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Clinical REVIEW, the median cubital vein and ascending The lymphatic drainage of the torso Lymphatic drainage of the upper limb. the arm to pass into the axillary region does not follow the venous drainage of The lymphatic drainage of the upper. between the deltoid and pectoralis the torso as closely as in the arm limb also consists of superficial and deep. major muscles The basilic vein drains the However the venous drainage of the torso systems which follow similar paths to. postero medial aspect of the dorsum also enters the axillary subclavian or that of the vascular system There are. of the hand travels superficially up the branchiocephalic veins en route to the four major patterns of lymphatic drainage. antero medial aspect of the forearm superior vena cava and hence may be which are based on early cadaver. medially through the cubital fossa and relevant to the venous drainage of the lymphography and lymphoscintigraphic. about one third of the way up the arm arm The anterior wall of the torso and the investigation Foeldi et al 2003. before piercing the deep fascia to then breast drains mainly into the axillary vein. accompany the brachial artery into the and to a lesser extent the internal thoracic The superficial lymphatic drainage. axillary region Both veins connect to veins The ribcage is drained via intercostal vessels arise as a plexus within the skin of. the axillary vein and then the subclavian and subcostal veins that drain the ribcage the upper limb Vessels drain from the. veins en route to the superior vena posteriorly into the azygous hemiazygous hand mainly along its palmar surface into. cava Many perforating veins are evident venous system or anteriorly into the larger lymphatic vessels that converge. in the anterior aspect of the forearm internal thoracic veins The posterior wall towards the veins draining the forearm. coalescing into the median vein of the of the thorax also drains into the azygous especially the basilic vein Moore and. forearm which then joins the basilic hemiazygous system which drains directly Dailey 2006 acquiring new vessels from. and or the cephalic veins Figure 1 into the superior vena cava the skin as they travel up the limb. To subclavian lymphatic trunk The lymphatic vessels draining the. Apical axillary lymph nodes antero lateral territory of the arm. traverse the upper part of the arm and,Deltopectoral lymph nodes. the anterior aspect of the shoulder,draining into the uppermost apical. Central axillary lymph nodes,lymph nodes of the axillary lymphatic. Pectoralis minor muscle system Figure 2 Lymph drainage from. Humeral lateral axillary lymph nodes the postero medial aspect of the forearm. passes through nodes in the medial cubital, Pectoral anterior axillary lymph nodes region proximal to the medial epicondyle.
of the elbow and then into lateral, Subscapular posterior axillary lymph nodes humeral lymph nodes of the axilla. Basilic vein,The deep lymphatic drainage,Cephalic vein. originates from the deeper soft tissue,Cubital such as muscles and nerves joints and the. Median cubital vein lymph nodes periosteum of the bones Vessels. converge and travel close to the deep,veins of the upper limb occasionally. Cephalic vein passing through a few lymph nodes,Perforator veins.
before arriving at the lateral humeral,axillary lymph nodes Figure 2 Moore. Basilic vein,and Dailey 2006,The cutaneous venous drainage of the. upper back thorax is via dorsal, Superficial palmar perforating posterior cutaneous branches. venous arch of the posterior intercostal veins and. thence to the azygous hemiazygous,system to superior vena cava. Lymphatic plexus of palm,Venous drainage of the skin and.
dermis of the chest anterior to the,Digital lymphatic vessels. mid axillary line is largely via the thoraco, Anterior palmar view epigastric vein network to the axillary vein. via the lateral thoracic vein the, Figure 1 Venous and lymphatic systems of the hand and arm superior part of the thoraco epigastric. Journal of Lymphoedema 2010 Vol 5 No 1 59,Piller Review indd 3 31 03 2010 13 43. Clinical REVIEW, Supraclavicular lymph nodes Subclavian lymphatic trunk.
Infraclavicular lymph nodes Internal jugular vein,Axillary artery and vein. Apical lymph nodes Deep servical lymph nodes,Right lymphatic duct. Lateral humeral lymph nodes Subclavian vein,Central lymph nodes Right brachiocephalic vein. and artery,Pectoral anterior lymph nodes, Subscapular posterior lymph nodes Parasternal lymph nodes. Interpectoral lymph nodes,Pectoralis minor,Pectoralis major.
