Table of Contents
Lymphedema of the Head
Like so many areas that may involve lymphedema, there has been little written or discussed in the medical record pertaining to head lymphedema. The incidence of head lymphedema has dramatically increased as our ability of detecting and treating cancer has sky rocketed.
Fortunately, there is not only treatment available for this, but compression garments as well. Included on our page is not only information regarding it, but a list of supplier of compression garments and supplies.
Lymphedema of the head is generally caused by removal of lymph nodes for cancer biopsy. Other causes may include surgical removal of tumors, infections (cellulitis, lymphangitis, lymphadenitis), radiation damage to existing lymph nodes and medications indicated for hypertension. In rare cases neck edema and/or lymphedema may be caused by tumors, cystic hygromas or other growths.
While most swelling is resolved by treatment of the underlying or causative medical condition, there are times when the swelling becomes permanent.
Related Terms Head edema, Facial edema, Eyelid Edema, Head lymphatics
If the swelling becomes permanent, whether the cause is known or unknown, the diagnoses of lymphedema must be considered.
What is Lymphedema?
Lymphedema is defined simply as an accumulation of excessive protein rich fluid in the tissues of the leg. The accumulation of fluid causes the permanent swelling caused by a defective lymph system.
A conservative estimate is that there may be 1-2 million people in the United States with some form of primary lymphedema and two to three million with secondary lymphedema.
How is Lymphedema Treated?
The preferred treatment today is decongestive therapy. The forms of therapy are complete decongestive therapy (CDT) or manual lymphatic drainage (MLD), there are variances, but most involve these two type of treatment.
It is a form of massage therapy where the leg is very gently massaged to actually move the fluid out of the leg and into an area where the lymph system still functions normally.
With these massage treatments, swelling is reduced and then the patient is fitted with a pre-measured custom pressure garment to keep the swelling down and/or is taught to use compression wraps to maintain the leg size.
Manual lymphatic drainage plus compression bandaging, lymph node stimulation (clearance), exercises are indicated for lymphedema. See our revised page Treatment for a full description of treatment methods.
What are some of the complications of lymphedema?
1. Infections such as cellulitis, lymphangitis, erysipelas. This is due not only to the large accumulation of fluid, but it is well documented that lymphodemous limbs are localized immunodeficient.
2. Draining wounds that leak lymphorrea which is very caustic to surrounding skin tissue and acts as a port of entry for infections.
3. Increased pain as a result of the compression of nerves usually caused by the development of fibrosis and increased build up of fluids.
4. Loss of Function due to the swelling and limb changes.
5. Depression - Psychological coping as a result of the disfigurement and debilitating effect of lymphedema.
6. Deep venous thrombosis again as a result of the pressure of the swelling and fibrosis against the vascular system. Also, can happen as a result of cellulitis, lymphangitis and infections.
7. Sepsis, Gangrene are possibilities as a result of the infections.
8. Possible amputation of the limb.
9. Pleural effusions may result if the lymphatics in the abdomen or chest are to overwhelmed to clear the lung cavity of fluids.
10. Skin complications such as splitting, plaques, susceptibility to fungus and bacterial infections.
11. Chronic localized inflammations
Can lymphedema be cured - what is the long term prognosis?
No, at the present time there is no cure for lymphedema. But it can be treated and managed and most of the complications can be avoided. Life with lymphedema can still be active and full, with proper treatment, patient education, and patient life style adaptation.
Lymphedema in Head and Neck Cancer
Because lymphedema is a late effect of head and neck cancer and its treatment, occurring well after a patient has completed treatment, it is often overlooked, although it occurs fairly commonly. Formal reports on its incidence in the United States are not available, but based on European research, researchers estimate its occurrence to vary from 12%–54%. Lymphedema in the head and neck can cause distressing symptoms that interfere with patients’ quality of life and body image.
In their article in the January 2011 Oncology Nursing Forum, Deng, Ridner, and Murphy described the risk factors for and presentation, measurement, and management of lymphedema after head and neck cancer treatment. The oncology nurse’s role in managing patients with this condition, as well as in future research into the condition, is also discussed.
Lymphedema of the Head and Neck
Lymphedema can involve both internal and external structures in the head and neck. External symptoms can result in decreased range of motion in the neck and shoulders, which can affect quality of life and ability to perform activities of daily living. Severe external symptoms can cause visible swelling in the face, neck, and shoulders, which affects patients’ quality of life and body image, sometimes leading to depression, self-isolation, and social avoidance.
