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Fig. 10 - Other examples of perforating vessels in an operated rat (AND).
Zoomed view of the left arm and shoulder. In picture (a), the white circle shows the surgical site (removed brachial nodes), the white arrow indicates a perforating vessel, and the grey arrow depicts a lymphatic dead-end. In the image (b), a global view is presented of the left front paw (following skin resection), as well as the main lymphatic pathway after Evans Blue dye injection in the dorsal face of the forefoot. On the close-up view of the shoulder following muscles incisions (c), the white arrow indicates a perfo- rating vessel and the black arrow depicts the main lymphatic pathway.
following successive tissue inflammatory processes (Mendez et al., 2012). An effective protection against external aggression leading to tissue inflammatory processes may be considered as the second key to prevent secondary lymphoedema in a rat.
Human Clinical Applications
Following breast cancer treatment in humans, ICG mappings or lymphoscintigraphies are two complementary diagnostic tools for lymphatic insufficiency detection and FSLP (Mihara et al., 2012). Functioning anterior or posterior substitution lymphatic pathways during BCRL are described in literature (Leduc et al., 1993-1994). However, a description of lymphatic perforating vessels following AND is rare. An anatomical description of both superficial and deep lymphatic system in a female cadaver who underwent an AND but presented no clinical signs of BCRL was published by Suami et al (2017). There was evidence of a more developed deep lymphatic network on the operated side compared to the non- operated side and was due to the presence of lymphatic perforating vessels at the level of the elbow. Perforating vessels substitution pathways seem to be present at birth. Poor and inconstant observations in foetuses at the levels of forearm, elbow and upper arm have been observed (Leduc et al., 1981). None seems to be functional in a normal situation, but could function in upper limb
lymphatic system injuries such as AND (abnormal situation). Functional substitution lymphatic pathways as well as lymphatic perforating vessels play a major role in the therapy of lymphoedema. Physical treatment of lymphoedema consists of Manual Lymphatic Drainage (MLD) and Compression Therapy (Multilayers Bandages, Medical Elastic Compression Garments and Intermittent Compression Therapy (ICT) (Lympho, 2013)). They aim at evacuating the fluid stasis through the functional lymphatic vessels and the venous system. Lymphatic perforating vessels allow a rerouting of superficial obstructed lymph flow toward the deeper located lymphatic network. Opening and stimulating the function of lymphatic perforating vessels certainly may be influenced by local massage which induces lymph entrance and lymph flow progression inside the lymphatic perforating vessels. Till now, MLD and Multilayers bandages seem to be the best mechanical methods to take up fluid stasis. Lymph resorption and lymph flow (Lympho, 2013) is increased by local massage (MLD) (Leduc et al., 2011) or “pump local massage” during muscular contractions (Multilayers bandages) (Wilputte et al., 2005).
Part 2
Lymph node dye accumulation and effect of stochastic vibration (Andullation®)
A short time exposure to multidirectional whole body vibrations which are mechanically generated and stochastically modulated accelerates lymph reabsorption and lymph flow. The increase of dye accumulation in the lymph nodes could be deduced from the mechanical effect of vibrations on mouse skin. In the present study, mice were placed in the ventral decubitus position to obtain a maximum of contact between the EBD injection site and the platform which produced mechanical vibrations. The positional conditions allowed the whole body to vibrate and the local skin to undergo massage at the injection site. When Indocyanine Green Dye (ICG) was injected during other experiments, massage improved tracer evacuation from the injected area into the lymphatic system (Unno et al., 2008). It was demonstrated as well that massage increased the lymph flow in comparison to no manual intervention. When injected subcutaneously, EBD binds to endogenous proteins (Tsopelas and Sutton, 2002). The bound EBD-proteins as well as free EBD are absorbed by the lymphatic vessels and transported along with the lymph flow. This might explain why local massage on the injection site increases reabsorption and lymph flow of EBD and accelerates EBD accumulation in the lymph nodes as well (sacral nodes). A similar mechanism (local massage of the injection site) in addition to whole body vibration explains the more impressive quantified results.
Spectrophotometry
The spectrophotometric technique is rarely used in fundamental lymphatic research. Nevertheless, spectrophotometry is a validated technique, simple to apply, and often used as an assessment procedure in pharmacology and medicine. Regarding ‘fundamental’ research of the lymphatic system, the spectrophotometric
THE EUROPEAN JOURNAL OF LYMPHOLOGY - Vol. XXIX - Nr. 75 - 2017
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