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Lurie F, Malgor RD, Carman T, Dean SM, Iafrati MD, Khilnani NM, Labropoulos N, Maldonado TS, Mortimer P, O'Donnell TF, Raffetto JD, Rockson SG, Gasparis AP. The American Venous Forum, American Vein and Lymphatic Society and the Society for Vascular Medicine expert opinion consensus on lymphedema diagnosis and treatment. Phlebology 2022; 37:252-266. [PMID: 35258350 PMCID: PMC9069652 DOI: 10.1177/02683555211053532] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Lymphedema imposes a significant economic and social burden in modern societies. Controversies about its risk factors, diagnosis, and treatment permeate the literature. The goal of this study was to assess experts' opinions on the available literature on lymphedema while following the Delphi methodology. METHODS In December of 2019, the American Venous Forum created a working group tasked to develop a consensus statement regarding current practices for the diagnosis and treatment of lymphedema. A panel of experts was identified by the working group. The working group then compiled a list of clinical questions, risk factors, diagnosis and evaluation, and treatment of lymphedema. Fifteen questions that met the criteria for consensus were included in the list. Using a modified Delphi methodology, six questions that received between 60% and 80% of the votes were included in the list for the second round of analysis. Consensus was reached whenever >70% agreement was achieved. RESULTS The panel of experts reached consensus that cancer, infection, chronic venous disease, and surgery are risk factors for secondary lymphedema. Consensus was also reached that clinical examination is adequate for diagnosing lymphedema and that all patients with chronic venous insufficiency (C3-C6) should be treated as lymphedema patients. No consensus was reached regarding routine clinical practice use of radionuclide lymphoscintigraphy as a mandatory diagnostic tool. However, the panel came to consensus regarding the importance of quantifying edema in all patients (93.6% in favor). In terms of treatment, consensus was reached favoring the regular use of compression garments to reduce lymphedema progression (89.4% in favor, 10.6% against; mean score of 79), but the use of Velcro devices as the first line of compression therapy did not reach consensus (59.6% in favor vs 40.4% against; total score of 15). There was agreement that sequential pneumatic compression should be considered as adjuvant therapy in the maintenance phase of treatment (91.5% in favor vs. 8.5% against; mean score of 85), but less so in its initial phases (61.7% in favor vs. 38.3% against; mean score of 27). Most of the panel agreed that manual lymphatic drainage should be a mandatory treatment modality (70.2% in favor), but the panel was split in half regarding the proposal that reductive surgery should be considered for patients with failed conservative treatment. CONCLUSION This consensus process demonstrated that lymphedema experts agree on the majority of the statements related to risk factors for lymphedema, and the diagnostic workup for lymphedema patients. Less agreement was demonstrated on statements related to treatment of lymphedema. This consensus suggests that variability in lymphedema care is high even among the experts. Developers of future practice guidelines for lymphedema should consider this information, especially in cases of low-level evidence that supports practice patterns with which the majority of experts disagree.
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Affiliation(s)
- Fedor Lurie
- 92661Jobst Vascular Institute of Promedica, Toledo, OH, USA.,University of Michigan at Ann Arbor, Ann Arbor, MI, USA
| | | | - Teresa Carman
- 5718Vanderbilt University Medical Center, Nashville, TN, USA
| | - Steven M Dean
- 12306The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mark D Iafrati
- 1867Tufts University School of Medicine, Boston, MA, USA
| | - Neil M Khilnani
- 12295Weill Cornell Medicine-New York Presbyterian Hospital, New York, NY, USA
| | | | | | | | | | - Joseph D Raffetto
- VA Boston Healthcare System, Boston, USA.,Harvard Medical School, Boston, USA.,Brigham and Women's Hospital, Boston, USA
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Abstract
Lymphedema-the accumulation of fluid in tissues, usually in the upper and lower extremities-often results from lymph node dissection or radiation and can cause painful and debilitating swelling that may interfere with a patient's daily living activities and quality of life. The goal of treatment for lymphedema is to reduce the volume of fluid in the affected area. Lymphedema is staged according to presenting characteristics, and interventions may be surgical or nonsurgical, such as complex decongestive therapy. Lymphovenous bypass is a surgical procedure performed for the management of lymphedema and involves rerouting microvascular channels to allow for the drainage of fluid that has accumulated in the lymphatic tissue of the upper or lower extremities. It requires supermicrosurgery techniques because of the small size of the vessels being anastomosed. Perioperative nursing implications for lymphovenous bypass include OR preparation and providing emotional support for patients living with lymphedema.
