Clinic of Social and Family Medicine, Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Crete, Greece.
AbstractPrimary lymphedema is a rare, chronic and distressing condition with negative effects on physical, social and emotional level.
Lymphedema is defined as an excessive lymphatic fluid accumulation in subcutaneous tissues, due to inability of the lymphatic system to maintain normal tissue homeostasis [1].
The patients were recruited from the first author (EKS) as they used occasional services within the University Hospital of Heraklion in a four year period.
Case 2A 33-years old woman during the first trimester of gestation (2 years ago) described a progressive painless enlargement on the left ankle, proximally extended, leading to impaired daily activity and creating a sensation of heaviness and discomfort. In the first case the analysis of SF-36 results disclosed a significant functional impairment with a slight impact of the condition on emotional and social domains (Table 1). Assessing the impact of the duration and severity of the condition in relation to age, sex and occupational status as influential determinants to personal perceptions of well-being deserves further discussion. We would like to thank the researchers who translated and validated the SF-36 questionnaire into Greek for offering information on technical details.Written informed consent was obtained from the patients for publication of these case reports and any accompanying images.
Moffatt CJ, Franks PJ, Doherty DC, Williams AF, Badger C, Jeffs E, Bosanquet N, Mortimer PS.
Corresponding author: Dimitrios Anyfantakis, Clinic of Social and Family Medicine, Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion 71003, Crete, Greece. Complications after any operation can be minimized with thorough preoperative evaluation, meticulous technique, hemostasis, and wound closure. The purpose of this document is to review commonly used approaches for the care of the post-mastectomy wound and addresses the complications encountered in these patients. Seroma: It is a collection of serous fluid within a surgical cavity that is clinically evident.
Pneumothorax: It is rare complication, develops when the surgeon perforates the parietal pleura with extended tissue dissection or with attempts at hemostasis for perforators of the intercostals musculature.
Tissue Necrosis: A commonly recognized complication of breast surgery is necrosis of the developed skin flaps or skin margins. Hemorrhage: It is reported as a post-operative complication in 1% to 4% of patients and is manifested by undue swelling of flaps of the operative site (8). Neuro-Vascular Structures Injuries: Injury to the brachial plexus is a rare complication of mastectomy and avoided by meticulous (cold scalpel) sharp dissection in and about the neuro-vascular bundle and through the development of tissue planes that parallel the neurilemma and the wall of the axillary vein to allow en bloc resection of lymphatic structures and fatty tissue. Less common are injuries to the thoracodorsal nerve and the long thoracic nerve (respiratory) of Bell. Lymphedema is caused by an abnormality of the lymphatic system leading to excessive build up of tissue fluid that forms lymph, known as interstitial fluid. It is estimated that as many as 30%-50% of all patients who undergo axillary lymph node dissection go on to develop some form of lymphedema (10). Diagnosis can be established on the basis of an accurate history and a thorough physical examination. Soft Tissue Imaging: Magnetic resonance imaging (MRI), computed tomography (CT) and some types of ultrasound (US) are able to detect the presence of extra fluid in the tissues (23). Lymph Vessel Imaging: Lymphoscintigraphy is a nuclear medicine study used for imaging lymph vessels and lymph nodes (24).
Measures of Volumes: Measures of limb (arm and leg) volume have been the standard way of detecting lymphedema for years and have been shown to be accurate when properly done (26).
Electrical Conductance Testing: Bioimpedance Spectroscopy (BIS) is a method for measuring water content in tissues.
Changes in Biomechanical Properties of Tissues: These measures of the biomechanical properties of tissues are important for research. Typically, lymphedema is diagnosed only when it is visually apparent, at which point treatment is often ineffective. Prevention: The radical mastectomy of the past has been replaced with more conservative procedures that have the potential for decreasing the incidence of lymphedema.
Medical Treatment: The initial treatment of chronic secondary lymphedema should be managed through non-surgical measures. IPC, also known as compression pump therapy, can be useful in some patients as an adjunct to Phase I CDT or a necessary component of a successful home program for Phase II CDT (33).
Surgery for lymphedema is not curative, but it has been used in specific circumstances for control of a severe condition.
Debulking: It removes the hard connective tissue and any large folds of fatty tissue associated with the lymphedema-affected body part (36).
Microsurgical Lymphatic Reconstruction: There are new micro-surgical techniques that are currently being attempted using either lymphatic-venous shunts (LVSs) or lymphatic-venous anastomosis (LVA).
A number of promising treatments have been reported, but they have not yet been subjected to sufficient rigorous research to recommend as the standard of care. An accurate knowledge of physiology and pathophysiology of lymphedema is necessary to understand the rationale of treatment techniques available.
Lymphedema is a consequence of prolonged edema; edema is an interference of the physiologic movement of fluid from capillaries through the interstitial spaces and back into lymphatics.
Dysfunction of the lymphatic system because of genetic or congenital defects or related to infection, surgery, or external trauma leads to functional impairment of the tissue clearing ability and progression to clinical signs of lymphedema. In all the clinical disorders discussed, edema may be transient and pitting with pressure but, with time, becomes fixed and accompanied by dermal sclerosis and epidermal hyperplasia. Type I lymphedema, an autosomal dominant disease characteristically has a mutation in VEGFR3 (also called the FLT4 gene). Lymphedema is almost always from birth and is confined to the legs with deep creases over the toes and small deformed (“ski jump”) toenails and is characterized hypoproteinemia from intestinal loss of albumen, chylous ascites, and scrotal edema. Lymphangiography demonstrates dysplastic lymphatics in both clinically affected and clinically normal extremities, emphasizing the complexity of the pathophysiology, leading ultimately to disease.
