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Enlargement of extremities: Acromegaly Diagnosis, Symptoms & Treatment

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Treatment for Acromegaly: Johns Hopkins Pituitary Center

What is acromegaly?

Acromegaly is the Greek word for “extremities” and “enlargement.” When the pituitary gland produces excess growth hormone, this results in excessive growth – called acromegaly. The excessive growth occurs first in the hands and feet, as soft tissue begins to swell. This rare disease affects mostly middle-aged adults. Untreated, the disease can lead to severe illness and death.

What causes acromegaly?

Overproduction of growth hormone (GH) by the pituitary gland over a long period of time causes acromegaly. There are several reasons for overproduction of GH. The most common reason is the presence of a pituitary adenoma, which is a benign (non-cancerous) tumor of the pituitary gland. These tumors produce excess GH.

According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), more than 95% of people with acromegaly have a pituitary adenoma.

Tumors outside the pituitary gland can also cause acromegaly, but this is rare. Learn more about pituitary tumors.

What are the symptoms of acromegaly?

Symptoms of acromegaly vary depending on how long the patient has had the disease. The following are the most common symptoms of acromegaly. However, each individual may experience symptoms differently. Symptoms may include:

  • swelling of the hands and feet
  • facial features become coarse as bones grow
  • body hair becomes coarse as the skin thickens and/or darkens
  • increased perspiration accompanied with body odor
  • protruding jaw
  • voice deepening
  • enlarged lip, nose, and tongue
  • thickened ribs (creating a barrel chest)
  • joint pain
  • degenerative arthritis
  • enlarged heart
  • enlargement of other organs
  • strange sensations and weakness in arms and legs (carpal tunnel syndrome)
  • snoring
  • fatigue and weakness
  • headaches
  • loss of vision
  • irregular menstrual cycles in women
  • breast milk production in women
  • impotence in men
  • diabetes
  • high blood pressure

The symptoms of acromegaly may resemble other conditions or medical problems. Always consult your physician for a diagnosis.

How is acromegaly diagnosed?

Due to the subtlety of the symptoms, acromegaly is often not diagnosed until years later. In addition to a complete medical history and medical examination, diagnostic procedures for acromegaly may include:

  • serial photos taken over the years (to observe physical changes in the patient)
  • x-rays (to detect bone thickening)
  • blood tests (to check the growth hormone level)

Treatment for acromegaly:

Specific treatment for acromegaly will be determined by your physician based on:

  • your age, overall health, and medical history
  • extent of the disease
  • your tolerance for specific medications, procedures, or therapies
  • expectations for the course of the disease
  • your opinion or preference

Treatment of acromegaly depends on the cause of the disease. More than 95 percent of acromegaly cases are caused by benign tumors on the pituitary gland. Because the tumor is compressing the pituitary gland, the hormone production can be altered. Some other acromegaly cases are caused by tumors of the pancreas, lungs, or adrenal glands.

The goal of treatment is to restore the pituitary gland to normal function, producing normal levels of growth hormone.

Treatment may include removal of the tumor, radiation therapy, and injection of growth hormone blocking drugs.

Left untreated, acromegaly can lead to worsening diabetes mellitus and hypertension. The disease also increases a patient’s risk for cardiovascular disease and colon polyps that may lead to cancer.

For more information, contact the Pituitary Center.

To arrange evaluations and request appointments, patients can call 410-955-9270 to speak with an agent who can begin the scheduling process. Learn more.

 

 

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Acromegaly – NHS

Acromegaly is a rare condition where the body produces too much growth hormone, causing body tissues and bones to grow more quickly.

Over time, this leads to abnormally large hands and feet, and a wide range of other symptoms.

Acromegaly is usually diagnosed in adults aged 30 to 50, but it can affect people of any age. When it develops before the end of puberty, it’s known as “gigantism”.

Symptoms of acromegaly

Acromegaly can cause a wide range of symptoms, which tend to develop very slowly over time.

Early symptoms include:

  • swollen hands and feet – you may notice a change in your ring or shoe size
  • tiredness and difficulty sleeping, and sometimes sleep apnoea
  • gradual changes in your facial features, such as your brow, lower jaw and nose getting larger, or your teeth becoming more widely spaced
  • numbness and weakness in your hands, caused by a compressed nerve (carpal tunnel syndrome)

Children and teenagers will be abnormally tall.

As time goes on, common symptoms include:

  • abnormally large hands and feet
  • large, prominent facial features (such as the nose and lips) and an enlarged tongue
  • skin changes – such as thick, coarse, oily skin, skin tags, or sweating too much
  • deepening of the voice as a result of enlarged sinuses and vocal cords
  • joint pain
  • tiredness and weakness
  • headaches
  • blurred or reduced vision
  • loss of sex drive
  • abnormal periods (in women) and erection problems (in men)

Symptoms often become more noticeable as you get older.

See a GP straight away if you think you have acromegaly.

Acromegaly can usually be successfully treated, but early diagnosis and treatment is important to prevent the symptoms getting worse and reduce the chance of complications.

Risks of acromegaly

If you do not get treatment, you may be at risk of developing:

Because of the risk of bowel polyps, a procedure known as a colonoscopy might be recommended if you’ve been diagnosed with acromegaly. Regular colonoscopy screening may also be necessary.

Causes of acromegaly

Acromegaly happens because your pituitary gland (a pea-sized gland just below the brain) produces too much growth hormone.

This is usually caused by a non-cancerous tumour in the pituitary gland called an adenoma.

Most of the symptoms of acromegaly are due to the excess of growth hormone itself, but some come from the tumour pressing on nearby tissues. For example, you may get headaches and vision problems if a tumour pushes against the nearby nerves.

Acromegaly sometimes runs in families, but most of the time it’s not inherited. Adenomas usually spontaneously develop because of a genetic change in a cell of the pituitary gland. This change causes uncontrolled growth of the affected cells, creating the tumour.

Rarely, acromegaly is caused by a tumour in another part of the body, such as the lungs, pancreas or another part of the brain. It may also be linked to some genetic conditions.

Treating acromegaly

Treatment for acromegaly depends on your symptoms. Usually the goal is to:

  • reduce growth hormone production to normal levels
  • relieve the pressure a tumour may be putting on surrounding tissues
  • treat any hormone deficiencies
  • improve your symptoms

Most people with acromegaly have surgery to remove a pituitary tumour. Medicine or radiotherapy may sometimes be needed after, or instead of, surgery.

Surgery

Surgery is usually effective and can completely cure acromegaly. But sometimes the tumour is too large to be removed entirely, and you may need another operation or further treatment with medicine or radiotherapy.

Under general anaesthetic, the surgeon will make a small cut inside your nose or behind your upper lip to access the pituitary gland.

A long, thin, flexible tube with a light and video camera at one end, called an endoscope, is fed into the opening so your doctor can see the tumour. Surgical instruments are passed through the same opening and used to remove the tumour.

Removing the tumour should instantly lower your levels of growth hormone and relieve pressure on the surrounding tissue. Facial features often start to return to normal and swelling improves within a few days.

With surgery, there’s risk of:

  • damaging the healthy parts of your pituitary gland
  • leakage of the fluid that surrounds and protects your brain
  • meningitis – although this is rare

Your surgeon will discuss these risks with you and answer any questions you have.

Medicine

Medicine may be prescribed if your growth hormone levels are still higher than normal after surgery, or if surgery was not possible.

3 different types of medicine are used:

  • a monthly injection of either octreotide, lanreotide or pasireotide – this slows down the release of growth hormone and can sometimes also shrink tumours
  • a daily pegvisomant injection – this blocks the effects of growth hormone and can significantly improve symptoms
  • bromocriptine or cabergoline tablets – these can stop growth hormone being produced, but they only work in a small proportion of people

Each of these medicines has different advantages and disadvantages. Speak to your doctor about the options available to you, and the benefits and risks of each.

Radiotherapy

If surgery is not possible, or not all of the tumour could be removed, or if medicine has not worked, you may be offered radiotherapy.

This can eventually reduce your growth hormone levels, but it may not have a noticeable effect for several years and you may need to take medicine in the meantime.

2 main types of radiotherapy are used to treat acromegaly:

  • stereotactic radiotherapy – a high-dose beam of radiation is aimed very precisely at your adenoma; you’ll need to wear a rigid head frame or a plastic mask to hold your head still during the treatment, which can usually be done in one session
  • conventional radiotherapy – this also uses a beam of radiation to target the adenoma, but it’s wider and less precise than the one used in stereotactic radiotherapy; this means this treatment can damage the surrounding pituitary gland and brain tissue, so it’s given in small doses over 4 to 6 weeks to give your tissues time to heal between treatments

Stereotactic radiotherapy is more commonly used to treat adenomas because it minimises the risk of damage to nearby healthy tissue.

Radiotherapy can have a number of side effects. It will often cause a gradual drop in the levels of other hormones produced by your pituitary gland, so you’ll usually need hormone replacement therapy for the rest of your life. It may also have an effect on your fertility.

Your doctor will be able to talk to you about these risks and other possible side effects.

Follow-up

Treatment is often effective at stopping the excessive production of growth hormone and improving the symptoms of acromegaly.

After treatment, you’ll need regular follow-up appointments with your specialist for the rest of your life. These will be used to monitor how well your pituitary gland is working, check you’re on the correct hormone replacement treatment and make sure the condition does not return.

Diagnosing acromegaly

Because the symptoms of acromegaly often develop gradually over several years, you may not get a diagnosis straight away. Your doctor may ask you to bring in photographs of yourself that span the past few years to look for the tell-tale gradual changes.

Blood tests

If your doctor suspects you have acromegaly, you’ll need to have a blood test to measure your growth hormone levels.

To make sure the blood test gives an accurate result, you may be asked to drink a sugary solution before having a series of blood samples taken. For people without acromegaly, drinking the solution should stop growth hormone being released. In people with acromegaly, the level of growth hormone in the blood will remain high. This is called a glucose tolerance test.

Your doctor will also measure the level of another hormone, called insulin-like growth factor 1 (IGF-1). A higher level of IGF-1 is a very accurate indication that you may have acromegaly.

Brain scans

If your blood tests show a high level of growth hormone and IGF-1, you might have an MRI scan of your brain. This will show where the adenoma is in your pituitary gland and how big it is. If you cannot have an MRI scan, a CT scan can be carried out, but this is less accurate.

National Congenital Anomaly and Rare Disease Registration Service

If you have acromegaly, your clinical team will pass information about you on to the National Congenital Anomaly and Rare Disease Registration Service (NCARDRS).

The NCARDRS helps scientists look for better ways to treat and prevent acromegaly. You can opt out of the register at any time.

Page last reviewed: 12 October 2020
Next review due: 12 October 2023

Acromegaly | UCLA Pituitary Tumor Program

Acromegaly is condition that is nearly always caused by a pituitary adenoma, a tumor of the pituitary gland. The term acromegaly literally means enlarged extremities; acro means extremity and megaly means enlargement of.

Acromegaly Treatment in Southern California

Our comprehensive approach to diagnosis and treatment of pituitary conditions, including acromegaly, sets the UCLA Pituitary Tumor Program apart. Our physicians treat a high volume of patients every year and perform over 100 pituitary surgeries a year, making us one of the top programs in the United States.

    Use these links to explore more about acromegaly:

 


Acromegaly: Physiology

The normal pituitary gland secretes growth hormone (GH):

  • In childhood, GH is important for proper development and growth of the body.
  • In adults, GH maintains healthy bone and muscle function.

GH has direct effects on the body, such as on muscle growth. It also acts on specialized gland cells in the liver:

  • This leads to the release of a hormone called insulin-like growth factor (IGF-1, or somatomedin-C) into the blood stream.
  • IGF-1 blood levels are much steadier compared to GH, which changes dramatically throughout the day.
  • IGF-1 affects many organs of the body, particularly bone and cartilage.

A pituitary tumor that secretes an excessive amount of GH causes changes in the body that lead to disfigurement. If the disfigurement severely affects the internal organs, it could lead to death.

While acromegaly is nearly always caused by an adenoma, there are rare cases when it occurs due to excess growth hormone secretion outside the pituitary. These tumors most commonly occur:

  • In the lung (bronchial carcinoid)
  • In the pancreas (pancreatic carcinoid)

Acromegaly typically presents in adulthood. Because the physical changes occur so slowly, it can take an average of seven to eight years before the condition is diagnosed. If a pituitary tumor produces an excessive amount of GH in childhood, gigantism occurs.


