Lower extremity lymphedema

INTRODUCTION — Lymphedema is defined as the abnormal accumulation of interstitial fluid and fibroadipose tissues resulting from injury, infection, or congenital abnormalities of the lymphatic system. Lymphedema most commonly affects the extremities but can also occur in other areas of the body (eg, abdomen, genital region, face, neck).

Issues relating to lymphedema affecting the lower extremities, including etiologies, clinical evaluation, and treatment outcomes, are reviewed. An overview of lymphedema, breast cancer-associated lymphedema, general conservative measures, and surgical treatment of lymphedema is provided separately. (See "Clinical features and diagnosis of peripheral lymphedema" and "Clinical staging and conservative management of peripheral lymphedema" and "Breast cancer-associated lymphedema" and "Surgical treatment of primary and secondary lymphedema".)

CLASSIFICATION AND ANATOMY — Lymphedema can be categorized as either primary or secondary. The direct cause of primary lymphedema is unknown and may develop at any point in life. Secondary lymphedema develops as a consequence of the natural history and/or treatment of another unrelated condition. (See "Clinical features and diagnosis of peripheral lymphedema".)

Lower extremity lymphatics — The superficial lymphatic system drains the skin and subcutaneous tissue, paralleling the pattern of venous drainage. The superficial lymphatic vessels then drain into the deep lymphatic system, and then into the lymph nodes of the pelvis.

The lymph nodes of the lower extremities consist of the popliteal and inguinal nodes (figure 1).

●Popliteal nodes – The popliteal nodes are small, deep lymph nodes located posterior to the knee, close to the popliteal vessels. They drain lymph from superficial vessels and deep areas of the leg and foot. The popliteal nodes drain into the deep and superficial inguinal nodes [1].

●Inguinal nodes – The lymphatics of the inguinal region are composed of a network of lymph nodes and vessels, connecting the lower extremities to the pelvic region and abdomen (figure 2). The inguinal lymph nodes are located in the femoral triangle and are grouped into superficial and deep (subinguinal) lymph nodes, relative to the deep fascia [2].

•Superficial inguinal nodes – The superficial inguinal lymph nodes arise from the superior part of the femoral canal immediately below the inguinal ligament. These facilitate drainage of the penis, scrotum, labia, perineum, buttock, and lower abdominal wall [3,4].

•Subinguinal nodes – The subinguinal nodes are classified as either superficial or deep.

-The superficial subinguinal nodes can be identified on both sides of the superior aspect of the great saphenous vein. These lymph nodes mainly receive afferents from the superficial lymphatic vessels of the lower extremity and also provide adjunctive drainage to the penis, scrotum, labia, perineum, and buttock.

-The deep subinguinal nodes are situated below the deep fascia, along the medial to the femoral vein. These nodes receive afferents from the deep lymphatic trunks, including the femoral vessels, the lymphatics from the glans penis or clitoris, and some of the efferents from the superficial subinguinal glands [1,3,4].

ETIOLOGIES — Secondary lymphedema is much more common in the lower extremity than primary lymphedema and is often associated with treatment of malignancy, trauma, or infection [5]. The differences between primary and secondary lymphedema are not absolute. Although some findings may be more common in one or other, patients with primary or secondary lymphedema can present with the entire spectrum of physical findings.

Primary lymphedema — Lymphedema that presents without an inciting factor is termed primary lymphedema [6]. Primary lymphedema, which is associated with pathologic development of the lymphatic vessels, most commonly involves the lower extremities but can occur in the upper extremities. (See "Clinical features and diagnosis of peripheral lymphedema", section on 'Primary'.)

There are many chromosomal or genetic conditions in which lymphedema is a reported feature [7]. If there is a genetic inheritance pattern arising without an etiology, the term familial lymphedema can be used to categorize this type of lymphedema. Some genetic disorders such as Fabry's disease (Anderson-Fabry's disease) may be associated with the development of lymphedema, but it is considered secondary lymphedema [8]. (See "Clinical features and diagnosis of peripheral lymphedema", section on 'Epidemiology and risk factors'.)

Primary lymphedema is categorized according to the age at which lymphedema symptoms first present.

●Congenital lymphedema – Congenital lymphedema is defined as lymphedema that is present at birth or presents within the first year of life. Congenital lymphedema may be either sporadic or familial. It is estimated that congenital lymphedema accounts for about 10 to 25 percent of primary lymphedema cases, affecting females twice as often as males [6].

●Lymphedema praecox – Lymphedema praecox is the most prevalent type of primary lymphedema, presenting between ages 1 to 35, most often during puberty. Similar to congenital lymphedema, lymphedema praecox is more frequent in females than males (ratio of 4:1). Seventy percent of patients with lymphedema praecox present with unilateral lower extremity lymphedema [9].

●Lymphedema tarda – Lymphedema tarda is the least common type of primary lymphedema, accounting for <10 percent of cases. Lymphedema tarda manifests clinically after age 35, typically affecting the lower extremities. As with other types of primary lymphedema, lymphedema tarda is more common in women than men [10].

Secondary lymphedema — Secondary lymphedema develops as a result of another condition or treatment. Secondary lymphedema may be secondary to cancer or cancer treatment, infection, trauma, surgery, or obesity. (See "Clinical features and diagnosis of peripheral lymphedema".)

Cancer and cancer treatment — Cancer-related lower extremity lymphedema has been reported as a complication following the treatment of extremity melanoma, gynecologic, or genitourinary malignancies. The incidence of cancer-related lymphedema varies by type of malignancy and treatment. In a systematic review that included 43 studies (genitourinary, gynecologic, lower extremity melanoma), the overall incidence of lower extremity lymphedema was estimated to be 20 percent [11].

Gynecologic cancers — The incidence of lower extremity lymphedema in patients with a history of gynecologic cancers is as high as 25 percent [11,12]. Treatment for gynecologic cancers often involves a combination of radiotherapy, chemotherapy, and surgical procedures. Surgical interventions that remove lymph nodes significantly increase the risk of developing lower extremity lymphedema. The risk is even higher when patients undergo postoperative radiotherapy [13]. Clinical interventions to prevent and manage postcancer lower extremity lymphedema are needed to preserve and improve the QoL in this patient population.

