WHERE DO LYMPH AND TISSUE FLUID ACCUMULATE IN LYMPHEDEMA OF THE LOWER LIMBS CAUSED BY OBLITERATION OF LYMPHATIC COLLECTORS?

Abstract

Obliteration of lymphatic collectingtrunks of limbs by infective processes, trauma,oncologic surgery and irradiation bring aboutretention of lymph and tissue fluid in tissues.Knowledge as to where excess lymph isproduced and accumulates as tissue fluid isindispensable for rational physical therapy.So far, this knowledge has been based onlymphoscintigraphic, ultrasonographic andMR images. None of these modalities providesdistinct images of dilated lymphatics and fluidexpanded tissue spaces in dermis, subcutisand muscles. Only anatomical dissection andhistological processing of biopsy material candemonstrate the remnants of the lymphaticnetwork and the sites of accumulation ofmobile tissue fluid. We visualized and calculatedthe volume of the “tissue fluid andlymph” space in skin and subcutaneous tissueof foot, calf, and thigh in various stages oflymphedema, using special coloring techniquesin specimens obtained during lymphaticmicrosurgical procedures or tissue debulking.When the collecting trunks were obliterated,lymph was present only in the subepidermallymphatics, while mobile tissue fluid accumulatedin the spontaneously formed spaces inthe subcutaneous tissue, around small veins,and in the muscular fascia. Deformationof subcutaneous tissue by free fluid led toformation of interconnecting channels. Inobstructive lymphedema caused by obliterationof collectors, lymph is present mainly insubepidermal lymphatics, and the bulk ofstagnant tissue fluid accumulates in subcutisbetween fibrous septa and fat globules as wellas above and underneath muscular fascia.These observations provide useful clues fordesigning pneumatic devices and rationalmanual lymphatic massage to move stagnanttissue fluid toward the non-swollen regions.