LEG LYMPHEDEMA

Traditionally, leg lymphedema has been thought of as a primary and or hereditary lymphedema condition. However, with cancer treatment become much more effective and with so many more cancer patients not only surviving cancer but literally achieving a cure, more and more incidents of leg lymphedema are coming to the forefront. We have long understood breast cancer as a leading cause of secondary lymphedema, but the frightening truth is that as statistics are kept we are finding similar ratios among cancers survivors of all types.

In conjunction with this the medical community is slowly coming to a clearer understanding of other conditions that could trigger lymphedema as well.

I hope this page will provide leg “lymphers” with information that is both helpful and that can enable them to have a better quality of life and lifestyle. Our page Your Emotions and Self Image with Lymphedema give helpful tips and insights on facing the emotional challenge of lymphedema.

Risk Factors for Leg Lymphedema

SECONDARY LEG LYMPHEDEMA

1.) Unexplained swelling of either part of or the entire leg. In early stage lymphedema, this swelling will actually do down during the night and/or periods of rest, causing the patient to think it is just a passing thing and ignore it.

5.) Any change involving hardening and/or thicking of the skin or areas of skin on the leg.

STAGES OF LEG LYMPHEDEMA

Lymphedema Of The Legs And Ankles

By Linda Fisher

The obstruction of the flow of lymph from a given area results in the accumulation of abnormally large amounts of tissue fluid in that area. Such an accumulation is called lymphedema. Lymphadema is not only uncomfortable, it may cause such problems as pain, infection and recurrent infection, difficulty in movement, clothing restrictions, and air travel restrictions.

Remembering that the lymph moves upward in the body toward the heart, from the finger tips in toward the heart, and from the top of the head down toward the heart, we can see that the fluid moving furthest in the body is from the lower extremities. Some causes of lymphedema of the lower extremities is congestive heart failure, trauma to the back or lower abdominal area, blockage in the groin (inguinal nodes), or blockage behind the knee (popliteal nodes).

I often use the analogy of a traffic accident on the freeway to explain movement of lymph. At the point of the accident, all traffic either stops or slows to a near halt, until the accident is cleared away, thus allowing the traffic to again flow naturally. Anatomically, at the point of blockage, everything slows down and begins to accumulate backward along the path of flow. If the feet and ankles are swollen, it generally means that there is a blockage "up ahead."

Even in slender young people, we sometimes see signs of lymphedema in the legs. This appears as "heavy ankles" or as a little pouch of fat on the inside curve of the knee area. When present in this portion of the population, we usually find that the individual is not getting the right exercise and eating largely of the wrong foods, or just the opposite. Many joggers, tennis players, and aerobic exercise enthusiasts exercise and eat properly, but they get this problem because repeated hard impact will slow lymph movement.

In the middle age and senior group, we may see a different, but very common, problem - shuffling the feet instead of walking comfortably. When you cannot lift your feet to step properly, you may just accept that you probably have an "arthritic problem." Many times, you may have a large mass of lymph fluid behind your knee that has pooled, and then hardened. Imagine the pain this would cause. It would be like strapping a tennis ball behind your knee and then attempting to walk!

There is more than one cause of lymphedema in the lower extremities. The ones mentioned above are just some of the more common ones.

Tips to Avoid Blockage:

Do not wear tight jeans or tight under garments.
Do not cross the knees when sitting; cross feet at the ankles instead.
For the exercise enthusiast, integrate some form of slow, rhythmic exercise - yoga and pilates are excellent, as is walking.
Bouncing on a trampoline is excellent - no need to jump. Bend your knees and get a gentle bounce going for a minimum of 12-15 minutes a day. If balance is a concern, hold onto a stationary item or purchase a balance bar that attaches to your trampoline. Also, if wheel chair bound, place your feet on the trampoline and have someone else bounce it for you - you will receive a positive benefit from this.
Lie on a slant board.
And, as always, drink plenty of clean water, practice deep belly-breathing, and eat plenty of fresh, unprocessed foods. Caution: In the case of congestive heart failure, be absolutely sure to check with your health care practitioner before attempting any form of exercise and, of course, no slant-boarding!
"Creating free lymphatic movement through the body is a vital part of any healing process."

