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Home , Axilla, Axillary lymph nodes, Axillary vein, Central lymph nodes, Cubital fossa, Intercostal veins

Clinical REVIEW

and physiology in relation to compression of the upper and

Colin Carati, Bren Gannon, Neil Piller

An understanding of arterial, venous and lymphatic flow in the upper body in normal limbs and those at risk of, or with lymphoedema will greatly improve patient outcomes. However, there is much we do not know in this area, including the effects of compression upon lymphatic flow and drainage. Imaging and measuring capabilities are improving in this respect, but are often expensive and time-consuming. This, coupled with the unknown effects of individual, diurnal and seasonal variances on compression efficacy, means that future research should focus upon ways to monitor the pressure delivered by a garment, and its effects upon the fluids we are trying to control.

More is known about the possible This paper will describe the vascular Key words effects of compression on the anatomy of the and , pathophysiology of lymphoedema when and will outline current understanding of Anatomy used on the lower limbs (Partsch and normal and abnormal drainage. It Physiology Junger, 2006). While some of these will also explain the mechanism of action Lymphatics principles can be applied to guide the use of compression garments and will detail Compression of compression on the upper body, it is the effects of compression on fluid important that the practitioner is movement. knowledgeable about the anatomy and physiology of the upper limb, axilla and Vascular drainage of the upper limb thorax, and of the anatomical and vascular It is helpful to have an understanding of Little evidence exists to support the differences that exist between the upper the vascular drainage of the upper limb, use of compression garments in the and lower limb, so that the effects of these since the lymphatic drainage follows a treatment of lymphoedema, particularly differences can be considered when using similar course (Figure 1). The venous in relation to the upper body and limbs. compression garments. system of the upper limb consists There is much we do not know about of superficial and deep systems, with the finer details of arterial, venous and numerous ‘perforating’ (so-called lymphatic flow in normal, at risk and Box 1 because they pierce the deep lymphoedematous limbs, and how separating the from the muscles this is affected by the application of Lymphatic drainage of the axilla and ) joining the two systems compression. However, despite this, (Moore and Dailey, 2006). the use of compression garments is a It is difficult to get optimum pressure, widely accepted and important part of if any, into the axillary/medial proximal The superficial system arises from treatment (Partsch and Junger, 2006). upper area using compression the capillary networks of the skin and garments. This, combined with a likely subcutaneous tissue, which drain into annulus of often inappropriate two major vessels. The anterolateral pressure on the and lateral tissue of the upper limb drains into the chest provided by the wearer’s bra (in cephalic . This vein originates from Colin Carati, Associate Professor; Bren Gannon, Associate Professor, Department of Anatomy/Physiology; Neil Piller, the case of a woman), means that the lateral dorsum of the and Professor, Director Lymphoedema Assessment Clinic, there are often very significant issues travels via the lateral border of the Department of Surgery, School of Medicine, Flinders of fluid accumulation (initially) and and , passing through the lateral University and Medical Centre, Bedford Park, South fibre (later) in this area. aspect of the cubital (where it Australia communicates with the basilic vein via

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the median cubital vein), and ascending The lymphatic drainage of the Lymphatic drainage of the upper limb the arm to pass into the axillary region does not follow the venous drainage of The lymphatic drainage of the upper between the deltoid and pectoralis the torso as closely as in the arm. limb also consists of superficial and deep major muscles. The basilic vein drains the However, the venous drainage of the torso systems, which follow similar paths to postero-medial aspect of the dorsum also enters the axillary, subclavian, or that of the vascular system. There are of the hand, travels superficially up the branchiocephalic veins en route to the four major patterns of lymphatic drainage antero-medial aspect of the forearm, , and hence may be which are based on early cadaver, medially through the and relevant to the venous drainage of the lymphography and lymphoscintigraphic about one-third of the way up the arm, arm. The anterior wall of the torso and the investigation (Foeldi et al, 2003). before piercing the deep fascia to then drains mainly into the , accompany the brachial into the and to a lesser extent the internal thoracic The superficial lymphatic drainage axillary region. Both veins connect to veins. The ribcage is drained via intercostal vessels arise as a plexus within the skin of the axillary vein, and then the subclavian and subcostal veins that drain the ribcage the upper limb. Vessels drain from the veins en route to the superior vena posteriorly into the azygous/hemiazygous hand mainly along its palmar surface into cava. Many perforating veins are evident venous system, or anteriorly into the larger lymphatic vessels that converge in the anterior aspect of the forearm, internal thoracic veins. The posterior wall towards the veins draining the forearm, coalescing into the median vein of the of the thorax also drains into the azygous/ especially the basilic vein (Moore and forearm, which then joins the basilic hemiazygous system, which drains directly Dailey, 2006), acquiring new vessels from and/or the cephalic veins (Figure 1). into the superior vena cava. the skin as they travel up the limb (Figure 1).

