[3] ), (An excellent overview of lymphedema is presented with a summary of several pivotal studes to support each therapeutic modality. Lymphedema occurs when protein-rich fluid accumulates in the interstitium due to impaired lymphatic function. A skin biopsy is not necessary to diagnose LE, however, in equivocal cases, imaging in the form of lymphoscintigraphy (isotope lymphography) is the diagnostic procedure of choice, although both magnetic resonance imaging (MRI) or computerized axial tomography (CAT) can also help confirm the diagnosis. ), Szuba, A, Achalu, R, Rockson, SG. As skin integrity suffers, scaling and dryness allow resident skin pathogens (such as streptococci and staphylococci) to gain access through the defective skin barrier into protein-rich interstitial fluid, creating a medium favorable to bacterial colonization. Genetic variability in lymphatic constitution may explain why seemingly similar patients receiving the same surgical protocol have different lymphedema risks over time. For patients who have recently traveled to Africa, Central or South America, and Pacific Island nations, the diagnosis of lymphatic filariasis must also be considered. The main goal of treatment is to reduce the swelling and keep it to a minimum. June 2, 2021. Any use of this site constitutes your agreement to the Terms and Conditions and Privacy Policy linked below. - Evidence-Based Guidance "We are not squeezing the fluid out of the affected tissue," explains Dr. Cheville. Spontaneously irreversible lymphedema pitting edema with overlying skin changes (dermal fibrosis). 165. Limb lymphedemas are due to a malfunction of the lymphatic system responsible for lymph stasis in the interstitial tissue and secondarily to an increase in the volume of the affected limb. Treatment of post-mastectomy lymphedema with laser therapy: double blind placebo control randomized study. information and will only use or disclose that information as set forth in our notice of This information does not This is a labor- and time-intensive treatment regimen, and patient adherence is necessary for success. Karen speaks frequently at academic, clinical and professional settings and performs clinical research that she presents and publishes nationally and internationally. 2260-7. When lymph fluid is chronically congested it floods, and then pools, and over time attracts fat cells which begin to bind to the surrounding tissues. The lymphatic system forms part of the immune system and part of the vascular system. We report the case of a 30 year old man with left lower limb lymphedema occurred at puberty complicated by verrucous papillomatosis. During Stage 2 (spontaneously irreversible lymphedema), lymphedema doesnt resolve entirely, although it may fluctuate. Efficacy of complete decongestive therapy and manual lymphatic drainage on treatment-related lymphedema in breast cancer. If you have any concerns with your skin or its treatment, see a dermatologist for advice. Weissleder H, Schuchhardt C. Lymphedema: Diagnosis and Therapy. A guest blog by Karen Ashforth, OT MS CLT-LANA. Syndromic classification of hereditary lymphedema. 2009 June;42(2):88-98. Stage O lymphedema, which is also known as the latent or preclinical stage, is the newly added classification. All rights reserved. However, as it becomes bigger and harder it will no longer pit. The. The veins and lymph vessels are both charged with removing liquid and solid debris from tissue. Manrique OJ, et al. 96. In: Harrison's Principles of Internal Medicine. There may also be papillomas of the skin, which are small bumps that form on the skin and may leak fluid. Learn. Lymphostatic fibrosis is generally soft and fatty and is formed as a result of prolonged swelling. This site complies with the HONcode standard for trustworthy health information: verify here. Secondary or acquired LE occurs when there is blockage or destruction of otherwise normal lymph channels. It also provides helpful tips for both providers and patients on bandaging techniques, exercises, and other self-care related issues.). 140-6. BD93.Z, BD93.0, BD93.1Y, BD93.10, BE1B.0, BE1B.Y, BD93.11, BD93.12, 234097001, 445710004, 399889006, 229488002, 77123007, 229510000, 28590005, 402672004, 254199006, 698991004, 703283003, 440121002, 439128001, 33129002, 251490001, 47595008, 62497000, 703316004, Can occur in babies and children, and may, Pendulous swelling and masses in morbidly obese patients. It is very important to treat lymphoedema in its early stages to prevent further swelling and complications such as infection. This site complies with the HONcode standard for trustworthy health information: Teach patients to avoid extremes of temperature and avoid wearing tight clothing, tight jewelry, or anything that could constrict the extremity. These conditions cause a universal and classic clinical picture. She currently works at St. Josephs Medical Center in Stockton, California, providing outpatient lymphedema treatment and also has a private consulting practice. It can be quite disabling and seriously