Acromegaly: Symptoms

Acromegaly: Symptoms Related to Excess GH

  • Abnormal enlargement of the hands and feet
    • Rings no longer fitting
    • Widening of the distal fingers and toes, sometimes referred to as “paddle” toes
    • Hands feeling soft like bread dough
    • Enlargement of the feet requiring a larger shoe size
  • Changes in facial features, sometimes quite prominent, including:
    • Enlargement of forehead and jaw, widening the spaces between teeth and enlarging tongue
    • Enlargement of the nose and lips
  • Deepening of the voice in males
  • Skin changes, including:
    • Increased number of skin tags
    • Oily skin and excessive sweating
  • Carpal tunnel syndrome, due to increase tissue in the wrists, leading to nerve compression
  • Sleep apnea
  • Arthritis
  • Headache

Serious conditions related to longstanding, untreated acromegaly, include:

  • High blood pressure
  • Diabetes mellitus (adult-onset or Type 2)
  • Heart disease, including heart failure due to heart enlargement

Acromegalic patients are at increased risk of developing other tumors or lesions of the body:

  • Thyroid cancer occurs at a higher frequency; speak to your doctor about screening tests.
  • Colon polyps; you may need regular colonoscopies to screen for polyps.

If a pituitary growth hormone producing tumor develops in childhood before bone growth is completed, gigantism results. Pituitary giants can grow over seven feet tall.

Acromegaly: Symptoms Related to Large Tumor Size (Macroadenomas)

Macroadenomas that grow upward into the brain cavity can compress the optic chiasm. Vision problems can include:

  • A loss of the outer peripheral vision, called a bitemporal hemianopsia
    • When severe, a patient can only see what is directly in front of them
    • Many patients do not become aware of their visual loss until it is quite severe.
  • Other visual problems can include:
    • Loss of visual acuity (blurry vision), especially if the macroadenoma grows forward and compresses an optic nerve
    • Colors not perceived as bright as usual

Pituitary Failure or Hypopituitarism

  • Compression of the normal gland can cause hormone insufficiency, called hypopituitarism. The symptoms depend upon which hormone is involved.
  • Reduction of sex hormones, luteinizing hormone (LH) and follicle-stimulating hormone (FSH).
    • In men, this can lead to a low testosterone level, causing decreased sexual drive and impotence.
      • In some cases, there can be loss of body and facial hair.
      • In women, this can lead to infertility.
  • Large pituitary tumors can slightly elevate blood prolactin levels. Doctors think this occurs because of compression of the pituitary stalk, the connection between the brain and pituitary gland. It is called the “stalk effect.”
    • In premenopausal women, this can lead to reduction or loss of menstrual periods and/or breast milk production (galactorrhea).
    • Prolactin levels are only slightly elevated, as opposed to prolactinomas in which the prolactin level is usually very high.

More severe hypopituitarism can lead to hypothyroidism or abnormally low cortisol levels, which may be life threatening. Symptoms of severe hypopituitarism include:

  • Loss of appetite
  • Weight loss or weight gain
  • Fatigue
  • Decreased energy
  • Decreased mental function
  • Dizziness

Changes in hormonal function can cause electrolyte imbalance in the blood, typically low sodium levels (hyponatremia). Symptoms could include:


Acromegaly: Diagnosis

A pituitary adenoma may be suspected based on symptoms, the medical history, and physical findings of acromegaly. Explaining your symptoms is a crucial part of diagnosis, as your doctor uses the information to determine whether a pituitary tumor is secreting an excess of hormones and if there is evidence of pituitary insufficiency.  Physicians at the Pituitary Tumor Program at UCLA have vast experience in diagnosing pituitary conditions.

Standard diagnostic tests include:

Hormone Testing

Doctors will order blood tests, specifically looking for an elevated level of IGF-1. In some rare cases, usually in premenopausal women, the GH levels can be high even though the IGF-1 levels are normal. This is an estrogen-resistant phenomenon.

Normally, the pituitary glands secrete GH in a pulsatile fashion, meaning the level increases and decreases significantly throughout the day. This affects diagnosis in two ways:

  • It is difficult to diagnose acromegaly based on a random GH measurement, because a measurement at one time differs drastically from one taken at a different time.
  • GH release also falls dramatically after eating a large quantity of sugar, whereas tumor cells do not exhibit this characteristic. This expected drop in hormone production is useful in helping diagnose acromegaly.

IGF-1 is released in a more steady fashion. Its levels do not go up and down quickly, making it a better hormone to measure to screen for acromegaly.

You may be asked to undergo an oral glucose tolerance test (OGTT) to confirm the diagnosis. Drinking 75 grams of a glucose solution should lower the GH level to lower than one nanogram per milliliter. In acromegalics, this suppression does not occur and may in fact increase.

Learn more about hormone testing at the UCLA Pituitary Tumor Program.

Magnetic Resonance Imaging (MRI)

One method we use to detect pituitary tumors is a magnetic resonance imaging (MRI) scan of the pituitary gland. We use a special MRI pituitary protocol to properly visualize the tumor.

Smaller tumors may not be visible using computed tomography (CT) scans.

The vast majority (90%) of GH-secreting tumors are macroadenomas.


Acromegaly: Treatment Options

The optimal treatment of acromegaly depends on multiple factors, including:

  • Size and location of the tumor
  • Age and medical condition of the patient

Invasive tumors may not be able to be cured surgically.

Typically, more than one specialist is involved in managing pituitary adenomas. At the Pituitary Tumor Program, your medical team includes a special endocrinologist called a neuro-endocrinologist who has specific expertise in the treatment of acromegaly.

Treatment options include:

Acromegaly Treatment: Surgery

Your doctor may recommend surgically removing the tumors as your best chance for a cure. If the tumor invaded beyond the sella (the space where the normal pituitary gland sits), however, there is a lower chance of a surgical cure. In that case, your doctor may recommend other treatment options, such as medication or radiation therapy.

Patients should strongly consider seeking the care of an experienced neurosurgeon, one whom performs a large number of pituitary surgeries each year. Studies have shown:

  • The first surgery offers the greatest chance of cure, while the cure rate with a second or third surgery is much lower.
  • Newer surgical techniques, such as the expanded, endoscopic endonasal approach allow surgeons to cure pituitary tumors previously thought to be unresectable (unable to be removed surgically).
  • Long-term cure of acromegaly after surgery occurs in approximately 80 percent to 85 percent of patients with smaller tumors (microadenomas) and in approximately 50 percent to 60 percent of patients with larger tumors (macroadenomas).

If the pituitary adenomas require surgery, typically the best procedure is through a nasal approach. Our neurosurgeons who specialize in pituitary tumor surgery are experts in the minimally invasive endoscopic endonasal technique. This procedure removes the tumor while minimizing complications, hospital time and discomfort. This advanced technique requires specialized training and equipment.

Very large tumors that extend into the brain cavity may require opening the skull (craniotomy) to access the tumor. Our surgeons are also experts in the minimally invasive “key-hole” craniotomy, utilizing a small incision hidden in the eyebrow.

Acromegaly Treatment: Medication

In recent years, the medical treatment of acromegaly has improved. In some cases, doctors use medication, and not surgery, as the first course of treatment. However, in many cases, patients require both medical and surgical therapies to control acromegaly.

Medications include:

  • Somatostatin analog (Octreotide, Lanreotide) injections, typically administered to patients on a monthly basis, suppress growth hormone production in about 70 percent of patients.
    • Significant tumor shrinkage occurs in 30 to 50 percent of patients.
    • Injections often improve symptoms of soft tissue swelling, headache, joint pains and sleep apnea.
    • Patients require lifelong treatment with somatostatin.
  • Drugs that block the action of growth hormone on liver cells, such as a daily injection of Pegvisomant. When effective, IGF-1 levels can normalize, but elevated growth hormones remain.
  • Drugs that mimic the effect of dopamine, such as cabergoline, are effective in a small number of patients. These medications are the same ones used to treat prolactinomas.

Acromegaly Treatment: Radiation Therapy

For some patients, surgery or medication is not sufficient to control the acromegaly. In these cases, doctors may recommend stereotactic radiosurgery. Stereotactic radiosurgery is a technique in which doctors aim a highly focused dose of radiation to the tumor. It takes an average of 18 months to lower the GH and IGF-1 levels.

The radiation beam is designed to target only the tumor. The surrounding brain structures receive only a fraction of the radiation dose and are typically unharmed, with the exception of the normal pituitary gland.

A consequence of radiation treatment is that it can cause delayed pituitary failure. This typically occurs several years after treatment, and therefore continued long-term follow-up with an endocrinologist is important. Hormone replacement may be required.


Clinical Trials

The UCLA Pituitary Tumor Program has clinical trials testing newer medications for the treatment of acromegaly.


Contact Us

To schedule an appointment with one of our physicians at the Pituitary Tumor Program, please call (310) 825 5111.

You can also email us at [email protected] 

Feline Acromegaly – Endocrine System

Feline acromegaly occurs in older cats (8–14 years old) and appears to be more common in males. Clinical signs of uncontrolled diabetes mellitus are often the first sign of acromegaly in cats; therefore, polydipsia, polyuria, and polyphagia are the most common presenting signs. Net weight gain of lean body mass in cats with uncontrolled diabetes mellitus is a key sign of acromegaly. Organomegaly, including renomegaly, hepatomegaly, and enlargement of endocrine organs, is also seen. Some, but not all, cats show the classic enlargement of extremities, body size, jaw, tongue, and forehead that is characteristic of acromegaly in people. Some of the most striking manifestations are seen in the musculoskeletal system and include an increase in muscle mass and growth of the acral segments of the body, including the paws, chin, and skull. Stridor may be detected as a result of increased soft-tissue enlargement of the epiglottis and surrounding tissues. Cardiovascular abnormalities such as cardiomegaly (radiographic and echocardiographic), systolic murmurs, and congestive heart failure develop late in the disease course. Azotemia also develops late in the course of the disease in ~50% of acromegalic cats. Neurologic signs of acromegaly in people, such as peripheral neuropathies (paresthesias, carpal tunnel syndrome, sensory and motor defects) and parasellar manifestations (headache and visual field defects), are not generally detected in acromegalic cats.

Impaired glucose tolerance and insulin resistance resulting in diabetes mellitus are seen in all cats with acromegaly. Measurement of endogenous insulin reveals dramatically increased serum insulin concentrations. Despite severe insulin resistance and hyperglycemia, ketosis is rare. Hypercholesterolemia and mild increases in liver enzymes are attributed to the diabetic state. Hyperphosphatemia without azotemia is also a common clinicopathologic finding. Urinalysis is unremarkable except for persistent proteinuria. In a recent study, acromegaly was the most common (25%) underlying cause of non-insulin–dependent diabetes mellitus in cats, and it should be suspected in any cat that does not respond to standard therapy for type 2 diabetes mellitus (high-protein, low-carbohydrate diet and glargine insulin) within 4 months of initiating therapy.

Gross necropsy findings in acromegalic cats may include:

  • a large, expansile pituitary mass

  • hypertrophic cardiomyopathy with marked left ventricular and septal hypertrophy (early) or dilated cardiomyopathy (late)

  • degenerative joint disease

  • lumbar vertebral spondylosis

  • moderate enlargement of the parathyroid glands

  • adrenocortical hyperplasia

  • diffuse enlargement of the pancreas with multifocal nodular hyperplasia

Histopathologic examination of the endocrine glands reveals:

  • acidophil adenoma of the pituitary

  • adenomatous hyperplasia of the thyroid gland

  • nodular hyperplasia of the adrenal cortices, parathyroid glands, and pancreas

UC San Diego’s Practical Guide to Clinical Medicine

The Upper Extremities

Exam of the hands and arms is usually quite brief in the asymptomatic patient. Pay particular
attention to the following:

The Hands:

  1. Appearance of hand and fingers: Any obvious deformity or discoloration?
    Do they appear relatively red and well perfused or white/mottled?

    For Additional Information See: Digital DDx: Nail Findings

  2. Nail shape and color (see below for discussion of cyanosis): Several examples
    of common nail pathology are shown below.

    Nicotine Staining

    Onychomycosis:

    Fungal Infection of the Nail

    Onycholysis:

    Separation of Nail from
    Underlying Bed, often due to onychomycosis

    Paronychia:

    Infection of skin adjacent to
    nail of middle finger

  3. Capillary refill: This is a mechanism for gauging arterial perfusion. Press
    the nail bed or tip of any finger for several seconds, causing the underlying
    skin to whiten. After releasing pressure, the normal pink color should return
    in 2-3 seconds. Delay implies under perfusion. Interestingly, while atherosclerotic
    vascular disease is a common cause of arterial insufficiency in the lower
    extremity, it rarely occurs in the arms or hands. Thus, delayed capillary
    refill in the hands more likely reflects vasospasm or hypovolemia then it
    does intraluminal arterial obstruction. Severe vasospasm, referred to as Raynaud’s
    Phenomenon, occurs most frequently in women after exposure to cool temperatures,
    causing both hands to become white and painful.