To subclavian lymphatic trunk The lymphatic vessels draining the Apical antero-lateral territory of the arm traverse the upper part of the arm and Deltopectoral lymph nodes the anterior aspect of the shoulder, draining into the uppermost (apical) Central axillary lymph nodes lymph nodes of the axillary lymphatic muscle system (Figure 2). Lymph drainage from Humeral (lateral) axillary lymph nodes the postero-medial aspect of the forearm passes through nodes in the medial cubital Pectoral (anterior) axillary lymph nodes region, proximal to the medial epicondyle of the , and then into lateral Subscapular posterior axillary lymph nodes (humeral) lymph nodes of the axilla. Basilic vein The deep lymphatic drainage Cephalic vein originates from the deeper soft tissue, Cubital such as muscles and , and the Median cubital vein lymph nodes periosteum of the bones. Vessels converge and travel close to the deep veins of the upper limb, occasionally Cephalic vein passing through a few lymph nodes, Perforator veins before arriving at the lateral (humeral) axillary lymph nodes (Figure 2) (Moore Basilic vein and Dailey, 2006).

The cutaneous venous drainage of the upper back (thorax) is via dorsal Superficial palmar perforating (posterior) cutaneous branches venous arch of the posterior and thence to the azygous/hemiazygous system to superior vena cava. Lymphatic plexus of palm Venous drainage of the skin and dermis of the chest anterior to the Digital lymphatic vessels mid-axillary line is largely via the thoraco- Anterior (palmar) view epigastric vein network, to the axillary vein (via the lateral thoracic vein — the Figure 1. Venous and lymphatic systems of the hand and arm. superior part of the thoraco-epigastric

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Supraclavicular lymph nodes Subclavian lymphatic trunk Infraclavicular lymph nodes Internal and vein

Apical lymph nodes Deep servical lymph nodes Lateral (humeral) lymph nodes Right and artery Pectoral (anterior) lymph nodes Subscapular (posterior) lymph nodes Interpectoral lymph nodes Pectoralis minor To contralateral (left) breast

Subareolar lymphatic plexus

To abdominal (subdiaphragmatic) (A) Anterior view lymphatics

Figure 2. The lymph nodes of the axilla.