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Video Tutorial for Indocyanine Green Lymphography in Lymphatic Surgery. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2609. [PMID: 32095412 PMCID: PMC7015613 DOI: 10.1097/gox.0000000000002609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 11/08/2019] [Indexed: 11/25/2022]
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Forte AJ, Huayllani MT, Boczar D, Cinotto G, McLaughlin SA. Ultrasound Elastography Use in Lower Extremity Lymphedema: A Systematic Review of the Literature. Cureus 2019; 11:e5578. [PMID: 31695997 PMCID: PMC6820675 DOI: 10.7759/cureus.5578] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Lower extremity lymphedema (LEL) is mainly assessed clinically. Ultrasound elastography (UE) is a promising imaging tool to assess this disorder. We conducted a systematic literature review to describe the studies evaluating the use of UE in LEL. The PubMed database was queried for studies that evaluated the use of UE in LEL. The keywords "elastography" AND "lymphedema" were used for the search. Original articles in English were included in our study, whereas reviews were excluded. Our search resulted in 12 articles, 4 of which met the inclusion criteria. UE methods included free-hand real-time tissue elastography and UE with transducer in B mode. The imaging parameters applied were the tissue strains and the area of red region, respectively. All studies tested UE use in the assessment of LEL, and only one considered its use for staging. All studies but one found a difference in strain parameters for assessment of patients with LEL. Our systematic review has shown that UE appears to be a great tool in the assessment of LEL in moderate-to-advanced stages of disease. However, further studies using new effective methods are needed to evaluate patients with early lymphedema.
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Affiliation(s)
- Antonio J Forte
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Maria T Huayllani
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Daniel Boczar
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Gabriela Cinotto
- Plastic Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
| | - Sarah A McLaughlin
- Surgery, Mayo Clinic Florida - Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Jacksonville, USA
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68Ga-NOTA-Evans Blue TOF PET/MR Lymphoscintigraphy Evaluation of the Severity of Lower Limb Lymphedema. Clin Nucl Med 2019; 44:439-445. [PMID: 30985414 DOI: 10.1097/rlu.0000000000002584] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE This study was designed to investigate the role of Ga-NOTA-Evans Blue (NEB) time-of-flight (TOF) PET/MR in evaluating lower limb lymphedema by visual analysis and novel parameters. METHODS Thirteen patients with unilateral lower limb lymphedema were divided into 3 groups according to the clinical severity: minimal (4 patients), moderate (5 patients), and severe (4 patients). All patients underwent Ga-NEB TOF PET/MR lymphoscintigraphy. The ratio of the standardized uptake value (SUV) of superficial lymphatic vessel (SLV) versus SUV of deep lymphatic vessel (DVL) (SUVslv/dlv) was designed to assess the level of lymphedema severity. The correlation between lymphedema severity and lymphoscintigraphy findings was determined using 1-way analysis of variance, the t test, and Pearson correlation analysis. RESULTS There was a significant difference in the SUVslv between the affected limbs and normal limbs in all subjects (affected limbs: 0.57 ± 0.32, normal limbs: 1.86 ± 1.43; P < 0.05), which was not found in the SUVdlv (affected limbs: 0.64 ± 0.39, normal limbs: 0.63 ± 0.31; P > 0.1). The SUVslv/dlv of the affected limbs showed statistical differences within the 3 groups (P < 0.05) (minimal group: 1.91 ± 0.45; moderate group: 0.84 ± 0.16; severe group: 0.42 ± 0.11). The statistical analysis revealed a negative correlation between SUVslv/dlv and the severity of lymphedema (r = -0.899; P < 0.01). CONCLUSIONS Ga-NEB TOF PET/MR lymphoscintigraphy can provide anatomical and functional information of lymphatic vessels to guide surgery plans. SUVslv/dlv was well correlated with clinical lymphedema severity and might be potential in evaluating bilateral lower limb lymphedema.