The incidence of lower extremity lymphedema varies depending on the type and stage of cancer. As an example, treatment of vulvar and cervical cancer more typically includes complete inguinal lymph node dissection and radiation compared with uterine and ovarian cancer. Treatment can include lymph node dissection and/or radiation therapy [14]. Reported incidence of lymphedema are:

●Endometrial cancer: 1 to 38 percent

●Cervical cancer: 17 to 81 percent

●Vulvar/vaginal cancer: 6 to 75 percent

●Ovarian cancer: 5 to 21 percent

Genitourinary cancers — The pooled incidence of lymphedema in patients with a history of genitourinary cancer (bladder, penile, prostate) is approximately 11 percent. The incidences for bladder, penile, and prostate cancers are approximately 16, 21, and 4 percent, respectively. In general, the incidences of lymphedema from the treatment of gynecological malignancies is not necessarily related to severity of disease but rather treatment protocols. As an example, patients with vulvar or cervical cancer would undergo inguinal lymph node dissection and radiation more frequently than patients undergoing treatment for ovarian or endometrial cancer.

Patients who undergo radiation therapy in addition to lymph node dissection for the treatment of genitourinary cancers are at an increased risk of developing lymphedema [11]. The observed incidence of lower extremity lymphedema is higher among patients who undergo an extended pelvic lymph node dissection (ePLND) compared with a standard pelvic lymph node dissection (sPLND) [15,16]. For the treatment of genitourinary cancers, in one review, the incidence of lower extremity lymphedema was 1.4 percent following sPLND and 8.8 percent following an ePLND [15].

Melanoma — Lower extremity lymphedema related to treatment of melanoma is primarily due to inguinal lymph node dissection required for the treatment of disease. However, direct nodal invasion can also result in lymphedema. The estimated incidence of lymphedema associated with melanoma is 16.3 percent overall, and 28 percent for lower extremity melanomas [11]. (See "Evaluation and management of regional nodes in primary cutaneous melanoma".)

The incidence of moderate lymphedema among patients who have had a total lymph node dissection has been reported to be as high as 46 percent [17]. A high incidence of 42 percent has also been reported among patients with melanoma who have undergone a deep (iliac/obturator) lymph node dissection [11]. However, the adoption of sentinel lymph node (SLN) biopsy for cancer staging (figure 3) has allowed surgeons to avoid extensive lymph node dissections, reducing the risk of lymphedema in node-negative patients. Patients with melanoma are still at risk for developing lymphedema following SLN biopsy, but the risk of lymphedema was significantly lower for patients who undergo SLN biopsy alone compared with lymph node dissection in a prospective assessment of 182 patients [17]. At one year following lower extremity melanoma surgery (SLN biopsy and total lymph node dissection), the overall incidence of moderate lymphedema (limb volume change >10 percent) was reported to be about 27 percent.

Kaposi sarcoma — Kaposi sarcoma is a rare sarcoma involving the cells lining the blood and lymphatic vessels that could contribute to secondary lymphedema [18,19]. The disease is typically limited to the lower extremities, although it may be more widespread in immunocompromised patients, such as patients with AIDS or those who have undergone a solid organ transplant. Lymphedema may occur in this population as a result of blocked lymphatic vessels, changes in the permeability of the lymphatics, regional lymph node involvement, and increased inflammatory cytokines [20]. (See "Classic Kaposi sarcoma: Clinical features, staging, diagnosis, and treatment".)

Infection — Infection can be both a direct cause of lymphedema and a risk factor for developing lymphedema. Early postoperative infections following lymph node dissection significantly increase the risk of lymphedema [10]. Cellulitis and infections have also been reported to increase the risk of gynecologic-related lymphedema.

Parasitic infections may also result in lower extremity lymphatic obstruction. The most common cause of secondary lymphedema worldwide is filariasis, a disease in which parasitic worms occupy and occlude lymphatic vessels [21]. The Centers for Disease Control and Prevention estimate that lymphatic filariasis affects over 120 million people in 72 countries throughout the tropics and subtropics of Asia, Africa, the Western Pacific, and parts of the Caribbean and South America [22]. (See "Lymphatic filariasis: Epidemiology, clinical manifestations, and diagnosis" and "Lymphatic filariasis: Treatment and prevention".)

Chronic venous insufficiency — Lymphedema shares many clinical features with chronic venous insufficiency (CVI). A careful evaluation can indicate if edema is the result of a venous inefficiency, lymphatic insufficiency, or a combination of both. (See "Clinical manifestations of lower extremity chronic venous disease".)

Lymphedema caused by insufficiency of both the venous and lymphatic systems is known as phlebolymphedema (PLE). PLE may be caused by a congenital defect of the venous and lymphatic systems or secondary to CVI. CVI results in an excessive fluid load at the tissue level, creating additional load to the lymphatic system. The increase in lymphatic flow may become much greater than the lymph transport capacity [23,24]. (See "Overview of vascular intervention and surgery for vascular anomalies" and "Pathophysiology of chronic venous disease".)

Obesity — Obesity is an independent risk factor for lymphedema (ie, obesity-related phlebolymphedema). Body mass index (BMI) greater than 50 may lead to the development of lymphedema without a history of lymphatic surgery or injury [25]. Although the exact pathophysiology is not completely understood, obesity has been implicated in the development of lymphedema due to increased production and retention of fluid by adipose tissue [26,27]. Patients with severe obesity may also be at risk for developing massive localized lymphedema (MLL; pseudotumor, pseudosarcoma), which is the formation of a large lymphedematous mass found in the lower extremity (picture 1) [28]. MLL is a benign, painless mass, often enlarging over many years [29].

The impact of obesity on lymphedema rates following cancer and cancer treatment has also been studied [10]. The effect of BMI cannot be completely separated from cancer treatment effects, in part because of potentially more difficult lymph node dissection in patients who are obese [30].

Extremity trauma — Injury to the lymphatic system is the cause of post-traumatic edema in 10.5 percent of patients [31,32]. Post-traumatic edema may originate from injured lymphatics, deep venous thrombosis (high risk associated with extremity trauma), or inflammation.

Traumatic injuries to the lower extremity that can cause damage to the lymphatic system include degloving injury (Morel-Lavallee injury), multiple fractures, compartment syndrome, and joint replacement. (See "Severe lower extremity injury in the adult patient".)