Linda Fisher owns the Lympathic Wellness Center in Santa Maria.

Lower limb and leg lymphedema

Just as lymphedema of the upper extremities can become a complication after post surgical removal of breast cancer, lymphedema of the lower extremities can be a debilitating condition with several cancers. Prostate, lung, liver, lymphomas, ovarian, and abdominal cancers can cause swelling of the legs. The swelling can come from any compression or surgical removal of the lymph nodes in the lower body. It can also come secondarily to production of fluid into the abdomen (ascites) which spreads into the legs. When under treatment for any cancer, if your protein levels fall into lower levels, fluid will leak into your whole body including legs

When you first notice swelling in your legs, you need to act to reverse it. Once you let the legs blow up to large size, it is harder to reverse the process. This must be discussed with your doctor. The use of elastic stockings with at least 30 mm hg pressure is the first step. If the edema is only at the ankles and feet, then you only need stocking to the knee. Any medical supply store can help fit the stockings. You should read the package and measure your ankle,calf and the length from the knee to the heel so that you are sure that they fit you correctly. These measurements are usually listed on the box. If the edema goes up to the knee or past, you will need thigh high stockings. You must keep pulling these up as the stocking fall down with wear during the day. The stockings are all hard to apply. You need someone with strong hands. Sometimes it helps to wear rubber gloves to get a better grip on the stockings. There are also leotards for edema that goes above the thigh. When you apply these stockings, they should be perfectly smooth. If you leave wrinkles, it will become painful underneath or you can cut the circulation in that spot. The stockings should be worn through the day from when you first get up. You do not sleep with them on. At night you remove the elastic hose and elevate your legs on pillows in the bed. Try to get them above your heart. You can wrap legs with elastic wraps.

This is difficult to do correctly. The wraps should be on a diagonal. If you go in straight circles, you could end up with a turnicate like constriction of the leg and make the edema worse. If you develop numbness in your toes or coldness, that means that you have wrapped it too tightly. You should totally remove it and apply it again.

For men, often the edema will go up into the scrotum. You should also elevate your penis at night to try to empty the water back in to the abdomen. Wearing a jock strap helps support the heavy and often painful scrotal sack when you are up and about.

When the edema is not responding, you can use the external pump devices if so desired. These devices can be rented from a medical supply house. They are usually covered by insurances. After pumping you must then wear the elastic stockings until bed time. You pump daily for 2-3 weeks to get the severe edema under control. You can also go to outpatient physical therapy or edema clinics for treatments.

When you are sitting you need to elevate your legs during the day or lie down at intervals with the legs elevated on pillows. Do not wear tight shoes as any kind of constriction only adds to the edema above or below the constriction. You must also be very careful not to cut yourself or open the skin. You must immediately see an MD if you have a weeping sore. It will take careful treatment to heal it without infection developing. Sometimes antibiotics are necessary.

Exercises like pumping your feet up and down, leg kicks, going up and down on your toes in standing will help decrease edema. A regular exercise program of walking, exercise with light weights or any kind of movement activity is also helpful. In some instances, decreasing your salt intake becomes necessary.

Other precautions are to be careful with heat or ice on severely swollen legs. That includes your shower or bath water. Bathe legs with regular soaps and rinse well. If you develop athlete's foot, be sure to treat it with one of the common sprays or powders. Be careful cutting your toenail. Get treatment for ingrown toe nails. The problems are more complex when severe edema is involved.

www.cancersupportivecare.com/lowerlymph.html

All the Lymphatic Drainage strokes are based on one principle motion.

Research has found that the initial lymphatics open up and the lymph angions are stimulated by a straight stretch, but even more so with a little lateral motion. After these 2 motions, we need to release completely to allow the initial lymphatics to close and the lymph to be sucked down the channels. In this zero pressure phase don’t completely disconnect from the skin, just return your pressure to nothing. Also don’t pull the skin back with you as you return, let it spring back by itself.