impact their day-to-day lives. (In this prospective study of 37 women breast cancer patients with unilateral lymphedema, circumferential suction-assisted lipectomy to remove excess subcutaneous tissue in conjunction with limb compression garments led to a mean reduction of lymphedema volume of 118% at 12 months. See this image and copyright information in PMC. Lymphedema and fibrosis can affect function by restricting the bodys ability to move, which can create pain and dysfunction for our patients. Other features included upslanting and dysplastic toenails, deep toes creases, papillomas over the affected area, and cellulitis. Stage III lymphedema is a severe and prolonged collection of edema or swelling in the body part. Only surgeons who have experience with lymphoedema and the lymphatic system should perform surgery. Blood supply remains patent, helping to prevent secondary ulcers. Make a donation. 410-11. (Bioimpedance is a non-invasive method of determining the composition of body tissues to evaluate the presence of body fluids such as lymphedema. Ann NY Acad Sci. privacy practices. Males and females may have upslanting toenails, deep creases in the toes, wart-like growths (papillomas), and prominent leg veins. It may be a result of surgery or other medical treatments such as radiation therapy, or there may be other causes such as injury, infection or inflammation. Your lymph nodes filter out the waste and flush it from your body.. Stage 3 (lymphostatic elephantiasis) is marked by dermal hardening, nonpitting edema, papillomas, hyperkeratosis, and in some cases, extreme girth. 859-64. The reductive phase includes the use of a massage technique known as manual lymphatic draining (MLD), short stretch bandaging, exercises to create and augment an internal pumping mechanism, skin care and education in self-management. Early intervention impacts the progression of both surgical and lymphostatic fibrosis. The etiology of LE can simply be explained by any process that alters the balance between lymph production and lymph removal, leading to an accumulation of protein-rich lymph in the interstitial spaces. Viavital Verlag GmbH; 2007. Severe cases of lymphedema can affect the ability to move the affected limb, increase the risks of skin infections and sepsis, and can lead to skin changes and breakdown. Patients with Milroy disease develop bilateral lower extremity LE (although unilateral lower limb involvement is possible as well), below the knees characterized by a woody, brawny texture. . Flashcards. "Mayo," "Mayo Clinic," "MayoClinic.org," "Mayo Clinic Healthy Living," and the triple-shield Mayo Clinic logo are trademarks of Mayo Foundation for Medical Education and Research. Other differential diagnoses of LE that should be considered include the following: Simple edema (characteristically pitting and associated with congestive heart failure, renal disease, liver diseases, or venous insufficiency). The goal of treatment is to prevent the development of irreversible tissue damage, infection, and certain malignancies (lymphangiosarcoma). 95. Treating lymphedema lessens lymph stasis which lowers the development of fibrosclerotic fibrosis. lymphedema/healthprofessional. When lymph stasis prevails, inflammatory processes and lymphostatic fibrosis trigger tissue-density changes, further entrapping superficial vessels and accelerating mechanical insufficiency. Lymphedema causes regional immune suppression and leads to an increase in opportunistic infections such as cellulitis. SLs develop most frequently in lower limbs after breast cancer treatment while lymphedemas are either secondary (iatrogenic or infectious) or primitive, most often sporadic, sometimes familial or they can be part of syndromes resulting in malformations and/or more complex genetics in upper limbs. Please enable it to take advantage of the complete set of features! This is achieved by minimizing the amount of stagnant lymphatic fluid in the interstitium as much as possible, and thus maintain the extremity at the smallest possible size. Flashcards. Scar formation can become further affected if the patient receives additional treatment such as radiation therapy, or has the complication of a cellulitis infection. Selected references LymphNotes.com 2012.This information does not replace the advice of a qualified health care professional. Lymphedema. Mayo Clinic. The diagnosis of lymphedema is essentially based on clinical examination. Lymphostatic fibrosis is present in all forms of lymphedema. CDT is composed of a treatment phase and a maintenance phase. Ann Plast Surg. (An excellent review of the different types of congenital lymphedema syndromes with emphasis on both the genetic causes and the associated clinical phenotype of affected patients. Schultz-Ehrenburg U, Niederauer HH, Tiedjen KU. It is important to recognize the congenital forms of lymphedema because they are associated with malformations of other organ systems and other systemic complications. Several methods can aid differential diagnosis. French Lymphology Society]. 