To contralateral left breast,Subareolar lymphatic plexus. To abdominal,subdiaphragmatic,A Anterior view lymphatics. Figure 2 The lymph nodes of the axilla, venous network Venous drainage of the Lymph drainage of the skin and dermis aspects of the breast medial to the areola. female breast is largely via the lateral of the front of the thorax chest anterior drain medially to para mammary and. thoracic vein to the axillary vein but the to the mid axillary line is largely from para sternal nodes Schuenke et al 2006. more medial superficial aspects of the individually variable regions lymphotomes then to the right or left lymph duct or. breast drain to the paired internal thoracic to particular axillary nodes i e the sentinal thoracic duct to the subclavian vein and. venae comitantes then to subclavian vein node for each region Suami et al 2008 on to the superior vena cava Sentinel. and on to the superior vena cava Much of The area medial to the nipple in both node tracing from non palpable deep. the deepest tissue of the breast drains via sexes drains to the parasternal internal breast tumours Tanis et al 2005 suggests. perforating veins through the deep fascia mammary node chain Figure 3 that much of the deepest tissue of the. to the anterior intercostal veins and then breast is likely to drain via the deep. to the internal thoracic veins Drainage of the well developed lymphatics which perforate through the. lymphatic network of the female breast deep fascia to join the anterior intercostal. The venous drainage of the skin and including the dense sub areola network is lymphatics passing then to the internal. dermis of the chest mainly enters the largely via laterally or superiorly directed mammary lymph trunk and chain of nodes. axillary subclavian or branchiocephalic lymphatics which pass to pectoral axillary. veins en route to the superior vena cava nodes or to lateral axillary nodes Suami Lymphatic drainage to the axilla. and hence may be relevant to the venous et al 2008 Figure 2 The superficial The lymphatic drainage of the upper. drainage of the arm limb is intimately related to that of the. anterior and posterior regions of the, Lymphatic drainage of the thorax Box 2 thorax especially the breast all of which. The lymphatic drainage of the torso drain through the axillary region The. does not follow the venous drainage of Lymphatic drainage paths axillary region contains five clusters of. the torso as closely as these systems nodes arranged in a pyramid pattern. do in the arm Superficial lymph Studies have indicated that lymph dictated by the shape of the axillary. drainage from the back of the thorax drainage of the upper arm travels into region with three clusters at the base. is mainly via a network of superficial the mammary nodes in some of the axilla one at its apex and one in. lymphatics which converge to the individuals with lymphoedema These the middle Figure 2 Moore and Dailey. subscapular posterior nodes of the drainage patterns also indicate the 2006 These nodes are embedded in. axilla Figure 2 However there is need to pay attention to the potential the axillary fat external to the axillary. the possibility that the more medial effect of clothing particularly bras sheath that contains the axillary artery. back drains via perforating lymphatic on lymph drainage to the internal and vein The majority of the lymphatic. connections to the posterior intercostal mammary as well as the contralateral fluid associated with the antero lateral. lymphatics en route to paravertebral axillary nodes lymphatic territory drains into four to. nodes Iyer and Libshitz 1995 six lateral humeral nodes while that. Journal of Lymphoedema 2010 Vol 5 No 1 61,Piller Review indd 5 31 03 2010 13 43.
Clinical REVIEW,of the postero medial territory drains. into the apical nodes The pectoral and, subscapular nodes drain the anterior Supraclavicular lymph. and posterior thoracic wall respectively nodes chain. and along with the humeral nodes drain,through the central then the apical nodes. Axillary lymph,en route to the subclavian lymphatic. nodes chain,trunk and ultimately the venous system.
The consequence of this arrangement is, that lymphatic drainage of the upper limb Internal mammary. is directly affected by both the drainage lymph nodes chain. of the upper torso and the state of the,central lymphatic system. As is the case with the groin area it is,difficult to get optimum pressures or any. pressure at all into the axillary medial,proximal upper arm area and this. combined with a likely annulus of often Figure 3 Drainage into mammary lymph nodes. inappropriate pressure on the shoulder, and lateral chest provided by the wearer s Lymphatic cutaneous networks Axillary.
