the shoulder.

Unilateral Secondary Upper Extremity Lymphedema

The following sequence should be used until the truncal quadrant is decongested (Fig. 5.20).

Patient in supine position:

1. Abbreviated manipulation of the lateral neck lymph nodes, including the shoulder collectors (observe contraindications)

2. Activation of the axillary lymph nodes on the contralateral side. Anterior thorax on the contralateral side (omit intercostal and parasternal techniques)

3. Activation and utilization of the AAA anastomosis to move lymph fluid from the affected to the unaffected side

4. Manipulation of the inguinal lymph nodes on the ipsilateral, affected side

Therapist moves to other side of table:

5. Activation and utilization of the AI anastomosis on the affected side

6. Manipulation of lymph fluid from the congested upper quadrant in the direction of the inguinal lymph nodes on the same side, utilizing the AI anastomosis. Rotary techniques and stationary circles should be used.

7. Intercostal and parasternal techniques on the affected trunk quadrant to utilize deep drainage pathways

Patient on the side (or prone position), with the affected extremity on top:

8. Rework of the AI anastomosis and shoulder collectors

Patient in prone position (or on the side):

9. Posterior thorax on the unaffected side (omit intercostal and paravertebral techniques)

10. Activation and utilization of the PAA anastomosis to move lymph fluid from the affected to the unaffected side. Stationary circles should be used.

Therapist moves to other side of table:

11. Manipulation of lymph fluid from the congested posterior upper quadrant in the direction of the inguinal lymph nodes on the same side, utilizing the AI anastomosis. Rotary techniques and stationary circles should be used.

12. Intercostal and paravertebral techniques on the affected trunk quadrant to utilize deep drainage pathways

13. Vasa vasorum technique in the area of the cephalic vein (see Fig. 4.9)

14. Manipulation of elbow, forearm, and hand as outlined in the basic sequence techniques

15. If necessary, edema or fibrosis techniques should be incorporated at this point

16. Rework of upper extremity, AAA anastomosis, axillary lymph nodes on contralateral side, inguinal lymph nodes on ipsilateral side, and shoulder collectors

Patient on the side (or prone position), with the affected extremity on top:

17. Rework of the PAA and AI anastomoses (on the same side)

18. Application of compression bandages on involved extremity

Bilateral Secondary Upper Extremity Lymphedema

The following sequence should be used until the truncal quadrant(s) is/are decongested (Fig. 5.21).

Patient in supine position:

1. Abbreviated manipulation of the lateral neck lymph nodes, including the shoulder collectors (observe contraindications)

2. Abdominal treatment: superficial and deep (modified) techniques as outlined in the basic sequences (observe contraindications). If abdominal techniques are contraindicated, diaphragmatic breathing should be used to substitute.

3. Manipulation of the inguinal lymph nodes on both sides

Unilateral Secondary Lower Extremity Lymphedema

The following sequence should be used until the truncal quadrant is decongested (Fig. 5.22).

Patient in supine position:

1. Abbreviated manipulation of the lateral neck lymph nodes (observe contraindications)

2. Manipulation of the axillary lymph nodes on the ipsilateral side

3. Activation and utilization of the IA anastomosis to move lymph fluid from the swollen lower quadrant toward the drainage area

4. Manipulation of the inguinal lymph nodes on the contralateral side

Bilateral Secondary Lower Extremity Lymphedema

This condition is most often the result of the removal and/or irradiation of the inguinal and/or pelvic lymph nodes in cancer surgery (prostate, bladder, female reproductive organs, melanoma). Secondary lower extremity lymphedema may also occur as a result of trauma and may be combined with swelling of the lower truncal quadrant on the same side, and/or the external genitalia. Ideally, bandages should be applied on both lower extremities. If this is not possible, compression bandages should be applied to the more involved extremity.

The following sequence should be used until the truncal quadrant(s) is/are decongested (Fig. 5.23).

Patient in supine position:

1. Abbreviated manipulation of the lateral neck lymph nodes (observe contraindications)

2. Manipulation of the axillary lymph nodes on both sides

3. Activation and utilization of the IA anastomoses on both sides to promote lymph flow from the congested quadrants to the drainage areas

4. Abdominal treatment: superficial and deep (modified) techniques as outlined in the basic sequences (observe contraindications). If abdominal techniques are contraindicated, diaphragmatic breathing should be substituted.

Patient in prone position (or on side):

5. Rework of IA anastomoses on both sides

6. Decongestion of the swollen lower truncal quadrants on both sides toward the axillary lymph nodes, using modified lumbar techniques: modified effleurage; rotary techniques starting at the sagittal watershed to the side, followed by stationary circles (dynamic technique) toward the axilla using the IA anastomosis; paravertebral techniques to utilize deep drainage pathways

Patient in supine position:

7. Rework of IA anastomoses and axillary lymph nodes on both sides

8. Rework abdominal area: superficial and deep (modified) techniques

9. Application of compression bandages on both or the more involved extremity

The following sequence should be used if the truncal quadrant(s) is/are decongested and the treatment of the lower extremities becomes the primary focus.

Unilateral Primary Lower Extremity Lymphedema

This condition is the result of developmental abnormalities (see Chapter 3, Primary Lymphedema) of the lymphatic system, which are either congenital or hereditary. Primary lower extremity lymphedema may be combined with swelling of the adjacent truncal quadrant and/or the external genitalia.

Congenital malformations of the lymphatic system may also be present in the contralateral leg. If the volume of the unaffected leg increases, or if any changes in tissue consistency are noted during the treatment, the use of interinguinal anastomoses (AII and PII) should be discontinued.

Treatment sequences for this condition are very similar to the treatment of secondary lymphedema of the lower extremity. The inguinal lymph nodes in primary lymphedema are still present and should be stimulated. The goal of intervention, however, is to relieve these lymph nodes; lymph fluid is therefore rerouted around the inguinal lymph nodes toward sufficient drainage areas located in the adjacent trunk territories.

The following sequence should be used until the truncal quadrant is decongested (Fig. 5.22).

Patient in supine position:

1. Abbreviated manipulation of the lateral neck lymph nodes (observe contraindications)

2. Manipulation of the axillary lymph nodes on the ipsilateral side

3. Activation and utilization of the IA anastomosis to move lymph fluid from the swollen lower quadrant toward the drainage area

4. Manipulation of the inguinal lymph nodes on the contralateral side

5. Activation and utilization of the AII anastomosis to move lymph fluid from the swollen lower quadrant toward the drainage area on the opposite side

6. Abdominal treatment: superficial and deep (modified) techniques as outlined in the basic sequences (observe contraindications). If abdominal techniques are contraindicated, diaphragmatic breathing should be substituted.

Bilateral Primary Lower Extremity Lymphedema

This condition is the result of developmental abnormalities (see Chapter 3, Primary Lymphedema) of the lymphatic system, which are either congenital or hereditary. Primary lower extremity lymphedema may be combined with swelling of the adjacent truncal quadrant and/or the external genitalia.

Treatment sequences for this condition are very similar to the treatment of bilateral secondary lymphedema of the lower extremities. The inguinal lymph nodes in primary lymphedema are still present and should be stimulated. The goal of intervention, however, is to relieve these lymph nodes; lymph fluid is therefore rerouted around the inguinal lymph nodes toward sufficient drainage areas located in the upper truncal territories (axillary lymph nodes).

The following sequence should be used until the truncal quadrant(s) is/are decongested (Fig. 5.23).

Patient in supine position:

1. Abbreviated manipulation of the lateral neck lymph nodes (observe contraindications)

2. Manipulation of the axillary lymph nodes on both sides

3. Manipulation of the inguinal lymph nodes on both sides

4. Activation and utilization of the IA anastomoses on both sides to promote lymph flow from the congested quadrants to the drainage areas

5. Abdominal treatment: superficial and deep (modified) techniques as outlined in the basic sequences (observe contraindications). If abdominal techniques are contraindicated, diaphragmatic breathing should be substituted.

Patient in prone position (or on side):

6. Rework of IA anastomoses on both sides

7. Decongestion of the swollen lower truncal quadrants on both sides toward the axillary lymph nodes, using modified lumbar techniques: modified effleurage; rotary techniques starting at the sagittal watershed to the side, followed by stationary circles (dynamic technique) toward the axilla using the IA anastomosis; paravertebral techniques to utilize deep drainage pathways

Patient in supine position:

8. Rework of IA anastomoses and axillary lymph nodes on both sides

9. Rework abdominal area: superficial and deep (modified) techniques

10. Application of compression bandages on both or the more involved extremity The following sequence should be used if the truncal quadrant(s) is/are decongested and the treatment of the lower extremities becomes the primary focus.

Therapy proceeds with the other leg, once the more involved extremity is decongested. Generally, a pantyhose-style compression garment is ideal for this condition, once both extremities are decongested. To preserve the results in the leg that was treated first, compression bandages should be applied. If this is not possible, the patient should be fitted with a thigh-high compression garment (preferably a relatively inexpensive standard-size garment) while the other extremity receives treatment, then be fitted with a pantyhose-style garment.

Patient in supine position. Abbreviated trunk preparation (pretreatment):

1. Abbreviated manipulation of the lateral neck lymph nodes (observe contraindications)

2. Manipulation of the axillary lymph nodes on both sides

3. Activation and utilization of the IA anastomoses on both sides to promote lymph flow across the watersheds into the drainage areas

4. Manipulation of the inguinal lymph nodes on both sides As discussed earlier, inguinal lymph nodes in primary lymphedema are used as additional drainage areas. Lymph fluid from more distal sections of the leg should not be manipulated toward the inguinal nodes, but rerouted around them, as in the treatment of secondary lymphedema (see secondary lower extremity lymphedema).

5. Abdominal treatment: superficial and deep (modified) techniques as outlined in the basic sequences (observe contraindications). If abdominal techniques are contraindicated, diaphragmatic breathing should be substituted.