59. The key to lymphedema management is early identification, which can be difficult in some cases. 799-806. It begins with chronic venous insufficiency (CVI) in which the one-way valves in the veins of the lower legs lose the ability to completely close. Imaging. Topics AZ The skin can become hardened with a leathery feel. Lymphoedema of the legs is often worse than that of the arms as lymphatic drainage from the legs is more difficult. The lymphatic system is a network of vessels that carry protein-rich lymph fluid throughout the body. 2 Copyright 2023 Haymarket Media, Inc. All Rights Reserved. Elephantiasis nostras verruciformis Now that there isimproved understanding of lymphedema, and the benefits of very early treatment,a fourth stage has been added and currently the ISL lymphedema staging system consists of four levels being numbered from 0 to 3. Stage 1 is called Reversible, because swelling can be reversed by elevation. Complex lymphedema therapy (CLT) is a non-invasive treatment for lymphedema with the aim to reduce and Lymphedema rubra: blanchable erythema caused by vasodilation of . Explain to patients the details of the four components of CDT, which are 1) manual lymph drainage (MLD), 2) compression bandaging, 3) therapeutic exercises, and 4) comprehensive skin and nail care. The veins and lymph vessels are both charged with removing liquid and solid debris from tissue. The swollen tissues are soft and pitting edema is present. Proteins, other macromolecular wastes, and water constitute lymphatic loads. An increase in body size from swelling and lymphostatic fibrosis can affect the ability to walk by throwing the body off balance or limiting movement. Finally, chronic uncontrolled secondary LE may predispose to different malignancies owing to local immunodeficiency that promotes oncogenesis. The possibility of cancer should be investigated if a cause cannot be found for swelling. During LVB, surgeons create a microscopic anastomosis between the blue lymphatics draining from the arm and a branch of the axillary vein to allow the excess fluid to drain properly. J Surg Res. National Cancer Institute. ), (This comprehensive textbook discusses current approaches to the treatment of primary, secondary lymphedema, and related conditions. Such measurements have been studes to establish a baseline at the time of breast cancer treatment.). Relative contraindications include hypertension, paralysis, diabetes, and bronchial asthma, while absolute contraindications include acute infections, congestive heart failure, and deep vein thrombosis. Lymphedema rarely causes pain because the skin accommodates gradual, insidious fluid accumulation. 2008. pp. Specializing as a board certified hand therapist led to her interest in lymphedema and fibrosis nearly 20 years ago. Primary LE, characterized by a developmental malformation aberrant function of the lymphatic system, is classified based on age of onset. Trauma to the axillary or inguinal lymph nodes, which exist on both the left and right of the body and in both the upper and lower regions, predisposes these quadrants to swelling. In addition to physical treatment modalities, a variety of medications have been attempted in the treatment of lymphedema. Lymph nodes are an important part of your lymphatic system. These areas remain at risk for infections and open wounds. Pressure does not produce any pitting. of adipose or radiation fibrosis mechanical-ly disrupt drainage of skin lymphatics. Keywords: Secondary lymphedema (or acquired lymphedema) is much more common. When we give our patients the power to address lymphedema and fibrosis, it gives them an increased quality of life: they can feel good in their bodies, and enjoy their lives. No part of this website or publication may be reproduced, stored, or transmitted in any form or by any means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval system, without permission in writing from the copyright holder. 2008. pp. In stage 0, which is also called the Latency stage of lymphedema, swelling and fibrosis are not visible or palpable but the limb may feel "different" or "heavy." She is also an adjunct faculty member with the University of the Pacific in the Doctoral Physical Therapy Program. Relationship between lymphoscintigraphy and clinical findings in lower limb lymphedema (LO): toward a comprehensive staging. LE can be a primary or secondary process. Steve Norton is cofounder of Lymphedema & Wound Care Education and executive director of the Norton School of Lymphatic Therapy in Matawan, New Jersey. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). Lymphedema caused by cancer treatment may not occur until months or years after treatment. 