The Impact of Living With Severe Lower Extremity Lymphedema: A Utility Outcomes Score Assessment.

March 2013

Sinno H, Izadpanah A, Tahiri Y, Christodoulou G, Thibaudeau S, Williams HB, Slavin SA, Lin SJ.

Source

From the *Division of Plastic and Reconstructive Surgery, Montreal General Hospital, †Faculty of Medicine, McGill University, Montreal, Quebec, Canada; and ‡Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.

Abstract

BACKGROUND: Debilitating lower extremity lymphedema can be either congenital or acquired. Utility scores are an objective measure used in medicine to quantify degrees of impact on an individual's life. Using standardized utility outcome measures, we aimed to quantify the health state of living with severe unilateral lower extremity lymphedema.

METHODS:

A utility outcomes assessment using visual analog scale, time trade-off, and standard gamble was used for lower extremity lymphedema, monocular blindness, and binocular blindness from a sample of the general population and medical students. Average utility scores were compared using a paired t test. Linear regression was performed using age, race, and education as independent predictors.

RESULTS:  A total of 144 prospective participants were included. All measures [visual analog scale, time trade-off, and standard gamble; expressed as mean (SD)] for unilateral lower extremity lymphedema± 0.22, and 0.76 ± respectively) were significantly different from the corresponding scores for monocular blindness (0.64 ± 0.18, 0.84 ± 0.16, and 0.83 ± 0.17, respectively) and binocular blindness and 0.62 ± 0.26, respectively).

CONCLUSIONS:

We found that a sample of the general population and medical students, if faced with severe lymphedema, is willing to theoretically trade 8.64 life-years and undergo a procedure with a 24% risk of mortality to restore limb appearance and function to normal. These findings provide a frame of reference regarding the meaning of a diagnosis of severe lower extremity lymphedema to a patient and will allow objective comparison with other health states.

PubMed

Caring for the lymphedema foot

Caring for the lymphedema foot

January 2013

Most people who have leg lymphedema also will have foot involvment. Thus, taking care of our feet becomes even more critical for lymphedema patients.

Feet that have damaged skin, cuts, scrapes or any open areas become entry foci for bacterial infections associated with lymphedema infections. Feet with unhealthy skin can become an open door for foot fungal infections. Both can cause further complications and worsening of our lymphedema.

Keith Smiley

The National Lymphedema Network (NLN) has been flooded with questions regarding foot and ankle care for patients with lower extremity lymphedema. Dr. Joseph Hewitson, a San Francisco Podiatrist, who has worked with many lymphedema patients, provided NLN a list of guidelines and suggestions for proper foot care for people suffering from lower extremity lymphedema. These guidlelines are excerpted from The July NLN newsletter.

Wear shoes.  

I love going barefoot, but with lymphedema, this can be downright dangerous and can give bacteria a splendid opening for an infection.  Resist that temptation to go barefoot.

Make sure you don't provide an opportunity in your shoes for bacteria or fungus spores to hide and grow.  I personally use an antifungal powder in even my street shoes.

Nail Care

Be sure to trim your toenails, but not necessarily straight across. If the corners have grown into the skin, trim the offending border.

If you get an infection, you should remove that side of the nail to resolve the infection. Antibiotics often will not work because an abscess (walled off infection) has occurred. Soaking may only provide temporary relief.

A lymphedema patient should never undergo a chemical matrisectomy (destroying root growth matrix with a chemical to permanently remove nail).

Fungal nails are common in lymphedema patients and should be soaked in 1:1 vinegar/water solution for 20 minutes, with antifungal solution applied afterwards.

Routine foot care every three months with a podiatrist if possible or your physician.

Meticulous nail care decreases the chance for inflammation and infection.

Taking Care of your Toes

The inner spaces between your toes need to be kept clean and dry.

Soaking in a 1:1 vinegar/water solution for 20 minutes at least once a week and running a piece of gauze between your toes to remove any debris will help keep your web spaces clean.

Using a drying agent/antifungal solution like Castelani's Paint decrease chances of irritation and infection.

Applying lambs wool (see your pharmacist) between the toes allows the web greater breathability.

Open toed compression garments will also allow greater breathability, as will breathable footwear that is fitted correctly.

Dr. Hewitson says that proper footwear is very important. He says always buy your shoes at the time of day when your foot is most swollen (usually the end of the day). If you wear a compression garment, make sure you fit your shoes to accommodate this. Good athletic shoes are excellent to wear because they are more supportive, and more breathable. For very large feet, a Velcro strap shoe is usually more accommodating.

