Chapter 20B | Short Notes in Plastic Surgery

February 22, 2025

Chapter 20B: Non-surgical Methods in the Treatment of Lymphedema

Filed under: Chapter 20B — ravinthatte @ 9:57 am

Over the last quarter century and more reconstructive plastic surgery has been transformed greatly by micro-surgical skills and these have become the basic skill set for any reconstructive surgeon. What has been added to this repertoire in the last couple of decades is microsurgery on very fine lymphatic vessels as well as the free microvascular transfer of live lymph glands to treat lymphedema. This blog already has chapters on that subject. In India filarial infections is a major cause of a large percentage of patients with lymphedema. Lymphedema due to congenital lymphatic dysplasia and as a result of cancer (mainly of the breast and pelvic pathology) as well as the treatment of those cancers involving removal of lymphatic tissue constitute a smaller subset of all cases of lymphedema. In very recent times surgeons have added protocols to anticipate which patients are likely to get lymphedema post breast cancer surgery and have devised surgical techniques to prevent lymphedema.

While these advances by surgeons are remarkable and the surgeons in a manner of speaking are in the lime light what are not well known are the foot soldiers in the battle against lymphedema namely the physiotherapists who have devised methods to reduce and contain the swellings in the limbs and other parts of the body by methods such as bandaging which in their hands is a fine art and craft both in the pre and post-operative period This fact tellingly came to the notice of the compiler of these short notes (Ravin Thatte) when Dr. Daptardar the chief scientist in the department of physiotherapy at the Tata memorial hospital in Mumbai spoke on the subject at bimonthly plastic surgeons meeting at the Nair hospital in Mumbai in July of 2024. Dr. Daptardaar followed this up with an All India Course on the bandaging and allied techniques with the help of her colleagues Drs Narkhede and Mahajan soon after which the compiler of this blog attended and was hugely impressed. They were therefore requested to contribute this pictorial atlas to acquaint surgeons with their techniques

Contraindications and care before starting treatment in words

Complete Decongestive Therapy (CDT), the gold standard treatment for Lymphedema globally, involves manual lymph drainage (MLD), Multi layered lymphedema bandaging (MLLB), compression garment, skin care and exercises.

Contraindications

Active Infection: Active infection is caused by pathogens. During localized infection, lymphatic vessels constrict to prevent pathogens & other harmful matter from escaping the area & entering the rest of the circulation. When MLD is performed, the spasm may be counteracted. This would allow normal flow to resume & potentially spread the toxin(s). In general, a person needs to be on a course of antibiotics for 2-3 days with signs of improvement (no fever; swelling, redness, pain have subsided) before MLD may resume. Some professionals wait up to 7-10 days before resumption as the inflammatory response can last that long. The multi-layer compression bandaging may hinder the body’s inflammatory response.
Deep Vein Thrombosis / Thrombophlebitis. MLD stretches the skin & may potentially dislodge a blood clot. Mild compression can be beneficial as it encourages clot adhesion to the vascular wall. It is advised to consult the physician prior to application of compression.
Cardiac Oedema. All lymph fluid returns to the circulatory system at the venous angles. In acute congestive heart failure, the heart is already compromised, overwhelmed by the increased volume of fluid. MLD also increases the fluid load which the heart must manage. The same is true for bandaging. Hence CDT will not help.
Peripheral Artery Disease. While MLD is not a concern, bandaging can compromise an already reduced arterial blood flow. Arterial pressure in the foot below 70 mmHg (as measured by Doppler Ultrasound) is a contraindication for compression.
Active Cancer. Malignant tumors with a tendency to metastasize are an absolute contraindication for MLD as MLD only speeds up lymphatic flow & cancer travels via the lymphatic system or the cardiovascular system. However, if a person is responding to chemo & the physician approves MLD, the massage may be performed. Care must be taken to avoid the immediate area of the tumour. Compression can be useful in helping to manage swelling.

Contraindications for Complete Decongestive Therapy and Potential Pathophysiologic Mechanisms

Relative Contraindications
Hypertension	Complete decongestive therapy (CDT) increases central venous blood volume
Paralysis	A flaccid limb may offer insufficient resistance for the application of compression bandages and garments; the limb will also be unable to create a muscle-joint pump with the absence of a muscle contraction; any decrease in sensation may result in injury from the compression bandages or garment
Diabetes	Diabetic vasculopathies and neuropathies may decrease the sensation of pain or improperly fitted compression garments, leading to injury and infection
Bronchial asthma	Parasympathetic stimulation can occur with CDT, which may result in an asthma attack
Absolute contraindications
Acute infections	CDT may exacerbate the symptoms or spread the infection; acute infections should be treated prior to the initiation of CDT because the infection itself provides an increased burden on the lymphatic system (CDT may decrease circulation in the area of the infection, diminishing access to the immune-fighting lymphocytes and macrophages)
Congestive heart failure (CHF)	CHF may be exacerbated by an increase in central venous volume or pressure (patients with mild CHF are still eligible for treatment, but the patient’s cardiologist should be consulted for clearance of the patient prior to the initiation of treatment)
Deep vein thrombosis	CDT may lead to embolism from dislodging of a clot

Before starting Complete Decongestive Therapy (CDT):

Get assessed

A detailed physical examination of the limb and medical history to check for conditions that could contribute to swelling.

Talk to a specialist

A lymphedema specialist can provide guidance.

Check for contraindications

CDT may not be suitable for people with certain conditions, such as hypertension, diabetes, paralysis, or bronchial asthma.

Avoid manual draining

Manual draining is not indicated during active infection or congestive heart failure

Skin Care

Proper skin care is paramount. The skin of patients with lymphedema is usually very sensitive, dry, and itchy due to disturbances of skin metabolism as a result of the macro-and microcirculation alterations making it susceptible to inflammation and infection. Due to the impaired healing process, skin injury can lead to severe inflammation, infection (e.g. cellulitis) or even ulcers, worsening the condition, thus therapeutic and protective measures are essential components of skin care.

The aim is to keep the skin in a normal and healthy state, or to heal it as well as possible. In order to keep the skin flexible and durable, patients should choose a mild, soap-free cleansing lotion that is neutral (pH=7) or slightly acidic (pH=5) for daily use as well as bath oils that replenish the skin oil.
Patients should take care to completely dry the skin after a bath or shower, especially in deep skin folds, to minimize the risk cutaneous fungal infection. After the skin has been cleaned, the skin must be hydrated using moisturizer or emollients. Products for skin care should be used sparingly and applied with gentle massaging movements.
All skin infections should be treated and cleaned by the treating physician. During treatment, special attention should be paid to the care of any secondary skin lesions resulting from radiation.
Avoiding perfumed lotions: Perfumed lotions can dry out your skin and cause irritation.

Pictorial of the methods of measurements both volumetric and by tape measure with legends