venous network). Venous drainage of the Lymph drainage of the skin and dermis aspects of the breast medial to the , female breast is largely via the lateral of the front of the thorax (chest) anterior drain medially to para-mammary and thoracic vein to the axillary vein, but the to the mid-axillary line is largely from para-sternal nodes (Schuenke et al, 2006), more medial superficial aspects of the individually variable regions (lymphotomes) then to the right or left or breast drain to the paired internal thoracic to particular axillary nodes (i.e. the sentinal thoracic duct to the subclavian vein, and venae comitantes, then to subclavian vein node for each region; Suami et al, 2008). on to the superior vena cava. Sentinel and on to the superior vena cava. Much of The area medial to the in both node tracing from non-palpable (deep) the deepest tissue of the breast drains via sexes drains to the parasternal (internal breast tumours (Tanis et al, 2005) suggests perforating veins through the deep fascia mammary) node chain (Figure 3). that much of the deepest tissue of the to the anterior intercostal veins, and then breast is likely to drain via the deep to the internal thoracic veins. Drainage of the well developed lymphatics, which perforate through the lymphatic network of the female breast, deep fascia to join the anterior intercostal The venous drainage of the skin and including the dense sub-areola network, is lymphatics, passing then to the internal dermis of the chest mainly enters the largely via laterally or superiorly directed mammary lymph trunk and chain of nodes. axillary, subclavian, or branchiocephalic lymphatics, which pass to pectoral axillary veins en route to the superior vena cava, nodes, or to lateral axillary nodes (Suami Lymphatic drainage to the axilla and hence may be relevant to the venous et al, 2008) (Figure 2). The superficial The lymphatic drainage of the upper drainage of the arm. limb is intimately related to that of the anterior and posterior regions of the Lymphatic drainage of the thorax Box 2 thorax, especially the breast, all of which The lymphatic drainage of the torso drain through the axillary region. The does not follow the venous drainage of Lymphatic drainage paths axillary region contains five clusters of the torso as closely as these systems nodes, arranged in a pyramid pattern do in the arm. Superficial lymph Studies have indicated that lymph dictated by the shape of the axillary drainage from the back of the thorax drainage of the upper arm travels into region, with three clusters at the base is mainly via a network of superficial the mammary nodes in some of the axilla, one at its apex and one in lymphatics, which converge to the individuals with lymphoedema. These the middle (Figure 2) (Moore and Dailey, subscapular (posterior) nodes of the drainage patterns also indicate the 2006). These nodes are embedded in axilla (Figure 2). However, there is need to pay attention to the potential the axillary , external to the axillary the possibility that the more medial effect of clothing (particularly bras) sheath that contains the axillary artery back drains via perforating lymphatic on lymph drainage to the internal and vein. The majority of the lymphatic connections to the posterior intercostal mammary, as well as the contralateral fluid associated with the antero-lateral lymphatics en route to paravertebral axillary nodes. lymphatic territory drains into four to nodes (Iyer and Libshitz, 1995). six lateral (humeral) nodes, while that

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of the postero-medial territory drains into the apical nodes. The pectoral and subscapular nodes drain the anterior Supraclavicular lymph and posterior , respectively, nodes chain and along with the humeral nodes drain through the central, then the apical nodes Axillary lymph en route to the subclavian lymphatic nodes chain trunk and ultimately the venous system. The consequence of this arrangement is that lymphatic drainage of the upper limb Internal mammary is directly affected by both the drainage lymph nodes chain of the upper torso and the state of the central .

As is the case with the area, it is difficult to get optimum pressures, or any pressure at all, into the axillary/medial proximal upper arm area and this, combined with a likely annulus of often Figure 3. Drainage into mammary lymph nodes. inappropriate pressure on the shoulder and lateral chest provided by the wearer’s Lymphatic cutaneous networks Axillary Upper limb bra (in the case of a woman), means that It is known that there is a greater density lymph nodes there are often very significant issues of of lymphatic vessels in patients with fluid accumulation (initially) and fibre lymphoedema compared to those with (later) in this area. normal healthy limbs. Paramammary Lymphatic drainage paths Mellor et al (2000) used fluorescence lymph nodes Anterior intercostal spaces Studies have indicated that lymph microlymphography to examine the drainage of the upper arm travels into dermal lymphatic capillaries of the the mammary nodes in some individuals forearm in 16 women with oedema Anterior chest wall with lymphoedema. Kawase et al (2006) following treatment for breast . Parasternal reviewed lymphoscintigraphy results from They reported that the superficial lymph nodes 1,201 clinically node-negative patients with lymphatic density and total length of Posterior chest wall invasive who underwent capillaries was greater in the swollen limb preoperative labial salivary gland (LSG) compared to the control arm. Paravertebral and axillary sentinel (SLN) Importantly, the distance travelled by the Posterior intercostal spaces lymph nodes biopsy. They reported a range of lymphatic relatively superficial lymph contents drainage patterns, and almost 25% of before draining to the sub-fascial system Figure 4. Normal drainage pathways of upper patients had drainage to extra-axillary was longer in the swollen limb compared limb and thoracic tissues to the lymph nodes. lymph nodes, especially the internal to the normal limb. Furthermore, there Note drainage from a breast can be to either mammary ones (Figure 3). This has also was no evidence of lymphatic dilation in the ipsilateral nodes (more commonly) or to the been confirmed by Ferrandez et al (1996) the swollen limb. These findings suggest contralateral nodes (less commonly). who after a session of manual lymphatic that there is a local re-routing of drainage (MLD) found Tc-labeled tracers superficial lymph and possibly angiogenesis in swollen limbs, Mellor et al moved to the internal mammary nodes in in the limbs of patients (2000) hypothesised that the increased 8% of patients with lymphoedema (n=47), with lymphoedema. Since the work of number (length) of lymphatic capillaries as well as to the contralateral nodes in others has shown capillary would possibly help to maintain the ratio 20% (Figure 4). What this means for the of drainage capacity to filtration capacity. end results of compression is that not The impact of external compression on only must we consider the compression Box 3 this change is possibly minor, but the level and its gradient in the limb, but also longer travel distance of the lymph in the the gradient across the truncal area. These Lymphatic cutaneous networks superficial lymph collectors may mean drainage patterns also indicate the need that the establishment and maintenance to pay attention to the potential effect There is a greater density of of a pressure gradient along the limb is of clothing (particularly bras) on lymph lymphatic vessels in patients with very important. drainage to the internal mammary, as well lymphoedema compared to those as the contralateral axillary nodes with normal healthy limbs. Tissue structure of the arm (Figure 3). The upper arm contains deep and