Orthopedic surgery — In addition to surgical treatment for malignancy, the lymphatic system may become damaged during orthopedic surgeries. While postsurgical edema is common, patients undergoing orthopedic surgeries are at risk of developing chronic lymphedema. Total hip and total knee arthroplasty are both associated with a potential risk of developing lower extremity lymphedema [33]. (See "Total hip arthroplasty" and "Total knee arthroplasty".)

Others — Other potential etiologies of lymphedema include thyroid dermopathy and inflammatory disorders, dermatitis, and sarcoidosis [6].

Lymphedema is a rare extraarticular manifestation of inflammatory joint disease and is most often seen in patients with rheumatoid or psoriatic arthritis. (See "Overview of the systemic and nonarticular manifestations of rheumatoid arthritis", section on 'Lymphatic obstruction'.)

CLINICAL EVALUATION — There are a number of preoperative evaluations that aid in the diagnosis of lymphedema, confirm a suspected cause, and evaluate the impact of this condition on a patient's life. The results are used to determine which nonsurgical and surgical treatments may benefit the patient.

Lower extremity clinical features — The treating clinician should first conduct a review of the patient's medical history and perform a physical examination. The history should include age of lymphedema onset, affected areas, details of disease progression, history of trauma, medical history, surgical history, and family medical history [34]. Physical examination should assess swelling, skin changes, and infection. The physical examination includes an assessment of the skin, soft tissues, and vascular system of the affected limb(s) [35]. (See "Clinical features and diagnosis of peripheral lymphedema", section on 'History and physical'.)

The inability or failure to pinch or pick up a fold of skin at the base of the toe (ie, Stemmer sign) is indicative of lymphedema complicated by skin fibrosis; however, a negative Stemmer sign does not rule out lymphedema. Because lymphedema provokes fat deposition, pitting will not occur with later stages of lymphedema, though it may be present early on. With increasing disease severity in the lower extremity, skin changes and fat deposition are progressive, leading to subcutaneous fibrosis, cobblestoning, skin overgrowth, and wart-like changes (lymphostatic verrucosis, lymphostatic papillomatosis).

In the lower extremity, foot swelling ("buffalo hump") or toe swelling ("boxcar toes") may be present but are not required to make a diagnosis of lymphedema. Foot involvement is more likely to be seen with primary lymphedema compared with secondary lymphedema. The presence of dysmorphic toes, transverse digital creases, and hypoplastic or upturned ("ski-jump") toenails is more indicative of primary lymphedema [36]. But while primary lymphedema is typically associated with marked foot/toe swelling and dysmorphic features, different primary lymphedema phenotypes may have varying degrees of foot swelling, and some patients with primary lymphedema can have foot sparing. Secondary lymphedema is typically but not invariably associated with only modest foot/toe swelling and no dysmorphic features, but there are exceptions.

Functional status should also be assessed during the examination. Some functional observations for patients with lower extremity lymphedema may include the presence of a limp, use of an ambulation aid, ability to bend over to remove shoes/socks, and ability to make a forward stride. If functional limitations are observed, the patient should be referred to physical therapy for evaluation and treatment [37]. Validated questionnaires, such as the Lymphedema Life Impact Scale, may also be used to measure patient-reported functional impairments, as well as physical and psychosocial impairments caused by lymphedema [38].

Lower extremity measurements — Lower extremity circumference measurements can be easily obtained, and the circumference values can be used to calculate limb volume. All methods of limb volume measurement are effective and accurate when properly performed [35,39].

Limb circumference measurements can be taken at any point on the leg, as long as the anatomic landmarks used are consistent [34,35,39]. Measurements should be taken from the affected as well as unaffected extremity for comparison. Extremity measurements should be taken during the initial evaluation and during follow-up visits to assess the status of the disease and its response to treatment (ie, pre- and post-treatment measurements). (See "Clinical features and diagnosis of peripheral lymphedema", section on 'Limb circumference'.)

In addition to calculating limb volume from circumference measurements, perometry and water displacement may be used to measure limb volume. Water displacement is considered the "gold standard" for assessing volume but is cumbersome and not frequently used [39]. Perometry uses infrared light to scan a limb and calculate highly accurate volumes but is expensive due to a high equipment cost. (See "Clinical features and diagnosis of peripheral lymphedema", section on 'Limb volume'.)

Another way to assess lymphedema is by using bioimpedance spectroscopy (BIS). This device measures fluid content, calculating the ratio of extracellular fluid by measuring the resistance to an electrical current in the measured limb. A benefit of this measurement is that fluid can be detected as it starts to accumulate, even before it may be physically noticeable to a patient or provider [37].

Diagnosis and clinical staging — For some patients with lower extremity lymphedema, a diagnosis can be made with history and physical examination alone (eg, most cases of secondary lymphedema). However, further imaging is used whenever the diagnosis is in question, which is more typically in patients with primary lymphedema or those with lipedema.

Several staging systems are used to classify the severity of lymphedema. Using the International Society of Lymphology (ISL) criteria (table 1), lymphedema is staged based on the examination of the lower extremity and the volume difference between the extremities as stage 0 through stage III, which correspond to subclinical lymphedema, mild lymphedema, moderate lymphedema, and severe lymphedema [40].The Campisi staging system stages lymphedema from stage 1 to stage 5 (table 2). Clinical staging is important as it affects the treatment plan for lymphedema. (See "Clinical staging and conservative management of peripheral lymphedema", section on 'Clinical stage'.)

Lower extremity lymphatic imaging — Although the diagnosis of lymphedema does not require radiographic evaluation, most, if not all, patients, benefit from lymphatic imaging to confirm the diagnosis, characterize the stage of lymphedema and determine if any functional lymphatics are present to determine if they are candidates for lymphovenous vascular anastomosis (LVA). Studies such as lymphoscintigraphy, magnetic resonance (MR) lymphangiography, and indocyanine green (ICG) lymphangiography may be performed for a variety of reasons in patients with lower extremity swelling. For patients suspected of having primary lymphedema, these studies are instrumental in confirming the diagnosis. For patients with secondary lymphedema, these same studies are useful for determining the severity of lymphedema. For patients who are proceeding with surgical treatment of the lymphedema, lymphatic imaging studies are used to identify patent lymphatic vessels. Although there are less invasive measures to monitor patients in the postoperative setting, lymphatic imaging can also be used to assess the degree of improvement after surgical intervention.