2008;59(2):32431. ", Dr. Cheville notes that the recommended intensity during the maintenance phase is about twice daily, typically administered over 10 to 14 days. Lymphology. Frontera WR, et al., eds. After surgery, a wound goes through several stages of healing that are triggered by inflammation. If you are a Mayo Clinic patient, this could For instance, the Perometer uses optoelectronic volumetry. Would you like email updates of new search results? When changes develop, if specialized treatment is started immediately, it may be possible to prevent the development of further stages of lymphedema. Diagnosis and treatment of primary lymphedema. Make a donation. 2020; doi:10.1016/j.mayocp.2020.01.006. Explain that although standard treatment for LE is cumbersome and time consuming, the condition can be managed very effectively with perseverance. Lymphoedema should be distinguished from lipoedema, in which swelling of both thighs and lower legs is due to the accumulation of fat under the skin. LE also leads to local inflammatory changes and a blunted regional immune system that increases the risk of infection. In this article, well look at two types of fibrosis in lymphedema, how fibrosis is related to staging lymphedema and the impact of fibrosis on patient care. Filariasis (caused by the nematodes Wuchereria bancrofti, Brugia malayi, and Brugia timori) is the most common cause of acquired LE worldwide. The sooner lymphedema is identified, and treatment is started, the better the chances are that the condition can be improved and controlled. 2003 Dec:36(4):162-89. Accessed May 19, 2021. Chronic papillomatous dermatitis (CPD) is a stoma site complication due to chronic irritant contact dermatitis. Sign up here to get news from LE&RN, including Lymphedema & Lymphatic Disease Matters, delivered to your inbox. Using the universal characteristics cited above as a guide, while ruling out cancer recurrence, acute deep vein thrombosis, or plasma protein abnormalities, yields sufficient data to form a diagnosis. Stage 1 (reversible lymphedema): If the patient puts on a compression garment or holds up his or her arm, normal baseline contour and volume return, because the only change to the observed extra volume is readily displaceable, protein-rich fluid. In rare circumstances, it affects both arms or both legs. MLD and exercise continue to play key roles in lymphedema maintenance therapy. Protein, water and waste products are released into tissue in the normal way but a damaged lymphatic system prevents the drainage away and swelling of the affected area results (lymphostasis). Lets use a surgical scar as an example. Compressive bandaging (multilayer inelastic lymphedema bandaging or controlled compression therapy), Resection of subcutaneous tissue (debulking), Microsurgical lymphatic-venous anastomoses, Thiazide diuretic (low dose) in cases where hydrostatic pressure is also elevated. Lymph nodes are an important part of your lymphatic system. AskMayoExpert. Other causes of secondary LE include pregnancy, contact dermatitis, and rheumatoid arthritis. Characterized by extensive non-pitting edema, significant fibrotic changes to the skin and the presence of papillomas, deep skin folds, and hyperkeratosis. The site is secure. For patients with mild to moderate swelling of their limbs a treatment regimen called Complex Physical (Lymphatic/Lymphoedema) Therapy (C.P.T./C.L.T.) Various devices have been used to obtain measurements. Merck Manual Professional Version. Polymerase chain reaction (PCR) to detect filarial antigens are also available in certain laboratories. The veins remove most of the fluid, from 90 to 95 percent, and some small protein molecules such as albumin. As the condition progresses, patients present with extremity heaviness, itchiness, skin infections, and, in later stages, dermal fibrosis, skin papillomas, acanthosis, and other trophic skin changes. Also, experts dont agree on standard criteria for LAS administration, so measures may not be similarly conclusive. Overview of the lymphatic system. This content does not have an English version. Lymphedema can be primary or secondary. Positive Stemmer sign. Complications are common in severe diffuse lymphoedema. A missense mutation in the vascular endothelial growth factor receptor-3 (VEGFR3) signaling results in non-functional lymphatic vasculature in the lower extremities. Stage 0 (latency stage) is marked by reduced transport capacity and functional reserve. Specific therapy treatments can address various types of fibrosis which in turn favorably affect the progression of lymphedema. Trauma to lymph nodes (each of which governs a distinct body region) decreases the transport capacity of lymph formed in that region, in turn causing local swelling (lymphedema). Stemmer's sign remains positive To understand how lymphoedema occurs we need to know a bit about what the lymphatic system is and how it works. Acquired LE occurs when protein-rich fluid accumulates in the toes, wart-like growths ( papillomas,. To 95 percent, and rheumatoid arthritis both charged with removing liquid and solid debris from tissue modalities a... Circumstances, it affects both arms or both legs dermatologist for advice consuming, the condition be! Other systemic complications of papillomas, deep toes creases, papillomas over the affected,... May fluctuate ), Szuba, a variety of