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fascia and its impact on the interchange substantial osmotic gradient (Figure 5). The Blood flow Interstitial fluid of fluids between the deep and superficial balance of these forces results in a net fluid lymphatics. We will not go into these flux into the tissue under normal pathophysiological changes here, since circumstances, which is then drained away they are well documented and in by the lymphatic system. mainstream literature (Foeldi et al, 2003; Hydrostatic Weissleder and Schuchhardt, 2008). It is important, however, to be aware Capillary pressure that the current textbook version of this Reduced epifascial depth, most often process has fluid being filtered from the Osmotic associated with a lesser amount of fat arterial end of the capillary, and resorbed pressure directly above the deep fascia means that at the venular end (e.g. Marieb et al, 2007), the lymph collectors (which are normally as the hydrostatic pressure decreases lying above the deep fascia) are more along the capillary (due to frictional losses Venous end superficial than those which are covered or resistance), and the balance of the with a greater depth of fat, thus generally so-called Starling forces shift from requiring a lower compression pressure. favouring filtration to favouring resorption Figure 5. Diagram of the hydrostatic and oncotic along the capillary. This view is now being pressures acting across the capillary wall, affecting Physiological factors affecting replaced by the opinion that, at least in transendothelial exudation of fluid from plasma to lymphatic drainage most capillaries in normal circumstances, the interstitium. Both normal and abnormal patterns of there is no resorption of fluid, and the net lymphatic drainage help to demonstrate flux is solely into the tissue from where it epifascial fat layers. The deep fat layer how fluid flows through tissues, so it is is cleared by the lymphatics (Michel, 1997; found in the posterior and deltoid region important to understand both previous Levick, 2004; 2009). of the arm is thin. In normal limbs the and current theories of lymph formation epifascial fat layer is circumferential, and movement. During this fluid movement, most but can hypertrophy in the proximal plasma of the blood are retained posterior one third of the arm. In In the healthy individual, the vascular in the vascular system as they do not cross lymphoedematous limbs this hypertrophy system runs into the capillaries, which are the capillary membrane in most tissues. is marked and not only has an influence small vessels that are bathed in interstitial The emerging consensus is that the on lymph load, but also on lymph fluid. The capillaries have thin, semi- ‘barrier’ to the transcapillary flux of plasma drainage, as the additional tissue pressure permeable walls made up of a single layer proteins and larger lipophobic solutes lies of the adiposites on the delicate walls of endothelial cells that allow the transfer at the glycocalyx, a complex luminal layer of the lymph collectors constrains them of oxygen and nutrients from the blood of anionic polysaccharides and from their optimal contraction. Chamosa into the tissues, and the transfer of waste glycoproteins secreted by, and attached to,