●Lymphoscintigraphy – Lymphoscintigraphy is the primary imaging test for diagnosing and assessing the function of lower extremity lymphatics. For lower extremity disease, this involves injecting a radioactive tracer into the dermis of the foot. Lymphoscintigraphy can reveal issues such as slow or absent lymphatic flow, areas of dermal backflow, and abnormalities in lymphatic uptake. This imaging technique primarily evaluates larger superficial lymphatic vessels and nodes but does not provide information on the deep transport lymph vessels.

●MR lymphangiography – MR lymphangiography is typically used for mapping the lymphatic system before surgery, rather than for diagnostic purposes. It is essential to identify patent (open) lymphatic channels before performing lymphovenous bypass. MR lymphangiography provides detailed images of the lymphatic vessels, helping surgeons plan their procedures effectively.

●ICG Lymphangiography – Similar to MR lymphangiography, ICG lymphangiography is mainly used for preoperative mapping. It involves the injection of indocyanine green dye, which can be visualized using near-infrared imaging technology. Identifying patent lymphatic channels is crucial for surgical interventions like lymphovenous bypass.

Vascular and soft tissue imaging — Duplex ultrasound should be performed on every patient with lymphedema to assess the patency and competency of the venous system (ie, rule out deep venous thrombosis) and to identify the presence of venous reflux. The grayscale (B-mode) evaluation of tissue layers in the affected limb can also provide information on the etiology, as well as the severity of lymphedema [41].

Cross-sectional imaging using MR or computed tomography (CT) may identify enlarged lymph nodes or other lesions that can cause lymphatic obstruction. It's important to note that MR or CT imaging of the extremity can detect the presence of increased interstitial fluid (honeycomb appearance), but this finding is nonspecific and may not directly indicate the grade of lymphedema [39,42]. Common CT findings in patients with lymphedema include thickening of the skin, thickening of the subcutaneous compartment, increased fat density, and thickened perimuscular aponeurosis. Similarly, common MR findings include circumferential edema, increased volume of subcutaneous tissue, and marked thickening of the dermis [43,44]. MR can also differentiate the cutaneous edema of lymphedema from other types of limb swelling such as lipedema and phlebolymphedema.

CONSERVATIVE CARE — The initial approach for the management of extremity lymphedema (upper or lower) begins with conservative management, which involves a combination of self-care (ie, skin care, weight management), physiotherapy, and compression therapy (ie, compression bandaging, compression garments) [35]. While these treatments do not address the underlying cause of lymphedema, they can control swelling and prevent development of long-term sequelae such as irreversible skin changes (ie, elephantiasis) [10]. Patients with mild lower extremity lymphedema may be adequately controlled with conservative measures.

The type and level or intensity of physiotherapy (simple lymphatic drainage, manual lymphatic drainage, complete decongestive therapy) and compression therapy (compression bandaging, compression garments, intermittent pneumatic compression) vary depending upon the stage of disease (table 1). (See "Clinical staging and conservative management of peripheral lymphedema", section on 'Conservative treatment by severity'.)

●Mild lymphedema – Patients with mild lymphedema (International Society of Lymphology [ISL] stage I) are treated with physiotherapy (simple lymphatic drainage, a commonly taught self-help maneuver) and compression garments.

●Moderate-to-severe lymphedema – Patients with moderate-to-severe lymphedema (ISL stage II to III) are treated with complete decongestive therapy (CDT).

●Severe lymphedema – Patients with severe lymphedema (ISL stage III) may also benefit from intermittent pneumatic compression (IPC) in addition to CDT.

Unfortunately, lower extremity lymphedema often progresses despite conservative treatment measures. Patient compliance can be difficult due to the time commitment, lifelong need for ongoing treatment, limited availability of certified lymphedema therapists, expense, insurance coverage issues, and patient discomfort due to the bulkiness of compression garments and use during high temperatures [6,13,45].

Conservative treatments are also recommended following surgical treatments to achieve optimal outcomes [13]. (See 'Surgery for lower extremity lymphedema' below.)

Skin care — Patients with lymphedema have an accumulation of protein-rich fluid in the interstitial space. This increased protein concentration can trigger inflammation, causing skin changes in patients with advanced stages of lymphedema. These changes may include dry skin and decreased elasticity, making a patient more susceptible to infection and ulceration [13]. Patients are advised to maintain good hygiene and to keep the affected limb properly moisturized [6]. Patients should seek medical attention if they observe any abnormalities on their affected limb or suspect that an infection may be present. (See "Clinical staging and conservative management of peripheral lymphedema", section on 'General measures'.)

Compression therapy — External compression is used with the aim of decreasing interstitial fluid production and reducing excess lymph fluid in the affected extremity. Different methods of compression include multilayer short stretch compression bandages, compression garments, and pneumatic compression devices. The benefits of compression therapy are largely dependent on patient compliance [13]. (See "Clinical staging and conservative management of peripheral lymphedema", section on 'Compression therapy'.)

In the lower extremity:

●Compression bandaging provides the greatest volume reduction in the early stages of lymphedema. For lower limb lymphedema, a minimum of two layers of bandages is most effective [6].

●Compression garments are custom-made elastic stockings that are used in the maintenance phase of lymphedema treatment to effectively prevent fluid reaccumulation [46,47]. New garments must be created when there is a decrease in limb volume to maintain these improvements.

●Compression garments are also an important component of surgical interventions for lymphedema. Compression therapy is used preoperatively to maximize limb volume reduction and improve surgical outcomes. Many patients are also required to continue compression therapy following surgical intervention to maintain long-term improvements.

●IPC is another form of compression therapy that applies pressure to the affected limb during an inflation and deflation process. This method is widely used in the treatment of lower extremity lymphedema and plays an important role in the movement of lymph fluid [13]. Following use of an external pump, patients are still required to wear compression garments due to the risk of excess fluid recurrence.

Decongestive therapy — Complete decongestive therapy (CDT), also known as complex physical therapy (CPT), is the standard approach for the initial treatment of lymphedema. (See "Clinical staging and conservative management of peripheral lymphedema", section on 'Complete decongestive therapy'.)