If you have painful corns and calluses, they should be routinely trimmed by a podiatrist or practitioner. Never use any callous removal pads, because they can cause burns and infections.

Dr. Hewitson also says to always work with reputable practitioners who are willing to further educate themselves on lymphedema. He adds, you may be their best and only teacher.

Suite 101

Simple measures which will promote healthy skin:

1. Inspect the skin daily for any crack, cuts or dry areas. Check carefully areas with reduced sensation or where there are skin folds.

2. Clean skin daily with non-perfumed soap

3. Dry skin completely, especially the area between the toes

4. Keep skin supple. Use a Iow pH lotion as Eucerin to keep the skin moist and pliable.

5. Check fingernails and toenails for any signs of infection, cracks, fungus, or hangnails. Do not cut nails or cuticles. Use an emery board.

6. Call your doctor at the first signs of any infection, redness or high temperature.

For Further Information on the skin, skin care, foot care, possible complications and infections, please see the below listed pages:

Infections Associated with Lymphedema

Skin Care

Blisters

Calluses

Bunions

Fungal Infections Associated with Lymphedema

How to Have Healthy Nails

Corns

Antibiotics

Cellulitis

Lymphorrhea

Skin Conditions and Skin Growths

Skin Infections

Skin Functions

Wrapping Lymphedema Toes - illustrated

Wrapping the Lower Limb (Leg) with Lymphedema - illustrated

Multilayer Compression Bandaging of the Lymphedema Leg

The earliest finding of indocyanine green lymphography in asymptomatic limbs of lower extremity lymphedema patients secondary to cancer treatment: the modified dermal backflow stage and concept of subclinical lymphedema.

Takumi Yamamoto, Nana Matsuda, Kentaro Doi, Azusa Oshima, Hidehiko Yoshimatsu, Takeshi Todokoro, Fusa Ogata, Makoto Mihara, Mitsunaga Narushima, Takuya Iida, Isao Koshima

Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.

Plastic and reconstructive surgery (impact factor: 2.74). 10/2011; 128(4):314e-321e. DOI:10.1097/PRS.0b013e3182268da8

ABSTRACT

Early diagnosis and treatment are as important for management of secondary lymphedema following cancer treatment as in primary cancer treatment. Indocyanine green lymphography is the modality of choice for routine follow-up evaluation of patients at high risk of developing lymphedema after cancer therapy.

Fifty-six limbs of 28 so-called unilateral secondary lower extremity lymphedema patients who underwent indocyanine green lymphography were compared with dermal backflow patterns of indocyanine green lymphography on 28 asymptomatic limbs and assessed using leg dermal backflow stage.

Of 28 asymptomatic limbs of secondary lower extremity lymphedema patients, the dermal backflow patterns were detected in 19 limbs but were absent in nine limbs. Significant differences were seen between asymptomatic limbs with dermal backflow patterns (n=19) and limbs without them (n=9): age, 51 versus 34, body weight 75 kg versus 34kg, body mass index 23 versus 19, leg dermal bacflow stage of symptomatice limb 3 versus 2.

The splash pattern is the earliest finding on indocyanine green lymphography of asymptomatic limbs of secondary lower extremity lymphedema patients. The leg dermal backflow stage allows early diagnosis of secondary lower extremity lymphedema even in a subclinical stage. The concept of subclinical lymphedema could play an important role in early diagnosis and prevention of lymphedema after cancer treatment.
Diagnostic, V.

Source: PubMed

Lower extremity lymphedema index: a simple method for severity evaluation of lower extremity lymphedema.

Takumi Yamamoto, Nana Matsuda, Takeshi Todokoro, Hidehiko Yoshimatsu, Mitsunaga Narushima, Makoto Mihara, Gentaro Uchida, Isao Koshima

Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan.

Annals of plastic surgery (impact factor: 1.29). 03/2011; 67(6):637-40. DOI:10.1097/SAP.0b013e318208fd75

ABSTRACT

Measurement of the circumference is the most commonly used method for evaluating extremity lymphedema. However, comparison between different patients is difficult with this measurement. To resolve this problem, we have formulated a new index, lower extremity lymphedema (LEL) index, which can be easily obtained from measurements of the body. We evaluated correlation between lower LEL index and clinical stage in patients with LEL. The LEL indices were significantly correlated with clinical stages and could be used as a severity scale. The LEL index makes objective assessment of the severity of lymphedema through a numerical rating, regardless of the body type. This numerical rating makes the index useful for evaluation of lymphedema severities between different cases.

Source: PubMed

Chyloperitoneum, chylothorax and lower extremity lymphedema in woman with sporadic lymphangioleiomyomatosis successfully treated with sirolimus: a case report.