This basic motion may resemble a circle, and is called stationary circles. All motions are based on this principle.

In orienting this motion, we always want to push the lymph towards the correct nodes, so the last, lateral stretch motion should be going towards the nodes.

Think about moving water. Visualize those initial lymphatics just in the skin, stretch, opening them up, then release and wait for the lymph angions to pump the lymph down the vessel. Remember how superficial this is. If you are feeling muscle, or other tissue under the skin, you are pushing too hard.

Here are four points remember when performing Lymphatic Massage-

1. Correct pressure is deep enough so that you do not slide over the skin, but light enough so that you don’t feel anything below the skin. This is about 1-4 ounces. It is very common for massage therapists trained in Swedish or deep tissue to apply too much pressure with lymphatic drainage massage. Sometimes it is hard to believe that something so light could be effective. Always remember- you are working on skin. How much pressure does it take to deform the skin? Almost nothing. Remember- if you push too hard you collapse the initial lymphatic.

2. Direction of your stroke is of great importance, because we always want to push the lymph towards the correct nodes. If you push the lymph the wrong way, your work will not be effective.

3. Rhythm is very important because with the correct rhythm and speed, the initial lymphatics are opened, and then allowed to shut and then there is a little time that is given for that lymph to get sucked down along the vessel. An appropriate rhythm will also stimulate the parasympathetic nervous system, causing the client to relax.

4. Sequence means the order of the strokes. When we want to drain an area, we always start near the node that we are draining to. Always push the lymph toward the node. Then as we work, we move further and further away from the node, but always pushing the fluid back in the direction of the node. In this way we clear a path for the lymph to move, as well as create a suctioning effect that draws the lymph to the node.

Self Manual Lymph Drainage for the Lower Extremity

v Rules for MLD:

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

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

o You should have NO PAIN.

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

o If redness occurs, you are pressing too hard.

o For lymphedema of BOTH legs, perform all moves on both sides.

o The best position to be in for this is seated reclined, or lying
down and propped up slightly.

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

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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

18 Preventive Steps For LOWER Extremities

For the patient who is at risk of developing lymphedema, and for the patient who has developed lymphedema.

WHO IS AT RISK?

At risk is anyone who has had gynecological, melanoma, prostate or kidney cancer in combination with inguinal node dissection and/or radiation therapy. Lymphedema can occur immediately postoperatively, within a few months, a couple of years, or 20 years or more after cancer therapy. With proper education and care, lymphedema can be avoided or, if it develops, kept under control. (For information regarding other causes of lower extremity lymphedema, see What is Lymphedema?) The following instructions should be reviewed carefully pre-operatively and discussed with your physician or therapist.

Absolutely do not ignore any slight increase of swelling in the toes, foot, ankle, leg, abdomen, genitals (consult with your doctor immediately).

Never allow an injection or a blood drawing in the affected leg(s).

Wear a LYMPHEDEMA ALERT Necklace.

Keep the edemic or at-risk leg spotlessly clean. Use lotion (Eucerin, Lymphoderm, Curel, whatever works best for you) after bathing. When drying it, be gentle, but thorough. Make sure it is dry in any creases and between the toes.

Avoid vigorous, repetitive movements against resistance with the affected legs.

Do not wear socks, stockings or undergarments with tight elastic bands.

Avoid extreme temperature changes when bathing or sunbathing (no saunas or hottubs). Keep the leg(s) protected from the sun.

Try to avoid any type of trauma, such as bruising, cuts, sunburn or other burns, sports injuries, insect bites, cat scratches. (Watch for subsequent signs of infection.)

When manicuring your toenails, avoid cutting your cuticles (inform your pedicurist).

Exercise is important, but consult with your therapist. Do not overtire a leg at risk; if it starts to ache, lie down and elevate it. Recommended exercises: walking, swimming, light aerobics, bike riding, and yoga.

When travelling by air, patients with lymphedema and those at-risk should wear a well-fitted compression stocking. For those with lymphedema, additional bandages may be required to maintain compression on a long flight. Increase fluid intake while in the air.