et al (2005) found that in normal , products such as CO2 and urea from the probably all capillary endothelial cells. The the anterior and distal third of the tissues into the blood. glycocalyx acts as a fine fibre filter upper arm tended to have less thick hindering larger molecule transit by stearic . Occasionally, a specific Fluid movement across the capillary exclusion in a size-dependent manner lipodystrophic zone can be found on the wall behaves according to the principles (Squire et al, 2001; Zhang et al, 2006). The posterior-external area of the normal first outlined by Starling (1896), whereby physical path for fluid leakage lies beyond arm, located between the proximal and the blood‘s hydrostatic pressure forces the glycocalyx, at infrequent short breaks medial thirds. Relatively speaking, the skin fluid from the capillaries down a substantial in junctional membrane strands along of the medial aspect of the normal arm pressure gradient into the tissues, while the inter-endothelial cell junctions, which is generally thin, devoid of follicles, colloid osmotic pressure of the blood elsewhere seal junctions tight (Adamson et and prone to sag. Overall, the skin is ‘sucks’ fluid back into the capillary ‘up’ a al, 2004; Curry, 2005). The net result of this mobile and overlies loose, nonfibrous arrangement is that fluid resorption at the fat. However, as lymphoedema develops, capillary is unlikely under normal there are a range of significant epifascial Box 4 conditions, and requires larger breaks in tissue changes which occur (mainly to endothelial integrity, such as those the amount of fat and fibre, as there is Factors affecting lymph drainage occurring during . A corollary a thickening of the deep fascia and the of this is that fluid fluxes through the fascia between the lobules of adiposites). There is no resorption of fluid, and lymphatic system are likely to be larger These will have significant effects on the the net flux is solely into the tissue than previously thought, since there is no outcome of external compression in from where it is cleared by the venular resorption of fluid under normal terms of its transmittance into the tissues lymphatics. Thus, fluid fluxes through physiological conditions. For this reason, and to the vascular and lymphatic systems the lymphatic system are likely to be improved knowledge of the impact of within it. Of particular importance is the larger than previously thought. compression on the superficial lymphatic increase in the thickness of the deep flow is essential.