Internal symptoms involve structures such as the tongue, larynx, and pharynx. Lymphedema in these areas can result in difficulty speaking, swallowing, and breathing, impacting patients’ quality of life and nutrition status.
Based on the results of two studies reported in the literature, Deng et al. concluded that tumor stage, radiation dose, and surgical disruption of the lymphatic system all place patients at risk for developing lymphedema. Other factors also have been thought to result in lymphedema, such as comorbid conditions, smoking, and lifestyle or occupation, but these have not been studied in clinical trials.
See remainder of article - ONS Connect
As Seen in the Oncology Nursing Forum [By Elisa Becze, BA, ELS, ONS Staff Writer]
π-Shaped lymphaticovenular anastomosis for head and neck lymphoedema: A preliminary study.
Oct 2012
Ayestaray B, Bekara F, Andreoletti JB.
Source Department of Plastic and Reconstructive Surgery, Nimes University Hospital, pl Pr Robert Debré, 30000 Nimes, France; Department of Plastic and Reconstructive Surgery, Breast Institute, 15, av Jean Jaurès, 90000 Belfort, France. Electronic address: bayestaray@yahoo.fr.
Abstract
BACKGROUND:
Head and neck lymphoedema secondary to jugular lymphadenectomy is a severe issue, without efficient solution. Successful treatment of lymphoedema of the upper and lower limbs has become possible with supermicrosurgical lymphaticovenular anastomosis. The technique based on two end-to-side anastomosis is named π-shaped lymphaticovenular anastomosis. We have evaluated this method for chronic head and neck lymphoedema.
METHODS:
From November 2010 to April 2011, four patients with a chronic head and neck lymphoedema were treated by π-shaped lymphaticovenular anastomosis. Three patients had a unilateral lymphoedema, and one patient had a bilateral lymphoedema. The mean age of the patients was 63.2 years (range, 46-77 years). The mean duration of the lymphoedema was 2.6 years (range, 1-5). Every patient was operated under local anaesthesia through a face-lift skin incision. One π-shaped lymphaticovenular anastomosis was performed at each operative site.
RESULTS:
The average operative time to perform one π-shaped lymphaticovenular anastomosis was 1.9 h (range, 1.8-2.5). The calibre of lymphatic vessels used for lymphaticovenular anastomosis ranged from 0.3 to 0.7 mm (average, 0.5). A venous back-flow was found in seven lymphaticovenular anastomosis (70%). Three patients (75%) had a qualitative improvement of skin tissue and a significant circumferential reduction after surgery. The average circumferential differential reduction rate was 3.7% (range, 0.6-7.8) (p = 0.006). The average cross-sectional area differential reduction rate was 7.2% (range, 1.2-15.1) (p = 0.007). The average volume differential reduction rate was 6.9% (range, 2-14.8) (p = 0.05).
CONCLUSIONS:
The authors present a new option to treat head and neck lymphoedema. π-Shaped lymphaticovenular anastomosis is an effective method to reduce the severity of skin tissue fibrosis and lymphoedema volume. Further studies with larger groups of patients are required to confirm the outcome of this preliminary study. EBM Level = level 4.
Abstracts and Studies
Impact of secondary lymphedema after head and neck cancer treatment on symptoms, functional status, and quality of life.
Deng J, Murphy BA, Dietrich MS, Wells N, Wallston KA, Sinard RJ, Cmelak AJ, Gilbert J, Ridner SH.
Source
School of Nursing, Vanderbilt University, Nashville, Tennessee. jie.deng@vanderbilt.edu.
Abstract
BACKGROUND: Lymphedema may disrupt local function and affect quality of life (QOL) in patients with head and neck cancer. The purpose of this study was to examine the associations among severity of internal and external lymphedema, symptoms, functional status, and QOL in patients with head and neck cancer.
METHODS: The sample included 103 patients who were ≥3 months after head and neck cancer treatment. Variables assessed included severity of internal and external lymphedema, physical/psychological symptoms, functional status, and QOL.
RESULTS: Severity of internal and external lymphedema was associated with physical symptoms and psychological symptoms. Patients with more severe external lymphedema were more likely to have a decrease in neck left/right rotation. The combined effects of external and internal lymphedema severity were associated with hearing impairment and decreased QOL.