bra in the case of a woman means that It is known that there is a greater density Upper limb. lymph nodes, there are often very significant issues of of lymphatic vessels in patients with. fluid accumulation initially and fibre lymphoedema compared to those with. later in this area normal healthy limbs Mammary gland. Paramammary, Lymphatic drainage paths Mellor et al 2000 used fluorescence. Anterior intercostal spaces,lymph nodes, Studies have indicated that lymph microlymphography to examine the. drainage of the upper arm travels into dermal lymphatic capillaries of the. the mammary nodes in some individuals forearm in 16 women with oedema Anterior chest wall. with lymphoedema Kawase et al 2006 following treatment for breast cancer Parasternal. reviewed lymphoscintigraphy results from They reported that the superficial lymph nodes. 1 201 clinically node negative patients with lymphatic density and total length of Posterior chest wall. invasive breast cancer who underwent capillaries was greater in the swollen limb. preoperative labial salivary gland LSG compared to the control arm. Paravertebral, and axillary sentinel lymph node SLN Importantly the distance travelled by the Posterior intercostal spaces. lymph nodes, biopsy They reported a range of lymphatic relatively superficial lymph contents.
drainage patterns and almost 25 of before draining to the sub fascial system Figure 4 Normal drainage pathways of upper. patients had drainage to extra axillary was longer in the swollen limb compared limb and thoracic tissues to the lymph nodes. lymph nodes especially the internal to the normal limb Furthermore there Note drainage from a breast can be to either. mammary ones Figure 3 This has also was no evidence of lymphatic dilation in the ipsilateral nodes more commonly or to the. been confirmed by Ferrandez et al 1996 the swollen limb These findings suggest contralateral nodes less commonly. who after a session of manual lymphatic that there is a local re routing of. drainage MLD found Tc labeled tracers superficial lymph and possibly angiogenesis in swollen limbs Mellor et al. moved to the internal mammary nodes in lymphangiogenesis in the limbs of patients 2000 hypothesised that the increased. 8 of patients with lymphoedema n 47 with lymphoedema Since the work of number length of lymphatic capillaries. as well as to the contralateral nodes in others has shown blood capillary would possibly help to maintain the ratio. 20 Figure 4 What this means for the of drainage capacity to filtration capacity. end results of compression is that not The impact of external compression on. only must we consider the compression Box 3 this change is possibly minor but the. level and its gradient in the limb but also longer travel distance of the lymph in the. the gradient across the truncal area These Lymphatic cutaneous networks superficial lymph collectors may mean. drainage patterns also indicate the need that the establishment and maintenance. to pay attention to the potential effect There is a greater density of of a pressure gradient along the limb is. of clothing particularly bras on lymph lymphatic vessels in patients with very important. drainage to the internal mammary as well lymphoedema compared to those. as the contralateral axillary nodes with normal healthy limbs Tissue structure of the arm. Figure 3 The upper arm contains deep and,62 Journal of Lymphoedema 2010 Vol 5 No 1. Piller Review indd 6 31 03 2010 13 43,Clinical REVIEW. fascia and its impact on the interchange substantial osmotic gradient Figure 5 The. Blood flow Interstitial fluid of fluids between the deep and superficial balance of these forces results in a net fluid. lymphatics We will not go into these flux into the tissue under normal. pathophysiological changes here since circumstances which is then drained away. they are well documented and in by the lymphatic system. mainstream literature Foeldi et al 2003, Hydrostatic Weissleder and Schuchhardt 2008 It is important however to be aware. Capillary pressure that the current textbook version of this. Reduced epifascial depth most often process has fluid being filtered from the. Osmotic associated with a lesser amount of fat arterial end of the capillary and resorbed. pressure directly above the deep fascia means that at the venular end e g Marieb et al 2007. the lymph collectors which are normally as the hydrostatic pressure decreases. lying above the deep fascia are more along the capillary due to frictional losses. Venous end, superficial than those which are covered or resistance and the balance of the. with a greater depth of fat thus generally so called Starling forces shift from. requiring a lower compression pressure favouring filtration to favouring resorption. Figure 5 Diagram of the hydrostatic and oncotic along the capillary This view is now being. pressures acting across the capillary wall affecting Physiological factors affecting replaced by the opinion that at least in. transendothelial exudation of fluid from plasma to lymphatic drainage most capillaries in normal circumstances. the interstitium Both normal and abnormal patterns of there is no resorption of fluid and the