    For Additional Information See: Digital DDx: Finger Pain, Ischemia, Ulcers


    Peripheral Vascular Disease, Hand

    Tissue death (i. e. gangrene)
    of the fingers secondary to severe
    peripheral vascular disease.

  4. Temperature: Cool hands occur most commonly as a result of exposure to a
    cold environment. However, this can also reflect vascular insufficiency, vasospasm,
    or hypovolemia.
  5. Obvious joint abnormalities, noting particularly if there is a specific
    pattern or distribution. For example, deformity of the metacarpal-phalyngeal
    joints on every finger of both hands is consistent with a systemic inflammatory
    process like Rheumatoid Arthritis. An isolated abnormality of a single, distal
    joint, however, is more likely secondary to local trauma or degenerative arthritis.

    Joint deformities secondary to rheumatoid
    arthritis


    And a few words about uncommonly encountered abnormalities… The presence or
    absence of these findings are frequently mentioned in clinical medicine, giving
    the impression that they are common and/or of great importance. This is more
    myth then fact as most patients with the disease states in question do not
    have these findings. Their clinical utility tends to be over emphasized.



    1. Clubbing: Bulbous appearance of the distal phalanges of all fingers along with
      concurrent loss of the normal angle between the nail base and adjacent skin.
      This is most commonly associated with conditions that cause chronic hypoxemia
      (e.g. severe emphysema), though it is also associated with a number of other
      conditions. However, in general it is neither common nor particularly sensitive
      for hypoxia, as most hypoxic patients do not have clubbing.


    2. Cyanosis: A bluish discoloration visible at the nail bases
      in select patient with severe hypoxemia or hypoperfusion. As with clubbing,
      it is not at all sensitive for either of these conditions.

    3. Splinter Hemmorrhages: Short, thin, brown, linear streaks in the nails of
      some patients (the minority) with endocarditis.
    4. Edema: While edema is a relatively common finding in the lower extremity,
      it rarely occurs in the arms and hands. This is because the lower extremities
      are exposed to greater hydrostatic pressure due to their dependent position.
      Upper extremity edema, when present, usually occurs focally over an area of
      local inflammation (e.g. cellulitis). Diffuse arm edema can occur if drainage
      is compromised, as when the lymphatics are disrupted following axillary lymph
      node surgery for staging and treatment of breast cancer. Upper extremity venous
      obstruction can also cause edema, though blood clots in this region are much
      less common then in the lower extremity.


      Note divit left (pitting) after
      application of pressure.

      Edema in this case is due to lymphatic obstruction.

      Right upper extremity DVT. Note diffuse
      swelling.

In the setting of injury or infection, the affected area should be examined in
greater detail. For example, acute inflammation secondary to cellulitis of the
upper extremity is demonstrated in the image below.

Lymph Nodes of the Upper Extremity:

Epitrochlear Nodes: Found on the inside of the upper arm, just above the elbow. These are
rarely
the site of pathology and thus not routinely examined. If there is clinical evidence of an
infection distal to the elbow, it makes sense to feel for these nodes as they are part of
the
drainage pathway. To examine, cup the patient’s elbow in your hand (left elbow with right
hand
and vice versa) and palpate just above the elbow, along the inside of the upper arm. When
inflamed, the nodes become large and tender.

For Additional Information See: Digital DDx: Adenopathy

Palpation of Epitrochlear Lymph Nodes

Axillary Nodes: Pathologic enlargement occurs most commonly in the following settings:

  1. Infection:
    • systemic (e.g. TB, HIV)
    • local (e.g. cellulitis of the hand/arm)
  2. Malignancy:
    • lymphoma, where the malignacy is based in lymph nodes
    • metastases, in particular breast, though could be from any site
  3. Other:
    • various systemic inflammatory illnesses (e. g sarcoidosis)

When examining healthy individuals, both axilla can be examined simultaneously. To do
this, ask the patient to lift both arms away from the sides of their body. Then extend
the fingers of both your hands and gently direct them towards the apices of the arm
pits. You can do this through the patients gown if you don’t want to place your fingers
in direct contact with the axilla. Now press your hands towards the patient’s body and
move them slowly down the lateral chest wall. This allows you to explore the axillary
regions in their entirety.

If you feel any abnormalities, repeat the exam of each axilla separately. When
examining the left axilla, grasp the patient’s left wrist or elbow with your
left hand and lift their arm up and out laterally. Then use your right hand to
examine the axillary region as described above. This technique permits the
patient’s arm to remain completely relaxed, minimizing tension in the
surrounding tissues that can mask otherwise enlarged lymph nodes. The right
axilla is examined in a similar fashion, though hand positioning is reversed.
This examination may also be performed while the patient is supine, as would be
done if you were to couple it with the female breast exam.

Most patients do not have palpable axillary nodes. If you are able to feel
adenopathy, make note of the following characteristics:

  • Size: Pathologic nodes are generally greater than 1 cm

  • Firmness: Malignancy makes nodes feel harder

  • Quantity: The greater the number of nodes, the more likely true
    pathology exists

  • Pain: Often associated with inflammation (e. g. infection)
  • Relation to other nodes and surrounding tissue: Nodes fixed to each
    other or adjacent
    structures are worrisome for malignancy
  • Changes over time: Nodes which regress spontaneously are obviously
    of less concern then those
    that increase in size, number, or appear to be growing in new
    locations. Making these
    determinations requires multiple evaluations over time.

Left Axillary Adenopathy

Lymphedema: Practice Essentials, Background, Pathophysiology

  • Arellano J, Gonzalez R, Corredoira Y, Nuñez R. Diagnosis of elephantiasis nostras verrucosa as a clinical mani-festation of Kaposi’s sarcoma. Medwave. 2020 Jan 20. 20 (1):e7767. [Medline].

  • Karlsson K, Nilsson-Wikmar L, Brogårdh C, Johansson K. Palpation of Increased Skin and Subcutaneous Thickness, Tissue Dielectric Constant, and Water Displacement Method for Diagnosis of Early Mild Arm Lymphedema. Lymphat Res Biol. 2019 Oct 9. [Medline].

  • Pereira de Godoy JM, Azoubel LM, de Fatima Guerreiro de Godoy M. Intensive treatment of leg lymphedema. Indian J Dermatol. 2010 Apr-Jun. 55(2):144-7. [Medline]. [Full Text].

  • Yimer M, Hailu T, Mulu W, Abera B. Epidemiology of elephantiasis with special emphasis on podoconiosis in Ethiopia: A literature review. J Vector Borne Dis. 2015 Jun. 52 (2):111-5. [Medline].

  • Elgendy IY, Lo MC. Unilateral lower extremity swelling as a rare presentation of non-Hodgkin’s lymphoma. BMJ Case Rep. 2014. [Medline].

  • Fife C. Massive localized lymphedema, a disease unique to the morbidly obese: a case study. Ostomy Wound Manage. 2014 Jan. 60(1):30-5. [Medline].

  • Chopra K, Tadisina KK, Brewer M, Holton LH, Banda AK, Singh DP. Massive localized lymphedema revisited: a quickly rising complication of the obesity epidemic. Ann Plast Surg. 2015 Jan. 74 (1):126-32. [Medline].

  • Greene AK, Sudduth CL. Lower extremity lymphatic function predicted by body mass index: a lymphoscintigraphic study of obesity and lipedema. Int J Obes (Lond). 2021 Feb. 45 (2):369-373. [Medline].

  • Prakash J, Kumar M, Singh V, Sankhwar S. Giant penile elephantiasis after circumcision: a devastating complication. BMJ Case Rep. Sep 16;2013. bcr2013200780. [Medline].

  • Namnyak S, Adhami Z, Toms G, Jenks P. Pasteurella multocida septicaemia in Milroy’s disease. J Infect. 1995 Sep. 31(2):175-6. [Medline].

  • Lambert PC, Micali G, Schwartz RA. Lymphedema. Lebwohl M, ed. Treatment of Skin Disease: Comprehensive Therapeutic Strategies. 5th ed. Elsevier; 2018. 470-71.

  • Connell F, Brice G, Jeffery S, Keeley V, Mortimer P, Mansour S. A new classification system for primary lymphatic dysplasias based on phenotype. Clin Genet. 2010 May. 77(5):438-52. [Medline].

  • Connell F, Brice G, Mortimer P. Phenotypic characterization of primary lymphedema. Ann N Y Acad Sci. 2008. 1131:140-6. [Medline].

  • Mellor RH, Hubert CE, Stanton AW, et al. Lymphatic dysfunction, not aplasia, underlies Milroy disease. Microcirculation. 2010 May. 17(4):281-96. [Medline].

  • Sheng J, Zeng F, Li C, Liu J, Wang Q, Liu M. [Identification of VEGFR3 gene mutation in a Chinese family with autosomal dominant primary congenital lymphoedema.]. Zhonghua Yi Xue Yi Chuan Xue Za Zhi. 2010 Aug. 27(4):371-5. [Medline].

  • Irrthum A, Karkkainen MJ, Devriendt K, Alitalo K, Vikkula M. Congenital hereditary lymphedema caused by a mutation that inactivates VEGFR3 tyrosine kinase. Am J Hum Genet. 2000 Aug. 67(2):295-301. [Medline].

  • Karkkainen MJ, Ferrell RE, Lawrence EC, et al. Missense mutations interfere with VEGFR-3 signalling in primary lymphoedema. Nat Genet. 2000 Jun. 25(2):153-9. [Medline].

  • Butler MG, Dagenais SL, Rockson SG, Glover TW. A novel VEGFR3 mutation causes Milroy disease. Am J Med Genet A. 2007 Jun 1. 143A(11):1212-7. [Medline].

  • Connell FC, Ostergaard P, Carver C, Brice G, Williams N, Mansour S, et al. Analysis of the coding regions of VEGFR3 and VEGFC in Milroy disease and other primary lymphoedemas. Hum Genet. 2009 Jan. 124(6):625-31. [Medline].

  • Ghalamkarpour A, Holnthoner W, Saharinen P, Boon LM, Mulliken JB, Alitalo K, et al. Recessive primary congenital lymphoedema caused by a VEGFR3 mutation. J Med Genet. 2009 Jun. 46(6):399-404. [Medline].

  • Evans AL, Brice G, Sotirova V, Mortimer P, Beninson J, Burnand K, et al. Mapping of primary congenital lymphedema to the 5q35.3 region. Am J Hum Genet. 1999 Feb. 64(2):547-55. [Medline]. [Full Text].

  • Berry FB, Tamimi Y, Carle MV, Lehmann OJ, Walter MA. The establishment of a predictive mutational model of the forkhead domain through the analyses of FOXC2 missense mutations identified in patients with hereditary lymphedema with distichiasis. Hum Mol Genet. 2005 Sep 15. 14(18):2619-27. [Medline].

  • Salim A, Pike M, Turner R, Mortimer P. Lymphedema: an additional finding in the charge association. Pediatr Dermatol. 2003 Nov-Dec. 20(6):547-8. [Medline].

  • Aghajan Y, Diaz J, Sladek E. Mysteriously puffy hand: puffy hand syndrome. BMJ Case Rep. 2018 Dec 22. 11 (1):[Medline].

  • Hoerauf A, Pfarr K, Mand S, Debrah AY, Specht S. Filariasis in Africa-treatment challenges and prospects. Clin Microbiol Infect. 2011 Jul. 7:977-85. [Medline].

  • Srivastava PK, Dhillon GP. Elimination of lymphatic filariasis in India–a successful endeavour. J Indian Med Assoc. 2008 Oct. 106(10):673-4, 676-7. [Medline].

  • Debrah AY, Mand S, Marfo-Debrekyei Y, Batsa L, Albers A, Specht S, et al. Macrofilaricidal Activity in Wuchereria bancrofti after 2 Weeks Treatment with a Combination of Rifampicin plus Doxycycline. J Parasitol Res. 2011. 2011:201617. [Medline].

  • Babu S, Nutman TB. Immunology of lymphatic filariasis. Parasite Immunol. 2014 Aug. 36(8):338-46. [Medline].

  • Lee R, Saardi KM, Schwartz RA. Lymphedema-related angiogenic tumors and other malignancies. Clin Dermatol. 2014 Sep-Oct. 32 (5):616-20. [Medline].

  • Piccolo V, Baroni A, Russo T, Schwartz RA. Ruocco’s immunocompromised cutaneous district. Int J Dermatol. 2016 Feb. 55 (2):135-41. [Medline].

  • Nikitenko LL, Shimosawa T, Henderson S, Mäkinen T, Shimosawa H, Qureshi U, et al. Adrenomedullin Haploinsufficiency Predisposes to Secondary Lymphedema. J Invest Dermatol. 2013 Jan 30. [Medline].