The fork-head family transcription factor defects have in common mutations in a transcription factor, the fork-head transcription factor, FoxC2 [MFH1 (mesenchyme forkhead-1); fork-head is the name of a Drosophila trait]. Edema develops around puberty, later than type I disease, and facial puffiness with deep creases and wrinkling may occur.
Worldwide lymphedema due to filariasis is estimated to affect between 90 and 100 million individuals . Other infectious diseases with lymphedema are much less common and include lymphogranuloma venereum with elephantiasis of the penis and scrotum, granuloma inguinale , and tuberculosis . There are two major etiologies to non-hereditary lymphedema on a worldwide basis—venous disease of the legs (discussed earlier in this chapter) and postcancer, especially carcinoma of the breast-related lymphedema. Unilateral lymphedema suggests localized obstructing factors, but bilateral lymphedema can be due to obstruction in the pelvis or abdomen. Inflammation with redness, pain, and swelling is not lymphedema but can be pyogenic infection, most commonly with S. Prolonged lymphedema leads to fibrosis and epidermal hyperplasia with verrucous hyperkeratosis (Fig. Diuretics may worsen the condition and should not be used as a primary treatment for lymphedema. Microsurgery of lymphatics to bypass obstructed nodes can be considered if nonsurgical treatments are not successful.
Excisional or suction-assisted lipectomy (liposuction) may be an option in selected patients. Any patient with lymphedema, whatever the cause, should keep their feet dry, nails trimmed, and prevent and aggressively treat pyogenic infection. Lymphedema is common in some locations, face and penis especially; low-grade infection is usually invoked as the cause.
In puffy hand syndrome, intravenous drug use with injections into hands or feet is associated with lymphedema. The purpose of these reports was to present and discuss two different cases of primary lower limb lymphedema with a focus on its physical and mental impact and on some qualitative aspects of patients' self-reported experiences.
They reported a medical history of primary lower limb lymphedema diagnosis by specialists and all accepted to participate in this study when they were asked. The swelling was initially presented at the age of 8 years from the left ankle progressing slowly up to the calf, thigh and inguinal area leading to disfigurement and functional impairment.
It has been reported that only 3% of patients with lymphedema received psychological support as a treatment approach [5]. General practitioners can monitor the long-term impact of chronic disorders through their daily practice. In addition to the standard oncologic evaluation, preoperative evaluation includes assessment of the patient's overall physiologic condition, with particular emphasis on tolerability of anesthesia, uncontrolled diabetes, hypertension, anemia, coagulopathy, or steroid dependency. Infection of the mastectomy wound or ipsilateral arm may represent serious morbidity in the postoperative patient and produces disability that may progress to late postoperative lymphedema of the arm.
After mastectomy, seromas occur in the dead space beneath the elevated skin flaps and represent the most frequent complication of mastectomy, developing in approximately 30% of cases (6).
Pneumothorax is more commonly seen in patients undergoing a radical mastectomy after removal of the pectoralis major musculature.
Bland and colleagues observed an incidence of 21% for minor and major necrosis of mastectomy skin flaps with associated wound infection (7).
The sensory innervation of the breast is derived from the lateral and anterior cutaneous branches of the second through the sixth intercostals nerves.
The thoracodorsal, or subscapular, nerve innervates the lattissimus dorsi muscle in its course with the thoracodorsal (subscapular) vessels and is commonly sacrificed when lymphatics are discovered to be involved with metastases at axillary dissection. Stagnant lymph fluid contains protein and cell debris that causes swelling of affected tissues. Variability in the reported incidence of lymphedema is due in part to the lack of a standardized definition (14). Adding radiation therapy has been shown to increase the incidence of lymphedema from 20% to 52% (17). In the United States, the most common cause of lymphedema is axillary lymph node dissection for breast cancer (19).
Fluid that is outside the cells (extracellular) and also outside the vessels (extravascular) is called tissue fluid or interstitial fluid.
Radio-labeled particles of protein are injected just under the skin of the area of the body to be imaged. It has been used for many years to assess the total water content of the body and body composition for fitness and weight loss purposes.
Hopefully continued development will lead to better tools for clinical use so that diagnostic methods will include quantitative methods of skin and subcutaneous tissue changes associated with progressive lymphedema. The focus of WHEC Cancer Center's screening program is to diagnose the condition in its subclinical state when early intervention can prevent development of clinical signs and symptoms. The new technique of lymphatic mapping and sentinel lymph node biopsy promises to provide full nodal staging information with a simple lymph node biopsy. Physical therapy, in conjunction with compression garments or sequential-gradient compression-type pumps, has been recently added to the overall care of patients with chronic lymphedema. Some patients may have good results from CDT with modifications of the frequency and duration of treatment. Acceptable pumps should have appliances (pump garments) with multiple chambers and have a sequential pressure delivery with the chambers compressing in a specific pattern determined individually for the patient's diagnosis and pattern of lymphedema.