Use an electric razor to remove hair from legs. Maintain electric razor, properly replacing heads as needed.

Patients who have lymphedema should wear a well-fitted compression stocking during all waking hours. At least every 4-6 months, see your therapist for follow-up. If the stocking is too loose, most likely the leg circumference has reduced or the stocking is worn.
Warning: If you notice a rash, itching, redness, pain, increase of temperature or fever, see your physician immediately. An inflammation or infection in the affected leg could be the beginning or a worsening of lymphedema.

Maintain your ideal weight through a well-balanced, low sodium, high-fiber diet. Avoid smoking and alcohol. Lymphedema is a high protein edema, but eating too little protein will not reduce the protein element in the lymph fluid; rather, this may weaken the connective tissue and worsen the condition. The diet should contain easily-digested protein such as chicken, fish or tofu.

Always wear closed shoes (high tops or well-fitted boots are highly recommended). No sandals, slippers or going barefoot. Dry feet carefully after swimming.

See a podiatrist once a year as prophylaxis (to check for and treat fungi, ingrown toenails, calluses, pressure areas, athelete's foot).

Wear clean socks & hosiery at all times.

Use talcum powder on feet, especially if you perspire a great deal; talcum will make it easier to pull on compression stockings. Be sure to wear rubber gloves, as well, when pulling on stockings. Powder behind the knee often helps, preventing rubbing and irritation.

Unfortunately, prevention is not a cure. But, as a cancer and/or lymphedema patient, you are in control of your ongoing cancer checkups and the continued maintenance of your lymphedema.

Revised (c) January 2003 National Lymphedema Network. Permission to print out and duplicate this page in its entirety for educational purposes only, not for sale. All other rights reserved. For more information, contact the NLN: 1-800-541-3259

They say it takes a minute to find a special person, An hour to appreciate them, A day to love them, but an entire life to forget them

Venous dynamics in leg lymphedema.

Kim DI, Huh S, Hwang JH, Kim YI, Lee BB.

Division of Vascular Surgery, Samsung Medical Center, College of Medicine, Sung kyun kwan University, Seoul, Korea.

To determine whether there is anatomical and/or functional impairment to venous return in patients with lymphedema, we examined venous dynamics in 41 patients with unilateral leg lymphedema. A Volometer was used for computer analysis of leg volume, a color Duplex Doppler scanner was used to determine deep vein patency and skin thickness, and Air-plethysmography was used to assess ambulatory venous pressure, venous volume, venous filling index and the ejection fraction. In the lymphedematous leg, volume and skin thickness were uniformly increased (126.4 +/- 21.3% and 156.9 +/- 44.5%) (mean +/- S.D.), respectively. The ambulatory venous pressure was also increased (134 +/- 60.7%) as was the venous volume (124.5 +/- 37.5%), and the venous filling index (134.5 +/- 50.5%). The ejection fraction was decreased (94.9 +/- 26.1%). Greater leg volume correlated with increased venous volume and venous filling index (values = 0.327, 0.241, respectively) and decreased ejection fraction (r = -0.133). Increased subcutaneous thickness correlated with increased venous filling index and venous volume (r = 0.307, 0.126, respectively) and decreased ejection fraction (r = -0.202). These findings suggest that soft tissue edema from lymphatic stasis gradually impedes venous return which in turn aggravates the underlying lymphedema.

PMID: 10197322 [PubMed - indexed for MEDLINE]

http://www.ncbi.nlm.nih.gov/pubmed/10197322

Limb Positioning and Movement For Lymphedema Patients

Careful positioning of an affected limb when resting or sitting can help to prevent further swelling. You can also use gravity to help drain away excess fluid. Avoid standing or sitting with your legs down if you can, as this allows fluid to pool around your feet and calves. Movement of your muscles helps to push fluid around the body, so regular gentle movement can help to prevent fluid accumulating.

These guidelines will help you to position your affected limb correctly

Don't cross your legs when you are sitting.

Don't sit with your legs down for long periods -- either lie with your legs up on a pillow, or have them fully supported on a footstool.