June 2012

Chachaj A, Drozdz K, Chabowski M, Dziegiel P, Grzegorek I, Wojnar A, Jazwiec P, Szuba A.

Source

Department of Internal Medicine, Wroclaw Medical University, Wroclaw, Poland.

Abstract

Lymphangioleiomyomatosis (LAM) is a rare disease characterized by diffuse thin-walled cysts throughout the lungs on computed tomography and diffuse proliferation of abnormal smooth muscle-like cells (LAM cells) on lung biopsy. LAM affects women almost exclusively, predominantly in their reproductive age. The most typical presenting symptoms include dyspnea, spontaneous pneumothorax, cough and chylothorax. Abdominal findings represent less common initial manifestations of the disease and may pose diagnostic difficulties. The treatment of LAM has not been fully established. Recent studies report effectiveness of sirolimus in LAM patients. We report the case of a 45-year-old woman with sporadic LAM, successfully treated with sirolimus, in whom the first manifestation of the disease was chyloperitoneum and after three and nine years, respectively, lymphedema of the left lower extremity and right sided chylothorax occurred.

PubMed

A novel approach to the treatment of lower extremity lymphedema by transferring a vascularized submental lymph node flap to the ankle.

July 2012

Cheng MH, Huang JJ, Nguyen DH, Saint-Cyr M, Zenn MR, Tan BK, Lee CL.

Source

Division of Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan, Taiwan. minghueicheng@gmail.com

Abstract

OBJECTIVE:

Vascularized groin lymph node flaps have been successfully transferred to the wrist to treat postmastecomy upper limb lymphedema. This study investigated the anatomy, mechanism and outcome of a novel vascularized submental lymph node (VSLN) flap transfer for the treatment of lower limb lymphedema.

METHODS:

Bilateral regional submental flaps were dissected from three fresh adult cadavers for histological study. A unilateral submental flap was dissected in another six fresh cadavers after latex injection. The VSLN flap was transferred to the ankles of seven lower extremities in six patients with chronic lower extremity lymphedema. The mean patient age was 61 ± 9.4 years. The average duration of lymphedema symptoms was 71 ± 42.2 months.

RESULTS:

There was a mean of 3.3 ± 1.5 lymph nodes around the submental artery typically at the junction with the facial artery, on the six cadaveric histological sections. Mean of 2.3 ± 0.8 sizable lymph nodes were dissected and supplied by the submental artery in six cadaveric latex-injected submental flaps. All seven VSLN flaps survived. One flap required re-exploration for venous congestion but was successfully salvaged. There was no donor site morbidity. At a mean follow-up of 8.7 ± 4.2 months, the mean reduction of the leg circumference was 64 ± 11.5% above the knee, 63.7 ± 34.3% below the knee and 67.3 ± 19.2% above the ankle.

CONCLUSION:

The transfer of a vascularized submental lymph node flap to the ankle is a novel approach for the effective treatment of lower extremity lymphedema.

Elsevier

The contralateral rectus abdominis musculocutaneous flap for treatment of lower extremity lymphedema.

One of my desires is to bring all types of information relating to leg lymphedema to the readers. I must admit,

I really had to grit my teeth on this article.

The authors speak of a long term follow up time frame as 31 months. This is hardly adequate when you are

investigating long term possible complications. Indeed, I had the Thompson'sprocedure done in three surgeries

from 1971 through 1973. The first 31 months did see a reduction in leg size and a slight reduction in cellulitis

episodes.

However, long term should mean a 10, 20 or even longer time frame. After twenty years, I experienced horrific

complications from the surgery, not the least of all was mixed b-cell lymphoma.

Also, if the research proves to be correct about the possibilities that secondary lymphedema patients

are people who are already "at risk" for lymphedema, then the introduction of yet another area of surgery (abdomen)

could prove to be disasterous as well. Any type of surgery that would injury, damage or adversly effect the lymph

system in the abdomen can (as has been well documented) cause abdominal lymphedema.

Please do not consider the posting of this article as an endorsement of any kind and I would further discourage

lymphedema patients from having it.

Pat

The contralateral rectus abdominis musculocutaneous flap for treatment of lower extremity lymphedema.