CONCLUSIONS: Lymphedema severity correlates with symptom burden, functional status, and QOL in patients after head and neck cancer treatment. Head Neck, 2012.
Factors Associated With External and Internal Lymphedema in Patients With Head-and-Neck Cancer May 2012
Deng J, Ridner SH, Dietrich MS, Wells N, Wallston KA, Sinard RJ, Cmelak AJ, Murphy BA. Source
School of Nursing, Vanderbilt University, Nashville, Tennessee.
Abstract
PURPOSE: The purpose of this study was to examine factors associated with the presence of secondary external and internal lymphedema in patients with head-and-neck cancer (HNC).
METHODS AND MATERIALS: The sample included 81 patients ≥3 months after HNC treatment. Physical and endoscopic examinations were conducted to determine if participants had external, internal, and/or combined head-and-neck lymphedema. Logistic regression analysis was used to examine the factors associated with the presence of lymphedema.
RESULTS: The following factors were statistically significantly associated with presence of lymphedema: (1) location of tumor associated with presence of external (P=.009) and combined lymphedema (P=.032); (2) time since end of HNC treatment associated with presence of external (P=.004) and combined lymphedema (P=.005); (3) total dosage of radiation therapy (P=.010) and days of radiation (P=.017) associated with the presence of combined lymphedema; (4) radiation status of surgical bed was associated with the presence of internal lymphedema, including surgery with postoperative radiation (P=.030) and (salvage) surgery in the irradiated field (P=.008); and (5) number of treatment modalities associated with external (P=.002), internal (P=.039), and combined lymphedema (P=.004). No demographic, health behavior-related, or comorbidity factors were associated with the presence of lymphedema in the sample.
CONCLUSIONS: Select tumor and treatment parameters are associated with increased occurrence of lymphedema in patients with HNC. Larger and longitudinal studies are needed to identify adjusted effects and causative risk factors contributing to the development of lymphedema in patients with HNC.
Cutaneous lymphatics and chronic lymphedema of the head and neck. Jan 2012
Keywords: solid facial edema; acne rosacea; Morbus Morbihan; acne vulgaris; lymphoscintigraphy
Feely MA, Olsen KD, Gamble GL, Davis MD, Pittelkow MR.
Source
Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota.
Abstract
Extensive attention has been directed to lymphedema involving the extremities. However, there has been relatively limited study of the cutaneous lymphatics of the head and neck. In this review of head and neck lymphatics, we capsulize the history of the lymphatics, the anatomy of the cutaneous lymphatics, lymphatic function and physiology, and imaging modalities used to define this intricate vascular system. To appreciate the clinical challenges associated with head and neck lymphatic dysfunction, we also provide an overview of disease processes of the cutaneous lymphatics and their treatment, theories on the etiology of lymphedema, and future directions to better understand lymphatic function and disease. Knowledge of the cutaneous lymphatics of the head and neck are critical to the clinical evaluation of patients, who present with this debilitating condition and to our understanding of its pathogenesis and appropriate management. Clin. Anat. 25:72-85, 2012. Wiley Periodicals/PubMed
Preliminary development of a lymphedema symptom assessment scale for patients with head and neck cancer. Nov 2011
Deng J, Ridner SH, Murphy BA, Dietrich MS.
Source
School of Nursing, Vanderbilt University, 461 21st Ave. South, 600B Godchaux Hall, Nashville, TN, 37240, USA, jie.deng@vanderbilt.edu.
Keywords: Secondary lymphedema – Head and neck cancer (HNC) – Symptom assessment – Instrument development – Late effect
Abstract
PURPOSE: Currently, no instruments are available to assess symptoms secondary to lymphedema in patients with head and neck cancer (HNC). The study aim was to develop and conduct preliminary tests of such an instrument.
METHODS: A preliminary item pool was generated from a literature review, previous work in breast cancer-related lymphedema, and an observational study. The item pool was revised based on an expert panel's suggestions and feedback from 18 patients with HNC. The current questionnaire, the Lymphedema Symptom Intensity and Distress Survey-Head and Neck (LSIDS-H&N), was then pilot tested in 30 patients with HNC.
RESULTS: Preliminary testing (1) demonstrated feasibility, readability, and ease of use of the LSIDS-H&N and (2) identified that there was a considerable level of symptom burden in the cohort of patients in the piloting sample.
