The largest lymphatic vessels. They originate from the confluence of efferent post-lymph node collectors and drain their lymph into the thoracic duct or directly into the venous bloodstream. The most important ones are the jugular lymphatic, subclavian, bronchomediastinal trunks (or ducts) and the great right lymphatic vein (specular to the thoracic duct).

 

Device used for mechanical “antigravitational” lymphatic drainage. Figure: A complex piece of equipment for mechanical lymphatic drainage with a mercury chamber, which can be used to treat lymphedema of the lower as well as of the upper extremities.

Lymphatic drainage obtained with manual manoeuvres. Today, there are several techniques available, among them the most popular ones are lymphatic drainage according to Földi-Vödder and the one according to A. Leduc. By means of several codified manoeuvres, the lymph is drained by pushing it towards residual outflow pathways, and, at the same time, by activating the peristaltic action of lymphangions, namely the functional unit of lymphatic vessels. According to recent studies, unlike mechanical drainage, which mostly acts on the lymph liquid component, manual drainage has a higher effect on protein content, thus also decreasing the fibrous component, which is a main feature of chronic lymphedema.

Surgical removal of a breast. It may be partial, such as in the case of quadrantectomies, or total, and is performed in patients (the great majority of them women) affected by tumors involving the mammary gland. This type of surgery is associated with concurrent loco-regional lymphadenectomy and radiation therapy, and is one of the main causes of secondary lymphedema. Figures: Lymphedemas of the right upper limb secondary to breast surgery.

Lymphatic drainage obtained with mechanical equipment. There are several types of equipment available on the market, which promote lymphatic drainage according to different mechanisms. The most common ones employ alternate pneumatic systems, which, by raising skin pressure in a sequential way in the various districts and along a caudo-cranial direction, enhance the centripetal flow of the lymph in lymphedematous limbs toward the major lymphatic structures of the trunk. The main action of this method is to drain the liquid component of the edema, with only an indirect impact on the fibrotic and protein component of the lymphatic edema.

 

This condition is brought about when the functional capacity of the lymphatic circulation system decreases and cannot cope any longer with a normal or only slightly higher lymphatic load. Figure: Chart illustrating the “mechanical lymphatic insufficiency” condition.

 

This eponym is sometimes used to identify primary, early onset (before 35 years of age) lymphedema.

 

This therapeutic method is quite common in aesthetic medicine. By means of multi-injectors fitted with ultra-thin, jagged, no more than 5 mm long needles, various types of pharmaceutical substances are injected into sub-dermal tissues. Its therapeutical goal is to inject substances that can reduce the fibrotic component of suprafascial tissues, thus enhancing microcirculation fluid exchange. In lymphology, in particular, it is only applied in patients with both lipedema and Edematous-Fibrosclerotic Panniculopathy (EFP, see), most commonly in the gluteal region and the hips. Since it is a relatively invasive treatment, and considering the poor outcome in patients with fibrosis due to chronic lymphatic stasis, it should not be used indiscriminately.

Contrast-based imaging technique, by which FICT-dextran (150,000 dalton p.m.) is injected into the sub-epidermal layer, in order to display lymphatic capillary and precollector (see) structures in the skin of all body districts and examine their morphology, average diameter, intralymphatic pressure, and any changes with breathing. Despite some interesting results attained, this imaging technique has not yet become common clinical practice.

 

Together with the operative microscope, it includes all surgical instruments that are key to a microsurgeon. They are not simply miniature reproductions of standard surgical instruments, but they have been duly designed and adjusted to meet different needs: for example, their tips must be very thin in order to handle highly fragile structures, they have to be used in very small spaces, and have no reflecting surfaces. Further, they must have the right ergonomic features to be extremely easy to hold and handle.

 

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