Topography of accumulation of stagnant lymph and tissue fluid in soft tissues of human lymphedematous lower limbs.
lymphedemapeople
tissues of human lymphedematous lower limbs.
Lymphat Res Biol. 2009 Dec
Olszewski WL, Jain P, Ambujam G, Zaleska M, Cakala M.
Department of Surgical Research and Transplantology, Medical Research
Center, Polish Academy of Sciences, Warsaw, Poland. w...@cmdik.pan.pl
BACKGROUND: The knowledge of where does excess tissue fluid accumulate
in obstructive lymphedema is indispensable for rational physical
therapy. However, it has so far been limited to that obtained from
lymphoscintigraphic, ultrasonographic, and MR images. None of these
modalities provide composite pictures of dilated lymphatics and
expanded tissue space in dermis, subcutis, and muscles. So far, only
anatomical dissection and histological processing of biopsy material
can visualize the tissue lymphatic network and the sites of
accumulation of the excess of mobile tissue fluid.
METHODS AND RESULTS: We visualized the "tissue fluid and lymph" space
in skin and subcutaneous tissue of foot, calf, and thigh in various
stages of lymphedema in specimens obtained during lymphatic
microsurgical procedures or tissue debulking, using special staining
techniques. The volume of accumulated fluid was calculated from the
densitometric data of stained tissue sections. We found that lymph was
present only in the subepidermal lymphatics, whereas the collecting
trunks were obliterated in most cases. Mobile tissue fluid accumulated
in the spontaneously formed spaces in the subcutaneous tissue, around
small veins and above and underneath muscular fascia. Deformation of
subcutaneous tissue by free fluid led to formation of interconnecting
channels. The volume of subcutaneous free fluid ranged around 50% of
total tissue volume and there were no significant differences in
various stages of lymphedema. This could be explained by the presence
of thick layers of subcutaneous fat tissue even in the most advanced
stage of lymphedema.
CONCLUSIONS: In lymphedema caused by obliteration of collecting
trunks, lymph is present only in the subepidermal lymphatics, whereas
the bulk of stagnant tissue fluid accumulates in the subcutaneous
tissue and above and beneath muscular fascia. These findings should be
useful for designing pneumatic devices for limb massage as well as for
rational manual lymphatic drainage in terms of sites of massage and
level of applied external pressures.