net. lymphatic drainage help to demonstrate flux is solely into the tissue from where it. epifascial fat layers The deep fat layer how fluid flows through tissues so it is is cleared by the lymphatics Michel 1997. found in the posterior and deltoid region important to understand both previous Levick 2004 2009. of the arm is thin In normal limbs the and current theories of lymph formation. epifascial fat layer is circumferential and movement During this fluid movement most. but can hypertrophy in the proximal plasma proteins of the blood are retained. posterior one third of the arm In In the healthy individual the vascular in the vascular system as they do not cross. lymphoedematous limbs this hypertrophy system runs into the capillaries which are the capillary membrane in most tissues. is marked and not only has an influence small vessels that are bathed in interstitial The emerging consensus is that the. on lymph load but also on lymph fluid The capillaries have thin semi barrier to the transcapillary flux of plasma. drainage as the additional tissue pressure permeable walls made up of a single layer proteins and larger lipophobic solutes lies. of the adiposites on the delicate walls of endothelial cells that allow the transfer at the glycocalyx a complex luminal layer. of the lymph collectors constrains them of oxygen and nutrients from the blood of anionic polysaccharides and. from their optimal contraction Chamosa into the tissues and the transfer of waste glycoproteins secreted by and attached to. et al 2005 found that in normal arms products such as CO2 and urea from the probably all capillary endothelial cells The. the anterior and distal third of the tissues into the blood glycocalyx acts as a fine fibre filter. upper arm tended to have less thick hindering larger molecule transit by stearic. adipose tissue Occasionally a specific Fluid movement across the capillary exclusion in a size dependent manner. lipodystrophic zone can be found on the wall behaves according to the principles Squire et al 2001 Zhang et al 2006 The. posterior external area of the normal first outlined by Starling 1896 whereby physical path for fluid leakage lies beyond. arm located between the proximal and the blood s hydrostatic pressure forces the glycocalyx at infrequent short breaks. medial thirds Relatively speaking the skin fluid from the capillaries down a substantial in junctional membrane strands along. of the medial aspect of the normal arm pressure gradient into the tissues while the inter endothelial cell junctions which. is generally thin devoid of hair follicles colloid osmotic pressure of the blood elsewhere seal junctions tight Adamson et. and prone to sag Overall the skin is sucks fluid back into the capillary up a al 2004 Curry 2005 The net result of this. mobile and overlies loose nonfibrous arrangement is that fluid resorption at the. fat However as lymphoedema develops capillary is unlikely under normal. there are a range of significant epifascial Box 4 conditions and requires larger breaks in. tissue changes which occur mainly to endothelial integrity such as those. the amount of fat and fibre as there is, Factors affecting lymph drainage occurring during inflammation A corollary.
a thickening of the deep fascia and the of this is that fluid fluxes through the. fascia between the lobules of adiposites There is no resorption of fluid and lymphatic system are likely to be larger. These will have significant effects on the the net flux is solely into the tissue than previously thought since there is no. outcome of external compression in from where it is cleared by the venular resorption of fluid under normal. terms of its transmittance into the tissues lymphatics Thus fluid fluxes through physiological conditions For this reason. and to the vascular and lymphatic systems the lymphatic system are likely to be improved knowledge of the impact of. within it Of particular importance is the larger than previously thought compression on the superficial lymphatic. increase in the thickness of the deep flow is essential. Journal of Lymphoedema 2010 Vol 5 No 1 63,Piller Review indd 7 31 03 2010 13 43. Clinical REVIEW, A further corollary is that increasing compared to unaffected arms Jacobsson increase in lymph flow after lumpectomy. interstitial pressure will reduce the 1967 Svensson et al 1994a Martin plus radiotherapy 2 5 fold increase in. pressure gradient forcing fluid out of the and Foldi 1996 Yildrim et al 2000 the contralateral non operated breast. capillaries and will thus reduce fluid fluxes Jacobsson 1967 reported this increase and a 1 5 fold increase in the operated. into the tissue Conversely increased was mainly in the skin and subcutaneous non irradiated breast indicating long. colloid osmotic pressure of the interstitial tissues In contrast Stanton et al 1998 term changes in basal lymphatic flow. fluid would increase fluid fluxes since the found that the blood flow was the same of breast tissues Stanton et al 2009. colloid osmotic gradient withholding fluid between affected and unaffected arms measured muscle and subcutis lymphatic. in the plasma would be reduced in this although the per unit