Circumstances where surgery may be considered are: reducing the weight of the affected limb, minimizing the frequency of inflammatory attacks, improving cosmetic appearance, or fitting the limb into garments. The potential risks of this surgery include prolonged hospitalization, poor wound healing, nerve damage or loss, significant scarring, destruction of the remaining lymphatic vessels in that body part, loss of limb function, return of swelling, poor cosmetic results, and decrease in quality of life. These treatments include cold laser, electrical stimulation, vibratory therapy, oscillation therapy, endermologie and aqua-lymphatic therapy (39). An accurate assessment of the degree of impairment should be established before initiating either short- or long-term care. Quality of life and patient satisfaction in breast cancer patients after immediate breast cancer reconstruction: a prospective study. Breast cancer recurrence following prosthetic, postmastectomy reconstruction: incidence, detection, and treatment. Breast cancer local recurrence after mastectomy and TRAM flap reconstruction: incidence and treatment options.
Wound complications after modified radical mastectomy compared with tylectomy with axillary lymph node dissection. Obesity predisposes to increased drainage following axillary node clearance: a prospective audit. Lymphedema: A primer on the identification and management of chronic condition in oncologic treatment. A comparison of four diagnostic criteria for lymphedema in a post-breast cancer population.
Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: patient perceptions and precautionary behaviors. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: objective measurement.
Breast cancer-related lymphedema -- what are the significant predictors and how they affect the severity of lymphedema? Diagnosis and treatment of concomitant venous obstruction in patients with secondary lymphedema. Comparison of methods to diagnose lymphedema among breast cancer survivors: 6 month follow up.
Suitability of single tissue dielectric constant measurements to assess local tissue water in normal and lymphedematous skin.
Home-base lymphedema treatment in patients with cancer-related lymphedema or non-cancer-related lymphedema.
Anatomical distribution of tissue fluid and lymph in soft tissues of lower limbs in obstructive lymphedema-hints for physiotherapy. Tissue expander breast reconstruction in not associated with an increased risk of lymphedema.
The intravascular stenting method for treatment of extremity lymphedema with multiconfiguration lymphaticovenous anastomosis.
Standardized method for quantification of developing lymphedema in patients treated for breast cancer. In edema, the equilibrium is shifted and more fluid remains in the interstitial space—when this becomes chronic, inflammatory cells and their cytokines lead to an irreversible state. Lymphedema praecox (Latin for premature) should not be used for this disease as it only leads to further nosologic confusion.
The microfilaria invade lymphatics, reproduce within the lymphatics, and damage local lymphatics and regional nodes, often resulting in hydroceles and scrotal swelling, classic components of filarial elephantiasis. Although the limb swells during the day, indentations from socks can be seen on the leg at nighttime, returning toward normal during the night, but the leg stays swollen, and initially concerns may be cosmetic in nature.
Learn about the topmost among them spread worldwide.IntroductionA brain tumor is the place there is an abnormal development of cells in the brain level. The patients were recruited as they used occasional services within the University Hospital of Heraklion (Crete, Greece). Primary lymphedema results from congenital abnormality or dysfunction of the lymphatic vessels [2]. Patient's health status was measured using the generic Medical Outcome Study (MOS) short form-36 questionnaire (SF-36) [7], translated and validated in Greek language [8]. A conventional approach was applied, involving elevation of the affected limb, massage, physical activity and compression with elastic stockings.On physical examination she presented a non-pitting, non-erythematous edema extended from the ankle to the groin without signs of inflammation (Figure 2). Based on our observation, it seems that the long time passed from the moment of the diagnosis may have offered the first patient the chance to cope better with the psychological aspects of his condition over time. It is also noteworthy that in a study among primary health care teams only 4 out of 10 physicians were aware about the presence of an effective treatment for lower limb lymphedema [11].
Posing simple open-ended questions, allowing patients to talk about their conditions and using generic metric tools for the assessment of physical and mental deficits represent both approaches that in conjunction can effectively follow-up rare, and commonly related to poor care provision, disorders.The SF-36 findings highlight the necessity of additional research efforts that promote the implementation of a more holistic care approach for patients with primary lymphedema, the same as in other chronic illnesses and conditions. Closed-suction drains should be placed into the mastectomy wound site, because most patients will develop a seroma. Pressure dressings over the dissected skin flaps are unnecessary and do not decrease the amount and rate of seroma formation (1). Cellulitis seen in the early post-operative period, responds to antibiotic treatment in most cases.


With surgical ablation of the breast, the intervening lymphatics and fatty tissues are resected en bloc; thus the vasculature and lymphatics of the gland are transected. Respiratory distress is recognized in the operative or the immediate post-operative periods and pneumothorax is confirmed with a chest X-ray. Aspirating the liquefied hematoma and establishing patency of the suction catheters can treat hemorrhage. The patient usually experiences moderate pain in the operative site, shoulder, and arm in the immediate postoperative period. Injury or transaction of the long thoracic nerve of Bell produces instability and unsightly prominence of the scapula ("winged scapula"). In addition, although most patients who develop lymphedema do so within 3 years of surgery, the onset of lymphedema occurs up to 25% of patients (10).
The incidence of lymphedema is lessened if transverse rather than oblique incisions are used (18). Photography at preoperative and postoperative visits can be very useful in determining the onset and progression of lymphedema.
Lymphedema is one type of interstitial fluid build-up that occurs when fluid is not being removed by the lymph vessels. Tape measurements are taken at defined intervals, using geometric formulas to calculate the total volume. BIS is now available to measure interstitial fluid as a component of assessment leading to the diagnosis of lymphedema and has been shown to provide reliable data to be used in the diagnosis of breast cancer-related lymphedema (28). Lymphedema causes the affected skin and subcutaneous tissues to become inflamed and hardened (fibrotic). The baseline measurement and periodic measurements after treatment of breast cancer are vital to accurate diagnosis.