CONCLUSION: Content validity of the LSIDS-H&N was supported by the expert panel during development of the LSIDS-H&N. Further testing is ongoing. Springer
Prevalence of Secondary Lymphedema in Patients with Head and Neck Cancer. Jul 2011
Deng J, Ridner SH, Dietrich MS, Wells N, Wallston KA, Sinard RJ, Cmelak AJ, Murphy BA.
Source
School of Nursing, Vanderbilt University, Nashville, Tennessee, USA.
Key Words: Secondary lymphedema; head and neck cancer; prevalence; late effect
Abstract
CONTEXT: Because surgery, radiation, and/or chemotherapy disrupt lymphatic structures, damage soft tissue leading to scar tissue formation and fibrosis, and further affect lymphatic function, patients with head and neck cancer may be at high risk for developing secondary lymphedema. Yet, no published data are available regarding the prevalence of secondary lymphedema after head and neck cancer treatment.
OBJECTIVES: The aim of this study was to examine prevalence of secondary lymphedema in patients with head and neck cancer.
METHODS: The study included 81 patients with head and neck cancer who were three months or more post-treatment. External lymphedema was staged using Foldi's lymphedema scale. Internal lymphedema was identified through a flexible fiber-optic endoscopic or mirror examination. Patterson's scale was used to grade degrees of internal lymphedema.
RESULTS: Of the 81 patients, 75.3% (61 of 81) had some form of late-effect lymphedema. Of those, 9.8% (6 of 61) only had external, 39.4% (24 of 61) only had internal, and 50.8% (31 of 61) had both types.
CONCLUSION: Lymphedema is a common late effect in patients with head and neck cancer, and it develops in multiple external and internal anatomical locations. During physical examination and endoscopic procedures, clinicians should assess patients with head and neck cancer for late-effect lymphedema. Referral for treatment should be considered when lymphedema is noted. Research is needed to examine risk factors of lymphedema in patients with head and neck cancer and its effects on patients' symptoms, function, and quality of life.
U.S. Cancer Pain Relief Committee\Elsevier
Near-infrared fluorescence imaging of lymphatics in head and neck lymphedema.
Maus EA, Tan IC, Rasmussen JC, Marshall MV, Fife CE, Smith LA, Guilliod R, Sevick-Muraca EM.
Source
Division of Cardiology and Hyperbaric Medicine, Department of Internal Medicine at The University of Texas Health Science Center, Houston, Texas, USA. erik.a.maus@uth.tmc.edu
Abstract
BACKGROUND:
Lymphedema is a complication that may occur after surgical resection and radiation treatment in a number of cancer types and is especially debilitating in regions where treatment options are limited. Although upper and lower extremity lymphedema may be effectively treated with manual lymphatic drainage (MLD) therapies and devices that use compression to direct proximal flow of lymph fluids, head and neck lymphedema is more challenging.
METHODS AND RESULTS: Herein, we describe the compassionate use of an investigatory technique of near-infrared (NIR) fluorescence imaging to understand the lymphatic anatomy and function, help direct MLD, and use 3-dimensional (3D) surface profilometry to monitor response to therapy in a patient with head and neck lymphedema after surgery and radiation treatment.
CONCLUSION: NIR fluorescence imaging provides a mapping of functional lymph vessels for direction of efficient MLD therapy in the head and neck. Additional studies are needed to assess the efficacy of MLD therapy when directed by NIR fluorescence imaging.
Special Note for Head Lymphedema
The tenth NLN (national Lymhpedema Network) Conference from September 5-9, 2012 will feature a special seminar for head and neck lymphedema:
[H5]Advanced Management: The Complex Patient with Head and Neck Lymphedema Brad Smith, CCC-SLP, CLT Sheila Ridner, PhD, RN, FAAN Jie Deng, RN, PhD, OCN
Description: While current treatment for cancers of the head and neck are typically effective in controlling the disease process, they often result in severe functional deficits and compromised quality of life. Often these patients undergo complex treatments combining surgery, radiation, and chemotherapies, all of which contribute to post-treatment performance deficits. Impairments of swallowing and communication, decreased cervical range of motion, postural changes, and impaired mobility of the upper extremity after cancer treatment are well documented. Patients with head and neck cancer often present with multiple comorbidities and complex symptom burden that create obstacles to provision of traditional lymphedema management services. Head and neck lymphedema is an area of increasing research interest. This session will address lymphedema evaluation and management strategies to address the needs of medically complex patients whose cases require modifications of traditional approaches. Topics will include:
Who is the medically complex patient? Modifications of evaluation and treatment strategies Complex compression strategies Symptom and palliative management Tricks and tips Objectives:
Participants will be able to identify and discuss differences in patient presentation and treatment between patients requiring basic vs more complex treatment methodologies. Participants will learn about complex facial compression garments, measurements, and how compression pads and garments can be safely and creatively applied for patients with severe head and neck lymphedema. Participants will be able to describe measurement techniques for internal and external head and neck lymphedema. Participants will be able to discuss strategies for symptomatic and palliative management of severe head and neck lymphedema.