Numerous studies have supported the effectiveness of CDT for lower extremity lymphedema compared with physical exercise or compression therapy alone. CDT achieves an average volume reduction between 31 and 73 percent in patients with lower extremity lymphedema [45,48-51]. However, the effects of CDT are not permanent and require lifelong continuation of phase 2 therapy to prevent recurrence. For patients who are relying on conservative therapies, self-care, daily use of compression garments, and daily exercise are all required for the successful long-term management of lymphedema [13].

The first phase of treatment uses a multimodality approach under the care of a lymphedema specialist to reduce extremity volume. This intensive phase includes manual lymphatic decompression (MLD), compression garment use, exercise, and skin care. MLD is a lymphatic massage technique that enhances filling of the cutaneous lymphatics and improves dilation and contraction of the lymphatic vessels [47]. Compression bandaging/garments are applied immediately following MLD, preceded by completion of a series of exercises to increase lymphatic flow [6]. MLD is an important component for achieving successful results with complete decongestive therapy. However, MLD alone is not recommended to attempt to achieve volume reduction [13]. (See "Clinical staging and conservative management of peripheral lymphedema", section on 'Manual lymphatic drainage'.)

Compression therapies and manual lymphatic drainage are generally contraindicated in the setting of active infection. Infection is typically diagnosed by the presence of increased temperature, erythema, and pain in the affected extremity. Cellulitis/lymphangitis should be treated with antibiotics appropriate for common skin flora (particularly Streptococcus species). Patients with signs of systemic sepsis (eg, fever, elevated white count, hemodynamic instability, altered mental status) may require admission to the hospital for parenteral antibiotics and limb elevation. (See "Acute cellulitis and erysipelas in adults: Treatment" and "Lymphangitis".)

After reducing the volume of the affected lower extremity, the second phase of CDT begins and is focused on volume maintenance. During phase 2, patients continue to wear compression garments and practice a healthy skin care regimen. Patients are also advised to continue exercise and perform MLD, as necessary [6,13,44,52].

SURGERY FOR LOWER EXTREMITY LYMPHEDEMA — Advancements in the field of microsurgery have improved options and the reliability of surgical treatment for lymphedema. Microsurgical intervention using lymphovenous anastomosis (LVA) or vascularized lymph node transfer (LNT) are the only potential options to halt, reverse, or minimize the degree of progression. Surgical treatment has been found to benefit patients with all clinical stages of lymphedema [53,54].

Overall, patients with International Society of Lymphology (ISL) stage I or II (table 1) lymphedema of the lower extremities do well with LVA while patients with stage III and IV lymphedema do better with LNT. However, patients with ISL stage III or IV lymphedema are often not candidates for LVA because there are no patent lymphatic vessels. A combination of LVA and LNT may offer improved results compared with either procedure alone, but this approach would most likely be applied to patients with earlier stages of disease because patients with more advanced stages of lymphedema often do not have any patent lymphatic channels to perform a combined procedure. (See 'Lymphaticovenous anastomosis' below and 'Free lymph node transfer' below and 'Combined procedures' below.)

A thorough preoperative assessment is essential when determining the most effective surgical treatment plan for each individual patient. It is important to note that these procedures do not eliminate the need for ongoing conservative care to maintain benefits long term. Patients must also be educated and willing to comply with the necessary pre- and postoperative protocol (eg, lymphedema therapy, compression garment use).

Indications — Indications for the surgical treatment of lower extremity lymphedema are listed below and discussed more fully separately. Earlier intervention prior to tissue fibrosis and severe adipose deposition is more effective for treating lower extremity lymphedema. (See "Surgical treatment of primary and secondary lymphedema", section on 'Indications for surgery'.)

Indications include:

●Lack of improvement or progression in spite of conservative measures (see 'Conservative care' above)

●Nonoperative management that has reached a plateau

●Recurrent cellulitis

●Limitation of function (eg, mobility, contracture)

●Leakage of lymph into body cavities, organs, or externally

●Deformity or disfigurement

●Pain

●Diminished quality of life, including emotional or psychosocial distress

Preoperative lymphatic imaging — When planning microsurgical intervention, it is beneficial to review the results of indocyanine green (ICG) or MR lymphography to help locate functional lymphatic channels for potential anastomosis [55-57]. Physiologic derangement of lymphatic drainage in the affected limb can be proven using ICG or MR lymphangiography [58,59].

ICG lymphangiography — ICG lymphangiography may be used preoperatively as well as intraoperatively to visualize lymphatic flow and identify any abnormalities. During this test, ICG is injected into the skin and imaged with a dynamic infrared florescence camera [39,56,57]. The severity of lymphedema can be graded depending on the diffusion pattern of ICG. In "normal" lymphatic systems, a linear pattern will appear. Patterns for the lower extremity are similar with those of the upper extremity (image 1). Splash, stardust, and diffuse patterns indicate an increasing severity of lymphedema and increased levels of fibrosis in the lymphatic channels [52].

One limitation of ICG lymphangiography is that only lymphatics within 2 cm of the skin's surface can be seen. To overcome this limitation, it has been recommended that MR lymphangiography also be performed, improving surgical planning by providing a surgeon with imaging of both the superficial and deep lymphatic systems [56].

The results of ICG lymphangiography can help determine an appropriate surgical intervention. It can help the surgeon identify potential sites for LVA surgery. According to Cheng's Grading System of Lymphedema and Available Options for Management, LVA may be a treatment option for patients who exhibit a linear, splash, or stardust ICG pattern (table 3 and picture 2) [60]. While there is no guideline for recommended number of LVAs, a greater number of anastomoses could be beneficial for reducing interstitial fluid levels [61]. Patients without active functional lymphatic channels would not be appropriate candidates for LVA.

When considering a lymph node transfer surgery, ICG lymphangiography can be used to locate the lymph nodes that drain the limb at a donor site. By identifying and excluding these from harvest at the time of a lymph node transfer procedure, the risk of developing donor site lymphedema can be greatly reduced [39,56,57].

MR lymphangiography — MR lymphangiography is a modification of 3D volumetric contrast-enhanced MR imaging that has been developed to depict the severity of lymphedema, the number and location of individual lymphatic channels, and the presence of dermal backflow. The imaging of individual subdermal lymphatic channels is useful for selecting which patients may be candidates for microsurgical lymphedema treatment.