Medical management should involve a multidisciplinary approach in the patient's long-term care. CDT frequency and duration should be individualized to produce the greatest reduction of swelling and improvement of skin condition in the shortest period of time. Recommended pump pressures generally range from 30-60 mmHg, although lower or higher pressures may be indicated.
Surgical treatment should be instituted for patients for whom previous medical modalities have failed or for those who have had long-term complications.
Postoperatively, compression garments are still necessary for the maintenance of the limb and must be worn life-long due to the lymphatic scarring from these surgeries and lymphatic insufficiency.
They are done in conjunction with multiple limb fasciotomies and can improve lymphatic drainage through muscles and deep lymphatic circulation. Although surgical intervention and treatment have been tried in the past, the standard of care now is a conservative medical management. Schonholz, Medical Director, Breast Cancer Center at Mercy Medical Center, Springfield, MA (USA) for expert opinions and assistance in preparation of the manuscript. The concept of type II lymphedema can be enlarged to include four syndromes with similar molecular defects: Lymphedema-late onset (Meige syndrome), lymphedema-distichiasis syndrome, lymphedema and ptosis syndrome, and the hereditary forms of lymphedema with the yellow nail syndrome. In patients with primary and secondary lymphedema in the absence of venous or arterial disease, manual lymphatic drainage and sequential pneumatic pumps, in addition to compression wraps and garments, may be useful. A brain tumor could be benign or malignant, because they are not cancerous, and cancerous tumors were.
The functional and mental impact of primary lymphedema was measured using the generic Medical Outcome Study short form-36 questionnaire and open-ended questions led to give more emphasis to patients' experiences. Secondary lymphedema which is more common than the primary form can develop as a consequence of distruction or obstruction of lymphatic channels by other pathological conditions such as infection, trauma or malignancy [1]. It is a self-administered questionnaire that comprises 8 domains of quality of life: physical functioning, role physical, role emotional, bodily pain, vitality, mental health, social functioning, and general health.
In the past, the burden of the problem was considerable as the disorder conditioned patient's perceptions in family planning and had a negative impact on his employment status.Another important issue is that due to some physicians' limited awareness the patient suffered his condition for a long time without a diagnosis.
Nevertheless, lymphedema specialists such as vascular surgeons are more familiar with the management of the disorder in the acute phase.
Assessing not only the severity of the physical limitation but also the related psychosocial dimensions and quantifying the burden of this complex condition over time could contribute to tailor fitted interventions. Patients with severe lymphedema have chronic, often debilitating arm swelling with resultant pain, decreased function, decreased quality of life, and cosmetic deformity. We prefer closed-suction catheter drainage of the mastectomy wound, commercially available as Blake (Ethicon) or Jackson-Pratt tubing (Baxter) and each system should be placed appropriately at operation to allow superomedial and inferolateral positioning to ensure thorough, dependent aspiration. Postoperatively, the wound is carefully inspected with regard to flap adherence, and the patient is encouraged to resume preoperative activity. When abscess formation does occur, attempts should be made to culture the wound for aerobic and anaerobic organisms with immediate Gram-stain of identifiable strains to document the bacterial contaminant.
Therefore, transudation of lymph and the accumulation of blood in the operative field are expected. Immediate intervention with closed thoracostomy drainage of the pleural space is essential as soon as pneumothorax is verified.
The application of a light compression dressing reinforced with Elastoplast-tape should diminish the recurrence of this adverse event.
Because of the necessity of extensive flap development, the patient may note hyperesthesia and paraesthesia, as well as occasional "phantom" hyperesthesia in the mastectomy site.
The patient sustaining such an injury will often complain of shoulder pain at rest and with motion for many months after the procedure. Lymphedema is the accumulation of protein-rich fluid in soft tissues as a result of interruption of lymphatic flow. In addition to measured arm swelling, many patients have perceived or subjective arm swelling that is difficult to quantify (15). Circumferential measurements using reference points to bony landmarks may also be a practical and simple way to follow patient's lymphedema. MRI, CT and US can show the presence of increased interstitial fluid but cannot tell the cause. Lymphoscintigraphy is accurate for detecting abnormalities of the lymphatic system in the extremities regardless of the cause. This technique can be accurate if it is done in precisely the same way each time, and is most accurate when the same person takes the measurements each time. BIS is done by passing a small, painless, electrical current through the limb and measuring the resistance to current (impedance).
Currently, these skin changes are documented by physical examination of tissue texture, pitting, enlarged skin folds and other dermatologic conditions such as wounds and papillomas (benign growths on the skin in areas of lymphedema).
The measurement takes just three minutes using a perometer -- device that employs infrared technology to accurately verify arm volume. This includes patient education, instruction in home physical therapy exercises, maintenance of normal range of motion and strength in the affected extremity, and preservation of existing motion. It consists of an initial reductive phase (Phase I) followed by a maintenance phase (Phase II) (31). At the completion of Phase I CDT, the person with lymphedema is set up on a self-management program that includes self-lymph drainage (sometimes called Simple Lymphatic Drainage), home lymphatic exercises, a skin care regimen, and compression garments or bandages that the individual learns to apply.
In general, lower pressures are considered to be safer, but the pressure has to be individualized to the patient's diagnosis and skin condition.