For a complete conference outline please see:
Self Massage for Face and Head
1. Clear lymph nodes at neck.
A. Clear both sides of neck
• Divide side of neck into 2 sections – below ear and above collar bone. • Gently stretch skin downward 5 to 10 times in each section.
B. Clear Terminus (notch above the collar bone)
• Gently perform “circles” 5 to 10 times.
C. Clear back of neck
• Divide back of neck into 2 sections – at hair line and base of neck. • Gently stretch skin downward 5 to 10 times in each section. D. Clear Terminus (notch above the collar bone) • Gently perform “circles” 5 to 10 times.
2. Clear lymph nodes in front of the ear.
• Place fingertips on each check, closest to the ear. • Massage gently downward in this area, 5 to 10 times.
3. Clear lymph nodes at back of the ear.
• Place fingertips on the bone behind each ear. • Massage gently downward 5 to 10 times.
4. Clear the temples on each side of the face.
• Place fingertips on temples. • Massage gently downward 5 to 10 times.
5. Clear the underside of chin.
• Divide underside of chin into three sections on each side of the face, from chin to jaw bone. • Gently massage 5 to 10 times in each section, moving in an outward direction.
6. Clear front of chin.
• Divide underside of chin into 3 sections on each side of the face, chin to jaw bone. • Gently massage 5 to 10 times in each section, moving in an outward direction.
7. Clear area from nose to corners of mouth.
• Gently massage on each side of nose downward with fingertips to corners of mouth 5 to 10 times.
8. Repeat clearing of nodes on sides of neck (see #1).
9. Clear the cheeks.
• Gently massage front of cheeks (each side) downward toward
jaw line 5 to 10 times.
10. Repeat clearing of nodes on each side of the neck (see #1).
11. Clear the area below each eye.
• Gently massage below eyes (on edge of bone) downward toward cheeks,
5 to 10 times each side.
12. Repeat massage of cheeks downward to chin (see #9).
13. Repeat clearing of nodes at sides of the neck (see #1).
14. Clear the nose.
• Divide each side of nose into three sections, starting at tip to bridge of nose. • Gently massage 5 to 10 times each section, moving in an outward direction
15. Clear the tear duct.
• Place one finger on each side of nose next to tear duct. • Gently massage downward 5 to 10 times.
16. Clear the eyelid.
• Place one to two fingers on each eyelid. • Gently massage outward 5 to 10 times.
17. Clear the eyebrow.
• Place one to two fingers on each eyebrow. • Gently massage upward 5 to 10 times.
18. Repeat clearing the cheeks (#9), clearing in front of the ear (#2), clearing back of the ear (#3), and clearing side of neck (#1).
External Links
Swollen Neck Lymph Nodes
wrongdiagnosis.com
http://www.wrongdiagnosis.com/sym/swollen_neck_lymph_nodes.htm
Irbesartan-associated persistent edema of the eyelids, face, and neck - Case Reports
Journal of Drugs in Dermatology
Philip R. Cohen
December 2002
http://www.findarticles.com/cf_dls/m0PDG/3_1/110220341/p1/article.jhtml
Morbidity of supraomohyoidal and modified radical neck dissection combined with radiotherapy for head and neck cancer. A prospective longitudinal study.
Jan 2012
Lymphaticovenous anastomosis for facial lymphoedema after multiple courses of therapy for head-and-neck cancer.
