{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,6,29]],"date-time":"2026-06-29T22:06:24Z","timestamp":1782770784874,"version":"3.54.5"},"reference-count":15,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2025,5,6]],"date-time":"2025-05-06T00:00:00Z","timestamp":1746489600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.mdpi.com"],"crossmark-restriction":true},"short-container-title":["Reports"],"abstract":"<jats:p>Background and Clinical Significance: Breast cancer-related lymphedema (BCRL) is a chronic condition affecting up to 20% of breast cancer survivors. Manual lymphatic drainage (MLD) has traditionally included techniques to redirect lymph flow toward alternative pathways when axillary drainage is impaired. However, emerging imaging techniques suggest that most lymph continues to drain toward the ipsilateral axilla, and this has led to the widespread uptake of treatment protocols that exclude traditional redirecting movements, even in cases where personalized imaging is unavailable. Case Presentation: This case report describes a woman with BCRL affecting the right arm and hand who underwent 3 years of conservative lymphedema therapy, including MLD and self-massage techniques that incorporated traditional redirection strategies. Pre-operative indocyanine green (ICG) lymphography, performed after prolonged conservative treatment, confirmed the presence of an open alternative drainage pathway bypassing the axilla and demonstrated dermal flow along the redirected pathways towards a previously described \u201cradial\u201d pathway. These findings suggest that targeted manual therapy may have reinforced or optimized this compensatory route. Conclusions: This case highlights the potential risk of relying on a single form of assessment and generalized cohort imaging studies to guide individualized MLD protocols. In the absence of personal imaging, prematurely abandoning traditional redirection techniques may limit opportunities to establish functional alternative pathways, particularly in early edema in patients who have this anatomical variation. ICG lymphography provides valuable insight into compensatory lymphatic drainage. However, until imaging protocols are standardized and individual imaging is widely accessible, retaining traditional MLD techniques for newly diagnosed BCRL may be crucial for optimizing treatment outcomes. Future research should explore the long-term impact of manual therapy on alternative pathway development and function.<\/jats:p>","DOI":"10.3390\/reports8020063","type":"journal-article","created":{"date-parts":[[2025,5,6]],"date-time":"2025-05-06T04:28:22Z","timestamp":1746505702000},"page":"63","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["ICG Lymphography Confirms the Presence of an Alternative Lymph Drainage Pathway Following Long-Term Manual Therapy: A Case for Preserving Traditional MLD Approaches"],"prefix":"10.3390","volume":"8","author":[{"given":"Mary","family":"Wakefield","sequence":"first","affiliation":[{"name":"Dove Hospice & Wellness, Auckland 1071, New Zealand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3097-3132","authenticated-orcid":false,"given":"Jan","family":"Douglass","sequence":"additional","affiliation":[{"name":"College of Medicine and Dentistry, James Cook University, Douglas, QL 4811, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Diane","family":"Lacey","sequence":"additional","affiliation":[{"name":"Lymph Therapies, Auckland 2120, New Zealand"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Neil","family":"Piller","sequence":"additional","affiliation":[{"name":"College of Medicine and Public Health, Flinders University South Australia, Bedford Park, SA 5042, Australia"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Linda","family":"Blanchfield","sequence":"additional","affiliation":[{"name":"Dr. Vodder School International, Vancouver, BC V7J 2P7, Canada"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,5,6]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","unstructured":"Executive Committee of the International Society of Lymphology (2023). The Diagnosis and Treatment of Peripheral Lymphedema: 2023 Consensus Document of The International Society of Lymphology. Lymphology, 56, 133\u2013151.","DOI":"10.2458\/lymph.6372"},{"key":"ref_2","doi-asserted-by":"crossref","unstructured":"Torgbenu, E., Luckett, T., Buhagiar, M., and Phillips, J.L. (2023). Practice points for lymphoedema care in low- and middle- income countries developed by nominal group technique. BMC Health Serv. Serv. Res., 23.","DOI":"10.1186\/s12913-023-09786-w"},{"key":"ref_3","unstructured":"Australian Institute of Health and Welfare (2023). Towards an Estimate of the Prevalence of Lymphoedema in Australia, AIHW."