How Can Manual Lymph Drainage Help You Recover Faster After Surgery?

Doctors, massgae therapists, and clients often recommend "lymphatic drainage" or "lymphatic massage" after plastic surgery procedures, especially liposuction. Unfortunately, there is a large degree of misunderstanding about what this actually means, even among surgeons. Here are some of the common things people mistake for the hands-on technique of manual lymph drainage (MLD) that is appropriate in postoperative care.

Incisional drainage or manipulation: This is often mistakenly called manual lymphatic drainage, which gives the impression that appropriate "massage" after plastic surgery procedures involves manually forcing or expressing body fluid out openings in the body - most commonly liposuction incisions. Lymphatic or lymph drainage actually means using the system of lymphatic vessels and nodes in the body to facilitate fluid uptake and removal from the tissues. We "push" fluid into the lymphatic system, not out of holes in the body. The techniques require significant training and practice to be used effectively postoperatively. To date the only credible medical reference I have found on the use of incisional drainage following liposuction is from the aftercare chapter from the book by the father of High Definition VASER Liposuction, Dr. Hoyos of Columbia. In this reference incisional drainage is only recommended for the first 2 postoperative days and is primarily to help expedite the removal of tumescent fluid. Starting post-op day 3, Dr. Hoyos and Dr. Prendergast recommend the Vodder style of Manual Lymph Drainage (MLD).

Needle Aspiration: I have had several clients tell me that they thought manual lymph drainage meant removal of body fluid "manually with a needle." This is not lymph drainage. Lymph drainage means moving fluid into the lymphatic system to speed the removal of fluid from the tissues. Removing fluid with a needle is needle aspiration and should be performed by a physician or APRN or a PA or RN under the direction and supervision of a physician. This is not needed nearly as frequently as the general post-op population (both clients and practitioners) would like to believe and can be harmful. It can increase scarring and inhibit good tissue healing. While it is very helpful to assist the body to remove fluid faster by its normal mechanisms, the inflammation and fluid production are part of the normal healing process.

Lymphatic Drainage Massage or Lymphatic Massage: Unfortunately, these terms have become a catch all for a number of different techniques and are now quite a misleading. From a marketing standpoint, many health and wellness professionals are tagging the word "lymphatic" to what they do from yoga to massgae techniques. I am not saying many of these techniques won't directly or indirectly improve lymphatic circulation in the healthy population. I am saying that most of these techniques are not appropriate for the postoperative population (6-12 weeks plus). Many massage therapists are trained or "certified" in "Lymphatic Drainage Massage." These are typically generalized lymphatic stimulation techniques. They are not appropriate techniques to apply postoperatively. In some cases they may help to a degree, and in other cases they may be harmful (e.g. after tummy tuck). They are not, however, complete enough to treat the protein rich fluid accumulation (or "transient lymphedema") we get after surgery, especially in the presence of lymphatic system damage from liposuction and long incisions. For effective treatment following plastic surgery, the techniques used in the the treatment of lymphedema are needed. These include manual lymph drainage (MLD) with specific adaptation for plastic surgery procedures. Even training and certification in MLD alone, however, is not enough by itself for the most effective level of treatment. Additional training is needed for appropriate adaption of the techniques including rerouting techniques. One of the most confusing things about this terminology is that both practitioners that use appropriate MLD and those who do not, use these terms because these are the ones that most people use to search for service.

Body Sculpting and/or Wood Therapy: Wood therapy stems from the esthetics industry when aggressive techniques with wood tools are used to mobilize the soft tissue in the hope of improving appearance. While these techniques do have some foundation and may temporarily help improve the appearance of tissue, they do not promote fluid reduction or lymphatic drainage, even though many claim that they do. These types of techniques increase tissue damage and fluid buildup as they increase the inflammatory process. This is not to say that the localized use of tools, wood or otherwise, or just manual techniques cannot be used in conjunction with manual lymph drainage to treat certain conditions and areas postoperatively. Fibrosis techniques or instrument assisted soft tissue mobilization may be appropriate as an ancillary technique in a localized area to treat a specific issue such as an area of fibrosis or tissue thickening. However, in these cases a practitioner really needs to know under what circumstance and during which stage of healing these are appropriate so as not to cause undue harm or increased edema. Again, proper training, knowledge, and experience are needed for the safety of these techniques.