  • Thielitz A, Bellutti M, Bonnekoh B, Franke I, Wiede A, Lotzing M, et al. Progressive lipo-lymphedema associated with increased activity of dermal fibroblasts in monoclonal gammopathy of undetermined significance: is there a causal relationship?. Lymphology. 2012 Sep. 45:124-9. [Medline].

  • Boneti C, Badgwell B, Robertson Y, Korourian S, Adkins L, Klimberg V. Axillary reverse mapping (ARM): initial results of phase II trial in preventing lymphedema after lymphadenectomy. Minerva Ginecol. 2012 Oct. 64(5):421-30. [Medline].

  • McPherson T, Persaud S, Singh S, et al. Interdigital lesions and frequency of acute dermatolymphangioadenitis in lymphoedema in a filariasis-endemic area. Br J Dermatol. 2006 May. 154(5):933-41. [Medline].

  • Levinson KL, Feingold E, Ferrell RE, Glover TW, Traboulsi EI, Finegold DN. Age of onset in hereditary lymphedema. J Pediatr. 2003 Jun. 142(6):704-8. [Medline].

  • Dürr HR, Pellengahr C, Nerlich A, Baur A, Maier M, Jansson V. Stewart-Treves syndrome as a rare complication of a hereditary lymphedema. Vasa. 2004 Feb. 33(1):42-5. [Medline].

  • Chopra S, Ors F, Bergin D. MRI of angiosarcoma associated with chronic lymphoedema: Stewart Treves syndrome. Br J Radiol. 2007 Dec. 80(960):e310-3. [Medline].

  • Aguiar Bujanda D, Camacho Galan R, Bastida Inarrea J, et al. Angiosarcoma of the abdominal wall after dermolipectomy in a morbidly obese man. A rare form of presentation of Stewart-Treves syndrome. Eur J Dermatol. 2006 May-Jun. 16(3):290-2. [Medline].

  • Azurdia RM, Guerin DM, Verbov JL. Chronic lymphoedema and angiosarcoma. Clin Exp Dermatol. 1999 Jul. 24(4):270-2. [Medline].

  • Komorowski AL, Wysocki WM, Mitus J. Angiosarcoma in a chronically lymphedematous leg: an unusual presentation of Stewart-Treves syndrome. South Med J. 2003 Aug. 96(8):807-8. [Medline].

  • Shehan JM, Ahmed I. Angiosarcoma arising in a lymphedematous abdominal pannus with histologic features reminiscent of Kaposis sarcoma: report of a case and review of the literature. Int J Dermatol. 2006 May. 45(5):499-503. [Medline].

  • Offori TW, Platt CC, Stephens M, Hopkinson GB. Angiosarcoma in congenital hereditary lymphoedema (Milroy’s disease)–diagnostic beacons and a review of the literature. Clin Exp Dermatol. 1993 Mar. 18(2):174-7. [Medline].

  • Sharma A, Schwartz RA. Stewart-Treves syndrome: Pathogenesis and management. J Am Acad Dermatol. 2012 Jun 7. [Medline].

  • Atillasoy ES, Santoro A, Weinberg JM. Lymphoedema associated with Kaposi sarcoma. J Eur Acad Dermatol Venereol. 2001 Jul. 15(4):364-5. [Medline].

  • Torres-Paoli D, Sanchez JL. Primary cutaneous B-cell lymphoma of the leg in a chronic lymphedematous extremity. Am J Dermatopathol. 2000 Jun. 22(3):257-60. [Medline].

  • Park G, Jeong HW, Lee J, Mun YC, Sung SH, Han SJ. Lymphedema Associated With Primary Amyloidosis: A Case Study. Ann Rehabil Med. 2017 Oct. 41 (5):887-891. [Medline].

  • Maltese PE, Michelini S, Ricci M, Maitz S, Fiorentino A, Serrani R, et al. Increasing evidence of hereditary lymphedema caused by CELSR1 loss-of-function variants. Am J Med Genet A. 2019 Sep. 179 (9):1718-1724. [Medline].

  • Karg E, Bereczki C, Kovacs J, et al. Primary lymphoedema associated with xanthomatosis, vaginal lymphorrhoea and intestinal lymphangiectasia. Br J Dermatol. 2002 Jan. 146(1):134-7. [Medline].

  • Samlaska CP. Congenital lymphedema and distichiasis. Pediatr Dermatol. 2002 Mar-Apr. 19(2):139-41. [Medline].

  • Lu S, Tran TA, Jones DM, et al. Localized lymphedema (elephantiasis): a case series and review of the literature. J Cutan Pathol. 2009 Jan. 36(1):1-20. [Medline].

  • Ridner SH, Deng J, Fu MR, Radina E, Thiadens SR, Weiss J, et al. Symptom burden and infection occurrence among individuals with extremity lymphedema. Lymphology. 2012 Sep. 45:113-23. [Medline].

  • Fukuda H, Saito R. Verruciform xanthoma in close association with isolated epidermolytic acanthoma: a case report and review of the Japanese dermatological literature. J Dermatol. 2005 Jun. 32(6):464-8. [Medline].

  • Wu JJ, Wagner AM. Verruciform xanthoma in association with milroy disease and leaky capillary syndrome. Pediatr Dermatol. 2003 Jan-Feb. 20(1):44-7. [Medline].

  • Wu YH, Hsiao PF, Lin YC. Verruciform xanthoma-like phenomenon in seborrheic keratosis. J Cutan Pathol. 2006 May. 33(5):373-7. [Medline].

  • Chavda LK, Vaidya RA, Vaidya AD. Yellow nail syndrome: missed diagnosis of a rare syndrome. J Assoc Physicians India. 2011 Apr. 59:258-60. [Medline].

  • Ghalamkarpour A, Morlot S, Raas-Rothschild A, Utkus A, Mulliken JB, Boon LM, et al. Hereditary lymphedema type I associated with VEGFR3 mutation: the first de novo case and atypical presentations. Clin Genet. 2006 Oct. 70(4):330-5. [Medline].

  • Vignes S. [Lipedema: a misdiagnosed entity]. J Mal Vasc. 2012 Jul. 37(4):213-8. [Medline].

  • Bollinger A, Amann-Vesti BR. Fluorescence microlymphography: diagnostic potential in lymphedema and basis for the measurement of lymphatic pressure and flow velocity. Lymphology. 2007 Jun. 40(2):52-62. [Medline].

  • Kim YB, Hwang JH, Kim TW, Chang HJ, Lee SG. Would complex decongestive therapy reveal long term effect and lymphoscintigraphy predict the outcome of lower-limb lymphedema related to gynecologic cancer treatment?. Gynecol Oncol. 2012 Sep 26. [Medline].

  • Schmitz KH, Ahmed RL, Troxel A, Cheville A, Smith R, Lewis-Grant L, et al. Weight lifting in women with breast-cancer-related lymphedema. N Engl J Med. 2009 Aug 13. 361(7):664-73. [Medline].

  • Mayrovitz HN. The standard of care for lymphedema: current concepts and physiological considerations. Lymphat Res Biol. 2009. 7(2):101-8. [Medline].

  • Pereira De Godoy JM, Amador Franco Brigidio P, Buzato E, Fátima Guerreiro De Godoy M. Intensive outpatient treatment of elephantiasis. Int Angiol. 2012 Oct. 31(5):494-9. [Medline].

  • Chang AY, Mungai M, Coates SJ, Chao T, Odhiambo HP, Were PM, et al. Implementing a Locally Made Low-Cost Intervention for Wound and Lymphedema Care in Western Kenya. Dermatol Clin. 2021 Jan. 39 (1):91-100. [Medline].

  • Lerner R. What’s New in Lymphedema Therapy in America?. Int J Angiol. 1998 May. 7(3):191-6. [Medline].

  • King B. Toe bandaging to prevent and manage oedema. Nurs Times. 2007 Oct 23-29. 103(43):44, 47. [Medline].

  • Gurdal SO, Kostanoglu A, Cavdar I, Ozbas A, Cabioglu N, Ozcinar B, et al. Comparison of intermittent pneumatic compression with manual lymphatic drainage for treatment of breast cancer-related lymphedema. Lymphat Res Biol. 2012 Sep. 10(3):129-35. [Medline].

  • Wang X, Ding Y, Cai HY, You J, Fan FQ, Cai ZF, et al. Effectiveness of modified complex decongestive physiotherapy for preventing lower extremity lymphedema after radical surgery for cervical cancer: a randomized controlled trial. Int J Gynecol Cancer. 2020 Feb 26. [Medline].

  • Debrah AY, Mand S, Marfo-Debrekyei Y, et al. Macrofilaricidal effect of 4 weeks of treatment with doxycycline on Wuchereria bancrofti. Trop Med Int Health. 2007 Dec. 12(12):1433-41. [Medline].

  • Yongyuth P, Koyadun S, Jaturabundit N, Sampuch A, Bhumiratana A. Efficacy of a single-dose treatment with 300 mg diethylcarbamazine and a combination of 400 mg albendazole in reduction of Wuchereria bancrofti antigenemia and concomitant geohelminths in Myanmar migrants in Southern Thailand. J Med Assoc Thai. 2006 Aug. 89(8):1237-48. [Medline].

  • Mand S, Debrah AY, Klarmann U, Batsa L, Marfo-Debrekyei Y, Kwarteng A, et al. Doxycycline improves filarial lymphedema independent of active filarial infection: a randomized controlled trial. Clin Infect Dis. 2012 Sep. 55 (5):621-30. [Medline].

  • Al-Kubati AS, Al-Samie AR, Al-Kubati S, Ramzy RMR. The story of Lymphatic Filariasis elimination as a public health problem from Yemen. Acta Trop. 2020 Dec. 212:105676. [Medline].

  • Milton P, Hamley JID, Walker M, Basáñez MG. Moxidectin: an oral treatment for human onchocerciasis. Expert Rev Anti Infect Ther. 2020 Nov. 18 (11):1067-1081. [Medline].

  • Feind-Koopmans A, van de Kerkhof PC. Successful treatment of papillomatosis cutis lymphostatica with acitretin. Acta Derm Venereol. 1995 Sep. 75(5):411. [Medline].

  • Boyd J, Sloan S, Meffert J. Elephantiasis nostrum verrucosa of the abdomen: clinical results with tazarotene. J Drugs Dermatol. 2004 Jul-Aug. 3(4):446-8. [Medline].

  • Warren AG, Brorson H, Borud LJ, Slavin SA. Lymphedema: a comprehensive review. Ann Plast Surg. 2007 Oct. 59(4):464-72. [Medline].

  • Drobot A, Bez M, Abu Shakra I, Merei F, Khatib K, Bickel A, et al. Microsurgery for management of primary and secondary lymphedema. J Vasc Surg Venous Lymphat Disord. 2021 Jan. 9 (1):226-233.e1. [Medline].

  • Onoda S, Nishimon K. The utility of surgical and conservative combination therapy for advanced stage lymphedema. J Vasc Surg Venous Lymphat Disord. 2021 Jan. 9 (1):234-241. [Medline].

  • Narushima M, Mihara M, Yamamoto Y, Iida T, Koshima I, Mundinger GS. The intravascular stenting method for treatment of extremity lymphedema with multiconfiguration lymphaticovenous anastomoses. Plast Reconstr Surg. 2010 Mar. 125(3):935-43. [Medline].

  • van der Walt JC, Perks TJ, Zeeman BJ, Bruce-Chwatt AJ, Graewe FR. Modified Charles procedure using negative pressure dressings for primary lymphedema: a functional assessment. Ann Plast Surg. 2009 Jun. 62(6):669-75. [Medline].

  • Borst GM, Goettler CE, Kachare SD, Sherman RA. Maggot Therapy for Elephantiasis Nostras Verrucosa Reveals New Applications and New Complications: A Case Report. Int J Low Extrem Wounds. 2014 May 25. 13(2):135-139. [Medline].

  • Devoogdt N, Christiaens MR, Geraerts I, Truijen S, Smeets A, Leunen K, et al. Effect of manual lymph drainage in addition to guidelines and exercise therapy on arm lymphoedema related to breast cancer: randomised controlled trial. BMJ. 2011 Sep 1. 343:d5326. [Medline]. [Full Text].

  • Torres Lacomba M, Yuste Sánchez MJ, Zapico Goñi A, Prieto Merino D, Mayoral del Moral O, Cerezo Téllez E, et al. Effectiveness of early physiotherapy to prevent lymphoedema after surgery for breast cancer: randomised, single blinded, clinical trial. BMJ. 2010 Jan 12. 340:b5396. [Medline]. [Full Text].

  • Armer JM, Stewart BR, Shook RP. 30-Month Post-Breast Cancer Treatment Lymphedema. J Lymphoedema. 2009 Apr 1. 4 (1):14-18. [Medline]. [Full Text].

  • Lowry F. Study finds genetic link to lymphedema. Medscape Medical News. Available at http://www.medscape.com/viewarticle/802874. April 22, 2013; Accessed: April 29, 2013.