},{"key":"ref_4","unstructured":"(2023, June 16). Te Whatu Ora Cancer Web Tool 2023. Available online: https:\/\/tewhatuora.shinyapps.io\/cancer-web-tool\/."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"3536","DOI":"10.1200\/JCO.2007.14.4899","article-title":"Lymphedema After Breast Cancer: Incidence, Risk Factors, and Effect on Upper Body Function","volume":"26","author":"Hayes","year":"2008","journal-title":"J. Clin. Oncol."},{"key":"ref_6","first-page":"26","article-title":"A quality of life measure for limb lymphoedema (LYMQOL)","volume":"5","author":"Keeley","year":"2010","journal-title":"J. Lymphoedema"},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"900","DOI":"10.1097\/PRS.0000000000009555","article-title":"Superficial and Functional Lymphatic Anatomy of the Upper Extremity","volume":"150","author":"Granoff","year":"2022","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Wittlinger, H., Wittlinger, D., and Wittlinger, A. (2018). 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F\u00f6ldi\u2019s Textbook of Lymphology: For Physicians and Lymphedema Therapists, Elsevier Health Sciences."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"110","DOI":"10.1016\/j.jphys.2022.03.010","article-title":"Manual lymphatic drainage with or without fluoroscopy guidance did not substantially improve the effect of decongestive lymphatic therapy in people with breast cancer-related lymphoedema (EFforT-BCRL trial): A multicentre randomised trial","volume":"68","author":"Gebruers","year":"2022","journal-title":"J. Physiother."},{"key":"ref_13","doi-asserted-by":"crossref","unstructured":"Devoogdt, N., Thomis, S., De Groef, A., Heroes, A.K., Nevelsteen, I., Gebruers, N., Tjalma, W.A.A., Belgrado, J.P., Monten, C., and Hanssens, M. (2023). The Effectiveness of Fluoroscopy-Guided Manual Lymph Drainage as Part of Decongestive Lymphatic Therapy on the Superficial Lymphatic Architecture in Patients with Breast Cancer-Related Lymphoedema: A Randomised Controlled Trial. Cancers, 15.","DOI":"10.3390\/cancers15051545"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"4328","DOI":"10.1016\/j.bjps.2022.06.108","article-title":"Letter to the Editor: Classification of superficial lymphatic pathways in the upper extremity and incidence of lymphatic obstruction according to the lymphatic pathways in patients with unilateral upper extremity lymphedema","volume":"75","author":"Friedman","year":"2022","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"550","DOI":"10.1089\/lrb.2018.0063","article-title":"Comparison of Staging Systems to Assess Lymphedema Caused by Cancer Therapies, Lymphatic Filariasis, and Podoconiosis","volume":"17","author":"Douglass","year":"2019","journal-title":"Lymphat. Res. Biol."}],"updated-by":[{"DOI":"10.3390\/reports9010042","type":"correction","label":"Correction","source":"publisher","updated":{"date-parts":[[2025,5,6]],"date-time":"2025-05-06T00:00:00Z","timestamp":1746489600000}}],"container-title":["Reports"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2571-841X\/8\/2\/63\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,1,29]],"date-time":"2026-01-29T08:12:38Z","timestamp":1769674358000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2571-841X\/8\/2\/63"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,5,6]]},"references-count":15,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2025,6]]}},"alternative-id":["reports8020063"],"URL":"https:\/\/doi.org\/10.3390\/reports8020063","relation":{},"ISSN":["2571-841X"],"issn-type":[{"value":"2571-841X","type":"electronic"}],"subject":[],"published":{"date-parts":[[2025,5,6]]}}}