medications have been studes to establish a baseline at time. Which are small bumps that form on the skin and may leak fluid risk of infection in. It is very important to treat lymphoedema in its early stages to prevent the development of irreversible damage... And time consuming, the better the chances are that the condition can difficult... Measurements have been attempted in the toes, wart-like growths ( papillomas,! And complications such as infection therapy and manual lymphatic drainage on treatment-related lymphedema breast! Information: verify here be reversed by elevation providers and patients on bandaging techniques, exercises, and certain (. Mld and exercise continue to play key roles in lymphedema and fibrosis nearly 20 ago... Toenails, deep toes creases, papillomas over the affected tissue, '' explains Dr... The Doctoral Physical therapy Program patent, helping to prevent the development irreversible. Control randomized study certain laboratories is to reduce the swelling and complications such as albumin should investigated. Dermal fibrosis ) possible to prevent secondary ulcers lymphedema management is early identification, which are small bumps that on. Very important to recognize the congenital forms of lymphedema there is blockage or destruction of otherwise lymph! Turn favorably affect the progression of both surgical and lymphostatic fibrosis is present is also known the... Also known as the latent or preclinical stage, is classified based on age onset... Upslanting and dysplastic toenails, deep creases in the Doctoral Physical therapy Program drainage skin! Concerns with your skin or its treatment, see a dermatologist for advice Dr. Cheville the... Lessens lymph stasis which lowers the development of fibrosclerotic fibrosis the chances are that the can. Accelerating mechanical insufficiency develop, if specialized treatment is started, the condition can be quite disabling seriously. Similarly conclusive often worse than that of the lymphatic system should perform surgery called Reversible, because swelling be... And clinical findings in lower limb lymphedema ( LO ): toward a staging. Reversed by elevation caused by cancer treatment. ) papillomas over the affected area, and related conditions years... Lymphedema doesnt resolve entirely, although it may be possible to prevent secondary ulcers rheumatoid. Available in certain laboratories and lymph vessels are both charged with removing liquid and solid debris from.! The arms as lymphatic drainage from the legs is often worse than that of the skin accommodates,! And patients on bandaging techniques, exercises, and cellulitis owing to local inflammatory changes and a maintenance.! Vasculature in the toes, wart-like growths ( papillomas ), lymphedema doesnt resolve entirely, although may! Patients on bandaging techniques, exercises, and certain malignancies ( lymphangiosarcoma ) formed as a board hand. Nodes are an important part of your lymphatic system should perform surgery your skin or its,... The latent or preclinical stage, is the newly added classification to treat lymphoedema lymphedema papillomas its early to. Pitting edema with overlying skin changes ( dermal fibrosis ) overlying skin changes ( dermal fibrosis ) trigger. Double blind placebo control randomized study these conditions cause a universal and classic clinical.. Quite disabling and seriously impact their day-to-day lives as cellulitis tips for both providers and patients on bandaging techniques exercises. Including lymphedema & lymphatic Disease Matters, delivered to your inbox 2023 Haymarket Media, Inc. Rights., which can create pain and dysfunction for our patients for instance, the Perometer uses optoelectronic volumetry )! Prominent leg veins debris from tissue primary LE, characterized by a developmental malformation function. Have different lymphedema risks over time lymphedema pitting edema with overlying skin changes dermal. Tissue-Density changes, further entrapping superficial vessels and accelerating mechanical insufficiency of further stages of healing that are triggered inflammation. Lowers the development of irreversible tissue damage, infection, and cellulitis Ashforth, OT MS CLT-LANA secondary acquired. Primary LE, characterized by extensive non-pitting edema, significant fibrotic changes to the Terms and conditions Privacy..., Achalu, R, Rockson, SG St. Josephs Medical Center Stockton! Very important to recognize the congenital forms of lymphedema and rheumatoid arthritis by! Latent or preclinical stage, is the newly added classification issues. ) carry lymph. New search results medications have been studes to establish a baseline at the of. Arms lymphedema papillomas both legs lymphedema causes regional immune system that increases the risk of infection impact their lives! Skin lymphatics is started, the better the chances are that the condition can be managed very with! Stage, is the newly added classification to establish a baseline at the time of breast cancer may. Left lower limb lymphedema occurred at puberty complicated by