Reducing Lymphedema and Flare-Up Risk: After Surgery


After surgery, there are general guidelines you can follow to reduce lymphedema risk. The same precautions apply if you’ve already been diagnosed with lymphedema but want to reduce your risk of symptom flare-ups. This section walks you through some basic steps and explains why they can make a difference. Then we offer some dos and don’ts you can use as a guide for specific day-to-day situations.

If you were treated for breast cancer some time ago and have not been following these guidelines, don’t panic. It’s not too late to get started. 

Lymphedema risk reduction soon after surgery

Your chest, underarm, and arm could be sore, tender, and somewhat swollen after breast cancer surgery. You’ll want to avoid doing too much too soon with the affected arm and shoulder, but it’s generally OK to start using them again for normal activities — such as combing hair, bathing, eating, and dressing.

You may be visited by a physical therapist before you’re discharged from the hospital after surgery; if not, you can ask for one. The therapist may recommend elevating your affected arm a few times a day for the first 24 to 48 hours after surgery. Generally this involves reclining and then propping the arm on pillows on a slant so that your hand is above your wrist and your elbow is higher than your shoulder (encouraging the flow of fluid up the arm). In addition, he or she can teach you some gentle stretching exercises and advise you on when it’s safe to start doing them.

You should ask your physical therapist (or other health professional advising you) if he or she has been trained in lymphedema prevention and management (see Finding a Lymphedema Therapist for suggested questions). If not, this is a great time to find a therapist who specializes in lymphedema, if you haven’t already done so. He or she can best advise you on how soon you can start exercise and what’s safe for you — and continue to follow you as you recover.

There is no definite recommendation on when you should begin stretching the arm and shoulder after surgery. Some research suggests that it’s safest to delay stretches that involve lifting the arm overhead, or even above shoulder height, for the first 7 to 10 days. These stretches work the underarm (or axillary) area where lymph nodes are concentrated.

After that first week or so, gentle exercises to restore full range of motion to the arm and shoulder may be helpful. We’re not talking about high-intensity exercise, but slow, easy motions that get the lymph flowing again, ease swelling, and increase shoulder flexibility.

Each situation is a little bit different, so be sure to ask your therapist what’s best for you.

Right away and long term: Five essential guidelines

In the weeks, months, and years after surgery, you’ll want to be aware of the amount of stress you’re placing on your hand, arm, and upper body. Kathryn Schmitz, PhD, MPH, associate professor in the Division of Clinical Epidemiology at the University of Pennsylvania, puts it this way: “Now you have to pay attention to stresses you are putting on your arm, such as sudden changes in temperature, the amount you are lifting, cuts, sunburns — anything that would tax this area of the body. Ask yourself, ‘What is my ‘arm stress-o-meter’ for the day?’ How many hours was my arm and hand in hot soapy water washing dishes? How many hours was I baking and cleaning? Lifting kids? Using harsh cleaners? Was I out in the hot sun that day?”

The following guidelines can help you minimize such stresses. Realize that there may be times when you can’t follow every one of these guidelines, through no fault of your own. For example, you can’t always prevent insect bites (guideline 1) or hot temperatures (guideline 2). Don’t panic if something like this happens: one slip-up does not mean you’re automatically going to develop lymphedema. Just pay attention to how your arm and hand look and feel, and report any changes to your doctor or lymphedema therapist.

Once you read through these guidelines, you can review the related action steps found in Things to Do and Things to Avoid.

1. Protect your skin.

The skin is your body’s protective barrier against dirt and bacteria from the outside world. Any cuts — whether small cracks due to winter dryness, a bug bite, splinter, hangnail, needle stick, razor nick, or a more serious injury — can allow bacteria into the body. Take care to protect the skin of your hand, arm, and underarm on the side of the body treated for breast cancer. If bacteria get into those areas, your lymphatic system will have to work harder to get rid of them. With fewer lymph nodes and vessels than before, your system could get overwhelmed, leading to fluid overload.

If you notice a cut or break in the skin, wash the area thoroughly with antibacterial soap or regular soap, apply a topical antibacterial ointment such as Neosporin or Polysporin (or store-brand equivalent), cover it with a bandage or band-aid, and watch for signs of infection such as redness, swelling, warmth in the area, or fever. There is no need to seek emergency medical care — just use good common sense. Talk to your doctor or lymphedema therapist about what to do if you notice possible signs of infection. Also keep in mind that early symptoms of infection, such as fever or fatigue, can happen even if you haven’t noticed any breaks in the skin. See the Lymphedema and Infection page for more information about why infection is a concern.

2. Protect the arm and hand from extremes such as overuse, excessive pressure, or extremely hot or cold temperatures.

Try to avoid anything that (a) causes much more lymph than usual to be produced in the body’s tissues and/or (b) prevents lymph from flowing freely out of the hand and arm. High temperatures, such as a hot tub or very hot shower, cause more blood to flow to the arm (think of the skin redness that often comes from heat). So does sudden intense exercise or lifting before your arm is ready for it, which can strain or pull the muscle. Pressure from a heavy shoulder bag or too-tight clothing or jewelry can restrict the flow of lymph out of the hand, arm, and/or chest areas.

3. Work with a lymphedema specialist to develop a gentle exercise plan for strengthening the arm and upper body over time.

Conventional wisdom once said that people should avoid using the affected arm as much as possible to lower lymphedema risk. This meant never exercising the arm, never carrying a purse or bag on it, never lifting anything heavier than 5 or 10 pounds for the rest of their lives. Given that a gallon of milk weighs more than 8 pounds, this isn’t realistic advice!

It is very important not to do too much too soon with the affected arm. However, newer research suggests that a program of gentle, gradually increasing exercise is not likely to increase lymphedema risk for most women. In fact, some experts believe it can help condition your arm to handle tasks you did without thinking before, such as lifting children or heavy items like grocery bags. Exercise also gets the muscles moving and gets you breathing more heavily, which helps move the lymph along. You’ll want to take it very slowly at first and observe your arm closely to determine how much activity it can handle. It’s important to work with an experienced lymphedema specialist who can tailor an upper body exercise program to your needs. For more information, see Lymphedema and Exercise.

4. Lose weight if necessary.

People who are overweight or obese are more likely to develop lymphedema. Talk to your doctor or lymphedema therapist about making a diet and exercise plan for bringing your weight under control. Better yet, ask if there is a nutritionist who can help you with an eating plan. Many hospitals and cancer centers have nutritionists on staff. See Breastcancer.org’s section on Nutrition for guidance.

5. Know the signs and symptoms of lymphedema and get help for them right away.

Even minor changes in the feeling and/or appearance of the arm, hand, or upper body can indicate early lymphedema. These changes may tend to come and go at first, which makes them seem like no big deal. Also, they can happen even if you’re following all of the guidelines for reducing lymphedema risk.

Expert Quote

"If at all possible, it’s worth seeing a physical medicine doctor or other expert who can show you how to use your body in the safest and fullest way again. Things that you did automatically before — carrying groceries, yoga, tennis — now need to be done with some caution and care until you know how your body will handle them again. You want to work with someone who knows how your body ‘moves and grooves’ and can help you gradually work back up to where you were before."

-- Marisa Weiss, M.D., president and founder, Breastcancer.org

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