Fig. 6.1
Measurement of limb volumes using water displacement
All patients undergo lymphoscintigraphy to determine their lymphatic function. Patients who reside outside of our region have their lymphoscintigram performed at our institution the day before their scheduled appointment. We have a standard lymphoscintigraphy protocol (images at 45 min, 2 h, 4 h). The use of a consistent protocol enables us to compare patients as well as follow the same individual longitudinally. We have found that when patients undergo lymphoscintigraphy at outside institutions the test often is not performed properly or is difficult to interpret (e.g., only a 2 h image is taken). We prefer to obtain a lymphoscintigram for most patients because it definitively diagnoses the condition. In addition, the test gives a subjective measure of the severity of lymphedema in patients who likely have the condition. For example, an individual who has transit to the inguinal nodes by 2 h and no dermal backflow would be considered to have “mild” lymphatic dysfunction, whereas a patient with no tracer in the inguinal nodes by 4 h and dermal backflow would be labeled as “severe” dysfunction. Patients with worse lymphoscintigraphic findings are counseled that their prognosis may be less favorable and that they should be vigilant with conservative interventions.
All individuals evaluated in our Lymphedema Center are entered into a database to facilitate research. Using this strategy, we have been able to publish demographic data on patients referred to a Lymphedema Center as well as characterize the disease obesity-induced lymphedema [1–6]. Collecting patients in regional referral centers allows retrospective and prospective clinical research studies to be performed. In addition, insights into the condition are more easily formed when patients are concentrated among specific providers. Our database also has allowed us to help patients contact other individuals with lymphedema who reside in their area. Often individuals obtain psychological benefit from speaking or meeting with others who share their disease (particularly in the pediatric population).
Interdisciplinary Management
Although many types of specialists care for patients with lymphedema, plastic surgeons have been particularly involved in patient management because they are most capable of providing surgical intervention. Currently performed physiologic procedures (i.e., lymphatic–venous anastomosis, lymph vessel transplantation, lymph node transfer) require the microsurgical expertise of plastic surgeons. Excisional procedures that are carried out (i.e., liposuction, staged skin/subcutaneous excision, Charles procedure) also require plastic surgical training.
A Lymphedema Center should be staffed by a plastic surgeon capable of providing operative intervention if necessary (Table 6.1). Compression experts must participate as well (e.g., rehabilitation medicine physician, physical therapist, occupational therapist, physician assistant, and/or nurse). Our clinic in Boston is staffed by a compression garment specialist who measures, fits, and troubleshoots garments during the patient’s appointment. In addition, we have a pneumatic compression expert who teaches pneumatic compression to patients during their visit.
Table 6.1
Multidisciplinary lymphedema center specialists
Plastic surgeon |