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Arrivé L, Derhy S, Dahan B, El Mouhadi S, Monnier-Cholley L, Menu Y, Becker C. Primary lower limb lymphoedema: classification with non-contrast MR lymphography. Eur Radiol 2017; 28:291-300. [PMID: 28695357 DOI: 10.1007/s00330-017-4948-z] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 06/12/2017] [Accepted: 06/14/2017] [Indexed: 12/16/2022]
Abstract
PURPOSE The purpose of the present study was to analyse the performance of non-contrast MR lymphography for the classification of primary lower limb lymphoedema in 121 consecutive patients with 187 primary lower limb lymphoedemas. MATERIALS AND METHODS 121 consecutive patients with clinically diagnosed primary lower limb lymphoedema underwent non-contrast MR lymphography with a free-breathing 3D fast spin-echo sequence with a very long TR/TE (4000/884 ms). MR examinations were retrospectively reviewed for severity of lymphoedema (absent, mild, moderate, severe) and characteristics of inguinal lymph nodes and iliac and inguinal lymphatic trunks graded as aplasic (no lymph nodes or lymphatic trunks), hypoplasic (less lymph nodes or lymphatic trunks), normal and hyperplasic (more lymph nodes or more and/or dilated trunks). RESULTS There was an excellent correlation between clinical stage and severity of lymphoedema (Cramer's V of 0,73 (p < 0.001)). Differentiation was feasible between inguinal lymphatic vessel aplasia (21%), hypoplasia (15%), normal pattern (53%) and hyperplasia (11%). Severe lymphoedema was observed in 46% of aplasic patterns and in 37% of hyperplasic patterns, but in only 15% of hypoplasic patterns and never observed in normal patterns (p < 0.001). CONCLUSION Non-contrast MR lymphography is able to classify primary lower limb lymphoedemas into hyperplasic, aplasic, hypoplasic and normal patterns. KEY POINTS • Non-contrast MR lymphography is able to classify primary lower limb lymphoedemas. • Lymphoedema can be classified in hyperplasic, aplasic, hypoplasic and normal patterns. • Non-contrast MR lymphography can optimize clinical management of primary lower limb lymphoedemas.
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Affiliation(s)
- Lionel Arrivé
- Department of Radiology, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France. .,Faculté de Médecine Pierre et Marie Curie, Sorbonne Universités, UPMC Université Paris 06, Paris, France.
| | - S Derhy
- Department of Radiology, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France.,Faculté de Médecine Pierre et Marie Curie, Sorbonne Universités, UPMC Université Paris 06, Paris, France
| | - B Dahan
- Department of Emergency Medicine, Cochin Hospital, 27 Rue du Faubourg Saint-Jacques, 75014, Paris, France
| | - S El Mouhadi
- Department of Radiology, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France.,Faculté de Médecine Pierre et Marie Curie, Sorbonne Universités, UPMC Université Paris 06, Paris, France
| | - L Monnier-Cholley
- Department of Radiology, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France.,Faculté de Médecine Pierre et Marie Curie, Sorbonne Universités, UPMC Université Paris 06, Paris, France
| | - Y Menu
- Department of Radiology, Saint-Antoine Hospital, Assistance Publique-Hôpitaux de Paris, 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France.,Faculté de Médecine Pierre et Marie Curie, Sorbonne Universités, UPMC Université Paris 06, Paris, France
| | - C Becker
- Department of Thoracic Surgery, HEGP, 20 Rue Leblanc, 75015, Paris, France
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Yoo JS, Chung SH, Lim MC, Kim YJ, Kim KG, Hwang JH, Kim YH. Computed tomography-based quantitative assessment of lower extremity lymphedema following treatment for gynecologic cancer. J Gynecol Oncol 2016; 28:e18. [PMID: 28028991 PMCID: PMC5323285 DOI: 10.3802/jgo.2017.28.e18] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Revised: 11/03/2016] [Accepted: 11/16/2016] [Indexed: 11/30/2022] Open
Abstract