Try not to stand still for long periods of time. If standing is unavoidable, do the following exercises to stimulate the pump action of your muscles: raise yourself up on to your toes frequently to tense and relax your calf muscles; shift your weight from one leg to the other and transfer your weight from heels to toes, as if walking on the spot.

http://www.lymphedemacare.com/reference/limbpos.php

You can do a simplified version of MLD yourself at home, called simple lymphatic drainage (SLD). SLD is done by using your fingers very gently to move the skin in a particular direction. If you find that the skin is red when you have finished, then the movement is too hard. It is often easier if your partner or a friend also learns the technique, so that they can help you in any areas you cannot reach. Your physiotherapist or nurse will be able to show you or your partner the technique. The diagrams and explanations on the following pages should also help.

Massage 1 - for both arm and leg swelling

Place your fingers, relaxed, on either side of your neck at position 1.
Gently move the skin in a downwards direction, towards the back of your neck.
Repeat 10 times at position 1, 2 and 3.
At position 4 (on the top of your shoulder) use a gentle inward scooping movement down towards the top of your breast bone (where the collarbones meet)
Repeat 5 times.

Massage 3 - for swelling of one leg

The aim of this massage is to clear a path ahead of the affected leg to allow excess fluid to drain away.

Starting at the armpit on the same side as your affected leg (position 1), use light pressure to stretch the skin up gently into the armpit. Your hand should be flat and not slide over the skin. Repeat 5 times.
Repeat 5 times each at chest level (position 2), waist level (position 3), then at your lower abdomen (position 4). Each time you will be gently pushing the skin up to the armpit on the same side as the swelling.

You must be properly taught these techniques before you start. These diagrams are intended as a guide only when you are doing your SLD

Hand-held massagers

Hand-held massagers can be useful for people who have restricted movement of their hands, perhaps due to arthritis. They are available at most large chemists and some electrical shops. As with all SLD techniques, a light touch is necessary. Massagers should never be used to press down on the skin. If you do this, you will obstruct your lymphatic channels and so the massage will not help lymph drainage. Hand-held massagers can be quite heavy to hold so try to hold it in the non-swollen hand. You may need your partner or a friend to help you.

Talk to your doctor or lymphoedema specialist before using a massager. It can be used to apply gentle pressure in the same sequence of movements as the exercises on the previous pages. Here are some guidelines for using a hand-held massager:

Use it for at least 15 minutes a day.
Use the lowest setting and a dimpled head.
Do not use oils or creams with the massager.
Do not use the heat setting. If possible, get a massager without a heat pad, as these are lighter and easier to use.
Use a gentle, circular movement, following the sequences of movement described earlier.
Avoid massaging abnormal or broken skin.

Deep breathing exercises

Before and after SLD, breathing exercises can help to stimulate lymphatic drainage. Use the following simple exercises:

Sit in a comfortable chair or lie on your bed with your knees slightly bent. Rest your hands on your abdomen.
Take deep breaths to relax.
As you breathe in -- direct the air down to your abdomen, which you will feel rising under your hands.
Breathe out slowly by `sighing' the air out. While breathing out let your abdomen relax in again.

Do the deep breathing exercises five times and then have a short rest before getting up.

Cancer BACUP UK

"One of the truely most comprehensive and best sites I have seen."

Lymphedema Leg Exercises
lymph ex

These exercises are best done lying on a bed or floor with the leg raised on pillows or cushions. You may support your head with a pillow if necessary.
lymph ex

Slowly and firmly bring one knee up to the chest.
lymph ex

Slowly straighten leg and lower down onto the pillows. Repeat alternate legs x 10.
lymph ex

Slowly and firmly point foot towards the floor then bring back as far as it will go. Repeat x 10.
lymph ex

Slowly and firmly rotate feet making circular movements with pointed toes. First clockwise then anti-clockwise. Repeat x 10.

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Primary lymphedema of the leg: relationship between subcutaneous tissue pressure, intramuscular pressure and venous function.

Christenson JT, Hamad MM, Shawa NJ.