  • Miaskowski C, Dodd M, Paul SM, West C, Hamolsky D, Abrams G, et al. Lymphatic and Angiogenic Candidate Genes Predict the Development of Secondary Lymphedema following Breast Cancer Surgery. PLoS One. 2013. 8(4):e60164. [Medline]. [Full Text].

  • Acromegaly — Symptoms and Treatment


    Image: “Image from page 818 of ‘Physiology and biochemistry in modern medicine’ (1918), A, To show the appearance before the onset of acromegalic symptoms; B, The ap-pearance after seventeen years of the disease.” by Internet Archive Book Images. License: No known copyright restrictions


    Definition and Overview of Acromegaly

    Description

    Acromegaly is a condition in which an adenoma within the pituitary gland produces excess growth hormone. Acromegaly is characterized by enlarged extremities and facial features, as well as joint pain and a protruding lower jaw. If the hormone-producing adenoma occurs in childhood, prior to growth plate fusion, the condition is referred to as gigantism.

    Synonyms: acromegaly (ancient Greek for ‘extreme’ and ‘large’), gigantism, Pierre Marie’s disease.

    Epidemiology of Acromegaly

    In the United States, acromegaly has a prevalence of approximately 20,000 patients, and approximately 1,000–2,000 new cases of acromegaly are diagnosed each year. 

    The median age of diagnosis of acromegaly is approximately 40 years. Even with advanced medicine, a lag of 9-10 years between the onset of acromegaly and its diagnosis is common. 

    Life expectancy is shortened by about 10 years in patients with acromegaly due to malignant tumors. No significant differences in its incidence have been found between men and women. 

    Etiology and Pathogenesis of Acromegaly

    Growth hormone (GH) in acromegaly

    Note: GH = growth hormone = somatotropic hormone = STH

    GH is a peptide hormone produced in the adenohypophysis and secreted predominantly during sleep and during puberty. Production of GH is also affected by nutrition. GH has insulin-antagonistic, growth-stimulating, and anabolic (i.e.↑ intracellular integration of amino acids, ↑ protein synthesis) effects. The effects of GH are indirect and mediated via insulin-like growth factor (IGF-1) synthesis in the liver. Levels of GH increase during:

    • Hypoglycemia
    • Stress
    • Physical exertion

    Note:

    1. GH is responsible for cell growth and mechanical signal propagation in the locomotor system and in connective tissue.
    2. GH increases gluconeogenesis in the liver and stimulates glucagon secretion.

    Hormonal regulation

    • The hypothalamus produces GH-releasing hormone (GHRH), also known as somatoliberin; GHRH ⇒ stimulation of GH production.
    • The hypothalamus synthesizes GH-inhibiting hormone (GHIH), also known as somatostatin; GHIH ⇒ inhibition of GH production.
    • GH acts peripherally via IGF-1 produced in the liver. In acromegaly, there is no negative feedback mechanism for GH. For more information on feedback mechanisms, read the Hypothalamus Pituitary Adrenal Axis article.

    GH-producing hypophyseal adenoma

    GH overproduction in acromegaly is typically caused by a monoclonal pituitary adenoma. GH-producing tumors constitute 20% of all hypophyseal adenomas. In rare cases, acromegaly is induced by a decrease in somatotropin (GHIH) synthesis or an excess of GHRH. Undue secretion of GH leads to enlarged organs and extremities underlying the characteristic facial appearance.

    Overproduction of GH in childhood, prior to growth plate fusion, results in a similar condition called gigantism. Afflicted patients are typically 6’6” tall. The characteristic malocclusion and enlargement of the temporomandibular joint are the domain of orthodontists and dentists, who are the primary consultants specializing in these abnormalities. 

    Symptoms and Clinical Presentation of Acromegaly

    Clinical symptoms of acromegaly are attributed to elevated stimulation of endochondral and appositional bone growth, increased stimulation of skin and skin appendages, and organ growth.

    Children (before growth plate fusion) Adults (after growth plate fusion)
    Hypophyseal gigantism > 6’6” Acromegaly, visceromegaly

    Typical characteristics and symptoms of acromegaly

    Image: Facial aspect of a patient with acromegaly. By Openi, License: CC BY 2.0

    • Visceromegaly (visible organ enlargement, e.g., goiter formation)
    • Enlargement of osseous extremities

    Image: Hand of a healthy woman (A) and a person with acromegaly (B). By Openi, License: CC BY 2.0

    • Thickening of the dermis (pachydermia): hypesthesia, paresthesia
    • Macroglossia: enlargement of the tongue with dysphonia
    • Enlarged nose
    • Formation of supraorbital bulges
    • Separation of the teeth and broadened interdental grooves
    • Headache, fatigue, bone pain, increased perspiration

    Note: Important anamnestic questions: Does your wedding band still fit? Has your shoe or hat size changed?

    Possible complications of acromegaly

    • Cessation of residual adenohypophysis function overgrowth symptoms 
    • Visual field disturbances (bitemporal hemianopsia due to compression of optic chiasm)

    Image: Pituitary macroadenoma with suprasellar extension, compressing the optic chiasm. By Openi, License: CC-BY 2.0

    • Carpal tunnel syndrome due to connective tissue hyperplasia

    Secondary complications in acromegaly

    • Sleep apnea (> 90% of patients are affected)
    • Diabetes mellitus
    • Secondary hypogonadism (women: secondary amenorrhea and menstrual cycle disturbances; men: loss of libido and potency), hyperprolactinemia, erectile dysfunction
    • Hypertension (30% of patients)
    • Spinal column and joint complaints
    • Increased incidence of colon and breast cancers

    Diagnosis of Acromegaly

    Acromegaly should be diagnosed as quickly as possible

    Early detection can minimize the patient’s suffering and consequences. When acromegaly is suspected, ask the patient for an older picture, such as an old driver’s license, and compare facial features.

    Laboratory studies

    The secretion of GH varies by the time of the day. Therefore, single observations of GH are not useful for the diagnosis of acromegaly. The easiest diagnostic test is the oral glucose tolerance test (OGTT) with a parallel observation of serum GH. In acromegaly, GH levels are not suppressed to <1 μg/L.

    Furthermore, hormone analysis will reveal pathologically high levels of IGF-1 and GH. Bound IGF-1 has a serum half-life of up to 18 hrs, which indicates that serum observation is sufficiently meaningful.

    To exclude the presence of other hormone-producing adenomas of the adenohypophysis, levels of luteinizing hormone/follicle-stimulating hormone (LH/FSH), thyroid-stimulating hormone (TSH), prolactin, and adrenocorticotropic hormone (ACTH) are also tested. Complete or partial hypopituitarism is often observed in parallel with acromegaly.

    Pathology

    Microscopically, the tumors in acromegaly can be differentiated into sparsely-granulated (aggressive) and densely-granulated (less aggressive) types. In one-third of acromegaly cases, elevated secretion of prolactin (monomorphic, mono-cellular, mixed cell adenomas) is also observed.

    Radiologic procedures

    Image: Pituitary macroadenoma with suprasellar extension, compressing the optic chiasm. By Openi, License: CC-BY 2.0

    Patients with acromegaly show an enlarged sella turcica on skull X-ray, the nasal sinuses, and the heart. MRI is indicated for tumor screening.

    Differential Diagnoses of Acromegaly

    Diseases similar to acromegaly

    GH disturbance without adenoma Hereditary acromegaly Further differential diagnoses
    Pituitary hyperplasia MEN-1 syndrome Constitutional tallness
    Ectopic/paraneoplastic GH-/GHRH-formation McCune-Albright syndrome Acromegaloid
    Familial acromegaly Primary hypertrophic osteoarthropathy or pachydermoperiostosis
    Carney complex

    Treatment of Acromegaly

    Surgical treatment

    Trans-sphenoidal adenoidectomy via endonasal access is the current standard of care. This surgery is curative, resulting in an immediate decline in GH levels following complete tumor excision.

    Note: GH levels declining below 2 µg/L indicate cure.

    Final evidence suggesting successful tumor removal and cure in acromegaly is obtained several weeks after the surgery based on a renewed endocrinologic examination.

    Radiation therapy

    Inoperable tumors or incomplete resection warrant stereotactic radiosurgery, proton therapy, and conventional radiation therapy. The effect of radiation, however, is often not immediate but occurs after several years under specific circumstances. Furthermore, one must consider the risk of anterior pituitary insufficiency.

    Therapeutic medication

    Pharmacologic intervention is indicated for patients with inoperable acromegaly and refractory to transient radiotherapy. If the patient’s tumor is large, preoperative pharmacologic treatment may be useful to induce tumor shrinkage and improve the patient’s general constitution. All medications aim to inhibit GH secretion:

    Drug group Effect Examples
    Dopamine D2-receptor agonists Inhibition of GH production by the pituitary adenoma Bromocriptine, Cabergoline
    GH receptor antagonists Normalization of the elevated IGF-1 level Pegvisomant
    Somatostatin analogs Decreased size of the adenoma, normalized GH levels Octreotide, Lanreotide

    Prognosis of Acromegaly

    Lowered life expectancy 

    The life expectancy of patients with acromegaly is shortened by approximately 10 years due to secondary complications. Lethality is twice as high and up to 4-fold higher than healthy individuals. The primary reasons for decreased life expectancy are usually hypertension, cardiovascular disease, and diabetes mellitus.

    An Acromegaly Case Report

    A 45-year-old man presented with the typical changes of acromegaly (i.e. enlarged nose, ears, lips, tongue, fingers, and toes). Endocrinology tests showed pathologically elevated GH levels; he was diagnosed with acromegaly. Subsequent magnetic resonance imaging (MRI) showed a small pituitary tumor with little contrast uptake, which suggested a GH-releasing adenoma.

    The tumor was surgically removed by gaining access through the right nasal cavity and the sphenoidal sinus using a surgical microscope and endoscope. After the operation, GH levels returned to normal. A post-surgical MRI showed complete removal of adenoma with adequate visualization of the normal pituitary gland. Postoperative hormone tests revealed normal functioning of the remaining pituitary gland without the need for hormone replacement. Acromegaly was cured with surgical intervention alone.

    90,000 Operation to get taller. Why do people decide to lengthen legs

    • Tom Brada
    • BBC

    Photo author, Dr S. Robert Rozbruch

    Photo caption,

    Sad underwent surgery in 2015, enlarging their height from 162 to 170 centimeters

    Every year hundreds of people around the world go to lengthy, sometimes very painful, leg lengthening operations in order to become several centimeters taller. Like any operation, this procedure carries a certain risk, and, according to doctors, some patients develop health problems after such “stretching”.

    Sam Becker was the tallest in high school, but his classmates soon outgrew him.

    “After going to college, I noticed that I was shorter than many other guys and even girls. It has an impact on you. Honestly, women generally prefer not to date guys who are shorter than they are. that I will never be able to find a wife for myself, “admits 30-year-old Sam, who lives in New York.

    For a while, he still hoped to grow up a little, although deep down he realized that, apparently, he had reached his limit: “I always thought that growth and success are interconnected.I had to find a solution. “

    ” Will I be able to walk? “

    Sam went through all the options, but temporary tricks like shoes with a hidden platform or stretching exercises did not inspire him.

    However, when he found out that you can lengthen the legs, it seemed tempting to him. After talking with his mother and weighing all the pros and cons, he decided to lie down on the operating table.

    In 2015, he underwent surgery and “grew” by 8 centimeters – from 162 to 170 centimeters.

    “At the very first consultation, the doctor clearly explained to me how difficult such an operation would be. I was concerned about what exactly I would be able to do after receiving these additional eight centimeters: can I walk? Will I be able to run?” …

    “After the operation, I went to special procedures three or four times a week, which took several hours. It took about six months. It was an enlightening experience. Of course, it sounds crazy … breaking both legs and then learning to walk again.It is considered cosmetic surgery, but my mental health was at stake for me, “Sam admits.

    Photo author, Dr S. Robert Rozbruch

    Photo caption,

    X-ray of Sam’s legs before and after surgery: in the photo on the right you can see inserted metal wires

    Shin lengthening surgery is available in more than ten countries around the world, and in some cases it can increase the patient’s height by 13 cm. that its popularity is growing.The BBC contacted a number of leading clinics around the world and found out that the number of such operations in different countries differs markedly.

    Leading clinics in the USA, Germany and South Korea perform from 100 to 200 such operations per year. In countries such as Spain, India, Turkey and Italy, it is about 20 to 40 annually. In Britain, this number is even lower – about 15 operations per year. But almost everywhere the BBC confirmed that the number of patients is growing from year to year.

    There are only a few private clinics in Britain that are regulated by the Care Quality Commission.Its cost can reach 50 thousand pounds (more than 67 thousand dollars), while in the United States the price varies from 75 thousand to 280 thousand dollars.