Patient on the side (or prone position), with the more involved extremity on top:

6. Rework of the IA anastomosis on the more involved side

7. Manipulation of the lateral thigh between the lateral knee and the iliac crest, using basic techniques (“bulk flow” techniques)

Patient in supine position:

8. Rework of IA anastomoses on both sides

Treatment of the lower extremity:

Genital Lymphedema

Genital lymphedema is a challenging condition that very often causes real and long-lasting physical, emotional, and social problems for the affected patients. This condition can affect both males and females but is more common in males due to the greater tissue elasticity of the scrotum and penis, combined with the effects of gravity (Fig. 5.24).

Reliable numbers on the incidence of genital swelling are unavailable because this condition often remains undiagnosed; genital edema is generally not a topic of conversation, unlike swelling of an extremity following surgery.

Genital lymphedema is usually irreversible without treatment, and once it develops, it tends to become more fibrotic and increases in size. It can be effectively controlled and maintained with complete decongestive therapy (CDT). In some cases, genital swelling may occur acutely following surgery or trauma and may resolve completely by itself.

In most cases genital lymphedema is combined with lower extremity lymphedema. For a detailed discussion of genital lymphedema treatment, see p. 280–291.

Filariasis is another common cause of genital swelling in endemic regions (see Chapter 3, Pathology, and Fig. 3.4a, b).

A very common reason for the onset of genital swelling is the use of pneumatic compression pumps for the treatment of lower extremity lymphedema. Boris, Weindorf, and Lasinski published a paper in the March 1998 edition of Lymphology and concluded that the use of external pneumatic compression pumps in the treatment of lower extremity lymphedema produces an unacceptable high incidence of genital edema¹ (See Chapter 3, Therapeutic Approach to Lymphedema).

Clinical Picture

Various combinations of genital anatomy swelling may occur. In males, isolated penile swelling is rare. Combined penile and scrotal swelling is a more common presentation. The scrotum may swell to such an extent that ambulation becomes difficult. The lower quadrants and/or lower extremities often accompany genital swelling. Additional involvement of the pubic area frequently causes the penis to retract into the scrotum.

In females, the labia minora and the labia majora may be included in the swelling. These areas could project several centimeters out of the vagina. Clear labial/vaginal discharge (lymphorrhea), the appearances of papillomas or warty growths are often symptoms indicating genital involvement, especially if the patient had pelvic or gynecological procedures. Vaginal discharge for other reasons is often a curdish, white, thick discharge.

Genital swelling frequently causes problems in urination and sexual activity, depending on the extent of the involvement.

Evaluation

Other conditions, such as active malignancies, renal, liver, cardiac or venous problems can cause genital edema. A thorough evaluation with a clear diagnostic picture is necessary before MLD/CDT can be initiated.

History

• What kind of surgery (if any) was performed and how many lymph nodes were excised?

• Were there any cellulitis attacks in the past? Where did they start?

• Pain? Some patients describe bursting sensation or an ache around the genital area (pain generally recedes with treatment). Males often complain about painful erections.

• Were/are there any problems with bowel or bladder function following surgery or radiation?

• Are appropriate hygienic measures possible?

• Is the patient circumcised?

Inspection

• Any moist areas, lymphatic cysts, lymphatic fistulas (Fig. 5.25), lymphorrhea (patients often use sanitary or incontinence pads)?

• Extent of the swelling? Penis/scrotum; external/internal labiae; pubic area; lower quadrant and/or lower extremity (unilateral/bilateral)

• Scars?

• Skinfolds in the genital region?

• Papillomas, warts?

• Bacterial or mycotic infections? (Patients with discharge from the area often complain about malodor; lymph itself has no odor, but is very high in protein content, which presents an excellent breeding ground for bacteria, causing malodor.)

Palpation

To maximize the therapeutic effect, genital bandaging may be performed prior to the application of hands-on techniques for the pretreatment of the drainage areas. Following the treatment sequence, the bandages are removed and the MLD techniques in the swollen genital area are performed (see page 283). The therapist then proceeds with the application of the final compression bandage. The application of compression bandages on the genital area is discussed later in this chapter.

Patient in supine position:

1. Abbreviated manipulation of the lateral neck lymph nodes (observe contraindications)

2. Manipulation of the axillary lymph nodes on both sides

3. Activation and utilization of the IA anastomoses on both sides to promote lymph flow across the watershed into the drainage areas

4. If inguinal lymph nodes are present, manipulation of the inguinal lymph nodes on both sides

5. Abdominal treatment: superficial and deep (modified) techniques as outlined in the basic sequences (observe contraindications). If abdominal techniques are contraindicated, diaphragmatic breathing should be substituted.

If the lower truncal quadrants are congested, the patient is turned into the prone position at this point, and the lumbar areas are decongested in the following manner. Decongestion of the swollen lower truncal quadrants on both sides toward the axillary lymph nodes, using modified lumbar techniques; modified effleurage; rotary techniques starting at the sagittal watershed to the side, followed by stationary circles (dynamic techniques) toward the axilla using the IA anastomosis; paravertebral techniques to utilize deep drainage pathways. The patient is then turned back into the supine position.

6. Treatment of the scrotum: stationary circles on both sides of the scrotum to manipulate the lymph fluid toward the pubic area, and from here toward the axillary lymph nodes on the respective side, utilizing the IA anastomoses.

7. Application of bandages (see Lower Extremity Bandaging, p. 256 and Compression Bandaging for Male Genital Lymphedema, p. 286 later in this chapter)

Phlebo-Lymphostatic Edema

This condition is a result of a venous insufficiency (for pathology, refer to Chapter 3, Chronic Venous and LymphoVenous Insufficiency). The deficient venous valves in chronic venous insufficiency (CVI) fail to prevent retrograde flow of venous blood during muscle pump activity, which in turn directly affects the lymphatic system.

Over time, and if CVI is left without treatment, damage to the lymphatic system, combined with reduction in transport capacity is unavoidable. The presence of lymphedema in stages II and III of CVI necessitates the application of the complete spectrum of complete decongestive therapy. If venous ulcerations are present, appropriate wound dressings and skin care products, prescribed by the physician, are applied before CDT starts (refer to Chapter 3, Complete Decongestive Therapy). The wound remains covered during the treatment, and MLD techniques are directed away from and around the ulcer bed. Treatment in and around the wound area is performed wearing sterile gloves. Decongestion of the extremity greatly increases the tendency of venous stasis ulcerations to heal.

The treatment protocol for lymphedema associated with CVI corresponds with the protocol for primary lymphedema; fibrosis and edema techniques are contraindicated.

Patient in supine position. Abbreviated trunk preparation (pretreatment):

1. Abbreviated manipulation of the lateral neck lymph nodes (observe contraindications)

2. Manipulation of the axillary lymph nodes on the ipsilateral side

3. Activation and utilization of the IA anastomosis to promote lymph flow across the watershed toward the drainage area

4. Manipulation of the inguinal lymph nodes on the contralateral side

5. Activation and utilization of the AII anastomosis to promote lymph flow across the watershed toward the drainage area on the opposite side

Lipolymphedema

Patient in supine position:

Head and Neck Lymphedema

Head and neck lymphedema (HNL) is much less common than edema of the extremities, but HNL is a particularly concerning complication for patients and their families, especially when severe, as in the case shown in Fig. 5.26a, b. When HNL causes eyelid swelling, tasks involving vision, such as reading, writing, walking, and driving, may be affected. When the lips and tongue are edematous, articulation, chewing, swallowing, and even respiration can be impaired, possibly requiring a tracheotomy. Breathing can also be affected in patients who have undergone a total laryngectomy when severe submental and anterior neck edema occludes the tracheostoma, requiring the use of a device such as a laryngectomy tube or laryngectomy button to maintain a patent airway, as in Fig. 5.26b. Even when the edema is relatively minor and does not create a functional impairment, cosmetic concerns can arise that create psychosocial and emotional issues, since neck and facial edema cannot be easily hidden. HNL is often overlooked, misdiagnosed, or minimized as an inevitable and untreatable outcome of cancer treatment. At other times, a clinician may identify HNL but be ill prepared to treat the patient because of a lack of experience of the condition. The ability to effectively evaluate and treat HNL is crucial to maximizing the patient’s quality of life. The information presented in this chapter is intended to reduce clinician concerns and assist in the evaluation, treatment planning, and management of HNL.

HNL may be present with primary lymphedema, either in isolation or as part of a syndrome, and is a characteristic of Hennekam syndrome, Turner syndrome, Milroy disease, Apert syndrome, and other disorders.2 Primary lymphedema of the head and neck, however, is less common than primary lymphedema of the extremities and will not be addressed in this chapter.

Inflammatory causes of facial lymphedema include severe rosacea (including rhinophyma and otophyma), acne vulgaris, Melkersson–Rosenthal syndrome, and other dermatologic conditions.² While the most common cause of lymphedema worldwide is filariasis,^3,4 this author is unaware of any articles documenting filarial lymphedema of the head and neck. More commonly, HNL presents as a secondary lymphedema due to injury of the lymphatic tissues from chronic infections, blunt force trauma, surgery, radiotherapy, or vascular obstruction by a mass (malignant lymphedema)² as shown in Fig. 5.27. Facial edema is a potential complication of certain cosmetic and dermatologic procedures, though chronic HNL after cosmetic procedures is not commonly reported. Manual lymph drainage (MLD) following facelift procedures has been used to reduce postoperative edema. Variations of traditional facial drainage pathways are implemented according to surgically altered tissue orientation.⁵ HNL is not common after surgery for noncancerous maladies of the head and neck, though with any surgery the potential exists for drainage impairment and edema due to scarring. One possible explanation for the higher incidence of HNL after the removal of malignant lesions compared with nonmalignant lesions is that the lymphatics are typically not removed in head and neck surgeries for patients not undergoing cancer treatment.^6–9

HNL after Cancer Treatment

HNL occurs most frequently in patients who have undergone surgery and/or radiotherapy for cancer³ and seems to be most severe when multimodality treatment is provided, though the role of chemotherapy in the development of HNL is not known. Taxane-based chemotherapy has been linked to lymphedema of the extremities,¹⁰ and

HNL has been reported in patients treated with cisplatin^10,11 combined with radiotherapy. There are no published accounts of HNL following chemotherapy in isolation for head and neck cancer, though pemetrexed-induced edema of the eyelid and periorbital region has been reported with lung cancer treatment.¹³ At this time, there are not sufficient data to suggest a causative relationship between most current chemotherapy regimens and chronic HNL.