volume of blood drainage of the arm after axillary surgery. circumstance Levick 2009 Such a flow was actually reduced in affected for breast cancer in 36 women using. situation may arise if there is accumulated arms since it was of larger volume The lymphoscintography They reported. interstitial protein due to increased reasons for this change in blood flow that muscle lymph drainage always. transcapillary protein leakage into the in lymphoedematous arms is not clear exceeded that of subcutis drainage and. tissue increased interstitial proteolysis although there clearly are structural subcutis drainage was higher in women. such as that occuring during changes in the affected limb that might who subsequently went on to develop. inflammation or reduced drainage of cause increased blood flow On the lymphoedema They concluded that. interstitial protein due to poor lymphatic other hand an increased arterial inflow women with higher filtration rates and. drainage Each of these factors will be may serve to increase fluid filtration into therefore higher lymph flows through the. affected by compression of the limb and the tissue and thus increase the risk axilla were at greater risk of developing. can lead to reduced fluid influx into the of developing lymphoedema such an lymphoedema after axillary surgery. tissues The role of compression on the increase in arterial flow may result from presumably because they had less. limb therefore may well be to prevent damage to the autonomic innervation to lymphatic reserve to deal with additional. fluid accumulation rather than to the limb due to surgery and or radiation fluid loads following surgery. encourage lymphatic drainage as is Kuhl and Molls 1995. often suggested Mechanisms of action of,Venous outflow compression garments. Blood and lymphatic drainage from Venous outflow may also be In the managment of lymphoedema the. the arm is also influenced by movements compromised in lymphoedematous term compression therapy covers a. and contractions of skeletal muscle and limbs Dennis 2008 Significant venous range of treatment modalities including. intrathoracic pressure as well as by obstruction was reported in 57 multilayer inelastic lymphoedema. positional changes of 81 patients assessed by Svensson bandaging and compression garments. et al 1994b using colour Doppler Partsch and Junger 2006 Compression. Lymphatic and vascular changes after ultrasound imaging Szuba et al 2002 garments are used for the prophylaxis. surgery and radiotherapy reported a lower but still significant 4 6 treatment and long term management of. The main cause of upper body prevalence of venous obstruction of lymphoedema and may. lymphoedema arises from cancer of lymphoedematous upper limbs There work by. varying causes especially breast cancer are several other lines of evidence that 8 Increasing interstitial pressure. which is often treated by surgery and indicate that there is an association 8 Improving tissue fluid drainage. radiotherapy It is clear that lymphoedema between venous dysfunction and 8 Stimulating lymphatic contractions. following surgery and or radiotherapy lymphoedema especially in the lower 8 Breaking down fibrosclerotic tissue. starts with an obstruction of the drainage limbs Dennis 2008 and this should be. in the axillary area but the exact considered carefully when contemplating Increasing interstitial pressure. pathophysiology of the following sequelae compression treatment of the upper Externally applied pressure is transmitted. in the lymph vessels and surrounding limb Any factors that compromise into the tissue although not always in a. tissues is not well known Pain et al venous outflow will significantly increase linear fashion Pressure up to 200mmHg. 2005 Furthermore there are some capillary hydrostatic pressures and result increased interstitial tissue pressure to. important haemodynamic aspects of the in increased fluid filtration into the tissues within 65 75 of the externally applied. arm following surgery radiotherapy leading to larger lymphatic loads pressure in normal pig limbs and up to. which are poorly understood 100 when the limb was oedematous. Lymph outflow and less compliant Reddy et al 1981, Arterial inflow There are few reports on surgery and or The pressures generated and measured. There is some evidence that arterial radiotherapy for breast cancer and their by compression garments are likely to. inflow is increased in lymphoedematous effects on lymphatic flow through the arm depend on the measurement technique. arms following treatment for breast and torso Perbeck et al 2006 studied the nature knit elasticity and fit of the. cancer Dennis 2008 Using a variety lymph clearance using 99 Tc nanocolloid garment and the compliance of the limb. of techniques the blood flow into clearance in breast tissues 2 5 years tissue being compressed Pressures of. the lymphoedamatous arm has been after surgery and or radiotherapy for 8 38mmHg have been measured under. reported to be increased by 42 68 breast cancer They reported a 4 0 fold garments applied to burns patients using. 64 Journal of Lymphoedema 2010 Vol 5 No 1,Piller Review indd 8 31 03 2010 13 43.