Compared with lymphoscintigraphy, MR lymphangiography can depict individual lymphatic channels, does not involve ionizing radiation, and requires a shorter examination time. However, it has limited availability, high cost, is uncomfortable (dye injection), and there is a potential for damage to the lymphatics as a result of dye injection.

MR lymphangiography consists of two primary sequences: a 3D heavily T2-weighted sequence to depict the severity and extent of the lymphedema, and a high-resolution fat-suppressed 3D spoiled gradient-echo sequence performed after an intracutaneous injection of gadolinium-based MR contrast to obtain an MR venogram. The MR venogram is used to differentiate lymphatics from veins (figure 4 and image 2) [55,62].

Techniques and effectiveness — Surgical treatments for lymphedema can be categorized as physiologic or reductive techniques. Physiologic techniques repair normal or create alternate pathways for lymph fluid to properly flow out of the affected limb. Reductive or "ablative" techniques surgically remove the edematous and fibrotic soft tissues in a lymphedematous limb [54]. Proper patient selection and careful surgical planning decrease the risk of potential complications, optimize potential physical benefits, and achieve an increased quality of life [63,64].

Physiologic techniques — Physiologic techniques improve lymphatic drainage by surgically creating bypasses and/or transferring lymph nodes. A systematic review identified four studies involving nearly 2000 reconstructive procedures for lower extremity edema [53]. The reported volume reductions were between 42 and 59 percent. (See "Surgical treatment of primary and secondary lymphedema", section on 'Physiologic techniques'.)

Physiologic procedures may be indicated for the following:

●Failure of nonoperative management

●Nonoperative management that has reached a plateau

●Recurrent cellulitis or lymphangitis

●Dissatisfaction with compression garments or impaired quality of life

Contraindications for physiologic procedures include:

●Medical comorbidities precluding a safe surgical procedure

●Patient noncompliance with compression therapy or postoperative care plans

Lymphaticovenous anastomosis — LVA is a microsurgical procedure that bypasses diseased lymphatics and restores adequate lymphatic drainage via direct drainage into the venous system. (See "Surgical treatment of primary and secondary lymphedema", section on 'Lymphaticovenous anastomosis'.)

During this procedure, the distal lymphatics are anastomosed to small superficial veins, creating a "bypass" for the lymphatic fluid into the venous system (ie, subdermal lymphaticovenular bypass [65]). Patients must have partially functional lymphatic vessels to create an effective anastomosis. The number and location of anastomoses varies based on the presence of functional and accessible vessels in each patient [66,67]. Both preoperative and intraoperative lymphatic mapping is necessary to achieve superior results following LVA [54]. ICG imaging provides the necessary lymphatic mapping to aid in identifying candidates for LVA and can also provide intraoperative imaging. ICG differentiates between patients who still have some degree of functioning lymphatics, evidenced by proximally progressing lines on the extremity, and those who do not, evidenced by a diffuse pattern. In those with functioning lymphatics, ICG imaging also provides direct data on the patient to indicate the location of surgery. (See 'ICG lymphangiography' above.)

LVA effectively treats lymphedema in the lower extremity. LVA is most effective for ISL stages I to IIa or Campisi stages Ib to IIIb (table 1), at which time the lymphatic vessels are still able to transfer lymph fluid [54]. The mean volume reduction after LVA continuously decreases as lymphedema stage increases. A study supporting this correlation reported limb volume reductions as 78.5 percent for stage II patients, 54.8 percent for stage III patients, and 47.4 percent for stage IV patients [68]. In a prospective study that included patients with lower extremity lymphedema, symptom improvement was reported by 96 percent of patients and quantitative improvement occurred in 74 percent of patients undergoing LVA [69]. The authors also noted a significant improvement in identification of lymphatics through the use of preoperative ICG imaging. LVA may also be useful for treating lymphatic disease secondary to lymph vessel injuries of the pelvis and groin, with rapid resolution and excellent outcomes reported. In one small retrospective review, lymphatic leakage ceased after a mean of six days after pelvis or groin LVA [70].

For lower extremity lymphedema, LVA also decreased pain scores. In a small study, the average visual analog scale scores decreased from 5.3 preoperatively to 1.8 postoperatively [58]. The average change in limb circumference in their sample was -4.7 percent.

Patient satisfaction following LVA for lower extremity lymphedema is high, with the most common improvements including a decrease in limb size, decreased weight of limb, improved quality of life, softer and improved texture of skin, and better-fitting clothing. In a study evaluating the correlation of limb volume reduction following LVA and quality of life, median volume reductions of 11 percent for unilateral lymphedema and 8 percent for bilateral lymphedema corresponded with a 23 and 14 percent improvement, respectively, in patient-reported quality of life using Lymphoedema Quality of Life Questionnaire (LYMQOL) [71]. A significant reduction in the frequency of infections, specifically cellulitis, has also been reported after LVA [68,72].

When LVA was first described, it was suggested that patients with primary lymphedema were not candidates for this procedure. Studies have since shown that LVA can also effectively treat patients with primary lymphedema. In most primary lower extremity lymphedema cases that have been studied, it has been possible for surgeons to find healthy lymphatics suitable for anastomosis. Reduction in lower extremity limb volume after LVA is similar for secondary and primary lymphedema [73].

Complications following LVA are low, with rates around 5.9 percent, including infection, lymphatic fistula, partial skin ulceration, and wound dehiscence [67]. Contraindications for this procedure include venous incompetence, venous hypertension, and a lack of functional lymphatics on ICG imaging. (See "Surgical treatment of primary and secondary lymphedema", section on 'Physiologic techniques'.)

Free lymph node transfer — Free or vascularized LNT is another physiologic microsurgical technique used for the treatment of lymphedema [74]. LNT involves a free tissue transfer of lymph nodes taken from one area of the body and transferred to the area of lymph node deficiency, to improve drainage of the affected limb. There are two proposed mechanisms for improved lymphatic flow with LNT: lymphovenous communication preexisting within the transferred lymph nodes and via efferent lymphatic vessels from the lymph nodes [61]. (See 'Preoperative lymphatic imaging' above and "Surgical treatment of primary and secondary lymphedema", section on 'Vascularized lymph node transplant'.)