HNL has been documented in as many as 48% of patients who received radiotherapy to the head and neck.¹⁴ The insult to the lymphatic system that occurs from radiotherapy can be widespread, since the primary tumor, adjacent soft tissues, bony structures, and relevant lymphatic drainage pathways may all be irradiated in an effort to shrink existing tumors, treat persistent microscopic disease, and prevent metastasis. Tissue fibrosis is a common complication of radiotherapy and can inhibit lymphangiomotoricity and effective tissue drainage. Patients who receive radiation to the head and neck often develop chronic edema of tissues within the irradiated field, which commonly encompasses the lower face, neck, and supraclavicular fossa. When re-irradiation is required to treat cancer recurrence, further tissue damage occurs, increasing the severity of tissue fibrosis and associated HNL.15

Surgery to address head and neck cancer commonly requires the removal of the tumor and the surrounding soft tissues. Removal of bone may also be required if there is tumor invasion or if there is severe damage to the bone from radiotherapy (osteoradionecrosis).¹⁶ Depending on the extent of the surgery, reconstruction may be required with pedicled flaps such as pectoralis and rotational flaps, which retain their native venous, arterial, and lymphatic vessels. In more complex cases, free tissue transfers from one part of the body to another may be required. For example, tissue from the forearm or thigh may be used to replace a portion of the tongue or pharynx or to cover the surgical defect after removal of a portion of the face, as shown in Fig. 5.28. These “free flaps” require microvascular surgery to reattach blood vessels for flap viability. Lymphatic vessels are not commonly reconnected in these procedures, however, leaving only the venous system to drain the free flap, which can swell substantially at times. Lymphadenectomy is a common surgical procedure in the treatment of head and neck cancer, often requiring removal of more than 30 cervical, facial, mediastinal, paratracheal, or supraclavicular lymph nodes.^17–19 When sacrifice of jugular veins is required due to tumor involvement or severe radiation scarring, the disruption of the venous drainage system in the head and neck increases the risk of HNL. This lymphatic and venous disruption results in a lympho-venous or “mixed edema,” which is typically less responsive to treatment than a pure lymphedema. Additionally, surgical scarring can directly impact the development of HNL due to a “trapdoor effect,”²⁰ in which a scar prevents drainage through the lymphatic channels of the skin, resulting in edema above the scar but not below. Multimodality cancer treatment creates a unique environment for the development of both mild and severe lymphedemas in the face and neck that can be challenging to evaluate and treat.

Evaluation

Piso et al. published a reliable assessment protocol for facial edema in 2001,²¹ yet HNL evaluations vary from facility to facility and often from clinician to clinician. Inconsistency in evaluation methodology hinders objective data acquisition and analysis to determine best treatment practices, forcing reliance on subjective data such as visual assessment, patient questionnaires, and clinicianscored rating scales. Development of high-tech solutions to evaluate HNL has been limited, though ultrasound and magnetic resonance imaging have been reported as diagnostic tools for edema assessment in the head and neck.^2,22,23 Efforts are being made, however, to implement standard evaluation protocols for HNL.^24,25 Components of a basic HNL evaluation are suggested below.

Clinical assessment of the patient is the most important aspect of any lymphedema evaluation, but there are specific concerns when evaluating a patient with HNL. The traditional assessment of tissue integrity, warmth, color, firmness, pitting, and tissue changes must be included. An accurate, thorough medical history is crucial, since intraoral, facial, or neck edema may result from infection, hypothyroidism, allergic reactions, postoperative seroma, hematoma, angioedema, lymphatic metastasis, or other causes.2,26 When the presentation and history do not support the diagnosis of lymphedema, referral to the patient’s physician for further evaluation is appropriate. For example, distended jugular veins in the presence of facial edema suggests superior vena cava syndrome, which is often caused by a mass compressing the superior vena cava and can constitute a medical emergency.²⁷

A significant history of upper-quadrant deep vein thrombosis (DVT), cerebrovascular accident (CVA), transient ischemic attack (TIA), carotid artery compromise, congestive heart failure (CHF), renal disease, hyperthyroidism, tissue breakdown, or other medical concerns may be sufficient to withhold lymphedema treatment, despite the severity of the swelling.²⁶ Lymphedema treatment may result in a CVA or increased edema if provided inappropriately and could cause death if there is tumor invasion of the carotid artery and manipulation results in rupture of the vessel (carotid blow-out). Lymphedema management may be requested as a palliative treatment to temporarily alleviate discomfort or reduce functional impairments that result from massive facial edema. Palliative treatment can improve the patient’s quality of life and should be provided if it appears that treatment can be effective and there is no immediate risk of harm, but treatment is not appropriate in all cases. If you have concerns about the patient’s safety, further discussion with the patient’s physician may be warranted, since physician approval is essential before initiating any HNL treatment.

Table 5.1 Obtaining a composite neck measurement

Adapted from Smith and Lewin, 2010²⁴

Tape Measurement

Tape measurements are an essential tool for documenting change over time and assessing the effectiveness of treatment. Consistent tape placement and tightness are required for the most accurate measurements possible, though the potential for error exists with all manual tape measurement practices. For consistency, the following guidelines should be observed. If possible, obtain measurements while the patient is sitting upright with the head in a neutral position to assess edema in a natural posture. Mark the measurement landmarks on the skin to ensure consistent tape placement. Measurements should be obtained in centimeters and recorded on a tracking form or in a database for future comparison. The patient’s trunk and head positions should be replicated in each evaluation to ensure consistent data acquisition. The measurement protocol published by Smith and Lewin²⁴ includes a combination of neck circumferences, head circumferences, and point-to-point facial measures to provide a comprehensive assessment of the face and neck. These are described below.

The superior, middle, and inferior neck circumferences, shown in Table 5.1 and Fig. 5.29, can be combined to obtain a composite neck measurement that reflects change throughout the entire neck rather than in just one area. The superior circumference should be obtained by placing the tape measure horizontally around the upper portion of the neck, just below the mandible and chin. The inferior neck circumference is obtained in a similar fashion at the base of the neck. The medial neck circumference is obtained at the midpoint between the superior and inferior neck measurement sites. Adding these three circumferences creates a composite neck score that can then be used for comparison over time. A difference of 2% or more between the baseline and follow-up composite scores has been considered significant.²⁸ Changes of less than 2% are not considered clinically significant because of the potential for errors in tape placement, positional inconsistencies, and other variables. Only composite scores, and not individual measurements, can be assessed using the 2% rule.

Facial Composite

A composite facial score can be achieved by combining seven point-to-point facial measurements, as shown in Fig. 5.30. These measurements are totaled on each side of the face to create left and right hemifacial scores. The hemifacial scores are then combined to create the total facial composite score, which can be compared with facial composite scores over time to assess facial changes using the 2% rule. The hemifacial scores cannot be compared with each other to determine the presence of edema in one side of the face, unlike comparisons made between right and left limbs. Treatment of the head and neck is often bilateral, and even when treatment is provided unilaterally, bilateral edema is common. There are no published data specifying a percentage of swelling to distinguish between edematous and normal facial tissues. Therefore, measurements of facial edema should be reported as a total facial composite.

Additional measurements as shown in Fig. 5.31 can be used to assess submental or lateral facial and mandibular edema. Distances between the right and left tragus or between the right and left mandibular angles can be helpful, as can vertical and diagonal circumferences of the head. These measurements are not included in the neck or facial composite scores and are not subject to the 2% rule, but they can provide valuable feedback regarding treatment changes. Additional circumferential measures can be obtained when there is substantial edema in the forehead, eyebrows, eyelids, or lips. Measures of lip or tongue protrusion and swelling of the nose or ear can also be obtained if necessary, but these are not commonly utilized.

Facial Irregularities

Sometimes a total facial composite cannot be obtained because a facial landmark cannot be identified. This may result from surgical removal of the landmark, tissue breakdown, tumor eruption, nonremovable dressings, or excessive edema that prevents palpation. Comparison of partial composites or hemifacial scores may be helpful in these cases in which only certain measurements can be obtained, though the 2% rule cannot be applied if the total facial composite is unavailable. However, composite scores can be obtained if the correlate of the missing landmark can be used to replicate its position. For example, if the right mandibular angle cannot be identified, the vertical distance between the unaffected left tragus and the left mandibular angle can be measured. If this distance is 5 cm, a mark can be placed 5 cm below the tragus on the right side, providing a usable landmark for the affected side. Likewise, if the right tragus is not present, the clinician should first obtain a horizontal measurement from the existing tragus to the tip of the nose. If this distance is 13.5 cm, a mark can be made 13.5 cm from the tip of the nose to the approximate location of the left ear, providing an alternative tragus landmark that can be used to complete the facial composite score. If both landmarks are missing, as in Fig. 5.32, first recreate the tragus landmark, and then the mandibular angle location can be determined. Photographic documentation featuring the locations of the replicated landmarks and the distances between each anchoring point are helpful for recreating the landmarks in future evaluations.

The severity of lymphedema has traditionally been classified according to clinician-graded rating scales. The most well known is the Földi scale,3 which was developed on more than 100 000 patients and features stages 0, 1, 2, and 3, ranging from nonvisible but perceptible edema to irreversible swelling with severe fibrosis and tissue changes including hyperkeratosis and papillomatosis. Most lymphedema rating scales, including the Földi scale, were developed for assessment of limbs and have been applied to the head and neck by default. Unfortunately, these scales do not capture subtle differences that often exist with HNL, resulting in a forced classification that does not completely describe the HNL patient’s presentation. Recently, the Patterson scale25,29 has been used to assess internal edema of the pharynx, larynx, and base of the tongue, but it is limited to visual assessment via endoscopy and does not address “external lymphedema” in the neck or face. In 2010, the MD Anderson Cancer Center Head and Neck Lymphedema (MDACC HNL) Rating Scale was published.²⁴ The MDACC HNL scale is a nonvalidated tool developed to document lymphedema presentations common among patients with HNL, but not identified by Földi’s scale. It offers a stage 1a classification to identify patients with visible but nonpitting edema and stage 1b for patients presenting with pitting, reversible edema. Criteria for stages 0, 2, and 3 reflect the original descriptions by Földi. Table 5.2 compares these two scales. It should be noted that all clinician rating scales are subjective assessment tools, and clinician judgment can vary according to training and experience. Further investigation and development of a comprehensive, standardized, user-friendly scale that accurately depicts the characteristics of HNL would enable more consistent data comparison for future clinical research.

