What to do with a puffy eye after local skin cancer surgery?

Local puffiness that persists two months after surgery is called lymphoedema (Aus) or lymphedema (UK), a build up of lymph fluid.

Lymph is a clear fluid that continuously circulates around the body, looking to clean up waste and bring in immune system agents to the tissues of the body.

Lymphoedema requires special care to resolve or improve and you may get the help you need from a therapist trained in oncology scar treatment or lymphoedema.

This week my neighbour mentioned his sister-in-law, Julie*, had surgery in February to remove a skin cancer and was concerned that is wasn’t healing well, and, she was dropping in for coffee the next day. So I offered my services for an opinion.

Julie had just visited her Surgeon for a review of the surgery and and the news was good and bad. The good news; the cancer was successfully removed and the bad news was she would have to learn to live with the swollen eye.

After a quick visual inspection over- the- fence, I suggested:

• It is not lymphoma (the word she used) - but lymphoedema. You need the right word to google more information, right?

• Even though you’re 62yrs old, you do not need to live with this.

• Yes, there are special massage methods vs deep pressing the puffy skin under the eye

• Low level laser should be considered to soften the skin flap and help move the fluid on.

• Search online for a local lymphoedema therapist so you can get more recovery help.

Now let me explain more about my over-the-fence experience because at the time I was really put on the back foot by this lady; she was quite defensive and gruff and it took me a while to understand why.

Why untrained massage may not work

Firstly, her surgeon had mentioned the need for massage to manage the swelling once the wound had healed. Julie dutifully did what she thought was best- deep pressing of the puffy area and deep press into the skin flap. At her latest appointment, the doctor recommended to cease massage because it just wasn't working.

You can imagine then, when I spoke about the use of massage and low level laser as a healing option, Julie became quite defensive and cautious.

How come my doctor did not mention this?

I'm 62 yrs old, this won't get better.

Will this (your treatment) damage my skin flap?

Because of this sequence of events, Julie found my discussion about actively treating the swelling and using massage difficult to hear and understand as it was counter to her doctor's advice. She had just come from her last appointment and had done the hard thinking to make the decision that there was no other way; she would have to live with the swollen eye.

Learning to live with post surgical swelling is not the answer to me, so I quickly decided to jump the fence and do my usual "soft shoe shuffle" to convince Julie that further action would be beneficial. I say "usual" because this is such a common scenario i get to see, where the surgeon recommends the individual to use massage without any training or support, and that this doesn't resolve swelling that is months old.

Julie needed to know why her massage method was not working and why a different massage approach was required.

Let me explain why a different approach works

The lymphatics at the skin under the eye continuously drain immediately under the skin towards the throat and down to the heart. The lymphatic vessels leading to the flap area have been cut during the surgery to remove the cancer and are known to either regrow into the flap or more likely not to regrow into the flap area.

The first scenario means that eventually the lymph fluid drains by means of new vessels. The latter scenario; requiring continuous manual redirection of lymph fluid until a new pathway outside of the flap area is found.

These lymph vessels are so fine that they can't regrow into tight or scarred tissue; as they just don't have the capacity to forge forward. Thanks to mouse studies, researchers have found that softening the surgery scar tissue through low level laser, even months later, allows the lymph vessels to regrow into the previously no-go area.

In 2010 at a wound conference in South Africa, Professor Lievens showed microscopic images of lymphatic fluid bleeding into the tissues at the scar line of mice and then after low level laser intervention to the same mouse, the lymphatics move past the scar line and onwards in new vessels.

This has been demonstrated in a breast cancer related lymphoedema study in Australia where low level laser to fibrotic tissue at the armpit was followed by a long term reduction in the fluid build up in the arm, which was not seen in placebo or control groups. Read more from a systematic review of low level laser for breast cancer lymphoedema here

Low level laser can help to soften tight tissues, but is it enough?

I believe not; let me explain.

Firstly, we do know that tightness in the damaged tissues following cancer surgery, and especially after radiotherapy, can remain for years and years. Tightness of scars and adhesions in the skin and muscles means that many breast cancer survivors experience limited arm movement in the years after their surgery. This is some tightness! I truly can't believe that one modality alone, low level laser, can be enough to stretch really tight tissues.

Massage of scar tissue has been a recognized treatment for burns scars, but has had slow uptake in the treatment of scars from cancer surgery. There has been some single case studies and a small study of scar massage methods for scars after breast cancer. But this too has not extended into the rehab care provided for other cancers where scar tissue is significant, such as after serious head and neck cancer surgery, prosate and melamoma cancer.

Also another local issue for a skin cancer removal near the eye is the skin under the eye is super soft and stretchy and deep pressure in this area is never advised by our cosmetic service providers. This means that the massage method to the skin in this area, does need to be really gentle; Lewit Barrier Release is one such method that can be used in this way.

Seeing and feeling a difference can encourage people to take the right rehab actions

Back to my over-the-fence consult: because of what I saw as caution and defensiveness, I decided to ask to demonstrate the Lewit Barrier release method on the skin flap. With approval, I jumped the fence, washed my hands and then applied the technique; then talked the woman through the steps and asked her to check the change in the tissue.

I find this process only takes 5 mins and is a great way to appreciate differences in massage methods and also determine the outcomes that can be gained immediately and quickly.

I find that using this approach of softening the area where the lymph fluid wants to flow, can result in these steps: fluid moving away during the night time, does not build up as much in the day time and in some cases does not build up at all.

At this point I felt that my over-the fence opinion became a little more believable, so I suggested the woman search for a local therapist with low level laser and a therapist with oncology scar tissue training and lymphatic drainage skills.

Summary

I jumped back over the fence thinking:

1. Recovery after a treatment for skin cancers or deeper cancers continues to be poorly managed in Australia and results in many people learning to live with side-effects.

2. This situation could have been avoided by a quick referral from the surgeon to a lymphoedema or oncology scar+ lymphoedema therapist in the weeks after healing.

3. I will continue to help people, even if it is an over-the-fence opinion, discover new ways to resolve the side- effects to cancer treatments, as many of these can be managed well.

4. I should have written down the word lymphoedema, as it is such a hard word to remember, let alone spell.

If you have persistent swelling that goes past two months since your surgery, then know that your doctor may not think to tell you about conservative/non surgical options like scar tissue and lymphoedema services.

For a 15 min complementary video call or to book an appointment go to the CONNECT NOW button at the top left of the page.

*Julie is not her name.

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