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A further corollary is that increasing compared to unaffected arms (Jacobsson, increase in lymph flow after lumpectomy interstitial pressure will reduce the 1967; Svensson et al, 1994a; Martin plus radiotherapy, 2.5-fold increase in pressure gradient forcing fluid out of the and Foldi, 1996; Yildrim et al, 2000). the contralateral (non-operated) breast capillaries, and will thus reduce fluid fluxes Jacobsson (1967) reported this increase and a 1.5-fold increase in the operated into the tissue. Conversely, increased was mainly in the skin and subcutaneous non-irradiated breast, indicating long- colloid osmotic pressure of the interstitial tissues. In contrast, Stanton et al (1998) term changes in basal lymphatic flow fluid would increase fluid fluxes, since the found that the blood flow was the same of breast tissues. Stanton et al (2009) colloid osmotic gradient withholding fluid between affected and unaffected arms, measured muscle and subcutis lymphatic in the plasma would be reduced in this although the per unit volume of blood drainage of the arm after axillary surgery circumstance (Levick, 2009). Such a flow was actually reduced in affected for breast cancer in 36 women, using situation may arise if there is accumulated arms since it was of larger volume. The lymphoscintography. They reported interstitial due to increased reasons for this change in blood flow that muscle lymph drainage always transcapillary protein leakage into the in lymphoedematous arms is not clear, exceeded that of subcutis drainage, and tissue, increased interstitial proteolysis although there clearly are structural subcutis drainage was higher in women (such as that occuring during changes in the affected limb that might who subsequently went on to develop inflammation), or reduced drainage of cause increased blood flow. On the lymphoedema. They concluded that interstitial protein due to poor lymphatic other hand, an increased arterial inflow women with higher filtration rates and drainage. Each of these factors will be may serve to increase fluid filtration into therefore higher lymph flows through the affected by compression of the limb, and the tissue, and thus increase the risk axilla, were at greater risk of developing can lead to reduced fluid influx into the of developing lymphoedema; such an lymphoedema after axillary surgery, tissues. The role of compression on the increase in arterial flow may result from presumably because they had less limb, therefore, may well be to prevent damage to the autonomic innervation to lymphatic reserve to deal with additional fluid accumulation, rather than to the limb due to surgery and/or radiation fluid loads following surgery. encourage lymphatic drainage, as is (Kuhl and Molls, 1995). often suggested. Mechanisms of action of Venous outflow compression garments Blood and lymphatic drainage from Venous outflow may also be In the managment of lymphoedema the the arm is also influenced by movements compromised in lymphoedematous term ‘compression therapy’ covers a and contractions of and limbs (Dennis, 2008). Significant venous range of treatment modalities including intrathoracic pressure, as well as by obstruction was reported in 57% multilayer inelastic lymphoedema positional changes. of 81 patients assessed by Svensson bandaging and compression garments et al (1994b) using colour Doppler (Partsch and Junger, 2006). Compression Lymphatic and vascular changes after ultrasound imaging. Szuba et al (2002) garments are used for the prophylaxis, surgery and radiotherapy reported a lower but still significant 4.6% treatment and long-term management of The main cause of upper body prevalence of venous obstruction of lymphoedema and may lymphoedema arises from cancer of lymphoedematous upper limbs. There work by: varying causes, especially breast cancer, are several other lines of evidence that 8 Increasing interstitial pressure which is often treated by surgery and indicate that there is an association 8 Improving tissue fluid drainage radiotherapy. It is clear that lymphoedema between venous dysfunction and 8 Stimulating lymphatic contractions following surgery and/or radiotherapy lymphoedema, especially in the lower 8 Breaking down fibrosclerotic tissue. starts with an obstruction of the drainage limbs (Dennis, 2008), and this should be in the axillary area, but the exact considered carefully when contemplating Increasing interstitial pressure pathophysiology of the following sequelae compression treatment of the upper Externally applied pressure is transmitted in the lymph vessels (and surrounding limb. Any factors that compromise into the tissue, although not always in a tissues) is not well known (Pain et al, venous outflow will significantly increase linear fashion. Pressure up to 200mmHg 2005). Furthermore, there are some capillary hydrostatic pressures and result increased interstitial tissue pressure to important haemodynamic aspects of the in increased fluid filtration into the tissues, within 65–75% of the externally applied arm following surgery (+/– radiotherapy) leading to larger lymphatic loads. pressure in normal pig limbs, and up to which are poorly understood. 100% when the limb was oedematous Lymph outflow and less compliant (Reddy et al, 1981). Arterial inflow There are few reports on surgery and/or The pressures generated (and measured) There is some evidence that arterial radiotherapy for breast cancer and their by compression garments are likely to inflow is increased in lymphoedematous effects on lymphatic flow through the arm depend on the measurement technique, arms following treatment for breast and torso. Perbeck et al (2006) studied the nature (knit/elasticity) and fit of the cancer (Dennis, 2008). Using a variety lymph clearance using 99 Tc-nanocolloid garment, and the compliance of the limb of techniques, the blood flow into clearance in breast tissues 2.5 years tissue being compressed. Pressures of the lymphoedamatous arm has been after surgery and/or radiotherapy for 8–38mmHg have been measured under reported to be increased by 42–68% breast cancer. They reported a 4.0-fold garments applied to burns patients using

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standardised protocols (Mann et al, 1997), veno-lymphatic drainage of intradermally but there was wide variation within injected sodium-fluorescein solution in and between measurement sites; for both normal limbs and those with venous

