Reduction and Maintenance Therapy
Early treatment is key in achieving long-term control of lymphedema. The medical treatment of lymphedema involves two phases: reduction therapy which focuses on actively decreasing the swelling and maintenance therapy which is used to maintain or keep the reduced size gained in the reduction phase. Reduction therapy involves aggressive wrapping of the limb with compression bandages sometime of a stiff material or sometimes with elastic material or a combination of both. Short stretch or low stretch (not elastic) wraps are most often used since the compression is more constant especially when the patient walks. The idea is to push the fluid out of the affected part by applying the wraps during the entire day with rewrapping whenever the compression seems less tight. By measuring the size of the limb frequently during this phase of treatment, the limb can be decreased to its near normal size when compared to the other limb (leg or arm). By compressing the limb the fluid is forced back up into the trunk where it can be reabsorbed by the body. The wraps should only be taken off just before bathing or just before a massage therapy session. Exercise is important during compression treatment to help get the fluid out of the affected part of the body. A therapist will give the patient special instructions on best exercise. Skin care is also an important part of the care of patients with lymphedema. Pressure and friction from the wraps and the appearance of dry skin as the swelling decreases may contribute to problems. The patient must pay close attention to dry or cracked heels, toes or fingers and if prone to athletes foot, the use of an anti-fungal powder or cream to skin creases such as between toes, and skin folds daily or more often may help to decrease infections. A daily moisturizer to prevent dry skin may also help. If you notice a scratch or break in the skin of the affected limb, ask your doctor if an antibiotic ointment applied to the skin might be helpful.
Manual Lymph Drainage (MLD)
In addition, there are many lymphedema treatment programs available in the US. The therapists are specially trained to use a special type of massage to decrease lymphedema swelling. This treatment requires certification after special training. This technique called manual lymph drainage (MLD) is a type of specialized massage which is different from deep congestive massage for reducing lymphedema. The technique encourages the natural flow of lymph fluid out of the affected limb by first clearing out the lymph vessels further up the limb before encouraging the lymph fluid at the most distal part of the limb. The therapist uses a specific set of hand movements and sequences to gently move the fluid away to more healthy lymph vessels. Stimulating (rubbing) the lymph vessels allows them to function more normally and filter and remove the excess fluid. Areas of skin may be especially thick with (protein) fibrinous tissue. The MLD technique can soften these areas to become more like normal skin. You or a family member may be taught to use this technique at home although it can be challenging to do it on yourself. MLD is not used as a therapy alone. It is most often combined with other therapies including compression wrapping, exercise, garments, and skin care.
Surgical Treatment for Lymphedema
A variety of surgical techniques have been proposed to treat patients with lymphedema especially when it has become too difficult to manage by medical therapy alone. The type of lymphedema may determine if a surgical treatment is possible for your condition. Excisional operations remove (cut out) excess tissue to help decrease the size of the limb. The most extensive excisional operation is the Charles’s procedure which removes all the skin and subcutaneous tissue from the knee down to the ankle. This procedure may be done when there have been multiple infections in the skin and fatty tissue under the skin, skin sloughing or the patient is having difficulty in performing normal daily functions. Reducing the bulk of skin is usually helpful but this invasive procedure can have complications such as poor wound healing, prolonged hospitalization, long scars, changes in feeling, and swelling in the foot and ankle. A less extensive form of surgery to reduce lymphedema tissue is liposuction. Lymphedema tissue in time turns into fat which can not be helped by compression so liposuction does this for the body. In rare cases and when there are nicely open lymph vessels above and below an area of damage, lymphatic reconstruction or direct reconnections of the lymph vessels to each other or a vein is possible. These are called lymphovenous anastomosis or lymphatic grafting and use microsurgery. It is noted that this procedure is most useful when done early in the course of lymphedema, before subcutaneous fibrosis occurs and lymphatic vessel sclerosis or hardening begins and the lymphatic vessels still have the ability to contract. It has been done in patients with surgical damage to lymph vessels (such as after breast cancer surgery), chylus reflux, and in people affected with filariasis who often have very large lymph vessels. It is very delicate work working with very small vessels so it is done only in very select cases and the results are not well known.