Radiofrequency or Ultrasonic Cavitation: These do not promote lymph drainage to any significant degree, or at all. These are typically used in body sculpting or for localized fat reduction. Cavitation is merely a type of vibratory force or side effect. In the case of the human body, this force is propagated by sound waves applied to the tissues. These should not be used postoperatively and can cause undesirable tissue damage and scarring. Please know that cavatition is a matter of degree as well. There is stable cavitation and unstable cavitation. Cavitation used for the purpose of body sculpting or localized fat reduction is typically a much lower sound frequency (typically in the neighborhood of 40 kHz) than what we refer to as a therapeutic frequency (typically 1-3 MHz). The lower the frequency and higher the intensity, the greater degree of unstable cavitation. Also know that heat is also generated in the tissues to varying degrees based on the various parameters of the sound waves. While there is research that indicates radiofrequency and ultrasound can contribute to localized fat reduction, it is not known if this phenomena is caused by the heat, the cavitation, or some combination of both. Also keep in mind that there is a direct correlation of heating the tissues to increasing fluid in the tissues. What is also interesting is that studies have found that sound waves in both the low and the therapeutic range contribute to local fat loss and neither contribute to reduced body weight or BMI. Might this be useful to tweak up an area at an appropriate point after liposuction? The answer is possibly, but your practitioner really needs to know what they are doing, why they are doing it, when it is appropriate, and what parameters are appropriate.

Therapeutic Ultrasound: This does not promote lymph drainage to any significant degree, or at all. Therapeutic ultrasound at 3-3.3 MHz may be appropriate to use after post-op day 7, but it is not a substitute for appropriate manual lymph drainage or something to be used on large areas of body at one time. This has sadly and too commonly become a service that can be performed by an "unskilled" technician while waiting for the "skilled" practitioner to be ready or a way to increase the overall treatment time for billing purposes when it provides no real added benefit. The best use of therapeutic ultrasound postoperatively is for its heating benefit on a small area if hardened or thickened tissue. This helps soften an area so that fibrosis techniques, soft tissue mobilization, or manual lymph drainage may be more effective.

Manual Lymph Drainage (MLD): This is the most appropriate base hands-on treatment technique following plastic surgery. It can actually be helpful in speeding fluid reduction after most surgeries and injures but is especially helpful in the presence of lymphatic system damage following liposuction. It is also very helpful following procedures that change lymphatic system anatomy (abdominoplasty) and procedures with long incisions such as breast, body, leg, and arm lifts. MLD has been around and studied extensively since the 1930's. It is not novel or new. It is part if the system of treatment for the disease of lymphedema. Lymphedema is the development of permanent protein rich swelling in the presence of permanent lymphatic system damage or compromise. The most well known and respected techniques are Vodder, Klose, and Ludec. Certified Lymphedema Therapists (CLT) are lymphatic system specialists and proficient in MLD, compression management, and other appropriate techniques and should be your ideal goto as long as they are also knowledgeable about application to postoperative plastic surgery procedures. Plastic surgery procedures frequently cause excessive buildup of protein rich fluid, making MLD highly effective in assisting the body to remove this excess fluid and relieve many uncomfortable symptoms associated with it. As the lymphatic system is part of the immune system, MLD also helps speed healing and reduce the risk of infection and wounds. If you cannot find an appropriately trained CLT, I encourage you to at least find a practitioner certified in MLD by a reputable school (https://www.clt-lana.org/training-programs) as well as trained in the adaptation of MLD to plastic surgery procedures. Training in the basic MLD techniques is not sufficient for the most effective treatment. It is highly important that your practitioner know techniques to reroute fluid away from areas of lymphatic system damage from liposuction and long surgical incisions.