In eight patients with unilateral primary lymphedema, subcutaneous tissue and intramuscular pressure were measured in both legs using the slit-catheter technique. Venous function was assessed by venography, or Doppler or photoplethysmography. Both at rest and during exercise, subcutaneous tissue pressure was elevated in the lymphedematous leg (17.9 +/- 7.6 and 33.0 +/- 10.8 mmHg respectively) compared to healthy contralateral leg (0.4 +/- 2.6 and -0.6 +/- 3.6 mmHg; p less than 0.001). The intramuscular pressure in the anterior tibial compartment was also increased at rest and during exercise in the edematous leg (24.9 +/- 4.4 mmHg and 43.6 +/- 11.2 mmHg respectively) compared to control leg (9.6 +/- 5.6 and 25.8 +/- 10.00 mmHg). These findings suggest that derangements in both the superficial and deep lymphatic systems as well as venous dysfunction contribute to the clinical appearance of "primary lymphedema."

PMID: 4033199 [PubMed - indexed for MEDLINE]

Effect of sequential intermittent pneumatic compression on both leg lymphedema volume and on lymph transport as semi-quantitatively evaluated by lymphoscintigraphy.

Miranda F Jr, Perez MC, Castiglioni ML, Juliano Y, Amorim JE, Nakano LC, de Barros N Jr, Lustre WG, Burihan E.

Vascular Surgery Division, Federal University of Sao Paulo, Paulista School of Medicine, SP, Brazil.fmirandajr.dcir@epm.br

Sequential Intermittent Pneumatic Compression (SIPC) is an accepted method for treatment of peripheral lymphedema. This prospective study evaluated the effect in 11 patients of a single session of SIPC on both lymphedema volume of the leg and isotope lymphography (99Tc dextran) before SIPC (control) and 48 hours later after a 3 hour session of SIPC. Qualitative analysis of the 2 lymphoscintigrams (LS) was done by image interpretation by 3 physicians on a blind study protocol. The LS protocol attributed an index score based on the following variables: appearance, density and number of lymphatics, dermal backflow and collateral lymphatics in leg and thigh, visualization and intensity of popliteal and inguinal lymph nodes. Volume of the leg edema was evaluated by measuring limb circumference before and after SIPC at 6 designated sites. Whereas there was a significant reduction of circumference in the leg after SIPC (p<0.05), there was no significant difference in the index scores of the LS before and after treatment. This acute or single session SIPC suggests that compression increased transport of lymph fluid (i.e., water) without comparable transport of macromolecules (i.e., protein). Alternatively, SIPC reduced lymphedema by decreasing blood capillary filtration (lymph formation) rather than by accelerating lymph return thereby restoring the balance in lymph kinetics responsible for edema in the first place.

PMID: 11549125 [PubMed - indexed for MEDLINE]

J Reconstr Microsurg. 2003 May;19(4):209-15.

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

Over the last 9 years, the authors analyzed lymphedema of the lower extremity in a total of 25 patients, comparing the use of supermicrosurgical lymphaticovenular anastomosis and/or conservative treatment. The most common cause of edema was hysterectomy, with or without subsequent radiation therapy for uterine cancer. Among 12 cases that underwent only conservative treatment, only one case showed a decrease of over 4 cm in the circumference of the lower leg. The average period for conservative treatment was 1.5 years, and the average decreased circumference was 0.6 cm (8 percent of the preoperative excess). Thirteen patients were followed after lymphaticovenular anastomoses, as well as pre- and postoperative conservative treatment. The average follow-up after surgery was 3.3 years, and eight patients showed a reduction of over 4 cm in the circumference of the lower leg. The average decrease in the circumference, excluding edema in the bilateral leg, was 4.7 cm (55.6 percent of the preoperative excess). These results indicate that supermicrosurgical lymphaticovenular anastomosis has a valuable place in the treatment of lymphedema.