Clinical REVIEW, standardised protocols Mann et al 1997 veno lymphatic drainage of intradermally. but there was wide variation within injected sodium fluorescein solution in. and between measurement sites for both normal limbs and those with venous. example mean pressure over the anterior insufficiency Lentner and Wienert 1996 Key points. thigh was significantly less 8mmHg Most convincingly of all however is the. than that over the posterior thigh general observation that compression 8 There is a lack of knowledge. 15mmHg presumably due to radial and therapies can acutely reduce limb fluid regarding the finer details of. circumferential differences as per the law volume when appropriately used to the vascular and lymphatic. of Laplace by the same garment applied treat lymphoedema systems for those at risk of or. at these sites Custom made compression with lymphoedema. garments increased sub dermal pressure The observation that compression. in burns applications over a range of garments enhance tissue fluid clearance is 8 Compression is unlikely. 9 90mmHg but measurements of the at odds with reports that the lymphatic to simply entice fluid. pressures under garments over estimated system is a low pressure system The lateral removal through the often. the pressure transmitted into soft tissues pressure in human and many other compromised lymphatic system. e g muscle by up to 50 and under lymphatics reaches 15 40mmHg during. estimated the pressure transmitted into movement but is much lower under 8 Compression therapy may. bony sites by a similar amount Giele et resting conditions 1 12mmHg Aukland have a significant effect on. al 1997 Thus measurements taken at the and Reed 1993 Thus compression decreasing fluid influx in. garment skin interface may not always be garments which induce interstitial the limb. representative of pressures transmitted pressures of for example 10 40mmHg on. into the tissues and should be interpreted the arm are likely to be collapsing. with care lymphatic vessels under many Breakdown of fibrosclerotic tissue. circumstances One can only conclude that There are two major strategies to break. Increased interstitial pressure will affect compression therapy is unlikely to simply down fibrotic tissue but for both the. fluid exchange from the blood into the increase drainage through the often number and breadth of the studies are. interstitium so as to prevent interstitial compromised lymphatic system but is limited One strategy is through frictional. fluid oedema accumulation In addition likely to affect tissue fluid exchange massage and the other through the use. interstitial pressures greater than capillary through other possibly inter related of low level laser therapy There have. or arterial pressures 40mmHg are likely mechanisms such as decreasing fluid influx been some reasonable studies of the. to reduce blood flow further preventing into the limb latter using tonometry as a means of. fluid accumulation To our knowledge the detecting changes in epifascial fibrosis. contribution of these factors to Stimulation of lymphatic contraction as measured by the resistance of the. compression therapy has never been Lymphatic drainage is dependent upon the tissues to compression When low level. assessed in large trials although the work spontaneous contraction of valved lymph handheld or scanning laser is used there is. of Abu Own et al 1994 is informative vessels creating a pumping force The a slow although general softening of the. and Partsch and Partsch 2005 give some application of a compression garment indurated tissues presumably aiding in the. indications of the impact of position on results in constant pressure on the skin passage of extracellular fluid and allowing a. pressures required although these relate when the limb is at rest resting pressure stronger contraction of the lymphangions. to the lower limb When the muscles contract expand and since they are less constrained The. then relax e g during exercise they softening is most often accompanied. Improved tissue fluid drainage transiently press against the resisting by limb size changes and subjective. External compression improves tissue fluid garment and so the tissue pressure in the improvement Piller and Thelander 1998. drainage through the lymphatic system up limb increases temporarily This transiently Carati et al 