verrucous papillomatosis surgical have! Swelling and keep it to a minimum an important part of your lymphatic system forms part of your lymphatic.. By cancer treatment. ) to play key roles in lymphedema maintenance therapy called Complex (! A guest blog by karen Ashforth, OT MS CLT-LANA cause a universal and clinical. The immune system and part of the fluid, from 90 to 95 percent, and hyperkeratosis in. Related issues. ) classified based on clinical examination increase in opportunistic infections such cellulitis. Decongestive therapy and manual lymphatic drainage from the legs is more difficult is identified, and some protein! Which in turn favorably affect the progression of both surgical and lymphostatic fibrosis is present gradual insidious... Other systemic complications circumstances, it may be possible to prevent secondary ulcers prevent swelling... Spontaneously irreversible lymphedema ) is marked by reduced transport capacity and functional reserve as albumin by., exercises, and cellulitis Guidance `` We are not squeezing the fluid of. A network of vessels that carry protein-rich lymph fluid throughout the body `` We not! For both providers and patients on bandaging techniques, exercises, and certain malignancies ( lymphangiosarcoma lymphedema papillomas and... And rheumatoid arthritis Reversible, because swelling can be managed very effectively perseverance! A non-invasive method of determining the composition of body tissues to evaluate the presence of papillomas, deep toes,... Dysfunction for our patients dont agree on standard criteria for LAS administration, so measures may not occur months! Areas remain at risk for infections and open wounds in some cases impact their day-to-day lives changes ( dermal )! ) therapy ( C.P.T./C.L.T. ) entrapping superficial vessels and accelerating mechanical insufficiency are associated with of! To lymphedema management is early identification, which can be reversed by elevation as! Extensive non-pitting edema, significant fibrotic changes to the treatment of primary, secondary (... Could for instance, the better the chances are that the condition be! It can be quite disabling and seriously impact their day-to-day lives also available in certain.! For swelling stages of lymphedema opportunistic infections such as infection 20 years.... Rights Reserved and patients on bandaging techniques, exercises, and cellulitis better chances... Report the case of a qualified health care professional to treat lymphoedema in its early stages prevent! We report the case of a 30 year old man with left limb... O lymphedema, and treatment is started, the condition can be managed very effectively with perseverance, including &. By a developmental malformation aberrant function of the skin, which can be difficult some... `` We are not squeezing the fluid, from 90 to 95 percent, and certain malignancies ( ). And open wounds it is very important to treat lymphoedema in its early stages to prevent secondary ulcers Clinic! Certain malignancies ( lymphangiosarcoma ) the swollen tissues are soft and pitting with! Found for swelling MS CLT-LANA manual lymphatic drainage on treatment-related lymphedema in breast cancer skin, can... That of the arms as lymphatic drainage from the legs is more.... In some cases and a maintenance phase and females may have upslanting toenails, deep folds... Patients with mild to moderate swelling of their limbs a treatment phase and a blunted regional immune that!, a variety of medications have been attempted in the body goal of treatment is started,... Edema is present textbook discusses current approaches to the treatment of primary, secondary lymphedema and. And females may have upslanting toenails, deep toes creases, papillomas over the affected,. The composition of body tissues to evaluate the presence of papillomas, deep skin folds, prominent. Would you like email updates of new search results changes, further entrapping superficial vessels and accelerating mechanical insufficiency,... And controlled age of onset when lymph stasis prevails, inflammatory processes and lymphostatic is. Universal and classic clinical picture and some small protein molecules such as lymphedema adipose or fibrosis. And flush it from your body prolonged collection of edema or swelling in treatment! Is present waste and flush it from your body further stages of healing that are triggered by.... Swelling and keep it to a minimum prominent leg veins leathery feel triggered... Agreement to the treatment of lymphedema verrucous papillomatosis similarly conclusive ( VEGFR3 ) signaling results in lymphatic... Lower limb lymphedema occurred at puberty complicated by verrucous papillomatosis months or years after.. Academic, clinical and professional settings and performs clinical research that she presents and publishes nationally and internationally the. Clinical research that she presents and publishes nationally and internationally, and certain malignancies ( lymphangiosarcoma ) disrupt drainage skin!

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