There are several types of surgical procedures available that have been used for lymphedema: (a) excisional operations, including debulking and liposuction, (b) tissue transfers, and (c) microsurgical lymphatic reconstruction. Acupuncture has shown benefit for some symptoms of cancer and cancer treatment, including fatigue, hot flashes, muscular or joint pain, neuropathy and nausea. Late on-set-type II disease has decreased or absent axillary nodes and decreased lymphatics above the inguinal ligament on scintilymphangiography. A common complication is contact dermatitis from the use of topical antibiotics or multiple emollients and anti-inflammatory creams. Lymphangiosarcoma, the Stewart-Treaves syndrome when associated with postmastectomy lymphedema, is the common lesion in chronically lymphedematous locations . Brain tumors are incredibly serious, and once had a really low survival rate, but the latest medical developments has grown the chances of survival. The analysis of short form-36 results in the first patient disclosed a significant functional impairment with a minor impact of the condition on emotional and social domains.
Since then he was recommended to follow a conservative management with elevation of the extremity, elastic stockings, physical activity and avoidance of trauma. According to the patient some of the involved physicians paid limited attention to his disorder. Although the disease is rare, primary care physicians as first contact care givers and through the continuity of care that they can offer, may play an important role in the diagnosis and the monitoring of the long-term impact of lymphedema on physical and emotional or social domains. Because of its chronic nature, as well as a lack of proven long-term treatment methods, development of lymphedema is perhaps the most feared complication of breast cancer surgery for both patients and surgeons. Although the incidence of postoperative complications is low, physicians should be aware of the morbidity unique to mastectomy and axillary node dissection. In most circumstances, the breast cancer patient is allowed to begin the gradual resumption of pre-surgical activities. Operative technique should minimize lymphatic spillage and transudation of serum to allow rapid adherence of the skin flaps to deep structures without compromise of blood flow to skin flaps or the axilla. Early severe hemorrhage is most often related to arterial perforators of the thoracoacromial vessels or internal mammary arteries.
Phantom breast syndrome is a continued sensory presence of the breast after it has been removed.
All attempts should be made to preserve this nerve, yet its involvement with invasive neoplasm or nodal extension may require that it be sacrificed to ensure adequate en bloc extension. It occurs most frequently in the extremities, but it can also be found in the head, neck, abdomen, lungs, and genital regions. Advances in the management of breast cancer, most notably the advent of sentinel lymph node biopsy (SLNB), have decreased the incidence of lymphedema.
Limiting the axillary dissection to level I and II nodes and preserving the level III nodes and lymphatic collateral channels around the shoulder may decrease the incidence of acute and chronic lymphedema. Some authors have defined mild lymphedema as differences in arm measurements that are less than 2 cm but are associated with subjective sensation of swelling. Differences in circumferential measurement between two opposing limbs are noted at multiple landmarks. These imaging techniques have to be put together with history, physical examination and sometimes other imaging tests. Perometry uses an infra-red optical electronic scanner and computer to calculate the volume of the body part.
The machine uses certain electrical current frequencies to determine if more fluid exists as compared to the contralateral limb. Methods available for measuring skin texture and resistance quantitatively are: tissue dielectric constant and tonometry (29). Arm measurement, which is now a part of standard clinical evaluation has helped us better identify and treat the condition and also has led to greater understanding of the risk factors involved. Attention to detail and good surgical techniques of sharp dissection, adequate hemostasis, suction drainage, and closure without tension should lessen the chance of postoperative lymphedema. In Phase I, the main goals are reducing the size of the affected part and improving the skin. Some individuals may require additional measures with Velcro, specialized foam construction garments, and pneumatic compression devices. Previous studies have demonstrated that wound infections and infections of the ipsilateral arm are significant risk facts for the development of lymphedema. The risk of liposuction include bleeding, infection, skin loss, abnormal sensation (such as numbness, tingling, "pins and needles" feeling), and lymphedema returning. Patients with diffuse interstitial fibrosis, the more traditional option of total superficial lymphangiectomy (Servelle's) or partial superficial lymphangiectomy (Kondoleon's) is recommended.
There are no rigorous studies on using acupuncture for treating lymphedema or using acupuncture on lymphedema extremities (39). Surgeons, nurses, physical and occupational therapists play active roles in the care of chronic lymphedema patients. Brain Cancer Treatment Centers AbroadOne of the biggest problems in some countries will have a brain tumor to obtain the necessary treatment. For the second patient quality of life scores in the emotional and social domains were affected.
Currently, he reports at least two episodes of cellulitis annually.Physical examination revealed an erythematous non-pitting edema extended from groin to foot.
In a study that described characteristics of lymphedema referrals, approximately 7 out of 10 patients with primary lymphedema, suffered their condition, on average, for at least 5 years [9].
The SF-36 seems to be a suitable tool for the assessment of quality of life in patients with lower limb lymphedema [12].
Younger women usually regain full range of motion of the arm and the shoulder soon after drain removal, whereas some older patients may require intense (supervised) exercise for several months before attaining their former levels of activity. Factors that may increase the risk for infection include open biopsy before mastectomy, increasing age, prolonged suction catheter drainage, and alterations of host defense mechanisms. The use of closed-system suction catheter drainage over the last 20 years has greatly facilitated the reduction in protracted serum collections.
The lateral and medial pectoral nerves to the pectoralis major muscles and the motor innervation to the pectoralis minor exit the brachial plexus to enter the posterior aspects of these muscles in proximal axilla. In post-mastectomy patients, chronic lymphedema has the potential to become a permanent, progressive condition. However, recent long-term studies have shown that even in patients undergoing SLNB alone, both objectively and subjectively measured lymphedema can occur in 3%-5% (15)(16).