Sep 2011
Treatment options for head and neck lymphoedema after tumour resection and radiotherapy. Sep 2011
Near-infrared fluorescence imaging of lymphatics in head and neck lymphedema. Nov 2010
Severe cheek and lower eyelid lymphedema after resection of oropharyngeal tumor and radiation. Mar 2010
Lippincott, Williams & Wilkins
Preliminary Experience With Head and Neck Lymphedema and Swallowing Function in Patients Treated for Head and Neck Cancer 2011
Jan S. Lewin, Katherine A. Hutcheson, Denise A. Barringer and Brad G. Smith
American Speech-Language-Hearing Association
Deep Neck Spaces and Infections
Elizabeth J. Rosen, MD and Byron J. Bailey, MD
04/17/02
Slides and Commentary
http://www.utmb.edu/otoref/Grnds/Deep-Neck-Spaces-2002-04/Deep-NeckSpaces-2002-04-slides.pdf
Neck Lymphedema and Compression Dr. Tony Reid - Dr. Reid's Corner
Head and Neck Compression Garments
These types of garments always need to be custom made, the following vendors offer products:.
Lymphedema in Head and Neck Cancer
JoViPak
http://www.jovipak.com/index.shtml
http://www.jovipak.com/pdf/Head_Custom_Packet.pdf
Solaris - Tribute Garments
http://www.solaris-tribute.com/lymphedema/consumers/garments/collection.html
Related Lymphedema People Pages
Lymphedema Online Support Groups
Join us as we work for lymphedema patients everywehere:
Advocates for Lymphedema
Dedicated to be an advocacy group for lymphedema patients. Working towards education, legal reform, changing insurance practices, promoting research, reaching for a cure.
http://health.groups.yahoo.com/group/AdvocatesforLymphedema/
Subscribe: AdvocatesforLymphedema-subscribe@yahoogroups.com
Pat O'Connor
Lymphedema People / Advocates for Lymphedema
Children with Lymphedema
The time has come for families, parents, caregivers to have a support group of their own. Support group for parents, families and caregivers of chilren with lymphedema. Sharing information on coping, diagnosis, treatment and prognosis. Sponsored by Lymphedema People.
http://health.groups.yahoo.com/group/childrenwithlymphedema/
Subscribe: childrenwithlymphedema-subscribe@yahoogroups.com
…………………
Lipedema Lipodema Lipoedema
No matter how you spell it, this is another very little understood and totally frustrating conditions out there. This will be a support group for those suffering with lipedema/lipodema. A place for information, sharing experiences, exploring treatment options and coping.
Come join, be a part of the family!
http://health.groups.yahoo.com/group/lipedema_lipodema_lipoedema/
Subscribe: lipedema_lipodema_lipoedema-subscribe@yahoogroups.com
…………………
MEN WITH LYMPHEDEMA
If you are a man with lymphedema; a man with a loved one with lymphedema who you are trying to help and understand come join us and discover what it is to be the master instead of the sufferer of lymphedema.
http://health.groups.yahoo.com/group/menwithlymphedema/
Subscribe: menwithlymphedema-subscribe@yahoogroups.com
…………………
All About Lymphangiectasia
Support group for parents, patients, children who suffer from all forms of lymphangiectasia. This condition is caused by dilation of the lymphatics. It can affect the intestinal tract, lungs and other critical body areas.
http://health.groups.yahoo.com/group/allaboutlymphangiectasia/
Subscribe: allaboutlymphangiectasia-subscribe@yahoogroups.com
…………………
Lymphatic Disorders Support Group @ Yahoo Groups
While we have a number of support groups for lymphedema… there is nothing out there for other lymphatic disorders. Because we have one of the most comprehensive information sites on all lymphatic disorders, I thought perhaps, it is time that one be offered.
DISCRIPTION
Information and support for rare and unusual disorders affecting the lymph system. Includes lymphangiomas, lymphatic malformations, telangiectasia, hennekam's syndrome, distichiasis, Figueroa syndrome, ptosis syndrome, plus many more. Extensive database of information available through sister site Lymphedema People.
http://health.groups.yahoo.com/group/lymphaticdisorders/
Subscribe: lymphaticdisorders-subscribe@yahoogroups.com
…………………
Teens with Lymphedema
http://health.groups.yahoo.com/group/Teens_with_Lymphedema/
…………………
All About Lymphoedema - Australia
http://au.groups.yahoo.com/group/All_About_Lymphoedema/
…………………
Contact:
Updated June 23, 2012
Page Tools