Ann Plast Surg. 2009 Jan

Parrett BM, Sepic J., Pribaz JJ

Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115

Lymphedema is common after inguinal lymphadenectomy or resection of groin tumors. Animal studies have shown success using the rectus abdominis musculocutaneous (RAM) flap as a treatment for lymphedema. Four patients with acquired lower extremity lymphedema were treated with a contralateral RAM flap with an inferior cutaneous pedicle left intact to facilitate lymphatic drainage into the unaffected groin. One patient also had lymphaticovenous anastomoses performed during flap transfer. All flaps survived with no postoperative complications. With a mean follow-up of 31 months, the mean reduction in limb circumference from the preoperative excess was 81% at the thigh, 70% at the calf, and 71% at the ankle. None of the patients with recurrent cellulitis had further incidences of groin cellulitis. Two patients required future flap debulking. Lymphoscintigraphy was performed in 1 patient and demonstrated reconstitution of lymphatic flow from the affected leg through the flap. According to this preliminary study, transfer of a contralateral RAM flap to the groin of a lymphedematous leg improves lymphedema and decreases the incidence of cellulitis.

PubMed

For further information on surgeries used for the treatment of lymphedema, please see:

Surgery for Lymphedema

and

The Thompson's Procedure

The role of operative management of varicose veins in patients with lymphedema and/or lipedema of the legs.

The role of operative management of varicose veins in patients with lymphedema and/or lipedema of the legs.
Lymphology. 2000 Dec

Földi M, Idiazabal G.
Földiclinic for Lymphology, Hinterzarten, Germany.

The role of operative management of "symptomatic" varicose veins in patients with lower extremity lymphedema or lipedema is controversial. We reviewed the clinical outcome of 261 patients between 1989-1997 at the Földiclinic with lower extremity lymphedema (68 patients), lipo-lymphedema or lympho-lipedema (103 patients) or lipedema (90 patients) who had undergone operation for varicose veins. In each group, the results were dismal as leg swelling worsened or was unchanged in greater than 90% whereas symptoms such as heaviness, fatigue, cramps (termed varicogenic symptomatology) were improved in less than 10%. These findings support that operations for varicose veins in the legs of patients with lymphedema, lipedema, or combinations of these disorders should be undertaken only if there is an absolute indication present (ascending phlebitis and/or bleeding). Otherwise, complete decongestive physiotherapy is still the best treatment approach for these groups of patients.

PMID: 11191657 [PubMed - indexed for MEDLINE]

Self Manual Lymph Drainage for the Lower Extremity

Self Manual Lymph Drainage for the Lower Extremity

Rules for MLD:

The strokes should be made with arcing motions or half circle motions.

Do not slide over your skin, but rather, keep your fingers in contact with your skin and stretch it gently over the underlying tissues.

You should have NO PAIN.

Each stroke should be done 10-15 times SLOWLY, taking about 2 seconds for each stroke.

If redness occurs, you are pressing too hard.

For lymphedema of BOTH legs, perform all moves on both sides.
The best position to be in for this is seated reclined, or lying down and propped up slightly.

Make sure you can make skin-to-skin contact for all of these strokes. They won't work when done over clothing.

1. Neck: Place the flats of your fingers on your opposite shoulder, in the triangular part just above the collarbone and next to your neck. Move your hand in an arcing motion stretching the skin forward and down towards your chest. Repeat this on the other side.

2. Armpit: Raise your arm (on the same side as the leg in which you have lymphedema), bend you elbow, and place the hand behind your head. Place the flat of your opposite hand in your armpit. Stretch the skin in an arcing motion up towards the neck.

3. Above the waist: Place the flat of your opposite hand on the side of your body (on the side on which you have lymphedema) below the breast, but above the waist. Move your hand upwards in an arcing motion in the direction of your armpit, stretching your skin.

4. Below the waist: Place the flat of your opposite hand on the side of your body (on the side on which you have lymphedema) on or just below the waist, but above your hip. Move your hand upwards in an arcing motion in the direction of your armpit, stretching your skin.

5. Deep (diaphragmatic) breathing: Place both open palms on top of each other below the belly button. Take a slow breath in and feel your belly rise up into your hands as it expands to take in the air. Then breath out and feel your belly sink in as the breath leaves you. As you get better at this you can use your hands to resist your stomach slightly as you breath in, and press in slightly with your hands as you breath out. Don’t get dizzy. Start with only 2 or 3 breaths and work up to 10 as you get stronger.

6. Groin: Place the flat of your hand on the front of your groin, right where your underwear falls. Make a scooping motion in the groin, rolling your hand from the thumb to the little finger. Imagine that your hands are the bottom of a water wheel.

7. Back of knee: Place the flat fingers of both hands behind your knee. Perform a scooping motion up towards the body.

8. Repeat steps 3, 4 and 6 (waist and groin areas)

A very special Thanks to Katy from

LymphedemaTherapists · Lymphedema Therapists