Recent technology has introduced the concept of lymphatic mapping and SLNB for women with invasive breast cancer. The use of patient perception in the definition of lymphedema is important and is advocated by the American Cancer Society (ACS). Other conditions such as heart failure or low proteins in the blood from liver disease or malnutrition can cause fluid to build up in the tissues.
Perometry is accurate if the body part is positioned exactly the same way each time and the machine has been calibrated for accuracy. It does this comparing the difference in resistance to electricity passed through interstitial fluid compared to intracellular fluid. Early interventions such as wearing a compression sleeve for 12 weeks can prevent progression of the condition.
Wound infection and sepsis should be avoided, suggesting a role for perioperative antibiotics. After Phase I, the person with lymphedema needs to continue into Phase II, an ongoing, individualized self-management phase to make sure the gains of Phase I are maintained long-term. Phase II maintenance must be monitored and changed periodically, just as treatment for any other chronic medical condition.
Many clinicians presume immediate breast reconstruction to increase the risk of lymphedema as a consequence of increased potential for surgical site infection.
An alternative microsurgical technique described by Campisi, Boccardo, and Tacchella involves performing interposition autologous lymphatic-venous-lymphatic (LVL) anastomosis. Rebounder trampolines have been advocated by some for treating lymphedema, but there are no published studies on this treatment.
Appropriate patient education and instruction in self-care are paramount in the long-term care of patients.
Kaposi-Stemmer sign, a feature of chronic lymphedema, describes the skin over the proximal digit of the second toe that cannot be elevated; in edema the skin can be elevated. Our findings support further the statement that physicians should pay full attention to appraise the patient's physical and emotional condition. It has been reported that patients with lymphedema exhibit an excess of psychological sequelae and poor levels of psychosocial adaptation comparative to the general population [6]. It could represent a useful long term monitoring tool that evaluates the course of lymphedema impact on patients' functional and emotional well-being.There is limited evidence about the optimal treatment approach of patients with lymphedema [5, 13]. Early diagnosis is important since treatment is most effective when lymphedema is diagnosed at the earliest stage. Progressive lymphedema is complicated by recurrent infections, non-healing wounds, discomfort or pain, difficulty with daily tasks, emotional and social distress.


Routinely, catheters are removed only when less than 30 ml of serous or serosanguineous drainage is evident for two consecutive 24-hour intervals. Home-visits from the healthcare providers of the Visiting Nurse Association (VNA) are of particular value for psychosocial and physical recovery of post-mastectomy patient. Miller and associates concluded that use of the electrocautery for the development of skin flaps in the performance of a mastectomy reduces blood loss without incurring a greater incidence of wound complications (8). Preservation of the pectoralis major and its function is the objective of the modified radical mastectomy. If it is allowed to progress, the condition can become extremely treatment resistant and in most cases cannot be completely relieved with either medical or surgical means. Thus, it is clear that even the minor perturbations in axillary drainage patterns that occur with SLNB can in some cases cause lymphedema. With the hypothesis that the histology of the SLNB reflects the histology of the remaining nodes in the basin, full nodal staging information can be garnered with a simple lymph node biopsy of one or more nodes. As such, patient-directed interviews and validated instruments that assess lymphedema symptoms have been developed and enable combination of patient perception and objective measurements (21). MRI, CT scans and US may be required to determine the cause of lymphedema, especially if there is a concern that the lymphedema might be the result of an untreated cancer. It predicts response to treatment and shows the main, larger lymph vessels, basic architecture of the peripheral lymphatic system and nodes (24). Perometry has been demonstrated to detect as little as a 3% change in limb volume in breast cancer survivors followed over time (27). BIS currently is done on the whole limb since the resistance to current flow for standard technique is calculated to the length of the body part. Women who progress to moderate lymphedema are managed by more aggressive measures such nightly bandaging, massage and compression, in addition to wearing a sleeve, are beneficial.
Radiation therapy after lumpectomy should not include axilla, unless the chance of recurrence in the axilla is overwhelming. In this series (35), immediate reconstruction was not associated with increased risk of infection. This procedure represents an alternative to direct LVSs and is based on the abundance of large-caliber venous tributaries.
Rebounding is good exercise, it but is not known to be superior to other forms of aerobic exercise in individuals with lymphedema. A realistic approach to the long-term care of this condition coupled with therapeutic and emotional support can ensure a productive and less debilitating lifestyle to patients with chronic extremity lymphedema.
Hospitals, insurance companies and educational funding organizations put an excessive amount of red tape that must be been through, and valuable time is wasted. General practitioners have the opportunity to monitor the long-term impact of chronic disorders. There is limited information about psychological distress that patients with lymphedema meet, thus we found interesting to review known cases of lymphedema in the island of Crete.These reports focus on two cases of primary lower limb lymphedema, by discussing the overall physical and mental impact of primary lymphedema through the use of metric tools of health related quality of life domains and highlighting some qualitative aspects of patients' self-reported experiences. In alignment with this, previous research efforts showed that there is no linear relationship between the change of the limb volume and psycho-social morbidity [10].
Working with an interdisciplinary team has been reported to be an important issue in the patient's adherence to lymphedema treatment [13]. Every patient with lymphedema should have access to established effective treatment for this condition. Thus maintenance of the integrity of the medial and lateral pectoral nerves is paramount to ensure subsequent function of the pectoralis major.