Publication Types:

Tips on Wrapping a Lymphedema Leg

One of the best posts on how to wrap a leg...from LLLymphedema2@yahoo.com

Since you have the swelling in the feet (and toes), it is probably lymphedema, perhaps compounded with lipedema. The traditional bandaging technique is with a stockinet, then some artiflex (cotton padding), and lastly, the bandages. I bandage directly over the skin. The padding is supposed to even out if you should constrict some part of the bandaging, causing the lymph not to flow, but the bandages are really not like rubber bands -- properly spaced and overlapped, they will not cause constriction -- and the artiflex is a pain. The stockinet is just another thing to wash and dry. I went to www.bandages.com and found that they have new bandages that are thick enough to be used without layering (e.g. the stockinet and padding). Perhaps this is the way to go, or perhaps you want to bother with stockinets and padding. If you were seeing a therapist, they would also use foam instead of artiflex (just cotton padding). Some pictures of bandaging look absolutely monstrous. My so called therapist used some foam, etc., but I soon discovered that the leg went down more without it. The pad is supposed to "spread" the compression so there is no binding -- but what really happens is all the elasticity of the bandages goes to compressing the FOAM -- not compressing your leg. A little compression trickles down to the actual leg, but my experience was that the swelling went down better without the extra stuff. However, since this is against tradition, you should at least be aware if any part of your leg feels too tight, and, if so redo the bandages (which is at least an hour for two legs -- and bandages that were OK while you were up and around can suddenly become too tight in the middle of the night -- which means you have to get up and do it again.) Anyway, with or without stockinet and padding, here is one technique for bandaging:

materials (1 large leg not grossly larger than normal (I am 5'9" and the calf measure is 21" and I have wide, swollen feet - if you are substantially larger, you may need more)

optional: stockinet, artiflex, foam

required:

1 roll 1" professional strength masking tape.
1 ea 3" strip of heavy padding around the ankles
1 ea 1" x 5m medi-rip
2 ea 8 cm. x 5 m short stretch bandages
1 ea 10 cm x 10 m short stretch bandages
1 ea 6 cm x 5 m short stretch bandages.

Double for 2 legs, if you are very much larger than me, add another 1 ea 10 cm. x 5 m short stretch bandage for each leg.

I sit on my bed and have a low table I can rest my foot on, but two chairs will work also (one to sit on and one to put your foot on).

Wrap the 3" strip of heavy padding (or chock pads) around the ankles. The figure 8's you are making around your foot and from the foot onto the leg will tend to bind right at the intersection of the foot and leg (where the 90" turn is made. This is the only place padding is essential. Secure it with masking tape. Secure all the bandages after they have been wrapped with masking tape. Cut a lot of 5" strips of masking tape and have them ready. Stick them on the edge of the table, or a windowsill, or something.

First hold all the bandages so that you are drawing from the bottom of the bandage cylinder (the bandages rolled up are a cylinder), not the top. A little experimentation will show you that this is much easier.

Start with the 1" medi-rip (it is a self cohesive bandage, but looses some of the self cohesion with laundering). Use this tiny bandage to bandage along the toe line. That is, make the same arc that the joints of the toes to the feet make. Do not bind the toes. If you can, wrap each toe with it, but I find that this binds the toes and hurts, so I leave my toes unwrapped, even though they swell, but if you start with the larger short stretch bandages, there will be a half moon that swells even more (Since if you make a straight circle from just below the little toe to just below the big toe, this will leave some area of foot not bandaged and the lymph will be pushed into this area, and it will be worse than before. The little 1" medirip can be wrapped in a curved path that covers all of the foot. Overlap this 1" medirep by 1/2 and continue winding it around your foot until you get to the end of the arch, then take it up diagonally over the top of the foot, and you will still have enough bandage to wrap again just under the toe line again for a few wraps. The medi wrap has strands of elastic in an otherwise cotton strip, so pull the medirip tight (that is the elastic is extended, but not to the point of discomfort).

When you wrap the bandages, pull a bit at the end of each circle, but do not stretch them too hard, or with constant tension as far as they will stretch. You want them to exert a little spring, but don't strangle your legs. If you get them too tight, it will hurt, and you must undo your wrapping and redo it (a big pain). If you don't stretch them a little, they won't have much compression. Of course, it's always the bottom bandages on the feet that hurt, so you have to unwrap the whole deal to get to them.