Objective To develop an algorithmic quantitative skin and subcutaneous tissue volume measurement protocol for lower extremity lymphedema (LEL) patients using computed tomography (CT), to verify the usefulness of the measurement techniques in LEL patients, and to observe the structural characteristics of subcutaneous tissue according to the progression of LEL in gynecologic cancer. Methods A program for algorithmic quantitative analysis of lower extremity CT scans has been developed to measure the skin and subcutaneous volume, muscle compartment volume, and the extent of the peculiar trabecular area with a honeycombed pattern. The CT venographies of 50 lower extremities from 25 subjects were reviewed in two groups (acute and chronic lymphedema). Results A significant increase in the total volume, subcutaneous volume, and extent of peculiar trabecular area with a honeycombed pattern except quantitative muscle volume was identified in the more-affected limb. The correlation of CT-based total volume and subcutaneous volume measurements with volumetry measurement was strong (correlation coefficient: 0.747 and 0.749, respectively). The larger extent of peculiar trabecular area with a honeycombed pattern in the subcutaneous tissue was identified in the more-affected limb of chronic lymphedema group. Conclusion CT-based quantitative assessments could provide objective volume measurements and information about the structural characteristics of subcutaneous tissue in women with LEL following treatment for gynecologic cancer.
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Affiliation(s)
- Ji Sung Yoo
- Rehabilitation Medicine, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Seung Hyun Chung
- Rehabilitation Medicine, Research Institute and Hospital, National Cancer Center, Goyang, Korea
| | - Myong Cheol Lim
- Gynecologic Cancer Branch, Center for Uterine Cancer, and Center for Clinical Trials, Research Institute and Hospitaland Cancer Control and Policy, Graduate School of Cancer Science and Policy, National Cancer Center, Goyang, Korea
| | - Young Jae Kim
- Biomedical Engineering Branch, Division of Precision Medicine and Cancer Informatics, Research Institute, National Cancer Center, Goyang, Korea
| | - Kwang Gi Kim
- Biomedical Engineering Branch, Division of Precision Medicine and Cancer Informatics, Research Institute, National Cancer Center, Goyang, Korea
| | - Ji Hye Hwang
- Department of Physical and Rehabilitation Medicine, Center for Supportive Care, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yun Hee Kim
- Department of Physical and Rehabilitation Medicine, Center for Prevention and Rehabilitation, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea.
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Tassenoy A, De Mey J, Stadnik T, De Ridder F, Peeters E, Van Schuerbeek P, Wylock P, Van Eeckhout GPA, Verdonck K, Lamote J, Baeyens L, Lievens P. Histological findings compared with magnetic resonance and ultrasonographic imaging in irreversible postmastectomy lymphedema: a case study. Lymphat Res Biol 2010; 7:145-51. [PMID: 19778202 DOI: 10.1089/lrb.2008.1025] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Postmastectomy edema is a current complication after axillary lymph node dissection in cases of breast cancer treatment. Staging is important in order to select those patients who can benefit from complex physical therapy (CPT). Different imaging techniques can be used to evaluate the edema. Ultrasonography (US) is a harmless, cheap, and easily applicable technique to visualize the dermal and subcutaneous tissue, but interpretation of the obtained images is not always evident. The aim of this study was to compare ultrasound images of irreversible edema with tissue histology, magnetic resonance imaging (MRI) and magnetic resonance spectroscopy (MRS). Ultrasonographic images of the edematous dermis show an homogeneous hypoechogenic dermal layer that appears on tissue histology to be less compact, due to the excess of fluid in the interstitium separating the collagen fibres and making it more transparent on light microscopy. MRI of the dermis gives a hyperintense signal, indicating the presence of fluid. In the subcutis, increase of the adipose tissue could be observed on US, MRI, and tissue histology. In the case of lymphedema, the area and perimeter of fat cells is significantly (p < 0.05) increased. Hypoechogenic areas near the muscle fascia are registered on US corresponding with epifascial fluid on MRI, and hyperechogenic branches are embedded within the adipose tissue, on tissue histology seen as large fibrotic septa enclosing adipose cells. MRI has a honeycomb picture corresponding with fluid bound to fibrosis.