example, mean pressure over the anterior insufficiency (Lentner and Wienert, 1996). Key points was significantly less (8mmHg) Most convincingly of all, however, is the than that over the posterior thigh general observation that compression 8 There is a lack of knowledge (15mmHg), presumably due to radial and therapies can acutely reduce limb (fluid) regarding the finer details of circumferential differences (as per the law volume when appropriately used to the vascular and lymphatic of Laplace) by the same garment applied treat lymphoedema. systems for those at risk of, or at these sites. Custom-made compression with lymphoedema. garments increased sub-dermal pressure The observation that compression in burns applications, over a range of garments enhance tissue fluid clearance is 8 Compression is unlikely 9–90mmHg, but measurements of the at odds with reports that the lymphatic to simply entice fluid pressures under garments over-estimated system is a low-pressure system. The lateral removal through the often the pressure transmitted into ‘soft’ tissues pressure in (and many other) compromised lymphatic system. (e.g. muscle) by up to 50%, and under- lymphatics reaches 15–40mmHg during estimated the pressure transmitted into movement, but is much lower under 8 Compression therapy may ‘bony’ sites by a similar amount (Giele et resting conditions (1–12mmHg) (Aukland have a significant effect on al, 1997). Thus, measurements taken at the and Reed, 1993). Thus, compression decreasing fluid influx in garment-skin interface may not always be garments, which induce interstitial the limb. representative of pressures transmitted pressures of, for example, 10–40mmHg on into the tissues, and should be interpreted the arm, are likely to be collapsing with care. lymphatic vessels under many Breakdown of fibrosclerotic tissue circumstances. One can only conclude that There are two major strategies to break Increased interstitial pressure will affect compression therapy is unlikely to simply down fibrotic tissue, but for both the fluid exchange from the blood into the increase drainage through the (often number and breadth of the studies are interstitium, so as to prevent interstitial compromised) lymphatic system, but is limited. One strategy is through frictional fluid (oedema) accumulation. In addition, likely to affect tissue fluid exchange and the other through the use interstitial pressures greater than capillary through other, possibly inter-related, of low level laser therapy. There have or arterial pressures (>40mmHg) are likely mechanisms, such as decreasing fluid influx been some reasonable studies of the to reduce blood flow, further preventing into the limb. latter, using tonometry as a means of fluid accumulation. To our knowledge, the detecting changes in epifascial fibrosis contribution of these factors to Stimulation of lymphatic contraction as measured by the resistance of the compression therapy has never been Lymphatic drainage is dependent upon the tissues to compression. When low level assessed in large trials, although the work spontaneous contraction of valved lymph handheld or scanning laser is used there is of Abu-Own et al (1994) is informative vessels creating a pumping force. The a slow, although general softening of the and Partsch and Partsch (2005) give some application of a compression garment indurated tissues, presumably aiding in the indications of the impact of position on results in constant pressure on the skin passage of and allowing a pressures required, although these relate when the limb is at rest (resting pressure). stronger contraction of the lymphangions to the lower limb. When the muscles contract, expand and since they are less constrained. The then relax (e.g. during exercise), they softening is most often accompanied Improved tissue fluid drainage transiently press against the resisting by limb size changes and subjective External compression improves tissue fluid garment and so the tissue pressure in the improvement (Piller and Thelander, 1998; drainage through the lymphatic system up limb increases temporarily. This transiently Carati et al, 2003). to a point. Clearance of a radioactively increased interstitial pressure compresses labelled colloid in dog hind limbs increased the adjacent dermal lymphatics and Optimising the effects of exponentially (to a maximum of three- because the collecting and larger compression garments fold) with increasing externally applied lymphatics are valved, these vessels pump In order to achieve optimal effectiveness pressure up to 60mmHg. Above 60mmHg, passively so that lymph flows up the arm when using compression to treat patients clearance decreased to almost nothing without the lymphatics having to contract. with lymphoedema, it is claimed that ideally (Miller and Seale, 1981). Similar results The influence of muscle movement and of garments should be custom made and flat- were reported in human lower limbs, different external pressures (and of their knitted; however, large scale trials are except that the pressure at which transmittance to underlying tissue) required to support these claims. Of the maximum clearance occurred varied with depends on the elastic property of the upmost importance is accurate posture, being 30mmHg supine compared garment material and the compression measurement of the garment, accounting with 60mmHg sitting (Chant, 1972). In a pressure applied. There is no evidence to for changes in the limb volume with more clinical setting, below- stockings suggest that there is increased lymphatic position (elevated or in dependent ( pressure 30mmHg) doubled contraction under compression. positions), and whether the limb is likely to