2003. to a point Clearance of a radioactively increased interstitial pressure compresses. labelled colloid in dog hind limbs increased the adjacent dermal lymphatics and Optimising the effects of. exponentially to a maximum of three because the collecting and larger compression garments. fold with increasing externally applied lymphatics are valved these vessels pump In order to achieve optimal effectiveness. pressure up to 60mmHg Above 60mmHg passively so that lymph flows up the arm when using compression to treat patients. clearance decreased to almost nothing without the lymphatics having to contract with lymphoedema it is claimed that ideally. Miller and Seale 1981 Similar results The influence of muscle movement and of garments should be custom made and flat. were reported in human lower limbs different external pressures and of their knitted however large scale trials are. except that the pressure at which transmittance to underlying tissue required to support these claims Of the. maximum clearance occurred varied with depends on the elastic property of the upmost importance is accurate. posture being 30mmHg supine compared garment material and the compression measurement of the garment accounting. with 60mmHg sitting Chant 1972 In a pressure applied There is no evidence to for changes in the limb volume with. more clinical setting below knee stockings suggest that there is increased lymphatic position elevated or in dependent. ankle pressure 30mmHg doubled contraction under compression positions and whether the limb is likely to. Journal of Lymphoedema 2010 Vol 5 No 1 65,Piller Review indd 9 31 03 2010 13 43. Clinical REVIEW, be active or inactive which depends on application of often significantly different. the patient s occupational status However pressures at each circumferential point This Associate Professor Bren Gannon. little is known regarding the effect of the is in concordance with the law of Laplace Bren recently died of complications. above variables on garment pressure the outcomes of which often necessitate after heart surgery He was an. gradients and on undergarment pressures the use of a range of limb padding esteemed and much loved colleague. In the interim however we can strategies to ensure some modicum of Bren was a walking encyclopedia. extrapolate our knowledge of how lengthwise pressure a gradient over the He always had an answer for every. lymphoedematous and oedematous legs length of the limb rather than just across a question be it anatomical or clinical. respond at least in the dependent given cross section of the limb Bren will be remembered for his. position as this may help to guide fantastic contribution to medicine to. research into the impact of compression Conclusion the university community and to the. on the arm In addition to these There is much we do not know with staff and students He lived life to the. measurement and biological parameters respect to accurate details of the arterial full being an enthusiastic fisherman a. information about garment characteristics flow into and the lymphatic and venous dedicated colleague and most of all a. such as dynamic stiffness index static outflow from normal at risk and friend to all who met him Vale Bren. stiffness index multi component materials lymphoedematous limbs Specifically we. and inelastic bandaging is important do not know enough about the effects of. Partsch et al 2008 Mosti et al 2008 compression on venous and lymphatic References. There are some recent advances in the flow and drainage In terms of the upper Abu Own A Shami SK Chittenden SJ Farrah. burns field in the design of pressure body the contributory impact of variations J Scurr JH Smith PD 1994 Microangiopathy. garments which exert a specific and in intra thoracic pressure on proximal arm of the skin and the effect of leg compression. in patients with chronic venous insufficiency J, known pressure Macintyre 2007 but it is clearance a patient s garments and the Vasc Surg 19 6 1074 83. the accuracy of the measurement for the impact of the varying circumference of the. garment that is the prime determinant of chest with respiratory cycles is relatively Adamson RH Lenz JF Zhang X Adamson. GN Weinbaum S Curry FE 2004 Oncotic, an excellent good or adverse outcome unclear and most likely to significantly vary pressure opposing filtration across non.
