Oct 1996: Exercise, Obesity, Gout, Skin Flaps & LE; HMO's

LymphLink Question Corner - Archived from October 1996
Saskia R.J. Thiadens, R.N.

Q:  I had a Modified radical mastectomy in August 1994 and about 6 month ago developed mild lymphedema of my right arm. I want to resume exercising and need to know if push-ups and other arm exercises are precluded by the lymphedema.

A:  Anybody who has had breast cancer, with or without lymphedema, needs to exercise. However, it is important to know the proper type of exercise, as well as proper weight (not more then 15 lbs). The motion of lymph fluid through lymph vessels is supported by skeletal muscles. Deep breathing exercises also help by dropping the intrathoracic pressure which facilitates drainage in the thoracic duct. Also be sure to wear a compression sleeve/glove while in the gym to support the limb while exercising. Of course if you notice an increase of swelling, discontinue that particular exercise. (Note: An excellent exercise videotape is available for arms as well as for legs through Lymphedema Services in New Jersey - see the Resource Guide for contact information).

Q:  Is there any relationship between obesity and lymphedema?

A:  Several studies have described obesity or weight gain after treatment for cancer as increasing risk factors for the development of lymphedema 1 & 2. This may be due to the physical demands placed on the system due to increased fluid and body fat; those who are obese also have a tendency toward poor wound healing. Obese patients with lower extremity lymphedema often have a more difficult time since extra weight will compromise the already weakened lymphatics and, often, worsen the swelling. Obese patients who have lymphedema, or those who do not like to or cannot exercise, subsequently continue to gain weight. I urge all of you to please, please watch your diet. Drink lots of water and juices, and keep your salt intake low.

Q:  How do I deal with my HMO when I need treatment for lymphedema?

A:  Hopefully your primary doctor is familiar with lymphedema and can justify and coordinate an authorization for you. Ideally, the lymphedema therapist needs to submit to your physician a customized, detailed treatment plan, including information about why and how the treatment works, emphasizing the concern and possible complications if lymphedema is left untreated or under treated. It sometimes helps to add a photograph of the affected and non-affected limb, as well. If treatment is refused, advise your HMO that you will contact your attorney. It works!

Q:  I have had secondary lymphedema of unknown origin for about four years. I am a 57 year old male and wear 20-30 mm/hg knee high compression stockings on both legs. Usually there is no obvious swelling noted upon awakening. I also have gout in my right foot. Although I have never had an acute attack of gout, my right leg became swollen about 20 years ago (to the extent that the spaces between my toes closed up). I take 500 mg of Benemid twice a day. I sometimes wonder if I really have gout or if the swelling was perhaps an early phase of lymphedema. What do you think? Also, I have taken to wearing a one-piece Ace bandage on my ankle while exercising; it seems to help keep the swelling down and is not at hot as wearing a stocking. Is this a wise course of action?

A:  You might be your own diagnostician since very few doctors know much about lymphedema or are able to diagnose. Classic common symptoms of gout are increase of skin temperature in the area, localized swelling and pain in the joints. In addition, patients experience periodic onsets of excruciating pain or flare-ups. Also, there is a blood test that can be done to determine if indeed it is gout. If you do not have any of these symptoms, you may, in fact, be correct that you have lymphedema. Still, it will not make any difference in your treatment plan whether this is gout or primary/secondary lymphedema. You need to continue to wear your compression stockings, although I suggest you increase the compression class to 40-50 mm/Hg. Regarding wearing the Ace bandage while exercising: if you do, indeed, have lymphedema, it is recommended for the lower limbs that you wear at least a knee-high non-elastic, low-stretch compression stocking (Ace bandages are elastic, high-stretch bandages) and increase your stocking pressure from 20-30 to 40-50 mm/Hg.

Q:  I am very frustrated. I looked into all the information available about post-operative complications after breast cancer surgeries to decide on the best course of action. My surgeon advised me that if I had a modified radical mastectomy instead of a lumpectomy with radiation, I would not need radiation and would also lower my risk of developing lymphedema in the future. I chose the modified radical mastectomy and am very upset now since I have been left with a a large skin flap underneath my arm. My surgeon says this is called a "Dog Ear" and is, apparently, quite common. Not only is this uncomfortable, but it looks terrible when I am in my bathing suit or even wearing a dress without sleeves. Can you tell me if this is a form of lymphedema?

A:  I can understand that you are upset. No, this is not lymphedema. However, it appears that many breast cancer surgeons leave this extra skin on purpose, in case the patient is interested in reconstructive surgery at a later date. Also, for female patients who are obese or who have large breasts, when the incision of the mastectomy is closed, excessive tissue often remains. My suggestion is for you to wear a wide-banded supportive bra to fully cover this area. Unfortunately, if this extra skin is not removed at the time of the initial surgery, I do not recommend that it be surgically removed at a later date, since this procedure could cause lymphedema.

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