    The operation is not only expensive, but also difficult and painful. The method of bone lengthening was first developed by the Soviet orthopedic surgeon Gavriil Ilizarov, who treated wounded soldiers after World War II. And although his method has undergone a number of improvements over the past 70 years, the principle has remained the same.

    The bone is drilled in the thigh or lower leg and then broken in two.A metal spoke is inserted into the place of the break and secured with special nuts. Then the spoke is gradually lengthened – by 1 mm per day – by tightening the nuts to the length of the legs required by the patient.

    After that, the patient must follow a special rehabilitation regime for several months in order to start walking normally.

    The method is fraught with a number of complications – from injuries of nerve endings to the formation of blood clots and improper bone fusion.

    An 8 cm hole

    Barney went through it all.

    He underwent surgery in Italy in 2015 and grew by 8 centimeters – from 167 to 175 cm.But he did it not so much out of vanity as out of necessity – for medical reasons, he needed to straighten the leg bones, and he decided them at the same time and pull out.

    He was assured that these two procedures can be done at the same time and will not affect his postoperative recovery. But he still has not recovered from the consequences.

    “If I was 16 years old, then perhaps the problem would not have arisen.But I was 46 when I had this operation, says Barney. – My legs were stretched, but the bones never healed. I got an eight-centimeter hole … two stubs of bone on both sides and a metal pin in the middle. “

    Barney still recalls the physical pain he had to endure during the stretching process.

    ” It’s like pulling on every nerve on in your leg. There are times when the pain simply has nowhere to go. It’s totally unbearable, “he says.

    However, despite this tear in his leg bones, Barney was able to walk because the connecting rod could support his weight and hold the bones together.

    But it was also clear that the situation was not easy.

    “There was a moment when I thought:“ Well, that’s it, I’m finished. ”I was very lucky that my relatives and my boss supported me. But all this can very easily turn into torment, so it is necessary that your loved ones react to this with understanding. It couldn’t be worse when things don’t go according to plan, “he says.

    Photo caption,

    “I have a long time to recover,” says Barney

    Since limb lengthening operations are done in private clinics, there is very little data on complications.

    Professor Hamish Simpson of the British Podiatric Association also warns of potential risks.

    “This method and the whole procedure have advanced quite significantly over the past twenty years, and now the operation is much safer. However, in addition to the actual bone augmentation, it is also necessary to build up muscles, nerves, blood vessels and skin, so this procedure remains very difficult. with a high likelihood of complications, “- says the surgeon.

    British orthopedic surgeon David Goodyear points out that some of his patients who were about to undergo bone lengthening had psychological problems such as body dysmorphic disorder fictional or grossly exaggerated]. He says that as demand for this type of operation grows, fears that price will be prioritized over quality are growing.

    “When a patient has a choice – to go to a clinic specializing in reconstructive surgery of the extremities, or to a cheaper place, then I don’t think that he will be clearly warned about all the complications that can arise and very often occur. What will happen if you Will you go to another country, have an operation there, and then return home to Britain with complications? Answer: you will be sent to me through the National Health Service so that we correct other people’s mistakes, “says the doctor.

    Did it and forget it?

    As for Barney, the day after our meeting with him, the last wire was removed from his thigh – five years after the first operation. Despite the pain, the cost of the operation and several years of rehabilitation, he practically does not regret anything.

    “It’s foolish to regret. There are a lot of people for whom the same operation was successful, and you won’t even know about them. They just live in peace. I will have to recover for a long time, but the operation was worth it anyway.She gave me the opportunity to rebuild my life, which will not depend on the prejudices associated with small stature, “explains Barney.

    Academician Ilizarov’s method

    Orthopedic surgeon Gabriel Ilizarov became famous back in Soviet times, having developed a method for splicing and lengthening of the bones in the event of a broken leg

    Working in the post-war years as an orthopedic traumatologist, Ilizarov gained vast experience in treating injured limbs from former front-line soldiers.

    His fundamentally important discovery – the so-called “Ilizarov effect” – was the discovery of the ability of tissues to respond with regeneration to stretching, when the bone literally builds up a connective callus.

    Based on this, he developed a method of stimulating osteosynthesis, that is, joining and fusing bone fragments, by squeezing (compression) and stretching (distraction).

    Ilizarov developed and in 1952 patented his compression-distraction apparatus, which was based on metal rods, rings and pins, with the help of which bone fragments were fixed.

    At the end of 1971, under his leadership, the Kurgan Research Institute of Experimental and Clinical Orthopedics and Traumatology (KNIIEKOT) was opened, which has been named after him since 1993.

    Increase in height (lengthening of the legs by surgery)

    City Orthopedic Center (Volgograd)
    Low-trauma surgery to lengthen the limbs.

    Volgograd City Center of Orthopedics and Orthopedics
    Cosmetology offers the following service – an increase in growth for cosmetic purposes, as well as in the presence of medical indications.It became possible to lengthen the legs in a safe way for health thanks to the use of specially developed M.F. Egorov and O.G. Teterin low-traumatic techniques.

    After the formation of the bone skeleton and the closure of the growth zones of the bones, you can increase your growth only with the help of surgery.

    How are the legs lengthened?

    The increase in growth is based on a pattern discovered in 1989. G.A. Ilizarov. The regularity lies in the fact that when the bone and surrounding soft tissues are stretched, tension is formed, which stimulates the formation of bone tissue, i.e.That is, a new callus is formed. Within a year after surgery
    callus acquires the same structure and strength as other areas of the bone.

    Surgical increase in height due to lengthening of the legs is carried out on the basis of low-trauma techniques patented by the orthopedists of our clinic, which include an external fixation device, surgical approaches, various types of corticotomies, and instrumentation.

    Surgeries to increase the height at the expense of the hips are mainly carried out for medical reasons.For cosmetic purposes, such operations are rare due to the greater trauma and possible complications. Therefore, to achieve aesthetic goals, growth is increased by stretching the lower legs.

    The increase in growth is carried out in four stages:

    • planning the elongation value
    • operation
    • distraction (gradual lengthening of the limbs)
    • fixation in devices

    Before surgery, orthopedists measure the proportions of the patient’s body and determine the optimal lengthening value for him, which often varies from 4 to 7 cm.The magnitude of the maximum increase in length is determined by the elasticity of the soft tissues in a particular patient. In most cases, a 5.5-6 cm stretch is sufficient for a cosmetic increase in human height.

    The lengthening of the legs is impossible without surgical intervention on the bones. Both tibia bones of the lower leg are intersected (osteotomized). In order to reduce the trauma of the operation, the doctors of the Center cross the superficial and most durable layer of the bone – the cortical layer, therefore the operation is called corticotomy.Corticotomy, to a greater extent than osteotomy, preserves osteogenic cells, which are responsible for the formation of new bone tissue – regenerate.

    Surgical intervention is performed simultaneously on two legs. During the operation, the needles are drawn and the supports of the apparatus are fixed to each limb. The number of supports varies from two to four, depending on the initial segment length, the planned length increase and the level of the operation. After that, a corticotomy of the peroneal and tibial bones of the lower legs is performed from small incisions.The supports are connected by threaded rods. Cosmetic sutures are applied to the wounds.

    The day after the operation, the patient gets to his feet and walks independently with the help of crutches. On the 5-7th day, stretching of the bone tissue (distraction) begins by dosed tightening of the nuts in the apparatus. The rhythm and tempo of distraction are calculated individually using a special computer program “Osteokinesis”. Stretching of bone tissue is carried out on average by 0.25 mm 3-4 times a day, thus the leg is lengthened by 0.75-1 mm per day.The duration of the distraction stage is from 1.5 to 2.5 months, depending on the required amount of stretching. During the period of distraction, the patient walks with crutches and loads the operated limbs in doses.

    After the end of the distraction, the fixation period begins, which is necessary for the young callus to acquire the structure and strength of the bone tissue. The fixation period is 2-3 times longer than the limb lengthening period. The patient increases the motor regime, and accordingly increases the load on the legs.The devices are removed sequentially after the end of the fixation period on each lower leg. During the fixation period, patients develop knee and ankle joints with exercise therapy. After removing the apparatus, a therapeutic massage is performed.

    It is possible to increase your height for a period from 4 to 9 months from the moment of admission to the clinic until the removal of external fixation devices. The duration is determined by the achieved value of the lengthening of the legs, as well as the regenerative capacity of the bone tissue, which is individual for each organism.

    Rehabilitation period after leg lengthening surgery

    After the operation, small scars remain, which become invisible within a year (especially after the first sunburn).
    The rehabilitation period after surgical lengthening of the lower extremities lasts 2-3 months. During the rehabilitation period, dosed loads on the legs and swimming are recommended.
    Restrictions on sports and physical activity are removed after the end of the rehabilitation regime.

    Additional information

    If necessary to correct valgus or varus deformity,
    operative increase in the length of the legs
    can be combined with shin shape correction.

    An operation to lengthen only one leg is possible, which makes sense in the case of congenital or acquired as a result of trauma difference in the length of the lower extremities.
    Indication for stretching one lower limb (lower leg or thigh)
    there is a difference in length of more than 1.5 cm.

    Get acquainted with the conditions for the provision of services to increase height by lengthening the legs

    Sign up for treatment or consultation

    90,000 Leg lengthening with the Ilizarov apparatus: cost, how it is performed, painful or not

    Almost all of us are dissatisfied with ourselves in some way. There are a lot of reasons – from bad habits to appearance. Let’s talk about the most intrusive and difficult to correct – small stature. Small stature or too short legs can cause great psychological suffering.He prevents girls from making a career, young people add self-doubt. Is there really nothing you can do? Do not despair, there is always a way out. Surgical correction with leg lengthening is an effective method of increasing height. How is this possible? Due to the ability of bone tissue to grow.

    In our clinic, we perform leg lengthening operations based on low-traumatic techniques developed by Professor Akshin Bagirov using improved layouts of the Ilizarov apparatus.The success of the operation and the guarantee of its safety mainly depend on the quality of the preoperative examination. With the help of computed tomography, all the dimensional characteristics of the legs are determined: the length of each leg, each segment, their proportions down to a millimeter, as well as the condition of the hip, knee and ankle joints. The essence of the operation is that, after installing the Ilizarov apparatus on the lower leg, the tibia and fibula are intersected at different levels. Then, with the help of external structures (devices), the patient independently (with the help of simple devices) stretches the lower leg at the intersection of the bone.At the same time, the growing callus fills the increasing lumen of the cuts, lengthening the bones.

    The principle is based on the law discovered by G.A. Ilizarov, which consists in the fact that when the bone and surrounding soft tissues are stretched, tension is formed, which stimulates the formation of cellular tissue, i.e. a new callus is formed. The process of such “growth” is slow, but the effect is undeniable. A person becomes taller, and at the expense of his own bones. The next day after the operation, the patient gets up and walks on his own with the help of a walker.This happens as follows: on the 5-6th day after, stretching of the bone tissue (distraction) begins by dosed tightening of the nuts in the apparatus at a certain rhythm and pace, calculated for each patient individually using a special computer program.

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    The rate of distraction (stretching) used for lengthening the legs is 0.5 – 1 millimeter per day and is performed in two or four steps, 1/4 turn of the nut per day, respectively.It is performed by the patient independently under the periodic supervision of a doctor 1-2 times a month. The number of days required to achieve the lengthening selected by the patient is calculated as follows (lengthening by 3 cm will require 30 days of distraction – taking into account the rate of 1 mm per day, etc., sometimes even more extended periods, the amount comes from 0.5 to 1 mm).

    In the elongation zone, bone regenerate is formed, which increases in length during distraction. Subsequently, after the end of the lengthening (distraction) period, it takes time to complete the ossification (ossification) process of the newly formed regenerate.

    The timing of the use of external fixation devices depends on the lengthening value of the lower extremities (the greater the lengthening value, the longer the fixation period in the device), in addition, on the individual characteristics of the patient (gender, age, the presence of chronic diseases) and averages from 6 to 12 months.

    The external fixation device itself is very important in this process.

    There are various types and variants of external fixation devices, with the help of which lengthening is carried out, but almost all of them have a significant drawback of large dimensions, which cause inconvenience when wearing, and restrict movement in the joints.We solved this problem by creating a compact, small-sized layout of the Ilizarov apparatus with a rigid design of the fixators, capable of withstanding all loads during limb lengthening and at the same time not limiting movement in adjacent joints and wearing clothes.

    For the entire lengthening period, careful monitoring is carried out by a doctor using X-ray and computed tomography studies. After removing the structures (needles and rods), small marks remain on the skin, but over time they brighten and become almost indistinguishable.

    Thus, after enduring several difficult months, you will forever get rid of your complexes and problems associated with short stature, jump “above yourself”, reaching the top of your dream to become “higher”!