Table 5.2 Comparison of the MDACC HNL and Földi scales

Adapted from Smith and Lewin, 2010²⁴

Treatment of HNL

HNL has historically been perceived as a difficult condition to manage. This perception may be due to limited experience with head and neck cancer and its treatment, unfamiliarity with the anatomy of the head and neck, the various presentations of HNL, or uncertainty regarding treatment techniques, which can differ from traditional treatment of lymphedema in the extremities. Techniques used to manage HNL are often taught in advanced courses and are not typically addressed during training for certification in manual lymph drainage (MLD) or complete decongestive therapy (CDT), most likely due to the relatively low incidence of head and neck cancer compared with that of breast cancer and other conditions. Clinicians who do not practice in a tertiary care center³⁰ with an emphasis on head and neck cancer, which comprises only 3–5% of all cancers,³¹ may rarely encounter a patient with HNL.

HNL should be treated using a standard CDT approach, though MLD and compression are typically the two primary CDT components used to address the head and neck.32 Exercises and stretches for the neck, face, and shoulder region are commonly applied as part of post-treatment rehabilitation to address speech and swallowing function as well as cervical and upper extremity range of motion. These rehabilitation techniques are generally appropriate for HNL as well, especially while the patient is wearing compression. Skin and wound care is extremely important for patients recovering from surgery and for those undergoing radiotherapy. Skin and wound care should be performed under the guidance of the patient’s medical team when required, but once the skin is healed, persistent care is not commonly required for patients with HNL. Variations of MLD and compression techniques may be needed to treat HNL. Irradiated tissues should be addressed with caution, and certain precautions must be observed when applying compression to the head and neck region. While the differences between treating HNL and lymphedema of the extremities may be considered challenging, HNL can be treated very effectively with appropriate intervention, as shown in Fig. 5.33. Additional treatment considerations are outlined below.

Outpatient versus Self-Administered Treatment

Traditionally, lymphedema has been treated on an outpatient basis so that skilled MLD treatment, compression wrapping, and wound care can be provided by a certified lymphedema therapist (CLT) several times a week for a period of weeks or months. When possible, it is recommended that HNL be treated on an outpatient basis by a CLT, though the frequency and duration of treatment is often less than that required for lymphedema of the extremities. While extended therapy may be required in some cases, it is not uncommon for HNL treatment plans to feature 2 to 3 visits per week for 1–2 weeks, after which patients are discharged to perform their home program. Patients should always be trained in a home program during the early stages of rehabilitation to enhance carryover. After treatment, follow-up evaluations at 1, 3, and 6 months are recommended to ensure adequate home program follow-through and continued progress. However, treatment modifications are common and more frequent reassessments or prolonged treatment may be required depending on patient progress. Naturally, severe cases may require intensive treatment of greater frequency per week and longer duration overall.

A though outpatient treatment is preferred, patients with HNL have also been shown to benefit from training in the use of a “self-CDT” approach, primarily featuring self-administered MLD and compression.28 The self-administered therapy approach is most appropriate when the patient presents with mild edema and is physically and mentally capable of self-treatment or has good caregiver support. It can also be implemented when consistent access to a qualified lymphedema therapist is not available as a result of the patient’s illness, issues with finances, transportation, or because health care resources are limited in the patient’s home locale. Once the patient and/or caregiver are trained, the treatment is implemented at home, with follow-up evaluations to evaluate progress and address any changes required in the treatment plan.

Of course, treatment effectiveness is of the utmost importance, and self-CDT does have limitations. These may be related to the physical or cognitive abilities of the patient or caregiver, inconsistent or inaccurate performance of MLD routines, or lack of caregiver support. The absence of a CLT is a disadvantage, as well. However, Lewin et al.²⁸ reported compliance as the primary factor influencing successful edema reduction in patients primarily treated with a self-administered lymphedema management protocol. Significant edema reductions were observed at the first follow-up visit in 83% of patients who were compliant in their home management program and in 54% who were partially compliant. The noncompliant group did not demonstrate improvement as a whole.

Whether a self-administered home lymphedema management protocol is appropriate for a particular patient depends on the ability and willingness of the patient or caregiver to perform the prescribed routine independently. For example, when a patient requires posterior drainage due to significant neck scarring, it is preferable that the anterior and posterior trunk be decongested for maximum benefit. MLD of the back cannot typically be performed by the patient, mandating caregiver assistance. If a caregiver is unavailable and the patient must perform self-MLD, only anterior trunk decongestion can be achieved, which is less efficient and may not be as effective for posterior drainage. However, a capable caregiver may be able to perform the prescribed routine proficiently, so caregiver availability and willingness to assist should always be addressed in the evaluation. Simultaneous training of the patient and caregiver is preferred, and individual responsibilities should be clearly identified to ensure acceptable levels of involvement by both parties.

When outpatient treatment for HNL is recommended but is not convenient, the use of a self-CDT home program often becomes the primary intervention. While success has been achieved with some severe cases using a home management approach, many cases are simply too complex for self-administered treatment and require intensive outpatient treatment by a skilled, experienced clinician to achieve significant improvement. If it is clear during re-evaluation that the home program has been ineffective and reasonable treatment modifications are not possible, further discussion may be required to determine additional options to obtain treatment from a qualified lymphedema therapist.

MLD Treatment Sequences for HNL

In theory, MLD sequences for HNL are not vastly different from standard MLD protocols for limbs. Anterior and posterior MLD sequences for HNL are intended to mobilize lymph from the head and neck to the bilateral axillae, with sequence selection dependent on scarring or other obstructions. Stationary circles can be used as the primary MLD technique in almost all locations, making these routines easy to teach for self-MLD treatment. Other techniques may be substituted by certified lymphedema therapists as appropriate. Standard Vodder technique²⁶ pacing (once per second) and frequency (7–10 repetitions per location) apply until the edematous region is reached, where a minimum of 20–30 repetitions should be performed in each location. Progression to the next adjacent area is based on tactile changes identified by the clinician.

Positioning

Patient positioning during treatment can vary with HNL management. While a supine or reclined sitting position is preferred for posterior facial and neck drainage in patients with significant scarring or severe edema, many patients with HNL do not tolerate lying in a supine, prone, or even reclined position because of respiratory difficulties, kyphosis, neck fibrosis, or other conditions. In these cases, MLD should be performed with the patient lying on his or her side or sitting in an upright position. The most important benefit of seated treatment is that the patient can breathe more easily and remain comfortable during treatment. Although seated treatment may reduce the effectiveness of posterior drainage in severe HNL, seated MLD is very effective for most posterior, anterior, and trunk decongestion routines.

Trunk Decongestion

For maximum effectiveness, trunk decongestion must be performed to open lymphatic channels and promote lymph flow from congested areas to functional drainage basins. Many clinicians have started treatment for patients with HNL in the edematous face and neck without first decongesting the trunk. This is not recommended. Likewise, it is common to perform a neck decongestion routine in a “normal” neck before addressing the trunk as part of upper extremity treatment.26 This is not appropriate when HNL is present. Decongestion of the terminus, abdomen, axillae, and trunk should be addressed before the edematous head or neck is treated. An exception to this recommendation is when the patient has very mild edema and has not received radiotherapy to the neck or supraclavicular fossa. If the supraclavicular region is not damaged, it may be possible to treat with an abbreviated MLD routine that begins at the terminus and progresses directly to the neck and face, without the need to decongest the trunk or axillary lymph node beds. Otherwise, trunk decongestion is essential prior to addressing edema in the head and neck.

Strossenreuther and Klose previously described posterior trunk decongestion for HNL in a seated position.³² However, a standard trunk decongestion sequence featuring anterior and posterior trunk decongestion is preferred for maximum drainage. If the patient is in an upright seated position, a clinician or caregiver can decongest the anterior and posterior trunk simultaneously via the “sandwich technique” shown in Fig. 5.34. To perform the sandwich technique, the clinician or caregiver is positioned to the side of the patient. In steps 1, 5, 6, 7, and 8 in the sequence outlined below, hands are placed on the chest and back simultaneously, sandwiching the patient between them. Performing simultaneous stationary circles, pulling laterally toward the axilla, the clinician can simultaneously decongest the anterior and posterior trunk on one side. The clinician or caregiver can then move to the opposite side of the patient or reposition the patient’s chair so that the remainder of the trunk can be addressed, allowing for a complete trunk decongestion in 5–8 minutes, typically. This is a more efficient means of addressing the trunk, providing much more time to address the edematous regions of the face and neck during the treatment session.

Trunk Decongestion Manual Lymph Drainage Sequence

A standard trunk decongestion sequence is shown below. If pitting edema is present, the patient should wear a softening pad 30 minutes prior to and during the trunk decongestion sequence (steps 1–8). The softening pad should be removed at step 9 and a flattening pad applied after MLD is complete. Additional information regarding compression padding is outlined in the Compression section of this chapter. This sequence can be performed with the patient in any position, though is optimized in a seated position.

HNL anterior MLD routine: 1–8. Bilateral trunk decongestion, as described above.

In some cases, significant scars exist that prevent anterior drainage. Scars can frequently be softened and reduced with the use of scar massage, scar reduction creams, silicone sheeting, elastic therapeutic tape, and other techniques. Scar reduction can improve the ability to mobilize lymph through the scarred area, allowing a more direct drainage pathway. Reestablishment of drainage across scars in the head and neck has been recently documented,33 supporting longstanding clinical beliefs that with proper intervention, the effects of scarring can be overcome to some degree. However, thick scars, tissue breakdown, or erupted tumors may force a redirection of lymph from the preferred drainage channels, requiring posterior drainage.

Posterior Neck and Facial Drainage for HNL

The HNL posterior MLD sequence is designed to mobilize lymph away from significant scarring in the face or neck as discussed above. Stationary circles can be used as the primary technique in almost all locations. Before this sequence is performed, posterior trunk decongestion is required. This sequence should be performed by a caregiver or clinician. If self-MLD is required, please refer to the Combined Self-MLD sequence on page 320.