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be active or inactive, which depends on application of often significantly different the patient’s occupational status. However, pressures at each circumferential point. This Associate Professor Bren Gannon little is known regarding the effect of the is in concordance with the law of Laplace, Bren recently died of complications above variables on garment pressure the outcomes of which often necessitate after surgery. He was an gradients and on undergarment pressures. the use of a range of limb padding esteemed and much-loved colleague. In the interim, however, we can strategies to ensure some modicum of Bren was a walking encyclopedia. extrapolate our knowledge of how lengthwise pressure (a gradient) over the He always had an answer for every lymphoedematous and oedematous legs length of the limb, rather than just across a question, be it anatomical or clinical. respond (at least in the dependent given cross-section of the limb. Bren will be remembered for his position), as this may help to guide fantastic contribution to medicine, to research into the impact of compression Conclusion the university community and to the on the arm. In addition to these There is much we do not know with staff and students. He lived life to the measurement and biological parameters, respect to accurate details of the arterial full, being an enthusiastic fisherman, a information about garment characteristics, flow into and the lymphatic and venous dedicated colleague and most of all a such as dynamic stiffness index, static outflow from normal, at risk and friend to all who met him. Vale Bren. stiffness index, multi-component materials, lymphoedematous limbs. Specifically, we and inelastic bandaging is important do not know enough about the effects of (Partsch et al, 2008; Mosti et al, 2008). compression on venous and lymphatic References There are some recent advances in the flow and drainage. In terms of the upper Abu-Own A, Shami SK, Chittenden SJ, Farrah burns field in the design of pressure body, the contributory impact of variations J, Scurr JH, Smith PD (1994) Microangiopathy garments which exert a specific and in intra-thoracic pressure on proximal arm of the skin and the effect of leg compression known pressure (Macintyre, 2007), but it is clearance, a patient’s garments and the in patients with chronic venous insufficiency. J Vasc Surg 19(6): 1074–83 the accuracy of the measurement for the impact of the varying circumference of the garment that is the prime determinant of chest with respiratory cycles is relatively Adamson RH, Lenz JF Zhang X, Adamson GN, Weinbaum S, Curry FE (2004) Oncotic an excellent, good or adverse outcome unclear and most likely to significantly vary, pressure opposing filtration across non- for the limb. Newer pressure-sensing not only between clients, but also in a fenestrated rat microvessels. J Physiol 557: materials may help to partially overcome client from day to day and hour to hour 889–907 poor measurement, although these must depending on their activity, body position Aukland K, Reed R (1993) Interstitial- not be used as an excuse for inaccuracy. and the activity level of their limb. lymphatic mechanisms in the control of extracellular fluid.Physiol Rev 73: 1–78 Anatomical differences between arms and legs Knowing more about the anatomy, Calbet J, Holmberg H, Rosdahl H, van Hall G, When applied to the upper limb the physiology, pathophysiology of the tissues Jensen-Urstad M, Saltin B (2005) Why do arms compression bandage or garment used is and structures of the upper body will help extract less oxygen than legs during exercise? less likely to be completely in a dependent us gain better outcomes for the client at Am J Physiol Regul Integr Comp Physiol 289(5): position in all its parts; the depth of the risk of, and with, lymphoedema. However, it 1448–58 deep fascia is often less than a similar would seem that the best way forward is Carati, C, Anderson S, Gannon B, Piller position on a leg, the depth of the often to acknowledge individuality, diurnal and N (2003) Treatment of post mastectomy closely adherent lymph collectors is seasonal variances and to develop better lymphoedema with low level laser therapy. Results of double blind placebo controlled trial. less (meaning a more marked effect of means to monitor the pressure effect of Cancer 98(6): 1114–22 external pressure application), the lymph the prescribed garment on the fluids we collectors are often of smaller diameter, are trying to control. Chamosa M, Murillo J, Vázquez T (2005) Lipectomy of arms and lipograft of (having less strong flow and reduced balance the upper body contour. Aesthetic Plast intra-lymphatic pressures). Combined, Perhaps for the majority of patients this Surg 29(6): 567–70 these factors mean that externally applied is an easier, more cost-effective option than Chant ADB (1972) The effects of posture, pressure, such as from compression attempting a range of tests on all patients exercise and bandage pressure on the clearance bandages or garments or clothing, is likely to determine the anatomy, physiology and of 24Na from the subcutaneous tissues of the to have a more profound effect. However, pathophysiology of the correct function . Br J Surg 59: 552–5 this relative superficiality of vessels means (or otherwise) of the patient’s blood, tissue Clark M, Krimmel G (2006) Lymphoedema it must be realised that too high a and lymph systems. Knowing the latter will, and the construction and classification of pressure may be counterproductive (Modi however, also help achieve the overall goal compression hosiery. 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