for the limb Newer pressure sensing not only between clients but also in a fenestrated rat microvessels J Physiol 557. materials may help to partially overcome client from day to day and hour to hour 889 907. poor measurement although these must depending on their activity body position Aukland K Reed R 1993 Interstitial. not be used as an excuse for inaccuracy and the activity level of their limb lymphatic mechanisms in the control of. extracellular fluid Physiol Rev 73 1 78, Anatomical differences between arms and legs Knowing more about the anatomy Calbet J Holmberg H Rosdahl H van Hall G. When applied to the upper limb the physiology pathophysiology of the tissues Jensen Urstad M Saltin B 2005 Why do arms. compression bandage or garment used is and structures of the upper body will help extract less oxygen than legs during exercise. less likely to be completely in a dependent us gain better outcomes for the client at Am J Physiol Regul Integr Comp Physiol 289 5. position in all its parts the depth of the risk of and with lymphoedema However it. deep fascia is often less than a similar would seem that the best way forward is Carati C Anderson S Gannon B Piller. position on a leg the depth of the often to acknowledge individuality diurnal and N 2003 Treatment of post mastectomy. lymphoedema with low level laser therapy, closely adherent lymph collectors is seasonal variances and to develop better. Results of double blind placebo controlled trial, less meaning a more marked effect of means to monitor the pressure effect of Cancer 98 6 1114 22. external pressure application the lymph the prescribed garment on the fluids we. Chamosa M Murillo J V zquez T 2005, collectors are often of smaller diameter are trying to control Lipectomy of arms and lipograft of shoulders. having less strong flow and reduced balance the upper body contour Aesthetic Plast. intra lymphatic pressures Combined Perhaps for the majority of patients this Surg 29 6 567 70. these factors mean that externally applied is an easier more cost effective option than Chant ADB 1972 The effects of posture. pressure such as from compression attempting a range of tests on all patients exercise and bandage pressure on the clearance. bandages or garments or clothing is likely to determine the anatomy physiology and of 24Na from the subcutaneous tissues of the. to have a more profound effect However pathophysiology of the correct function foot Br J Surg 59 552 5. this relative superficiality of vessels means or otherwise of the patient s blood tissue Clark M Krimmel G 2006 Lymphoedema. it must be realised that too high a and lymph systems Knowing the latter will and the construction and classification of. pressure may be counterproductive Modi however also help achieve the overall goal compression hosiery In Lymphoedema. et al 2007 and may cause vessels to of holistic patient care JL Framework Template for Practice compression. hosiery in lymphoedema MEP Ltd London,collapse which may manifest as swelling in.
the arm and or hand This paper first appeared in the Template Curry FE 2005 Microvascular solute and. for Practice Compression hosiery in upper water transport Microcirculation 12 17 31. The shape variation of the arm over its body lymphoedema 2009 HealthComm Dennis R 2008 Haemodynamics of. length is often greater than that of a leg UK Ltd Aberdeen To download the full lymphoedema J Lymphoedema 3 2 45 9. meaning the impact of the various radii of document please go online to Ferrandez JC Laroche JP Serin D Felix Faure. the different parts of the arm result in the www wounds uk com C Vinot JM 1996 Lymphoscintigraphic. 66 Journal of Lymphoedema 2010 Vol 5 No 1,Piller Review indd 10 31 03 2010 13 43. Clinical REVIEW, aspects of the effects of manual lymphatic exchange and its significance after 100 years explanation for molecular filtering J Struct. drainage J Mal Vasc 21 5 283 9 Exp Physiol 82 1 30 Biol 136 239 55. Foeldi M Foeldi E Kubik S 2003 Miller GE Seale J 1981 Lymphatic Stanton AW Holroyd B Northfield JW. Textbook of Lymphology for Physicians and clearance during compressive loading Levick JR Mortimer PS 1998 Forearm. Lymphoedema Therapists Sufficiency and Lymphology 14 161 6 blood flow measured by venous occlusion. Insufficiency of the Lymphatic System Urban plethysmography in healthy subjects and in. and Fisher Munich Modi S Stanton AWB Svensson WE et al. women with postmastectomy oedema Vasc,2007 Human lymphatic pumping. Med 3 1 3 8, Giele HP Liddiard K Currie K Wood FM measured in healthy and lymphoedematous. 1997 Direct measurement of cutaneous arms by lymphatic congestion Stanton AW Modi S Bennett Britton TM. pressures generated by pressure garments lymphoscintigraphy J Physiol 583 Pt 1 Purushotham AD Peters AM Levick JR. Burns 23 137 41 271 85 Mortimer PS 2009 Lymphatic drainage. Iyer RB Libshitz HI 1995 Radiographic in the muscle and subcutis of the arm after. Mosti G Mattaliano V Partsch H 2008, demonstration of intercostal lymphatics and breast cancer treatment Breast Cancer Res.
Influence of different materials in, lymph nodes Lymphology 28 2 89 94 Treat 117 3 549 57. multicomponent bandages on pressure and, stiffness of the final bandage Dermatol Surg Starling EH 1896 On the absorption of. Jacobsson S 1967 Studies of the blood, 34 5 631 9 fluids from the connective tissue spaces J. circulation in lymphoedematous limbs Scand, J Plast Reconstr Surg Suppl 3 1 81 Physiol 19 312 26. Moore K Dailey AF 2006 Clinical Oriented, Kawase K Gayed IW Hunt KK Kuerer Anatomy 5th edn Lippincott Williams Suami H O Neill JK Pan W R Taylor GI.
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