    Leg (limb) lengthening with FITBONE® rod. Booking Health

    Currently, due to the difficulties associated with the organization of treatment in Turkey, Switzerland, South Korea and India, we have suspended the processing of applications in these areas.

    If you are interested in organizing treatment in Germany, please leave a request and our specialists will contact you as soon as possible.

    The Fitbone® Fully Implantable Distraction Intramedullary Rod is an innovative device that restores the symmetry and length of the lower limbs through the growth of the patient’s own bones. An important feature of this technique is that it is much less traumatic than the installation of the external Ilizarov apparatus, which has traditionally been used in such situations for more than a century and has not had a worthy alternative all this time.The anatomical design of Fitbone® does not limit the patient’s physical capabilities and makes his life during treatment as comfortable as possible.

    The cost of the leg lengthening procedure using the Fitbone® apparatus at the University hospitals in Germany can be found here. Leave a request and we will provide a free consultation with a doctor and organize the entire treatment process.

    This includes:

    • Issuing an invitation for treatment to quickly obtain a medical visa

    • Make an appointment at a convenient time for you

    • Preliminary organization of a comprehensive examination and discussion of a treatment plan

    • Provision of a transfer from the airport to the clinic and back to the airport

    • Provision of the services of an interpreter and personal medical coordinator

    • If necessary, assistance in organizing further surgical treatment

    • Provision of medical insurance against treatment complications with a coverage amount of 200,000 euros

    • Preparation and translation of medical extracts and recommendations from the clinic

    • Assistance in subsequent communication with your attending physician, including consultations on repeated X-rays through the unique medical document management system E- doc

    Contents

    1. The principle of therapeutic action of the Fitbone® intramedullary nail
    2. Therapeutic capabilities of the Fitbone® intramedullary nail
    3. How the Fitbone® intramedullary nail is inserted
    4. How does the author’s bone augmentation and fixation take place directly
    5. methods – Prof. Rainer Baumgart

    The principle of therapeutic action of the intramedullary nail Fitbone®

    The Fitbone® system consists of several components, each of which plays a specific role in the bone augmentation process:

    • Fitbone® rod .During surgery, the nail is placed inside the femur or tibia (the main bone of the lower leg). In this case, the surgeon does not rigidly fasten the sections of the bone separated for the introduction of the rod – it is in these zones that the missing bone tissue will form. The Fitbone® shaft is locked inside the bone, i.e. intramedullary, and creates a solid foundation for its lengthwise growth.
    • External control unit with transmitter (transmitter) . The electronic control unit allows the doctor to individually select the speed of distraction – the separation of the separated parts of the bone from each other.A well-chosen rate of distraction is important for the full growth of the bone and associated tendons, blood vessels and nerve endings. After determining all the necessary physical parameters, the control unit creates an electrical impulse corresponding to them. With the help of a transmitter, a transmitter, the pulse gets to the receiver.
    • The receiver (receiver) is located in the immediate vicinity of the Fitbone® rod – it is implanted under the skin of the thigh or lower leg. Receiving an electrical impulse from the transmitter, the receiver drives the miniature electric motor of the Fitbone® rod and provides the bone distraction process.Important features of the Fitbone® system are the transmission of impulses through intact skin and the autonomous operation of the nail within the bone. Moreover, after appropriate training, the patient can easily carry out all the necessary manipulations on his own, at home.

    The Fitbone® system, developed by Prof. Baumgart at the Munich Center for Corrective and Reconstructive Limb Surgery, creates new, artificial growth zones in the femur and / or tibia.Surgical separation of the bone, secure fixation on a strong metal rod and constant controlled tension create favorable conditions for the natural biological process of new bone formation.

    In fact, traditional steel or titanium intramedullary rods have been used in surgery for over 50 years. A fundamentally new feature of the Fitbone® system is to equip the rod with an internal electric motor, which provides minimal, but constant and uniform, bone tension, as well as uninterrupted operation from an external power source.In terms of clinical practice, the technique is quite young (it has been used for about 20 years), but it has already demonstrated its unique advantages and helped thousands of patients from all over the world.

    Send a request for treatment

    Therapeutic possibilities of Fitbone® intramedullary nail

    Fully implantable Fitbone® intramedullary intramedullary nail has been successfully used in patients:

    • for example, after treatment of bone tumors)
    • With underdevelopment of the lower extremities, including congenital pathologies and dysplastic processes arising in adulthood
    • With deformities of the limbs (for example, with cerebral palsy, O-shaped and X-shaped curvature)
    • 90 140 With general low stature against the background of impaired development of cartilage or bone tissue, hormonal disorders (for example, with achondroplasia or Russell-Silver syndrome)

    • With a general short stature in the absence of other pathology (familial short stature)

    Results of treatment with a Fitbo rod ne® are most noticeable in patients with severe disorders – the difference in the length of the legs is more than 6-8 cm, pronounced deformities after injuries and previous surgical interventions.In such cases, the use of the Fitbone® system completely removes the cosmetic defect and, more importantly, restores the function of the damaged limb. The latest models of the device extend the thigh up to a maximum of 85 mm and the lower leg up to 65 mm. To achieve the best result, the device can be simultaneously installed in both the thigh and the lower leg – this allows you to achieve even greater lengthening of the limb and increase the growth rate up to 2 mm per day.

    The Fitbone® rod is also used in lighter cases, for example, with a difference in leg length of 2-3 cm, minor axial deviations (O-shaped and X-shaped legs) or torsional deformations (incorrect turn of the foot or hip).Early restoration of the normal structure of the limbs allows avoiding future complications such as gait and balance disorders, back pain, spinal deformities, hip joint disease and even fractures. Often, patients try to be treated with conservative methods – they buy special shoes, use orthoses and walking sticks. However, this only partially alleviates the problem. With a high degree of probability, surgical treatment will still be required, but it will be carried out with a delay, at a more advanced stage of the disease.

    The Fitbone® nail implantation is the optimal solution for patients who want to increase their height. At the same time, the possibility of performing an operation does not depend on the reasons for short stature, be it a genetic syndrome, a systemic disease or individual characteristics. Naturally, in this case the Fitbone® rod is placed in both legs, and the duration of the treatment depends on the desired end result. In such a situation, at the initial stage of treatment, before the bone is strengthened, the patient will need to temporarily use a wheelchair.An increase in growth of more than 10-15 cm is possible subject to an intermediate surgical intervention.

    How the Fitbone® intramedullary nail is inserted

    Preparation for implantation of the Fitbone® intramedullary nail begins with a thorough examination, which includes:

    • Detailed clinical examination
    • Measurements of all lengths and axes of the lower extremities
    • Comprehensive X-ray examination
    • CT / MRI examination on high-resolution tomographs

    Then the doctor and the patient discuss in detail the desired result of the treatment.Based on all the information, the team of specialists determines the optimal zones of bone separation and the most suitable Fitbone® intramedullary nail model. If necessary, an individual rod is made, adapted to the needs of a particular patient.

    Specialists of the Munich Center for Corrective and Reconstructive Extremity Surgery ZEM use the “reverse planning” method – they go from the desired end result to the choice of operating technique, the speed of distraction and the intensity of physical rehabilitation in the postoperative period.After receiving all the recommendations, the patient has several months to prepare for treatment and choose the date of the operation. 6 weeks before hospitalization, a second outpatient consultation is held, during which you can additionally clarify all questions of interest directly with the operating surgeon.

    On the eve of the planned operation, the patient is admitted to a specialized partner clinic of the Munich Center for Corrective and Reconstructive Extremity Surgery ZEM – Munich Hospital of the Brothers of Mercy.After a preliminary laboratory examination and a conversation with the anesthesiologist, the patient is implanted with an individually fitted Fitbone® nail. The operation is performed under general anesthesia and, depending on the level of complexity, can last up to 3 hours. During the surgical procedure, a specific radiopaque mesh is used to ensure perfect alignment of the nail along the axis of the bone. After the operation, the patient is transferred back to the ward, there is usually no need to stay in the intensive care unit.

    The hospital stay is not limited to just passive observation by medical personnel. The very next day after the operation, the patient can move with support on crutches. Crutches or a cane are needed to reduce the weight of the operated leg; experts recommend limiting it to 20% of body weight. After the control radiographs, the patient continues to learn how to walk with crutches, special exercises and work with the external control unit of the Fitbone® system.6-10 days after the operation, the patient is discharged from the hospital and continues treatment at home.

    How is bone augmentation going and consolidation of the result

    The first session of distraction (leg lengthening) takes place on the 5th day of hospital stay, under the supervision of the attending physician. After that, the patient conducts such sessions daily at home, according to the intensity regimen recommended by the doctor. On average, a distraction session takes about 5 minutes a day and can be done at any time.

    Accuracy and reliability of the electronic control unit allow achieving uniform limb lengthening at the recommended speed of 1 mm per day. This speed ensures the normal growth of not only bone, but also the accompanying blood vessels and nerves, muscles and soft tissues. When a Fitbone® rod is implanted into the thigh and lower leg, the growth rate doubles at the same time and reaches 2 mm per day.

    Positioning of the Fitbone® rod inside the bone, without external fixation and damage to the skin, makes the treatment process completely painless.The absence of external fixators eliminates the risk of infections inherent in earlier methods of osteosynthesis, and damage to the soft tissues of the thigh and lower leg. The patient can wear normal daily clothes, bathe and shower, walk with crutches (until the new bone is hardened), and even drive (if the left leg has been operated on).

    If it is necessary to significantly lengthen the bone (by 5 cm or more), certain discomfort may occur due to the tension of the soft tissues and pressure on the joints.Consistent remedial gymnastics helps to cope with discomfort, as well as provides soft tissue elongation in accordance with bone growth and full motor function. If desired, the patient can additionally undergo a course of physiotherapy.

    The process of distraction and callus formation is closely monitored during weekly outpatient consultations with the treating surgeon. At each appointment, a physical examination and X-ray examination are carried out, so the doctor has a complete understanding of the dynamics of bone growth.Gradually, in the absence of complications and a good growth rate, consultations become more rare.

    After reaching the desired length of the limb, the next stage of treatment begins – consolidation, or strengthening of the new bone. The final formation of bone tissue takes 2-3 times longer than the process of distraction. All this time, the patient continues to use the Fitbone® nail, but without the daily distraction procedures. During the consolidation phase, the patient is advised to increase the load on the operated leg, and after this phase is completed, the Fitbone® rod is completely removed during the second surgery.Reoperation is carried out through a skin incision less than 5 mm in length, which allows to achieve a good cosmetic effect and ensure that there are no scars.

    Send a request for treatment

    Examination and treatment directly from the author of the method – Professor Rainer Baumgart

    In the course of his scientific and practical activities to eliminate limb asymmetry and stimulate bone growth, Professor, twice MD, Rainer Baumgart tried to preserve everything the indisputable advantages of the Ilizarov technique, as well as supplement them with comfort for the patient and a decrease in the risk of complications during treatment.A research project started in 1988 in Munich resulted in the development of the world’s first fully implantable Fitbone® intramedullary distraction nail. After technical improvement, the device entered clinical practice and has been successfully used for over 20 years.

    Specialists of the Munich Center for Corrective and Reconstructive Extremity Surgery ZEM annually admit more than 500 patients with similar pathology for examination and treatment. Given the high qualifications of Professor Baumgart and his colleagues, both German citizens and patients from other European countries, as well as America and Russia, apply to the clinic.It should be noted that the competence of the center’s staff includes exclusively the provision of medical services to international patients. Administrative work and organizational aspects of the trip are provided by the official partner of the Munich Center for Corrective and Reconstructive Extremity Surgery ZEM – a certified medical tourism operator Booking Health, which annually helps hundreds of patients with orthopedic problems to receive high-quality and effective treatment abroad.

    You can also undergo treatment in other clinics that have adopted the author’s method:

    1. University Hospital Heidelberg, Department of Adult and Pediatric Orthopedics, Traumatology
    2. University Hospital Rechts der Isar Munich, Department of Adult and Pediatric Orthopedics, Sports Medicine
    3. University Clinic of the University of MunichLudwig-Maximilian, Department of Adult and Pediatric Orthopedics
    4. School of Medicine Hannover (MHH), Department of Adult and Pediatric Orthopedics
    5. Medicana International Clinic Ankara, Department of Adult and Pediatric Orthopedics, Traumatology

    The cost of preliminary treatment and examination is:

    In order to start preparing for a trip for treatment, you need to leave a request with medical documents on the Booking Health website.After that, the patient manager will contact you, who will clarify the details of your condition and coordinate further actions for preparing documents for traveling abroad and an initial consultation with Professor Baumgart.

    For more than 15 years, our specialists have been happy to help patients from different countries improve their health and maintain it for many years. Start your journey to recovery as early as possible with us.