HNL posterior MLD routine: 1–8. Bilateral trunk decongestion

9. Posterior neck: Flat hands, perform MLD downward into upper back

10. Repeat inferior MLD movements, progressing up the posterior neck into the lower posterior scalp, mobilizing fluid into the neck and back

11. Progressively moving across the lateral scalp, perform posterior MLD techniques to mobilize fluid to the posterior head and upper neck

12. Move hands to the preauricular region, mobilizing upward and posteriorly to the lateral scalp using MLD techniques

13. Move hands to the anterior face, performing downwards stationary circles away from midline toward the preauricular region, avoiding upward pressure that can fill the eyelids

14. Move hands inferiorly to address the lateral jowls and mandibular regions. Perform MLD techniques upward to the preauricular region and primary drainage channel over the ear and into the lateral scalp.

15. If intraoral edema is present, perform intraoral techniques at this time

16. Move hands to the submandibular and submental regions, performing MLD techniques upward to the lateral face

17. Continue in this fashion in the upper neck, mobilizing away from midline and upward, away from the neck scar. Begin posteriorly, then advance anteriorly until the midline is reached.

18. Once the neck and face have been decongested, reverse the sequence and perform steps 17, 16, 15, 14, 13, 12, 11, 10, 9, 8, 7, 6, and 5 to mobilize the fluid to the axillary nodes

After completion, apply compression as directed.

Intraoral MLD

Intraoral edema may range from mild to severe and can impair articulation, chewing, swallowing, and respiration, depending on the structures involved. MLD can usually be performed to reduce intraoral swelling but should be avoided in patients with mucositis (Fig. 5.35), open surgical wounds, and other tissue injuries.²⁶ Depending on hand size, the presence of trismus, and the severity of the edema, the patient, caregiver, or clinician may only be able to use 1 or 2 fingers to address intraoral edema. Caution should be observed with loose or jagged teeth, stitches, and hypersensitive gag or bite reflexes to avoid injury. Due to the moisture in the mouth, fingers tend to slide along the mucosa. Water-based lubricants that are safe for intraoral use can be beneficial if the mouth and lips are excessively dry. In most cases, bilateral intraoral MLD is recommended due to the extensive contralateral drainage in this region.34 Occasionally, an oral free flap will be present and may also appear edematous. MLD is generally not recommended for free flaps due to the lack of lymphatic re-anastomosis, but MLD can be performed on the flap if trials prove effective. Free flaps atrophy over time, and MLD to this tissue does not typically affect the speed of flap reduction. As a result, intraoral MLD should address native tissues in most cases. A description of intraoral MLD is provided below.

MLD techniques for the tongue, floor of the mouth, and palate follow a similar pattern of lateral and posterior drainage. Decongestion should begin as far posterior as tolerated, with posterior and lateral stationary circles away from the midline.²⁶ Move anteriorly to the next adjacent area once judged appropriate. Repeat the sequence until the entire region is decongested. MLD of the tongue requires caution, since MLD without cushioning the underside of the tongue may result in tissue injury from friction against the teeth. If swelling is not too severe, it may be possible to position the tongue lower in the mouth between the teeth before treating. If the tongue is protruding from the mouth or lying against sharp teeth, the clinician should protect the underside of the tongue by using a finger, tongue depressor, gauze pad or by grasping and supporting it during MLD. Protection of the tissue is of utmost importance to avoid infection, and MLD in this region should be avoided if there is potential for injury as a result of tissue manipulation.

Decongestion of the lips also begins laterally, near the oral commissure. Place the lip between the thumb and forefinger, with the thumb inside the mouth, and stabilize with the outer finger. Finger and thumb placement can be reversed if necessary. Perform stationary circles laterally to the mouth corner. After the appropriate number of repetitions, move medially and repeat the sequence until reaching the midline. Reverse the sequence and drain laterally from the midline until the oral commissure is reached and the entire half of the lip is decongested. Repeat the sequences on the other half of the lip. In severely swollen lips, this sequence may need to be repeated multiple times in one session but immediate reductions can often be obtained. Pressing the lips together for 10–20 seconds during brief stoppages of MLD can also help prevent the rapid refilling of tissues during treatment.

MLD for the cheek and buccal mucosa should address the inner and outer tissues. Place 1 or 2 fingers against the swollen buccal mucosa. Support the outer cheek with the opposite hand.²⁶ Begin as far posteriorly as possible and perform posterior overhand stationary circles. Repeat the sequence in the anterior, superior, and inferior portions of the buccal mucosa until the entire cheek is addressed. The exterior cheek can also be addressed in this fashion, with the internal fingers providing support. Patients can perform a one-handed approach using the thumb inside the opposite side of the mouth and using the remaining fingers to support the cheek. Again, posterior overhand stationary circles can be applied. This method is usually less efficient since less tissue is being manipulated during MLD, but may be beneficial in some cases.

Intraoral MLD can be a very effective tool for reducing edema of the oral cavity. Unfortunately, MLD has not been proven effective in the reduction of edema that is present in the pharynx or larynx, sometimes called internal lymphedema,25 which can affect swallowing and pose airway concerns. While the presence of edema in these regions for 3–6 months is not uncommon and edema around the internal carotid artery has been identified 2 years after completion of radiotherapy,^15,23,35,36 there remains debate whether persistent swelling in the pharynx and larynx is edema or lymphedema. The inability to assess tissue characteristics with techniques other than endoscopic examination currently limits clinical evaluation of edema in the upper aerodigestive tract. Regardless of etiology, treatment options available to address internal lymphedema have been limited to medical management with steroids or other anti-inflammatory regimens. Traditional approaches for direct lymphedema management, such as MLD, are impractical for addressing internal structures such as the pharynx and larynx. No studies that demonstrate the effectiveness of CDT for reducing internal edema of the larynx and pharynx are available, though anatomic connections suggest that MLD to the external tissues of the neck should reduce edema internally.³⁴ Additional research is warranted.

Compression for HNL

The use of compression garments and wrapping for the head and neck is a controversial subject, with proponents utilizing a wide variety of compression techniques and opponents using no compression at all. The primary concern related to compression in this region is the potential for compression of major blood vessels in the neck and complications from resultant vascular events, such as hypoxia, thrombosis, and CVA/TIA.^37,38 This risk is markedly increased in patients with blockages of the carotid artery, significant cerebrovascular disease, history of CVA, or other vascular abnormalities like tumor invasion of a major blood vessel in the neck. These contraindications should have been identified during the initial evaluation, but their absence must be verified before the application of compression. Excessive anterior neck compression is also problematic, often creating respiratory distress in patients with a compromised airway or other pre-existing respiratory conditions.

Compression of the head and neck is not without risk, and not all patients with HNL are candidates for its use, though modifications can sometimes allow treatment despite the area of concern. For example, if severe neck edema is compromising the airway of a laryngectomized patient with one blocked carotid artery, it may be possible to modify the compression and MLD regimens sufficiently to avoid the area of concern and still apply appropriate pressure to the remainder of the neck and face. When in doubt regarding medical contraindications for use of compression for HNL, the therapist should contact the patient’s physician to determine the patient’s risk for adverse effects. If excessive risk exists, compression may be completely contraindicated. In most cases, however, compression can be applied safely and effectively. The proper use of compression has been shown to be an effective and essential component of CDT for HNL39,40 and should be implemented when appropriate. However, specific instructions and training must be provided to ensure patient safety. Use of excessive compression by a patient may be accidental or intentional, to increase the effect of treatment. If repeated instances of misuse occur, modifications must be made or the compression garment/wrap should be discontinued for the patient’s safety, despite the potential impact the loss of compression will have on treatment effectiveness.

Compression Padding

Historically, lymphedema therapists may or may not have elected to use foam padding as a component of compression treatment. The use of foam padding as an adjunct to compression wrapping has been reported to improve uniform pressure distribution to the tissues, provide structure for wrapping irregular surfaces, and soften fibrotic tissues.³⁹ Many padding options can either be fabricated or purchased, but in general, HNL treatment benefits from softening pads and flattening pads, such as those shown in Fig. 5.36. These pads are held in place by either a short-stretch bandage or an off-the-shelf compression garment.

Softening pads, also known as “chip bags” or “Schneider packs,”^39,41 are used prior to MLD when pitting edema is present. The pad softens the edematous tissue, increasing skin pliability and responsiveness to treatment. In most cases, softening pads should be worn for a minimum of 30 minutes before beginning MLD and throughout the trunk decongestion portion of the routine. After trunk decongestion is complete, the pad and compression garment should be removed as the neck and face are addressed. Softening pads are typically not used after MLD except in cases of very hard, fibrotic tissues.

Softening pads can be constructed from open or closed cell foam, depending on the firmness of the tissues being addressed. Chip bags are most appropriate for soft pitting edema and are constructed by filling a length of tubular gauze or stockinette with small (about 6–12 mm) blocks of 12 mm gray open cell foam. The spongy, resilient texture of the gray foam makes it an excellent choice for this application. Advantages of the chip bag include flexible positioning for irregular surfaces and the ability to reach crevices and skin contours when necessary. Disadvantages of the chip bag are its lack of durability and the need to redistribute the foam blocks within the stockinette to ensure even coverage with each application. Closed cell foam blocks do not stay evenly distributed within chip bags and are better suited for Schneider packs.

Schneider pack-style pads can be constructed by placing foam blocks between two sheets of soft cloth surgical tape, moleskin, or other flexible adhesive-backed material to create a flat, flexible pad with an uneven surface that can be used to soften firm edema and enhance the pliability of even somewhat fibrotic skin. To increase durability and decrease skin irritation, these pads should be covered by a stockinette or similar material before use. A pad made with small blocks of 12 mm gray open cell foam usually is sufficient to address a soft pitting edema. However, firm edema typically requires the use of closed cell foam cut into 6 mm blocks. Advantages of Schneider packs include their low profile, flexibility, and effectiveness on both soft and firm edemas. Another advantage is the fact that the foam blocks are held in position, providing a consistent application of pressure with each application. Also, Schneider pack pads can be cut into various shapes or modified to add an extended pad where additional coverage is required, as shown in Fig. 5.36b. Disadvantages are lengthier time for fabrication, difficulty with coverage of concave surfaces, and the potential for tissue damage from the closed cell foam if not used properly.