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Affiliation(s)
- An Tassenoy
- Department of Rehabilitation Research, Free University Brussels, Brussels, Belgium.
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Righetti R, Garra BS, Mobbs LM, Kraemer-Chant CM, Ophir J, Krouskop TA. The feasibility of using poroelastographic techniques for distinguishing between normal and lymphedematous tissues in vivo. Phys Med Biol 2007; 52:6525-41. [PMID: 17951860 DOI: 10.1088/0031-9155/52/21/013] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Lymphedema is a common condition involving an abnormal accumulation of lymphatic fluid in the interstitial space that causes swelling, most often in the arm(s) and leg(s). Lymphedema is a significant lifelong concern that can be congenital or develop following cancer treatment or cancer metastasis. Common methods of evaluation of lymphedema are mostly qualitative making it difficult to reliably assess the severity of the disease, a key factor in choosing the appropriate treatment. In this paper, we investigate the feasibility of using novel elastographic techniques to differentiate between lymphedematous and normal tissues. This study represents the first step of a larger study aimed at investigating the combined use of elastographic and sonographic techniques for the detection and staging of lymphedema. In this preliminary study, poroelastographic images were generated from the leg (8) and arm (4) subcutis of five normal volunteers and seven volunteers having lymphedema, and the results were compared using statistical analyses. The preliminary results reported in this paper suggest that it may be feasible to perform poroelastography in different lymphedematous tissues in vivo and that poroelastography techniques may be of help in differentiating between normal and lymphedematous tissues.
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Affiliation(s)
- Raffaella Righetti
- Department of Diagnostic and Interventional Imaging, Ultrasonics Laboratory, The University of Texas Medical School, Houston, TX, USA
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Stanton AWB, Mellor RH, Cook GJ, Svensson WE, Peters AM, Levick JR, Mortimer PS. Impairment of lymph drainage in subfascial compartment of forearm in breast cancer-related lymphedema. Lymphat Res Biol 2005; 1:121-32. [PMID: 15624420 PMCID: PMC1351042 DOI: 10.1089/153968503321642615] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In arm lymphedema secondary to axillary surgery and radiotherapy (breast cancer-related lymphedema), the swelling is largely epifascial and lymph flow per unit epifascial volume is impaired. The subfascial muscle compartment is not measurably swollen despite the iatrogenic damage to its axillary drainage pathway, but this could be due to its low compliance. Our aim was to test the hypothesis that subfascial lymph drainage too is impaired. METHODS AND RESULTS Quantitative lymphoscintigraphy was used to measure the removal rate constant (local lymph flow per unit distribution volume) for technetium-99m-human immunoglobulin G injected intramuscularly in the forearms of nine women with unilateral lymphedema. The removal rate constant was on average 31% lower in the ipsilateral swollen forearm than in the contralateral forearm (swollen arm: -0.096+/-0.041% min(-1), contralateral arm: -0.138+/-0.037% min(-1); mean+/-SD, p = 0.037). The decrease in subfascial rate constant correlated strongly with increase in arm volume (r = -0.88, p = 0.002), even though the swelling is mainly epifascial. There was no convincing evidence of dermal backflow. CONCLUSIONS Lymph flow in the subfascial muscle compartment is decreased in breast cancer-related lymphedema. The correlation between impairment of subfascial drainage and epifascial arm swelling could be because both depend on the severity of axillary damage, or because loss of function in subfascial lymphatics impairs drainage from the epifascial to the subfascial system.
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Affiliation(s)
- A W B Stanton
- Department of Medicine, St George's Hospital Medical School, London.
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