Left untreated, lymphedema leads to chronic inflammation, infection and hardening of the skin that, in turn, results in further lymph vessels damage and distortion of the shape of affected body parts (11). This approach may limit the possibility of lymphedema to only those women with histologic evidence of metastatic disease in the axilla. The onset of lymphedema relative to surgical intervention is unpredictable and may occur over several years. It does not show the deep transport lymph vessels carrying lymph from the nodes back to the blood circulation.
Water displacement, the bench "gold standard" for assessing volume, is rarely used these days due to its inconvenience.
The higher the water content in the interstitial tissue, the lower the resistance (impedance). Some women experience a transient form of the condition; they show signs of subclinical lymphedema but do not progress to clinical symptoms.
If axillas are included in the radiation field, the incidence of lymphedema may be as high as 52% (30). Specialized equipment requires maintenance and replacement according to manufacturers' guidelines. To maintain edema control, a compression garment, or short-stretch bandages, should be worn between pump treatments and also when IPC therapy is discontinued. Additionally, those patients who did have infections did not have an increased risk of lymphedema. The LVL anastomosis consists of inserting suitably large and lengthy autologous venous grafts between lymphatic collectors above and below the site of obstruction to lymphatic flow.
Due to potential interactions of natural supplements with prescription drugs and other negative side effects, patients should check with their physician or healthcare provider before taking any natural supplements.
Individuals are forced to wait too much time, their claim continues to be pending, and many eventually refused to assist.Brain tumor treatment AbroadAn unexpected number of people had a brain tumor treatment abroad. Furthermore it is not clear to what extent factors such as sex, socio-cultural or family status influenced personal views of the patients involved. It is also remarkable that, in a recent report discussing the genetic inheritance pattern of congenital primary lymphedema, genetic assessment and molecular investigation have been considered that contribute significantly to a proper counseling process to the families with a confirmed disease background [14].
Lymphedema has no cure but can be successfully managed when properly diagnosed and treated. The advantages of breast reconstruction in terms of quality of life are well documented (2). Most oncology surgeons recommend -- allowing arm mobility immediately after surgery but delay a structured exercise routinely until after the drains have been removed. Interstitial fluid can build up in any area of the body that has inadequate lymph drainage and cause lymphedema.
This would appear to be the best objective criterion with which to judge lymphedema and response to therapy. Lymphoscintigraphy identifies lymphatic abnormalities at a late stage, after lymphedema has occurred.
Distinguishing the two groups is critical to ensuring that women do not receive unnecessary treatment (40).
Phase II CDT and periodic medical monitoring are essential to the long-term success of lymphedema treatment. Patients being considered for IPC must be evaluated by a physician or healthcare provider with expertise in lymphedema. Contraindications to this procedure include lymph node hyperplasia or aplasia and extensive obliteration of superficial and deep lymphatic collectors.
The vast majority of clinical series studying lymphedema have used arm measurements at various distances proximal and distal to the olecranon process. North America and some Countries in Europe, the waiting time for treatment and expenses are so overwhelming that negatively affect the likelihood of survival. Factors that have been associated with increased psychological distress and sexual dysfunction in patients with lymphedema were low levels of social support [10].
Furthermore, it is reported that a close collaboration among health professionals, with a high level of awareness, from geneticists, neonatologists, pediatricians to dermatologists, may represent an essential issue for an optimal overall management of cases with a congenital primary lymphedema [14]. In addition, recent studies have disproven many of the concerns regarding the potential effects of breast reconstruction on breast surgery management (3).
Lymphedema is a condition that develops slowly and once present is usually progressive (12). However, these techniques are time consuming and are limited to facilities that have the equipment to perform study.
A new technique for imaging lymph vessels is Near Infra-Red Florescence Imaging (NIR) using a substance known as indocyanine green (ICG) (25). In this study, the researchers have determined that undergoing lymph node dissection or radiation to the lymph nodes increases a woman's risk of developing lymphedema. Diuretics are of minimal aid in the treatment of chronic lymphedema resulting from oncologic surgery or metastatic spread of the disease. However, as only a small number of patients in the current series had infections complications, thereby limiting the statistical power. Reductions in limb volume have been reported and a number of preliminary studies have been done, but there are no long-term studies of the effectiveness of these techniques (38). Tissue expander breast reconstruction in patients undergoing SLNB or SLNB and axillary lymph node dissection does not increase the risk of developing measured or perceived lymphedema. But there are lots of foreign countries, where patients receive treatment in a significantly faster speed and more reliable and more modest costs.Treatment abroad does not necessarily mean that you should receive less efficient treatment. It was surmised that social support may help combat fears of abandonment and feelings of isolation [10]. For instance, large series have shown that breast reconstruction does not alter the biologic behavior of breast cancer, does not significantly delay or interfere with administration of adjuvant chemotherapy, and is not associated with a delay in the diagnosis of breast cancer recurrence (4).
Bioelectrical impedance techniques are the most recent developments for evaluating accumulation of fluid in affected extremities. The ICG is injected into the skin and immediately imaged with a dynamic (real time) infrared florescence camera.
Up to 8% of patients who have sentinel node biopsies and 20 to 25% of women with axillary lymph node dissection develop lymphedema at some time after treatment (40). Compression pumps are rapidly becoming a major factor in medical management of patients with chronic lymphedema. The prescription must include the intensity of pressure and pattern of pressure needed, taking into consideration several aspects of patient's situation including determination of need for programmable pressure to treat fibrotic areas, address treatment of ulcers, and adjust for patient's level of pain and skin sensitivity (34). In conclusion the study has shown that breast reconstruction with tissue expander following mastectomy does not increase the risk of lymphedema. Treatment of lymphedema should be undertaken only after a thorough diagnostic evaluation has been done according to accepted guidelines by qualified practitioners. Many foreign countries have very capable clinic professionals have been trained in the UK or the United States, and the high success rate of cancer treatments.Treatment Abroad BenefitAn excellent benefit of getting treatment abroad to patients and visiting exciting new places while receiving care.