Next,step 2 take a 8 cm. x 5 m short stretch bandage, and start at the tip of the foot, but do not bind any toes, and since you already have the medi-rip, allow a little breathing space to make sure you don't bind toes. Then wind around your foot overlapping the bandages by about 1/2 to 2/3 (I probably overlap 2/3) until you have gotten almost to the leg (your foot should be at a 90 degree angle to the leg, and for me this is 2 or 3 wraps), then go around the heel itself, and, as you come off the other side of the heel, take the bandage diagonally up on the top of the foot to just below the top of the first wrap (just under the bottom of the big toe), go around the bottom of the foot, and then bring the bandage back around the ankle just above the heel, then around the ankle, and back up diagonally across the top of the foot just like before, overlapping 1/2 to 2/3 of the previous path. This will make large figure 8s. Continue with the figure 8's each layer a little higher around the ankle, until you again are wrapping just in front of the leg (no more space to do another figure 8) and use the rest of the bandages going in straight circles (not figure 8's) around the ankles.

Next,step 3 take the second 8 cm x 5 meter short stretch bandage, and start at the base of the leg (around the ankles), go around once or twice, to anchor the bandage, then on the next turn go down around the bottom of the foot close to the heel, and then around the bottom of the foot and then over and up around the leg, then continue making figure 8's up the leg overlapping by about 2/3. To make a figure 8 around the leg, on one side of the front of the leg, the bandage is going uphill (or towards your knee), then it goes more or less straight around the back of the leg at the high end of the 8, then goes downhill (or towards the foot), as you come across the front of the leg again, then more or less straight across the back of the leg at the low end of the 8 and then up again for the next figure 8. On me, this bandage is finished just about at the beginning of the calf (a little above the bottom of the muscle -- it would be ideal if this bandage ended just before the muscle begins, but it will be a bit different for everyone depending of how much they overlap and how large their leg is.

Next,step 4 do figure 8's with the 10 cm x 10 m bandage. Begin at the bottom of the leg with the beginning of the bandage facing upward, so the first direction is in a downward direction, (the end pointing up) coming around and then going up again. The 10 cm x 10 m bandage should take you up to just below the knee, but if the legs are very large, you may need another 10 cm. bandage. Each course of the figure 8 should overlap a little less or evenly, but not more than the previous course. The more you overlap the greater the compression, and you must always have less compression proximally (towards your heart) than distally (towards your toes).

Finally,step 5 take the last 6 cm. x 5 meter short stretch bandage and start at about mid calf or a little higher, and wind in straight circles until just below and as close as possible to the knee. This last bandage gives compression over the tops of the top 8's where there is not as much overlap, and sort of holds it all up, as the circumference of the leg is actually smaller at the knee than at the mid calf (doesn't slide down because a smaller circle would have to slide over a larger circumference of the leg).

I have been complemented on my ability to wrap, but It is hard to know if a novice can make much sense of my directions -- but I tried. Look at some photographs of the bandaging while you are at www.bandages.com. You don't see to many photographs of the figure 8's, but they give more compression and stay up better, and bind less. You will get the general idea of winding up the leg, and overlap by looking at the photographs, however. It may seem complicated to follow my directions (I tried to be clear), but the real technique is not very hard at all.

The new thick bandages that do not need padding (padding is included) are : KomprimED. They are located on the bandagesplus web site under bandages, then under two way stretch bandages. I think you should start with these, as the padding may be more important for someone who is just beginning bandages. This is much simpler than all those stupid layers.

*Soft and comfortable directly on patient's skin
*Thicker texture avoids application of foam and padding in many cases
*Suitable for lymphedema and venous ulcers
*Patient-friendly application requires less layers
*All bandages are short-stretch/low stretch
KomprimED 4cmx5m

Other wise, the standard short stretch bandages are rosidal or comprilan. I use rosidal. The medi-rip is under the section
cohesive bandages on page 2 under the more general category bandages.

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Special Thanks to: Linda

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