    Choose treatment abroad and you will undoubtedly get an excellent result!


    Authors: Dr. Nadezhda Ivanisova, Dr. Vadim Zhilyuk

    Read:

    Why Booking Health – Questions and Answers

    How not to be mistaken in choosing a clinic and a specialist

    Treatment of joint diseases in the Orthopedic Center Munich Ost

    Diagnostics IHD in Germany

    Send a request for treatment

    90,000 Top 15 Exercises to Increase Height – Ozon Club

    What Promotes Growth?

    Unless a person has a medical diagnosis that explains their small stature, they may get slightly taller with lifestyle changes.

    • Quitting bad habits. Most of them block growth hormone and disrupt metabolic processes in the human body.
    • Regular physical activity. During sports, muscles are stretched and strengthened, blood circulation in tissues is improved, joints and tendons are developed.
    • Proper nutrition. For normal development and growth, the body needs to consume a sufficient amount of nutrients, beneficial trace elements and vitamins. The diet should be balanced.
    • Compliance with sleep patterns. The hormone responsible for human growth is produced during sleep. You need to sleep for about 8 hours, and you should go to bed until 23:00. Interestingly, sleeping during the day will not give the same result, since the hormone is activated at night.
    • Experts also recommend avoiding stress. The nervous state of a person negatively affects the work of the whole organism, including the ability to slow down the growth process.

    Power supply

    To provide the body with sufficient nutrients and activate the growth process, the following foods must be included in the daily diet:

    • A small handful of nuts.They can be consumed as a snack or added to other meals.
    • Chicken eggs cooked in any way. It is recommended to eat them in 2 pieces – in the morning and in the evening.
    • Lean meats: beef, chicken, rabbit, veal. The product is rich in protein, iron and zinc, which are building materials for the body. They help the body develop properly.
    • Porridge – a source of fiber and slow carbohydrates. Oatmeal, buckwheat, lentils, millet, pearl barley are especially useful.

    Vitamin deficiency can slow growth. But taking vitamins of groups B, A, C and D along with a healthy lifestyle will help the body grow. They can be purchased individually or in capsule form. It is recommended that you consult your doctor before taking it.

    Effective Growth Exercises

    At home, regular simple exercises can help increase your height.

    Glute bridge

    Those who spend most of their time in a sitting position may have not only spinal problems, but also short stature.Exercise “gluteal bridge” will help to neutralize the negative impact of incorrect body position. If done regularly, you can correct your posture and stimulate the growth process.

    The exercise is performed lying on your back, with your shoulders pressed to the floor and your arms extended along the body. Slowly bend your knees and, without lifting from the floor, pull your feet to your buttocks until an angle of 90 ° is formed. Raise your pelvis, arch your back, and tighten your glutes. In this position, you need to linger for 30 seconds.Return to the starting position and repeat the exercise at least 9 more times.

    Vis on the crossbar

    This exercise allows you to increase your height by stretching the muscles of the whole body with your own weight. It is recommended to start it by jumping up to the horizontal bar. The height should be larger than your height so that your feet do not touch the ground.

    Having firmly grasped the bar, you need to relax your body and hang for 30 seconds. Pull-ups can be added for greater efficiency and additional strengthening of the arm muscles.You need to repeat the exercise 3 times a day.

    Jumping on one leg

    Leg exercises, especially jumping, are recommended to develop and strengthen your abs and lower body.

    Stand up straight with your arms outstretched. Bend your right leg at the knee. Make 10 jumps. Then stand on your right leg, bend your left knee and do 10 more jumps.

    Side slopes

    To increase your height, you need to not only strengthen your muscles, but also improve their elasticity.Stretching exercises will help with this.

    Stand with your feet together, raise your hands up and close them in the lock. Slowly tilt your body to the left, pausing for 20 seconds. Return to starting position and then lean to the right. Repeat the exercise at least 10 times.

    The cobra exercise is recommended to strengthen the back and stretch the abdominal, chest and shoulder muscles. It is performed in a prone position.

    Place your palms on the floor under your shoulders.Raise your upper body with outstretched arms. At the same time, tilt your head back and arch your back. In this position, you need to hold on for 30 seconds. Then return to the starting position and repeat the exercise several more times.

    “Sky rise”

    Another effective workout for increasing height, which is based on stretching. The muscles of the arms, back, neck and abs are involved.

    Stand with your feet together. Place your hands parallel to the floor and slowly lift them forward and then up.Stretch your whole body towards the sky, but do not lift your feet off the floor. At the same time, it is important to monitor your breathing. It should be calm and deep. Inhale through the nose, exhale through the mouth. Raise your head gently, look at your palms. While inhaling, hold your breath, slowly return to the starting position and exhale through your mouth. Then do a few more repetitions of the exercise.

    This exercise not only promotes growth, but also improves mood, strengthens leg muscles and promotes weight loss. You can just jump in place or use a trampoline, jump rope.

    When jumping, you must simultaneously lift your feet off the floor and land in the same way.

    This exercise is contraindicated in people who are overweight and have knee problems.

    Forward bends

    By stretching the calf muscles, a person may lengthen their legs slightly.

    Starting position: standing, back straight, legs slightly apart. Lean forward slowly, reach with your hands to the floor, trying to touch it. Do not bend your knees.Hold this position for 5 seconds and return to the starting position. Do some repetitions.

    Standing Stretch

    This exercise is similar to the previous one for gaining height. But it is a little more complicated by the fact that the legs must be together. In this case, the tension in the calf muscles will be more noticeable. In addition, the back of the thigh is involved.

    Gently lean towards the floor trying to touch it. Try not to bend your knees.Repeat the exercise at least 5 times.

    Breaststroke

    Swimming involves the muscles of the whole body. They stretch and strengthen. With regular exercise, an increase in growth is observed, both in children and in adults.

    This exercise has other benefits as well: strengthening the spine, developing the muscles of the back, arms and legs.

    Toe stretch

    Another way to increase height by stretching the calf muscles.Stand up straight with your back straight. Stand on your toes and stretch your whole body up.

    To make this exercise more effective, you can make the task a little more difficult. Stand in front of the wall, put your hands on it and crawl up, as if trying to reach the ceiling.

    A simple but very effective way to increase height is leg raises. This stretches the back of the thigh and spine.

    Lie on the floor with your arms at your sides. Raise your legs up.They should be straight. Stretch your toes towards the ceiling. In this case, the weight should be transferred to the upper body. Your hands can be resting on the floor, palms down, but they can also support your back.

    In this position, you need to hold out for about 1 minute. A total of 10 reps are recommended.

    This growth exercise is borrowed from the Korean martial art, taekwondo. It is based on a defensive movement. Its implementation requires a person to be well balanced and stretched.

    Stand with your feet together and your hands clenched into fists near your chest. Stretch your whole body up, while lifting one leg bent at the knee. Swing it forward. Repeat the movements for 30 seconds. After that, do the same with the other leg.

    Morning stretching

    Any exercise is most effective in the morning, when the body has just awakened. This is especially true of stretching, thanks to which you can maximize the capabilities of the body, including growth.

    After sleep, the spine is in a relaxed state, and in the evening its discs are compressed and fluid circulates poorly between them. Therefore, morning exercises will be more productive.

    They should be done while lying in bed or standing. Stretch your arms over your head and reach up. You will feel a pleasant stretching of the spine. This position must be held for 30 seconds. After that, relax and do a few more reps.

    Cat-Dog

    It is stretching the spine that allows you to increase your height, so this part of the body should be given the most attention.Exercise “cat-dog” will help to achieve a good result. It must be performed from the “on all fours” position.

    Slowly arch your lower back, pulling your chin up. Then return to the starting position and arch your back up. In this case, the head and pelvis must be directed downward. It is worth staying in each position for 5 seconds. The exercise should be repeated 5 times.

    In addition to the listed methods of accelerating growth, it is also recommended to run at a moderate pace. It helps develop the entire body – muscles, joints and tendons.Just 15 minutes of running improves blood circulation and metabolic processes. Together, all this contributes to growth, and also the body becomes fit and takes on beautiful outlines.

    Lipofilling of the breast (mammary glands) with own fat in St. Petersburg: prices in Mediaesthetic

    Beautiful and magnificent breasts are a wonderful adornment of a woman. But not everyone is naturally satisfied with their shape and size. Sometimes you want to adjust them a little, to bring them closer to your own idea of ​​perfection. At the same time, I do not want to insert implants.It is in such cases that you should think about such a procedure as breast lipofilling.

    The essence of the procedure

    This is a breast augmentation with own fat. Material from the places of its deposition is taken with the help of a cannula. After that, it is injected into the mammary glands, in pre-marked places, in the planned amount. The procedure has a number of advantages that distinguish it favorably in comparison with an alternative technique that requires the use of implants.

    The advantages of this operation

    Breast lipofilling is remarkable in that:

    • You can not only increase the volume, but also correct the shape, and also eliminate asymmetry.This is especially important if the woman is generally comfortable with her size.
    • Absence of traces. The fat is pumped out and injected using a thin cannula. The instrument does not injure the skin, so the intervention will be invisible.
    • Natural beauty. In addition to the fact that the operation does not involve scars, it gives the most natural result: both visually and by touch. This is one of its key advantages over implants.
    • Possibility to hide the stitches from implantation.Sometimes lipofilling is also used in order to level the surface in the places through which they were inserted into the mammary gland.
    • There is no need to change the implant every 7 years. However, adipose tissue tends to dissolve. Therefore, although the procedure has a cumulative effect, it will need to be repeated to achieve it.
    • Low cost. Compared to the procedure for augmentation with implants.

    But it is important to understand: plastic surgery using adipose tissue allows you to increase the breast by one size, no more.Therefore, the method is suitable for those women who want to make small changes to the appearance of their bust. Also, the procedure is possible only if the woman has enough body fat to carry it out.

    Indications and contraindications


    Indications:

    • Desire to make the breast a little fuller, fuller;
    • asymmetry of the mammary glands;

    Contraindications:

    The procedure is not recommended in the following cases:

    • cardiovascular diseases;
    • problems with the respiratory system;
    • arterial hypertension;
    • inflammations;
    • acute forms of skin diseases;
    • oncology;
    • pregnancy and lactation;
    • the beginning of the menstrual cycle.

    Preparation for surgery

    In order for lipofilling to be successful, you need to pass tests and undergo examinations prescribed by a doctor. It is also necessary for two weeks before the operation not to consume alcohol and drugs that affect blood clotting.

    The course of the procedure

    After all the preparatory measures, the procedure is carried out, which consists of the following stages:

    • Anesthesia. The operation is performed under general anesthesia. Previously, the woman’s body is examined for the tolerance of the drug used.
    • Adipose tissue collection. To do this, use places such as the thighs, abdomen and buttocks.
    • Introduction of the collected material into the mammary glands. A thin cannula is used during aspiration and insertion.

    Then the woman is transferred to another ward, where, under the supervision of an anesthesiologist, the patient departs from anesthesia.

    Rehabilitation

    At first, it is important to follow the following recommendations:

    • a week after the operation, sleep only on your back;
    • exclude physical activity for the first three weeks;
    • avoid overheating;
    • Apply ointments and creams prescribed by your doctor for speedy regeneration.

    In total, the rehabilitation period is a month. The final effect will be visible approximately three months after the operation.

    The achievements of aesthetic medicine help a woman to create harmony between her inner and outer beauty. Our clinic skillfully brings this idea to life, helping you to become even more beautiful.

    Swollen Legs

    Swelling of the feet, ankles and legs is called edema (Edema). It is caused by the accumulation of excess fluid in the tissues.Due to the force of gravity, excess fluid collects in the lower body. Therefore, the legs and feet are most affected.

    Some causes of edema.

    • Heart disease (congestive heart failure (CHF)

    • Prolonged standing or sitting (with legs down)

    • Infectious disease of the feet or legs

    • Venous insufficiency of the legs (stagnant blood in the legs)

    • Varicose veins (enlargement of the veins in the lower part of the legs)

    • Garters or clothing that compresses the legs.(Leads to stagnation of blood in the veins, preventing blood flow.)

    • )

    • Menses with fluid retention

    • Renal failure (kidney disease)

    • Liver failure

    • may indicate dangerous complications of pregnancy).

    Treatment depends on the cause of the swelling. You may be prescribed diuretics to remove excess fluid.

    Home Care

    1. Do not wear items of clothing that tighten your legs (such as garters).

    2. When sitting or lying down, keep your legs raised.

    3. If the swelling is due to infection, injury, or recent surgery, try to sit or lie down more until symptoms resolve.

    4. If your doctor tells you that the swelling is caused by venous insufficiency or varicose veins, do not sit or stand in one place for a long time. Take breaks every few hours to walk around. Brisk walking is a good exercise that helps to disperse the blood that has stagnated in your legs.