Plastic Surgery Procedures:
When you have removal of subcutaneous tissues, damage of the superficial lymphatic system can be present.
After surgery, Comprehensive Decongestive Therapy (CDT) is the best way for the body to try to form new connections of lymphatic vessels to help bring fluid and proteins out of the affected areas. Therefore compression and manual lymphatic drainage are the best techniques to reduce localized swelling and changes under the skin. Hyper-Fibrosis can occur with extra proteins forming hardened areas under the skin. You can do home lymphatic drainage with self massage techniques, dry brushing to intact skin areas, and using tools that cause vibration under the skin for example. We would never put intense pressure on any healing areas as this could cause further damage and pain so it is recommended to follow up with a professional for skilled manual drainage treatments with education provided on how to continue to manage on your own. Another important aspect is appropriate compression, sometimes surgeons may prescribe improper fitted or uncomfortable compression garments, but lymphatic therapists are skilled in fitting of these garments and can modify based on your needs. The ultimate goal would be to improve aesthetics of surgery, limit fibrosis, decrease pain and improve healing times and return to everyday activities.
Surgical scars:
Scars can be cosmetically unfavorable, but there are ways to improve their appearance and healing process!
Often the local superficial lymphatic system has been removed or damaged underneath so there is
decreased mechanical sufficiency of lymphatic fluids and circulation.
Scarring can cause keloid tissue or hardened fibrous tissue to adhere to underlying tissues, muscles, and even joints causing feelings of restrictions and tightness. Keloid formation can occur with some individuals where toughened raised scar tissue forms after trauma.
It is very important to work on scar adhesions early on before the tissue underneath heals improperly. But, don't massage a scar until at least 2 weeks of healing and wound has closed. Scars heal for about 2 years after surgery so it is most helpful to begin massages during this time. I recommend using a vitamin E oil to scar area to help build collagen and massage with lotion to help cut down on friction and discomfort. Use the pad of your finger and firmly massage in circular motions from the bottom to the top of scar then massage counter clockwise. Slide your finger up the scar while applying pressure, then change by sliding finger downward. Do this for about 5 minutes or so 2-3 x daily for best results. Remember to always cover scars initially and wear sunscreen as scars have no natural melanin or sun protection and are prone to sun damage.
Hyperkeratosis and papillomatosis:
Often found with advanced stage lymphedema and skin changes, hyperkeratosis is an abnormal thickening of the outer layer of the skin (the stratum corneum), and associated with an over-proliferation of keratin-producing cells.
I would describe this as a rough and often discolored skin with a sandpaper like quality. Keratin is the substance of hair and nails so as we can imagine this can become thick and much harder to the touch than regular skin. These areas can be apparent in affected body parts from progressive stage 3 lymphedema and occasionally after healing from surgeries. Normally, I have seen this occurrence on feet and in between toes. This can also cause loss of circulation of skin areas and is more susceptible to fungal infections as well. I stress the importance of keeping these areas dry and clean to prevent excess moisture and environments for bacteria and fungus to grow. Using ph balanced lotions and cleaning agents to keep the skin barrier as healthy as possible is also recommended.
Skin folds:.
Skin folds can present complications for compression bandaging. Skin folds can become crevices' that harbor bacteria and dead skin. With advanced stages of lymphedema this skin tissue can be folded on top and these is important to begin cleaning drying, using lotions and creams and start compression wrapping to soften areas and help the fluid drain from these sites. You may start to recognize a pattern, but keeping these areas clean, dry and using appropriate creams or powders is indicated.
Fungal infections:
With fungal infections, we can note angry, red erythematous tissues, yeast smell, and white crackling on skin.
Fungal infections are likely to contaminate other tissues as well, so we must be careful with infection spread. Thus, keep areas clean dry and reduce risk of spread of infection. One of the causes is an inability to find proper shoewear choices, accomating swelling by using a contaminated shoe or sock. Antifungal creams, ointments and or powders may help reduce and kill present fungus with attention to skin care and hygiene.
Radiation:
Telangiectasia- radiation damage to arterial blood vessels (specifically the precapillary sphincter muscle). In some patients the precapillary arteriole will become paralyzed. Capillaries will become varicosed and visible (broken or stretched capillaries). Usually this is not painful unless other soft structures have been damaged.
Sometimes the radiation can entrap other structures such as nerves, lymphatics and blood vessels, with severe radiation damage there can be necrosis to the bone/skeletal structures. This is usually extremely painful. In these cases, MLD can be modified on these tissues, we omit deep and stretch techniques working around the tissue instead. Compression will need to be very padded and soft to prevent further entrapment of discomfort to underlying areas.
Contractures- tautness/loss of pliability in tissue, which are important to assess. Tissues can adhere to other structures around and cause radiation fibrosis, and other hardening in deep to superficial areas.
We can still do stretching techniques on skin but regard boundaries and intensity levels. We want to improve range of motion and flexibility by using gentle techniques and exercises.
Axillary Web Syndrome- also known as cording, sometimes develops as a side effect of lymph node biopsies or other surgeries of the lymphatic nodes. This can become very painful and reduce motion. Stretching without pushing past pain daily is indicated in this case to help begin to loosen the entrapped connective tissue underneath.
Other Skin Changes:
Lymphatic cysts- clear blisters that develop in the skin of some patients that suggest hypertension in superficial lymphatics. Backup of pressure in the limb, in area of fragile skin. Lymph cysts often can leak. These are not structures that we can work with directly but we may use absorptive layers and monitor closely for cellulitis and infections.
Papillomas- benign overgrowth of epithelial tissues, similar to skin tags inflated with lymphatic fluid. If not addressed they will become larger and will become fibrotic. These papillomas are liability to future infections, trauma to compression, so it is recommend to consider surgical removal. These can be bumpy, not defined structures, but changes in whole surface of skin. This suggests the layers under the skin are subjected to intense amount of pressure and changes. We hope papillomas can decrease, reabsorb and go away with compression and therapy but this is not always the case.
Collateral Veins- Occurs with some obstruction to the return of venous blood, especially with diagnosis of secondary lymphedema, DVT, many of patients have received radiation, especially when methods are outdated, causing more deep tissue damage and entrapment of surrounding tissues. You may see apparent blue vein structures become varicose near the top of the skin.
Hopefully this begins to help you understand various skin changes and complications that can occur from cancer, surgeries or other lymphedema causes. Schedule a visit today and we can discuss a treatment plan to help with any of these conditions.