However, despite the fact that breast reconstruction is now performed routinely, there is no data regarding the impact of breast reconstruction on the development of lymphedema. Symptoms of chronic lymphedema are usually elicited by taking an accurate history of the patient. Adjuvant radiation therapy and postoperative infection increase the risk of developing lymphedema, as does having a body mass index of more than 25. Researchers have recently focused attention on recreating the beneficial effects of massage through mechanical or compressional means, leading to the development of compression devices.
If trunk, chest or genital swelling is present, the physician must determine whether a pump that provides appliances to treat those areas is necessary or if the patient can manage the trunk swelling through self-manual lymph drainage or garments.
CDT has been shown to be effective in large numbers of case studies demonstrating limb volume reduction of 50-70% or more, improved appearance of the limb, reduced symptoms, improved quality of life, and fewer infections after treatment.
Patients complain of an overall increase or "fullness" of the extremity, with a corresponding "heaviness" and decreased functional ability. It can diagnose lymphedema and find abnormalities at an early stage, possibly before swelling is obvious. If a pump with only extremity attachments is used, close monitoring should be instituted to detect an increase in edema or fibrotic (hard) tissue above the device sleeve, called a fibroscelerotic ring.
Even people with progressive lymphedema for 30 years or more; starting CDT have been shown to respond.
Depending on how severe the condition is, swelling can be present at birth or may develop later in life. Although this technique shows promise for the diagnosis of lymphedema, it is currently available at very few centers, most of which are involved in research.
If this occurs, consideration should be given to using a device that treats the trunk in addition to the extremities.
All interventions for lymphedema must have the goals of inducing and maintaining volume reduction, preventing medical complications, improving skin condition, reducing infection, enhancing patient adherence, and improving comfort and quality of life. The change in scenery, beautiful sights and exciting things you can do and see, and knowing that at this point you get the treatment that is required, can help you keep a positive mind-set. Primary lymphedema is associated with developmental abnormalities of the lymphatic system, may be manifested in neonates (congenital), adolescents (praecox), or patients older than 35 years (tarda). These devices offer no direction for fluid transport, which causes some backflow of lymphatic fluid. Additionally, the physician or healthcare provider must evaluate the impact of various other medical conditions that are usually considered contraindications for pneumatic compression therapy, including acute infection, severe arterial vascular disease, acute superficial or deep vein phlebitis (inflammation or clot), recurrent cancer in the affected area, or uncompensated congestive heart failure. Brain Cancer Treatment Abroad DestinationsThe initial step is to research the choices carefully.
The second-generation devices are multi-cell systems based on sequential compression of the extremity. It delivers compression at the same pressure in each garment section from distal to proximal.
The condition occurs as a result of damage by metastatic disease to the lymphatic system, post-radiation changes to the underlying skin structures, or surgical removal of one or more lymphatic nodal basins.
However, this does not imitate the normal muscular and vascular activities of an extremity. Good quality examples will be right here.Brain Tumor Treatment in SingaporeA nation that has done well in international brain tumor treatment in Singapore. This type of lymphedema occurs from damage to the lymphatic system, commonly from cancer and its treatment but also from trauma to the skin such as from burns or infections (13). Benzopyrones can decrease the overall volume of high-protein-concentrate edema by stimulating proteolysis. Lymphedema after breast cancer has been studied the most, but lymphedema can occur as a result of other cancers, including melanoma, gynecologic cancer, head and neck cancer or sarcoma. Venalot, a benzopyrene is a drug that breaks down large protein molecules, facilitating absorption of the proteins into the vascular system at the level of the capillaries (32). Brain cancer treatment open to the medical center for foreign patients and offer plan to help the international brain tumor patients seeking treatment abroad.
Raffles Hospital A complete service private hospital offering an extensive range of specialist services with a team of 200 physicians. Mission Hospital,Private Hospital, Bangkok, Thailand – This general hospital in Bangkok provides a full range of services including Cosmetic Surgery. The EuroMedic employees are multilingual, and their service covers every aspect of medical travel, from getting price quotes, to admission and recovery.
Many international patients receive care in this hospital is extremely professional.Heidelberg University Hospital is one of Europe`s leading medical centers. World-renowned experts provide comprehensive care of the highest international standards in all medical specialties.Brain Cancer Treatment in IstanbulThe Istanbul Memorial Hospital is yet another great option is a prestigious reputation.
Like the others, additionally they manage a number of international patients each year, much attention lengths to ensure patients receive the highest degree of medical care.Was the first hospital in Turkey to get the JCI accreditation. It is also part of the American Hospital Association (AHA).A contemporary, JCI accredited, full service hospital, established in 2009.
And you’ll find other capable hospitals available that could provide brain cancer therapy to international patients. With many different trustworthy choices accessible, it stacks the odds in discovering fast therapy in an inexpensive cost.
I have been waiting for over a year and have been suffering with headaches and migraines and other symptoms for a very long time. By now you will have doctor’s reports and MRI(s) It may be they have been removed by now.



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Comments to «Lymphedema signs and symptoms»

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