Once MLD is complete, immediate compression with a flattening pad under a wrap or garment is recommended, regardless of the edema stage. Flattening pads are intended for use with all patients receiving compression to reshape and flatten tissues after MLD, prevent refilling of edematous tissues, and promote continued lymph flow to the axilla. Flattening pads are typically cut from 12 mm open cell foam sheets into various shapes dictated by the area to be compressed. A typical shape for a flattening pad for the neck is a rectangle with a rounded top, shown in Fig. 5.36d. This allows the pad to fit well beneath the chin and curve along the top of the neck, staying below the mandible. The pad should cover the entire anterior and bilateral neck, extending back to the mandibular angles if bilateral edema is present, but can be customized as needed or constructed for unilateral use. The edges of the flattening pad should be beveled to lay flat against the skin, preventing creases that can occur if the edge is unbeveled. Modifications can be made if the pad is needed to compress the lower face or chin, and often, slots or vents can be cut into the exterior surface of the foam to enhance flexibility, as shown in Fig. 5.36c. The smooth side of the pad should always be against the skin. The flattening pad should be comfortable and should not restrict range of motion when in place.

Flattening pads should only be constructed of open cell foam to avoid tissue breakdown that can result if a closed cell pad is used. A pad constructed from 12 mm gray foam provides adequate pressure to the tissues without collapsing under the garment, which can occur with 6 mm foam. However, when a patient is very petite or supplemental padding is needed near the eyes, 6 mm foam is more appropriate. Also available are smaller open cell products with drainage channels to help direct lymph flow, as well as Velfoam, which connects directly to Velcro and is soft enough to use for padding in areas of increased sensitivity.

Anecdotally, there appears to be a positive correlation between the length of time the flattening pad is worn after MLD and the refilling of the tissues. However, it is often difficult for patients with HNL to wear a compression garment or wrap for extended periods of time for a variety of reasons. Some report feeling claustrophobic if they wear the compression garment or wrap for more than 1 hour, while others may be able to wear a compression mask all night while sleeping. The minimum recommended wear time is 3–4 hours immediately after MLD, but more time is encouraged if tolerated by the patient, since longer wear time will generally enhance the effect of the treatment.

An easier way of using a bandage for compression of the anterior neck and submental region is to cut the bandage and create a shorter compression wrap that can be directly connected to the compression pad. Depending on the portion of the neck to be compressed, the alignment may be more vertical than horizontal, as shown in Fig. 5.37. To create this type of wrap, hold the pad in place and wrap the bandage vertically or diagonally, as appropriate, until one circumference has been achieved with a single layer of the compression bandage. Mark the distance where the bandage overlaps. If the distance is 70 cm, double the length of that segment and cut the bandage at 140 cm. In most cases, the remaining bandage can be used to create a second compression wrap. Fold the bandage in half so the two loose edges of the cut bandage meet, and then secure them to the foam pad with a safety pin, tape, or by sewing. Hold the pad against the neck and wrap the folded bandage around the top or crown of the head; the end of the bandage should terminate in the middle of the foam pad. After ensuring proper tightness, secure the end to the pad with the bandage clips. Adjust the wrap alignment if necessary to ensure that the patient’s skin is not touched by any of the retention clips or pins. This technique features a double layer of bandaging with padding to provide adequate pressure to the edematous tissues. Once the bandage is attached to the pad, it is easily placed and removed by the patient in most cases, increasing patient independence.

Off-The-Shelf HNL Compression Garments

Noncustom or off-the-shelf garments are commercially available and can be used without detailed neck or facial measurements. They may be offered as “one size fits all” garments or in small, medium, and large sizes based on measurements of head or neck circumference. Chinstraps are indicated for HNL that is present in the neck and lower face only because they do not provide coverage for the upper or midface. Some chinstraps compress only the submental region while others address the neck as well. Two styles are shown with pads in Fig. 5.38. Other chinstraps are hybrids of these two styles and feature variations in neck length as well as general size options. These garments are generally less expensive than custom garments, though prices vary widely by manufacturer. Due to their lower cost and immediate availability, these garments are sometimes stocked by lymphedema clinics to be issued at the onset of treatment, whether for home program use or as an interim device to be used while awaiting a custom garment. These off-the-shelf chinstraps are generally considered appropriate for lymphedema management but must be used under the supervision of a CLT to ensure patient safety.

Custom-fit, made-to-measure chinstraps and full facial compression masks are almost always preferred if available. Custom face and neck measurements are required to fabricate these garments and may be obtained by a vendor representative or by clinicians using the manufacturer’s measurement templates. These measurements make it possible to accommodate the patient’s individual physical characteristics, and a proper fit is usually guaranteed by the manufacturer. Revisions are typically available for little or no charge, depending on the vendor. Another benefit of custom garments is the availability of options such as eye or mouth patches, closure of ear or mouth openings, ponytail openings, etc., as shown in Fig. 5.39. Quilted custom garments are also available, providing bulkier material to help soften tissues after MLD if necessary. The cost of custom garments varies widely and usually reflects differences in the materials used and the manufacturing process. These garments can cost several hundred dollars, which may delay or prevent their acquisition for some patients. The lower cost custom garments are functional, appropriate, and especially advantageous when finances are limited, but there is often a difference in quality and comfort. An additional disadvantage of custom garments is the delay in acquisition due to the need to fabricate the garment. Although some vendors can deliver a custom garment in a few days for rush orders, others require weeks for delivery. In some cases, immediate compression is necessary while awaiting the arrival of the custom garment, so consideration of all compression options is essential for each patient.

Elastic Therapeutic Tape

An adjunct to compression is the use of tape (such as K tape, kinesio tape, muscle tape, etc.). Its ability to stimulate lymphatic drainage by opening lymphatic channels during natural skin movement makes it a very appealing option for some patients. With proper application, elastic therapeutic tape can be a very effective tool to facilitate drainage outside of outpatient or home-based therapy sessions. It can also be used effectively for musculoskeletal support and scar management, though caution must be exercised due to concerns with skin irritation from the adhesive. Of particular concern is previously irradiated skin, though each patient should be considered individually and carefully monitored for adverse effects. For patients with HNL, the use of this product may meet with some resistance because of its high visibility when placed on the face or neck, but this is not true in all cases.

In general, the application of elastic tape is consistent with its use to facilitate lymphatic drainage in other parts of the body, anchoring with a solid piece of tape near the drainage destination, and radiating with “fingers” to drain the edematous region. As seen in Fig. 5.40, common anchor points for HNL use are the anterior chest near the axilla, the supraclavicular fossa, and the scapular region, depending on the location of the edema. The tape can be placed bilaterally or unilaterally and in certain cases may be applied to create contralateral drainage if significant scarring prevents drainage ipsilaterally. Adequate skin pliability can be achieved by placing the tape with “zero stretch” as the patient looks up and away from the clinician, resulting in tape contraction when the patient returns to the neutral position. The tape may be left in place for 2–3 days before removal in most cases. Again, careful observation of the skin is required to prevent adverse skin reactions, especially with irradiated tissue. Excessive wear time has been noted to cause significant skin irritation in some patients, even with no previous history of tape allergy. Elastic tape, when used appropriately, is an excellent option for HNL management.

Supplemental MLD Sequences

Alternative HNL MLD Sequence for Unilateral Axilla

Appropriate when one axilla is unavailable due to previous treatment.

1–8. Unilateral trunk decongestion on available side. See Trunk Decongestion routine.

9. Sequentially decongest upper chest of impaired side, MLD toward available axilla

10. Stationary circles in supraclavicular fossa, medially, away from impaired axilla

11. Proceed with anterior or posterior drainage of neck and face, as appropriate

12. Reverse head, neck, and trunk sequence to available axilla

Pediatric Lymphedema

In the majority of cases, pediatric lymphedema is caused by congenital malformations of the lymphatic system and may be present at birth or later in life. It can be divided into two groups, based on the age of onset. Primary lymphedema, which is present at birth and associated with a family history, is termed Milroy’s disease. This form of pediatric lymphedema is described as typically involving the lower extremities (Fig. 5.41), but the arms, hands, and face may be involved. It also may be associated with malformations of the lymphatics in the intestinal system. The term Meige’s disease (lymphedema praecox) is often used to describe primary lymphedema that occurs after birth, but before the age of 35; the age of onset is generally in adolescence. Both types can affect both sexes; however, the majority of cases occurs in females.

The most important aspect in the treatment of pediatric lymphedema is the education and training of the parents. It is necessary for the parents to invest time and effort to learn basic hands-on MLD skills and bandaging techniques from a lymphedema therapist in the clinic. Parents cannot learn these techniques from a book; interaction between the parent and the therapist in the clinic setting is necessary to provide for feedback, question-and-answer sessions, and so on. Early on in the treatment, the parent(s) should be actively involved in the treatment process. The treatment sequences and bandaging techniques can be observed during the therapy session and repeated at home. Well-educated parents are capable of providing good-quality care for their child.

Pediatric lymphedema may benefit greatly from a course of CDT initiated as early as possible. Following an intensive course consisting of daily treatments, routine check-ups with the lymphedema therapist ensure continuous feedback regarding the parents’ treatment skills and bandaging technique. Normal limb size may be achieved and maintained, and the typical secondary tissue changes associated with lymphedema may be greatly reduced or eliminated. The general approaches concerning MLD and compression therapy used in adult patients, as well as the duration of the individual treatment session, have to be modified significantly, especially in lymphedematous children of up to 3 years of age. It is also important to realize that treatment progress generally is slower in pediatric lymphedema.

Table 5.3 Klippel–Trénaunay syndrome and Parkes Weber syndrome comparison (From Cohen MM Jr. Klippel–Trénaunay syndrome. Am J Med Genet A. 2000;93(3):171–175. Reprinted with permission.)

Parkes Weber syndrome is a fast-flow anomaly that can resemble KTS but has the additional characteristic of arteriovenous malformation associated with true tissue hypertrophy. It can be associated with high output cardiac failure which does not occur in KTS patients. The comparison between KTS and PWS is outlined in Table 5.3.