The recommended indication for LNT is stage 2 or higher lymphedema (ISL) (table 1) with repeated episodes of cellulitis (ie, but no acute cellulitis) and failure to improve from complete decongestive therapy for six months [75,76]. Known surgical removal of lymph nodes and/or previous radiation therapy in an affected limb or a history of trauma can all be treated with LNT.

Potential lymph node donor sites include the groin, axilla, supraclavicular, and submental regions, and some advocate using omental lymph nodes or mesenteric lymph nodes to eliminate secondary lymphedema related to the donor site [65]. For lower extremity lymphedema, the groin, popliteal fossa, and ankle have all been described as potential recipient sites. The groin is the most common recipient site but often requires extensive lysis or excision of scar tissue in patients with a history of previous groin surgery and radiation (figure 5) [52,77].

The risk of complications following an LNT is low but may include flap loss, donor site lymphedema, seroma, lymphocele, infection, and wound healing complications [52]. Donor site lymphedema has been minimized with the use of reverse lymphatic mapping (RLM). This technique uses ICG fluorescence lymphography and/or radioactive tracer injection into the limb adjacent to the donor site, allowing a surgeon to identify which lymph nodes at the donor site drain the extremity to avoid harvesting them, or to select an alternative donor site. Using this technique, one review of 60 LNTs reported significant improvement in more than 50 percent of their patients with no cases of donor site lymphedema [78].

LNT is associated with high rates of improvement. Reductions in lower extremity volume and limb circumference occur as early as three months after LNT, with continued, significant improvements often being observed up to 12 months after surgery [52,54,77,79-82]. In one of the largest studies, 98 percent of patients reported experiencing some degree of improvement following LNT [83]. Larger total volume reductions have been reported in patients with lower preoperative excess volumes [79]. In a study of 35 patients undergoing submental vascularized LNT to the lower extremity for lymphedema due to treatment of gynecological cancer, all patients had significant reductions in limb circumference as well as reduction in the incidence of cellulitis [84].

Health-related quality of life scores also improve significantly following LNT for lower extremity lymphedema. At three months postoperatively, improvements in mood have been noted, and by six to nine months postoperatively, patients have reported improvements in symptoms, appearance, and function [80]. Another notable improvement following LNT is a decrease in the frequency of infections, which is a major health and financial burden associated with lymphedema. The reduction of this burden may also contribute to patient-reported improvements in quality of life [80,81].

Reductive techniques — Reductive techniques surgically debulk the affected limb using direct excision and/or liposuction. Patients who are not candidates for, do not see much improvement from, or do not wish to undergo a physiologic procedure may benefit from these techniques. While they do not improve lymphatic function, they can reduce the circumference and weight of lymphedematous limbs, resulting in improved function [85]. A retrospective review of surgical reduction using skin and subcutaneous tissue excision reported that 70 to 79 percent of lower extremity patients experienced a significant reduction in extremity size, improved function, and contour following surgery [86]. Reductive techniques can also be performed before or after a physiologic procedure to further improve surgical outcomes. (See "Surgical treatment of primary and secondary lymphedema", section on 'Reductive techniques' and 'Combined procedures' below.)

Direct excision — Direct excision involves complete excision of the tissue above the deep fascia with preservation of the overlying dermis, or with removal of the dermis, using skin grafting for wound closure [54,67]. Direct excision was first described in 1912 as the "Charles procedure" and involved circumferential excision, which often resulted in worsened lymphedema distal to the excision. While the Charles procedure is rarely used today, excision of localized areas of severe lymphedema is commonly performed.

Direct excision has successfully treated many cases of severe lower extremity lymphedema and may be the only, and possibly best, treatment option for patients with severe lower extremity lymphedema suffering from impaired physical function, recurrent infections, skin ulcerations, pain, and poor quality of life [75,87-89]. Indications for excision include advanced-stage lymphedema, lymphedema that does not improve from conservative treatment, recurrent episodes of cellulitis, and severe disfigurement or dysfunction. It is particularly useful for patients with massive localized lymphedema (MLL). These masses can weigh upwards of 30 pounds on each leg and can severely limit mobility, quality of life, and the ability to undergo complete decongestive therapy and compression therapy; excision can provide immediate improvement [29,90,91].

Excision can be effective in reducing extremity size, improving quality of life, and improving function. Potential complications include wound dehiscence, contour irregularities, scarring, infection, and skin graft failure that may require additional surgery [44]. Multiple modifications have been made to this procedure to improve outcomes. Examples include the use of negative-pressure dressing after an initial debulking surgery to delay skin grafting and a staged excision of skin and subcutaneous tissue to minimize morbidity or to address specific pockets of tissue [75,88,89].

Liposuction — Liposuction is a well-established surgical technique with a low complication rate. Lymphedema liposuction involves the removal of excessive adipose tissue that typically presents during late-stage lymphedema using a minimally invasive technique [61,67]. Liposuction does not improve lymphatic function but can reduce excess volume in affected limbs. Even when signs of fibrosis are present, power-assisted liposuction can facilitate the breakdown of the tissue, particularly in lower extremity lymphedema [35]. For patients who have been appropriately selected for liposuction, recurrence can be prevented with postoperative compression therapy [67,92,93].

Patients with stage II or III lymphedema (primary or secondary) who have failed conservative treatment may be candidates. Contraindications to liposuction include inadequate prior conservative management and noncompliance with compression. Prior to surgery, treatment with compression garments and massage must be implemented to control lymphatic fluid until minimal or no pitting is present. Before proceeding with surgery, patients must express their understanding and motivation to comply with lifelong postoperative compression therapy [52,67,92,94].

Liposuction was first applied in a therapeutic setting to treat patients with upper extremity lymphedema, with high success rate for long-term reduction in excess arm volume [78,94]. Studies focused on the use of liposuction for lower extremity lymphedema have shown similar promising outcomes [92,95]. Maximal reduction in leg volume can usually be achieved around six months after surgery. In a large series of lower extremity lymphedema patients treated with liposuction, an average reduction in excess limb volume of 79 percent was reported at two years after surgery [96]. Volume reduction after liposuction may be even greater for patients with secondary lymphedema (101 percent excess limb reduction). Combined with compression therapy, liposuction achieves long-lasting reductions in lower extremity limb volume [93-100]. In one study of 69 patients (72 legs), excess reduction in leg volume over a five-year period was as high as 90 percent [92].