KTS is a sporadic condition with an unknown cause. Each individual has unique characteristics with varying degrees of symptoms ranging from mild port wine stains to life-threatening pelvic or rectal bleeding. KTS characteristics may not be apparent at birth and become more evident as a person develops. It may be difficult to diagnose KTS due to the complexity and lack of awareness of the syndrome and therefore some patients aren’t diagnosed until later in life.

Lower extremity involvement tends to be the most common area affected, followed by upper extremity, pelvic and abdominal, thorax, and rarely head and neck involvement. The lower extremity KTS venous malformations are frequently related to persistent embryonic veins. The lateral marginal vein (vein of Servelle) and the sciatic vein are two common embryonic veins that are expected to disappear during normal development but often persist in KTS patients. The lateral margin vein presents along the lateral part of the foot and leg. Significant venous malformations of the leg can lead to syncope and lightheadedness when standing for which compression may be helpful in reducing the symptoms.

The use of compression garments during the day generally does not affect normal activities, such as sports and play, as long as they fit properly. The therapist or physician should check the compression garments) every 4–6 months for general condition, proper compression, and size. More frequent assessments may be required for children experiencing growth spurts.

Elastic Taping for Lymphedema

General Information

Elastic taping for edema conditions is postulated to create variations in pressure with resultant tissue deformation when correctly applied with convolutions (Fig. 5.42). A negative pressure effect under the superficial integument is also thought to lift the skin from the fascia and subcutaneous tissues below, which allows for increased lymphatic pathway flow. As the patient performs respirations, general daily movements, and therapeutic exercise, the tape creates a slight tug on the superficial integument which replicates the effect of manual lymph drainage. Taking up the elasticity of the skin through rhythmical movements results in pulling on the anchoring filaments and a resultant “open junction” of the initial lymphatic vessels allowing for uptake of lymphatic loads. Shim showed a 24%–37% increase of lymphatic flow rates when elastic taping and passive range of motion were combined (Shim, 2003). An early pilot study has also questioned whether Kinesio taping could replace bandaging and has shown Kinesio taping to have better patient comfort and quality of life indicators (Tsai 2009). Elastic taping has also been advocated for edema after post-traumatic and surgical interventions (Bialoszewski 2009). At this time, the remainder of current literature is limited to case studies or articles in nonpeer-reviewed trade journals.

Indications and Contraindications

Preparation and Materials

Application

• The tape is then cut into what is typically referred to as a fan shape with a 1 cm base on one end (see Fig. 5.42). The fan-shaped cut allows for the spreading of the tails to cover a larger surface area. Tail numbers can range from 3–8 typically; however, this depends on the skin’s properties, the experience of the practitioner, the surface area to be treated, and the width of the tape. Tails are usually 1–2 cm in width, with variability in this recommendation as well depending upon specific circumstances.

• Square edges are rounded with the scissors to discourage them from catching and peeling prematurely. The paper backing is then torn to allow for separation of the base from each individual tail for ease of precise application. Once the skin has been prepared and is free of oils, lotions, perspiration, and hair, the tape is ready to be applied.

Skin application: Place the patient’s skin into a position of full stretch if possible. Upon application in the stretched position, return to the natural resting state, allowing the skin and tape to recoil with the desired rippling convolutions visible (see Fig. 5.42).

• The base of the tape is adhered at the “end point” where flow is directed with the tails over the treatment area.

• Each tail strip is then adhered by removing the paper backing and placing the strip over the skin with no stretch applied to the tape. Repeat tail application individually until all strips have been placed over the treatment coverage area. Tape tails are allowed to overlap or cross one another.

• Once the tape is in place, the practitioner gently rubs over the tape longitudinally to adhere and warm the acrylic adhesive. Maximal adherence is achieved in 30–60 minutes due to body heat activation and tape removal should be avoided during the first 24 hours due to risk of skin damage upon removal (Fig. 5.43).

Ecchymosis/Focal Edema Specialty Technique

• The skin and tape are prepared in the same manner as described previously.

• Application of the focal area is in a criss-cross pattern, creating a grid over the involved area. The base and tails of one strip are nearly perpendicular to the other strip with an overlapping checkered pattern covering the area of involvement (see Figs. 5.44 and 5.45).

Stable Scar Technique

• An additional specialty technique can be utilized for stable scars that demonstrate hypertrophy, decreased mobility, pain, and adherence issues. This technique is most typically utilized for surgical incision sites, but can be adapted to other scarring as well. Scarring over large body surface areas (such as burns, wide range radiation fibrosis, etc.) is not an ideal application for this technique.

• Skin is prepared as previously described. The tape is cut into several 25 mm by 6 mm tablike strips, making sure that the stretch of the tape remains longitudinal.

• The base of the first tiny strip is placed near the edge and perpendicular to the scar. The backing paper is torn away with the base adhered with no stretch on the tape. The central portion of the tape is then pulled to a 50% stretch on the tape and adhered. The second base of the tape is then laid down with no stretch applied.

• The second strip is applied in the same manner; however, it is placed one tape-width further along the scar, pulling in the opposite direction. This continues to alternate in pull direction as the strips are placed along the length of the scar. With subsequent applications, the direction of pull can be alternated for increased mobilization of the tissues in all directions (see Fig. 5.46).

Anastomosis Technique

• The anastomosis taping technique is illustrated in Fig. 5.47.

Rerouting Technique

• The rerouting taping technique is illustrated in Fig. 5.48.

Patient Education for Elastic Taping

Patients are encouraged to perform muscle pumping exercise and stretches as well as general daily activities to facilitate maximal tape effectiveness and lymphatic uptake. Taping can be utilized with or without bandages, with combinations of techniques found to be highly effective in the clinic. Utilization of elastic taping and manual lymphatic drainage are also complementary and can be beneficial in conjunction with one another. The elastic properties of the tape pull on anchoring filaments and create a slow smooth stretch on the lymph collectors with resultant angion contraction, which has the same effect as manual lymphatic drainage. When taping is used in combination with manual techniques, the resultant effects are enhanced.

Removal

Treatment Strategies for Common Complications of Lymphedema

Surgical Scars

Surgical scars disrupt the superficial vessels in many patients especially where consideration of the superficial lymphatic collector anatomy has been disregarded. Lymphatic vessels are capable of repair and will, if undisturbed, re-anastomose via lymphangiogenesis. Upon close inspection vessels repair in a less structured fashion often missing valves or smooth muscle; however, this repair process is crucial to avoid secondary lymphedema in tissues distal to the node beds.42 When nodes are removed lymphedema is more likely since these represent the terminal point for a whole network of vessels. Without this inherent vessel repair process simple cuts and lacerations during a person’s lifetime would cause significant loss of lymphatic transport.

Assess Scars to Discern the Impact on Lymphatic Transport

With an understanding of the normal superficial anatomy of limb and truncal areas, assess the potential for interrupted flow within a territory. A poorly healed, disturbed scar, thickened, inflamed or keloid scar may entrap fluid on the distal side of the skin region. If so a palpable tissue change (fibrosis) and or pitting quality (congestion) of the edematous tissues will be present.

Treatment Strategy

The MLD sequence should relate to any collateral pathways around the scar rather than through the scar when possible. As a rule MLD should strive to utilize the most efficient intact pathways and substantiate the lion’s share of the session. Scar tissue mobilization techniques or other specialized scar work should only be administered during secondary treatment sessions to avoid inefficient use of valuable MLD session time. Remember the overarching treatment goal is improvement of collateral drainage pathways via intact and patent collectors rather than local scar improvement.

Debulking Scars

Primary lymphedema patients may also receive less radical procedures such as collector transplantation, microvascular bridging, lympho-venous anastomosis, or liposuction. Others, however, receive the most radical procedures which “debulk” the limb of much or all of the involved tissues with the foremost goal of limb girth reduction (Fig. 5.49). These radical procedures effectively remove the entire superficial lymphatic network leaving the therapist with little viable tissue with which to recruit efficient alternative drainage.

Debulking Procedures

• Staged excision techniques (Sistrunk, Homans, Thompson)

• Radical excision techniques (Charles)

Staged Excision Techniques

These procedures involve removal of the subcutaneous tissues (fat, lymphostatic fibrosis) down to the deep fascia via a large longitudinal incision. These incisions may extend along the medial and lateral calf and thigh and are usually planned as staged operations. The reduction involves more than the local incision area encompassing several centimeters of margin on either side effectively removing large strips of subcutaneous tissue. Strong tourniquets are applied and remain in place for as long as 2 hours. An Esmarch bandage, essentially a wide rubber band, is applied in spiral fashion to squeeze venous blood from the limb under great pressure in preparation for the surgery. Steinman pins are drilled into the calcaneus and proximal tibia to suspend the leg for circumferential access to all involved surfaces (Fig. 5.50).

These procedures involve complete removal of all skin from the surgical area. The deep fascia is exposed and split thickness skin grafts are harvested from the excision tissue to be sutured in strips back onto the muscle fascia. Similar presurgical prep techniques are used to minimize blood loss and improve access to all sites. The removal of all tissues leaves an extremely altered and unsightly appearance in all patient subjects. Commonly the calf region is excised using the Charles procedure.43 Thigh areas may more commonly employ Homans or Sistrunk procedures.⁴⁴

Status Post-Radical Charles Procedure (Fig. 5.51)

Since the entire superficial lymph vessel network has been removed, MLD treatment of the grafted tissues has no apparent impact or rationale. With skin grafted directly to the deep fascia, no true subcutaneous space exists where swelling can occur. Furthermore, skin grafts quickly scar down adhering to the fascia and lose normal elasticity, rendering manual traction (MLD) impossible. Distal nonexcised tissues on the foot, ankle, and toes (a typical occurrence), tend to worsen, progressing toward elephantiasis more rapidly than they would as a natural course. Effective long-term drainage of these tissues relies upon perforating collectors interfacing with the deep spared lymphatics of the limb. As such, treatment should encompass the following:

• Focus on proximal, spared areas and the deep lymphatic anatomy with MLD

• Moisturize the grafted skin areas liberally to improve hydration status and elasticity (slow improvement can be expected)

• Compress all tissues (edematous and scarred) from toes to proximal edema margins. Include grafted areas (although not swollen).