In addition to improvements in limb volume, liposuction improves quality of life. Significant subjective improvements in functional impairment, heaviness of limb, anxiety, perceived degree of swelling, self-consciousness, and impact on emotions have all been reported [92,93,96]. In a prospective study of 55 patients, average function scores improved from 7.4 preoperatively to 28.0 postoperatively using the Patient Specific Functional Scale (score ranges from "0" [not able to perform activities at all] to "30" [able to perform activities perfectly]) [93]. Patients with a history of cellulitis have a significant reduction in the number of annual episodes following lower extremity liposuction [92,96].

Combined procedures — Procedures that combine two physiologic techniques or combine physiologic and reductive techniques may offer additional benefits. Liposuction is a common adjunctive treatment option due to its low complication rate and its notable improvements in limb volume. It has been suggested that by combining microsurgery with liposuction, the need for ongoing compression therapy may be alleviated [39,67,93]. Liposuction may also be used as a secondary procedure following a primary physiologic surgery. Studies have shown that as many as 16 percent of LVA patients and 31.6 percent of LNT patients will benefit from an additional liposuction procedure postoperatively [67].

Combined physiologic procedures using LVA and LNT have been suggested to maximize patient outcomes as these two approaches work via different mechanisms. While these procedures are complex and require a surgeon with expertise in microsurgery, they have been found to decrease morbidity, resulting in greater improvements in quality of life and functional recovery [52,101].

In some patients, it may be appropriate to combine a physiologic and a reductive technique. Combining these procedures may be the most effective approach for treating severe lower extremity lymphedema. An evaluation of combined suction assisted protein lipectomy (SAPL) and LVA demonstrated a reduction in excess lower limb volume from 20.2 to 2.7 percent without damaging associated lymphatic vessels [102,103]. While reductive techniques such as liposuction can remove fatty and fibrotic tissue in the affected limb, an LNT and/or LVA procedure can improve lymphatic function.

Postoperative compression — To maximize the reduction in limb volume after surgery and prevent lymphedema recurrence following surgery, continued lymphedema therapy and compression therapy are essential. The combined treatment approach of surgical and nonsurgical techniques has proven to be effective in the treatment of primary and secondary lymphedema. Following a physiologic procedure, patients may eventually be able to discontinue compression garment use. However, the use of compression garment use is usually a lifelong requirement following reductive techniques to prevent recurrence [11,54,104].

●Following LVA, the recommended timing to begin using compression garments postoperatively varies based on a surgeon's preference. Garment usage may begin immediately after surgery but is often not implemented until four weeks after the procedure. Compression garments are used for at least six months postoperatively [104,105]. However, if there is significant improvement in patients, the use of compression garments may be discontinued over time. Approximately 56.3 percent of patients are able to discontinue use after an LVA procedure [104].

●Following LNT, compression garments may be worn immediately. It is often recommended to continue their use for at least two to six months after surgery [81]. Following LNT, as many as 78 percent of patients are able to discontinue compression therapy [104].

●Following reductive procedures, ongoing compression therapy (24 hours/day) is essential for maintaining or further reducing limb volume and preventing recurrence. Compression garments are applied immediately following surgery and are most important during the first three months after surgery, when the most notable changes in volume occur. After initiating compression therapy, limbs should be measured during each follow-up visit and garments should be adjusted in response to changes in limb volume [92,106].

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Lymphedema".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: Peripheral lymphedema after cancer treatment (The Basics)")

●Beyond the Basics topics (see "Patient education: Lymphedema after cancer surgery (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Lower extremity lymphedema – Lymphedema occurs when the load exceeds the transport capacity of the lymphatic system, which leads to the accumulation of protein-rich fluid (lymph) and fibroadipose tissue in the interstitium. Lymphedema in the lower extremity can result from injury, infection, or congenital abnormalities of the lymphatic system. Symptoms of lymphedema include limb swelling (including focal changes), skin changes, discomfort, and restricted range of motion. (See 'Classification and anatomy' above and 'Lower extremity clinical features' above.)

●Conservative treatment – Conservative therapy is important and should be the initial treatment for patients with lower extremity lymphedema. Conservative treatment consists of a multimodality regimen that includes general measures for care, physiotherapy (eg, simple lymphatic drainage, manual lymphatic drainage, complete decongestive therapy), and compression therapy (compression bandaging, compression garments, intermittent pneumatic compression), the type and the intensity of which depends upon the clinical stage (table 1). (See 'Conservative care' above and "Clinical staging and conservative management of peripheral lymphedema", section on 'Conservative treatment by severity'.)

•Patients with mild lymphedema (International Society of Lymphology [ISL] stage I), are treated with physiotherapy. Manual lymphatic drainage (MLD) is a massage-like technique that is typically performed by specially trained physical therapists, but a self-help maneuver (simple lymphatic drainage) has also been used for mild cases. Light pressure is used to mobilize edema fluid from distal to proximal areas.

•Patients with moderate-to-severe lymphedema (ISL stage II to III) are treated with complete decongestive therapy (CDT). CDT refers to a two-phase (treatment phase, maintenance phase) multicomponent technique that is designed to reduce the degree of lymphedema and to maintain the health of the skin and supporting structures.

•Patients with severe lymphedema (ISL stage III) may also benefit from intermittent pneumatic compression (IPC; also called sequential pneumatic compression) in addition to CDT. IPC devices use a plastic stocking that is intermittently inflated over the affected limb. Most pneumatic compression pumps sequentially inflate a series of chambers in a distal-to-proximal direction.

●Surgery – Surgery is effective in the treatment of lower extremity lymphedema in those with appropriate indications. Available surgical treatments have few contraindications, low risks, and good outcomes. Improvements after surgery include reduced limb volume, reduced rates of infection/cellulitis, improved physical function, ability to return to everyday activities, and improved quality of life. (See 'Indications' above and 'Techniques and effectiveness' above.)

•Physiologic procedures (lymphaticovenous anastomosis, lymph node transfer) improve lymphatic drainage by surgically creating alternate pathways for fluid egress.

•Reductive techniques (direct excision, liposuction) remove excess tissue to reduce the size and weight of an affected limb. This can also improve range of motion and restore patient mobility.

•Surgical intervention often involves a combined (physiologic and reductive surgery) or staged approach.