Hyperkeratosis

Hyperkeratosis can be described as an epidermal hyperplasia due to lymph stasis, which appears as a local overabundant thickening of the skin with rough calluses,45 wartlike formations or papillomas (Fig. 5.52). Hyperkeratosis is one of the key descriptors of stage 3 lymphedema (elephantiasis), which is a common consequence of chronic lymph stasis, which always involves secondary connective tissue disease. These skin changes are most commonly seen in the toes, but may encompass larger regions that are directly associated with the most chronic areas of static lymph. Sometimes the term “lichenization” is used to describe odd presentations of hyperkeratosis due to the mosslike appearance seeming to grow on the skin surface. It is important to note that the presentation of hyperkeratosis in venous disease (venous edema) changes the diagnosis more accurately to phlebo-lymphostatic edema.

Abnormal Folds

As lymphedema severity progresses skin creases develop due to edema filling forces, gravity, limb position, elasticity of the skin, and even genetic traits (Fig. 5.53). In some cases a limb enlarges without contour changes, in others the distortions can be remarkable and alarming. When abnormal limb contours exist the lymphedema therapist must adapt the compression strategy accordingly. Therapist considerations should include the following before commencing treatment:

• Is the current limb shape counterproductive to the Laws of LaPlace? (reverse cone shape, areas of narrowing, lobular outgrowths)

• Will the folds/creases entrap the fluid or allow for accumulations of bandages that are counterproductive to therapy?

• Are the folds/creases sites of recurrent infections?

• Are the areas within the skinfolds clean and dry or macerated and colonized with bacteria or fungus?

Treatment Strategy

During the pretreatment presentation lymphedema will appear in its most advanced and treatment-resistant form. Lobular outgrowths and distorted tissues typically exhibit a pitting-resistant texture due to extensive fibrosis, hyperkeratosis, and fluid pressure. It is important to adapt treatment with sensible, thoughtful approaches such as:

• Cleaning and inspecting folds and skin creases

• Treating with antibacterial preparations as necessary

• Drying and protecting skin-on-skin areas thoroughly; tissue fragility is likely in protected, unstimulated skin areas

• Packing the region with synthetic cotton and/or soft foam strips

• Building out valleys (with padding) to create a continuous, smooth plane

• Building out narrow girths (with padding) to avoid entrapment of fluid (Law of LaPlace)

In all cases a correctly bandaged limb will improve texturally each session allowing odd contours to become progressively more supple and compliant for each subsequent bandage application. In brief, the limb will transform rapidly from day to day so that even the most strikingly abnormal shapes will return toward normalcy again. Although cases involving abnormal lobes and folds are generally categorized as elephantiasis limbs, they should not be viewed as untreatable. However, commonsense modifications can be made to accommodate the abnormal contours. Bandage suggestions include:

Odors and Odor Control

With advancement through the stages lymphedema tissues become more prone to leaking lymph fluid. This stagnant lymph has a characteristic, malodorous smell that is difficult to describe but is largely consistent from one patient to the next. Usually with thorough hygiene and decongestion this problem can be managed and if small wound areas exist closure can be expected as the limb decongests. Sometimes lymph will encrust on regions around superficial wounds (cysts, abrasions, punctures) creating a scablike feature of yellow, dried exudate (Fig. 5.54).

Treatment strategy

• Clean meticulously with normal soap and water

• Protect fragile skin with soft materials or wound dressings

• Avoid maceration (use absorbent dressings)

• Watch for evidence of cellulitis (occurrence is common)

• Expect spontaneous closure of lesions with decongestive therapy

• Avoid active debridement of lymph crust. As with a scab fragile underlying skin loses protection. Allow sloughing to occur naturally

• Hyperhydrate crust areas with petroleum jelly to soften and promote sloughing

Fungal Odor

Fungal Infections

• Loss of normal contour of toes (square instead of round): decreases air flow and increases moisture, darkness and warmth (Fig. 5.55)

• Loss of footwear choices due to abnormal size and shape of foot: causes recontamination within same pair of shoes

• Decreased local immune function

Although fungal infections may be acute, they are usually not regarded as strict contraindications to therapy unless the tissues are fragile or open. A normal plan of care would dictate that fungal infections be arrested prior to commencement of therapy to reduce the avoidable complication of spread to other skin regions. However, should treatment begin during an active fungal infection of lesser severity, with caution, the therapist may carry out complete decongestive therapy bearing in mind the following suggestions:

Treatment Strategy

• Apply topical antifungal preparations, stockinette, and toe bandages with hands gloved

• Wrap to the knees first (prior to MLD) to cover distal involvement and avoiding contamination of other areas

• Administer MLD to proximal, truncal areas (above bandage) only to avoid contact and spread. MLD is not required in the infected areas temporarily.

• Discard all materials that are intimate with skin to avoid recontamination, daily

• Discard contaminated footwear and instruct patient as to how to avoid future problems

Radiation Trauma

Since radiation therapy is a mainstay of gold-standard care for many types of cancer, lymphedema therapists must carefully consider the secondary effects of this therapy on tissues within the field. MLD and compression, although approached with care, skill, and a low level of intensity can have harsh affects on irradiated tissue. Radiation causes a slow retreat of microcirculation (dieback) in soft issues leading to ischemia and scar-tissue formation. Soft tissues may become palpably altered and exhibit a loss of elasticity, supple texture, and normal color. When assessing radiation effects, lymphedema therapists should familiarize themselves with the conditions in the following sections.46

Telangiectasia

Upon close inspection in some cases a visual, palpably undetectable yet permanent change occurs in the superficial skin of the area of irradiation. Telangiectasia is a spider-veinlike presentation, where the capillary plexus of blood vessels is distinctly visible, engorged or even varicose in appearance (Fig. 5.56). Although the presentation may at first glance be alarming, it is generally not an indication of severe radiation trauma. Tissues remain elastic and normal to the touch. The cause of telangiectasia is related to the loss of sympathetic motor control of the precapillary arteriole’s ring of smooth muscle. This sphincter muscle controls the arterial inflow within the blood capillary plexus and when paralyzed relaxes to allow an excess of pressure locally. This increased blood capillary pressure dilates and enlarges the capillary bed making it more visibly apparent.

With extensive radiation damage soft tissues become chronically and severely altered exhibiting signs of color change (rusty red, brown) with a complete loss of elasticity and further adherence to the underlying structures (bone, soft tissues) (Fig. 5.57).

Complications from Deep Radiation Fibrosis

These include:

• Osteonecrosis: Damage to the periosteum causes bone necrosis, decalcification and possible bone reabsorption. This condition is irreversible.

• Limb paralysis: Motor and sensory nerve entrapment from direct damage to nerve plexuses with demyelination. Secondary connective tissue entrapment resulting in total loss of function and sensation. This condition is irreversible.

• Collateral vein formation: Fibrosis can slowly entrap veins and arteries. Deep vein strangulation results in collateralization of the venous blood causing visibly apparent vein formations in the skin.

Papillomas

A papilloma is defined as an overgrowth of the papillae of the skin or mucous membrane and is one of the key descriptors of stage 3 lymphedema.47 This benign formation could be characterized as a skin tag that has become inflated with fluid and is therefore a bulbous, balloon-like feature attached with a highly vascularized stem of tissue (Fig. 5.58). When lymphedema becomes chronic a direct relationship exists between the level of inflammation and the formation of hyperkeratosis and papillomatosis in certain individuals. Typically, papillomas form at the most chronic distal tissue regions or along scar formations following debulking procedures. Other papillomas form in thin pliable tissues such as those found in the genitalia. Notably, if regional decongestion is achieved through treatment and before the papilloma becomes impregnated with fibrosis, a dramatic shrinking and even complete disappearance of these formations can occur in many cases.

Due to the fragile nature of the papilloma, injury is common due to mechanical stresses such as toweling, donning and removing of garments, application of lotions, etc. For this reason they can often be cited as the entry point for pathogens and may be responsible for recurrent episodes of cellulitis. Leaking and bleeding are common and lead to great patient frustration. Lymph exudate is commonly malodorous and affects a patient’s sense of dignity, compounds quality-of-life constraints, and, in particular, affects his or her enjoyment of socialization.

Treatment Strategy: Considerations

Lymph Cysts and Varicosities

Lymph cysts occur due to congestion and dilatation of lymph vessels (Fig. 5.59). Cysts mostly occur due to congenital malformation; however, a local surgical interruption of lymph drainage can also create sufficient collector hypertension and reflux to cause cyst formation.⁴⁸ This is more commonly evident in areas where skin is thin and extensible such as the axillae and genital regions. Depending upon the tissue structure related to the cyst (collector, capillary) a distinction can be made as to the level of congestion of surrounding tissues and origin of the problem. If caused by primary malformation, cysts may be less correctable by decongestive therapy since the underlying cause may involve valvular incompetence or hyperplasia of the deep lymphatic system. In some cases chylous fluid is seen weeping from the skin.

White cysts rather than clear cysts indicate chylous reflux from deep intestinal lymphatics or the thoracic duct itself.⁴⁷ A lymph varicosity is similar to a varicose vein and involves a collector (Fig. 5.59). In thin-skinned (geriatric) patients visualization of hypertensive, engorged or varicosed lymphatics may be possible. This presentation is not common, however, where subcutaneous adipose is more substantial.

Treatment Strategy

• Cysts are extremely fragile and are likely to rupture when exposed to any mechanical stressors (bandages, garment, MLD, exercise). Apply a sterile, highly absorbent dressing over cysts prior to compression bandage application.

• Assess patients risk level for infection based upon history or level of concern. Always identify antibiotic of choice and attain full prescription as a precaution.

• Discuss signs and symptoms of cellulitis with the patient and a sensible plan for antibiotic administration (physician directed) if required

• Expect most cysts to resolve (shrink or disappear) once the involved territory is thoroughly decongested

• If chylous reflux is present, consider imaging studies to determine if a surgical solution is required. Recurrent cellulitis is life-threatening with pathogens gaining direct access to the deep lymphatic system via chylous cysts.

Collateral Veins

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