Lymphoedema is a challenging condition that can greatly impact patients’ quality of life. This article by Erika van der Mescht explores fluoroscopy-guided lymphoedema mapping (also known as lymphoscintigraphy), an innovative approach combining near-infrared imaging (NIR) with precise diagnostic techniques to improve treatment outcomes. Discover how this advanced method benefits patients, therapists, and medical teams in managing lymphoedema more effectively.
Lymphoedema is a chronic condition that occurs when the body’s lymphatic system malfunctions, causing a build-up of lymph fluid in the body’s tissues. This fluid build-up can lead to swelling in the arms, legs, chest, abdomen, genitals, and head.
There are two types of lymphoedema: primary and secondary, each with distinct causes.
Primary lymphoedema
Primary lymphoedema results from gene mutations affecting lymphatic system development. Faulty genes can impair fluid drainage, causing the condition, which may run in families, though not all offspring inherit it.
Secondary lymphoedema
Secondary lymphoedema occurs when a previously normal lymphatic system is damaged. Causes include:
- Cancer surgery: Removing lymph nodes, especially for cancers like breast, head and neck, melanoma, gynaecological, genitourinary, lymphoma, or advanced cancers, can increase risk.
- Radiotherapy: High-energy radiation may damage healthy lymphatic tissue, hindering fluid drainage.
- Infections: Severe cellulitis or lymphatic filariasis can scar or block the lymphatic system.
- Inflammation: Conditions like psoriasis or eczema can permanently harm lymphatic tissues.
- Venous diseases: Issues like DVT (deep vein thrombosis/ blood clot) or varicose veins can overwhelm the lymphatic system.
- Obesity: Excess fatty tissue may impede lymphatic flow.
- Trauma: Injuries causing severe bruising or tissue damage can disrupt lymph drainage.
- Immobility: Limited movement, from illness or conditions like nerve damage and arthritis, may reduce lymph flow.
How is lymphoedema treated? Read this article for the full low-down on treatments in South Africa.
Below is how lymph mapping can help form a tailored treatment plan, as well as help cancer patients pre-empt severe lymphoedema.
What is fluoroscopy-guided lymphoedema mapping?
Lymphatic mapping is one of the latest developments in the diagnostics and treatment of lymphoedema, boosted by the help of near-infrared imaging (NIR). NIR can identify and visualise, in real time, the superficial lymphatic collectors, allowing for the observation of dermal rerouting, dermal backflow, and functional lymphatic pathways.
This has enabled the therapist to map the lymphatic system, thereby gaining valuable knowledge of the patient’s individual lymphatic system and finding the best drainage pathways for more effective treatment. It is the first time functional lymphatics can be observed in real time. The therapist can now perform the best MLD (manual lymphatic drainage) techniques individually to each patient, enhancing and improving the overall results.
Lymphatic mapping is performed using a photodynamic eye as an NIR camera. The photodynamic eye, together with Verdye ICG (indocyanine green, monosodium salt), allows the lymphatics to be observed in real time. The ICG is used at 1/100th of the dose used in other surgeries such as angiology and ophthalmology. It is not a new medicine, but rather a much smaller dose of a well-known substance, injected subdermally.
What do I see and look for when doing mapping?
I will look for normal, healthy valvular flow of the lymphatic vessels. I will then further identify abnormal lymphatic flow patterns.

What will the benefit be to you as a patient?
- According to these abnormal lymphatic adaptations, I will inform your therapist on how to possibly adjust your lymph drainage pathways for more effective treatment.
- I will also explain in the report to the therapist/orthotist involved with garments what changes need to be made to provide the most comfortable and effective compression garments if indicated.
- I will assess the possibility of lymphatic surgery and refer you accordingly.
- I will teach you the basics of self-lymphatic drainage that your body would benefit from the most.
- You will receive a comprehensive report of the mapping to ensure that any medical professional involved in your care can understand your individual lymphatic pathways. This could assist with future medical decisions regarding surgery.
Here are some images from a patient report (used with patient consent), which included detailed information for the patient’s physiotherapist and orthotist to best tailor a treatment plan:



Benefit to the therapist
Lymphofluoroscopy mapping of a lymphoedema patient improves treatment outcomes by enabling the therapist to understand the precise drainage pathways, allowing for a more effective treatment plan. Lymphatic mapping is combined with a new, more effective technique called “fill and flush” (fluoroscopy-guided manual lymph drainage, or FG-MLD).
Using these new techniques, the patient is empowered with more knowledge of their pathways and is taught an effective, precise self-help FG-MLD. This makes patients more independent, speeds up the treatment time, and becomes cost-effective for the patient and the medical aid.
Benefit to your medical team
- If you need future surgery, I will be able to provide suggestions on what could possibly be done to prevent further damage to the lymphatic system.
- Knowing where the lymphatic vessels are functioning could help your nursing staff understand where and when to avoid procedures like IV treatments and blood pressure assessments.
Why use FG-MLD instead of standard MLD?
We now have an improved understanding of the lymphatic pathways and their drainage abilities. Lymphatic mapping has enhanced our technique regarding the hand contact positions, movements, and pressure that are most effective in draining the lymphatic pathways.
Lymphatic screening for preventing severe lymphatic disease
The early identification of lymphoedema is crucial for the advanced treatment of swelling. Research has found that radiation, chemotherapy, and surgery can result in the development of swelling in the affected areas. Screening affected areas before swelling is noticed by the patient or doctor can avoid the formation of lymphoedema and is crucial in preventing the long-term and more serious side effects.
A screening programme in cancer patients can recognise the presence of lymphoedema. This may result in early intervention and the prevention of lymphoedema. This is done through initial screening directly before and after treatment, which can include surgery and/or radiation. These screenings can be repeated as needed depending on what is seen initially for 24 months.
Lymphoedema is a chronic condition, and early recognition ensures that symptoms are managed early, often before visual changes have occurred. Screening can prevent the progression of lymphoedema in the affected area.
Erika van der Mescht has dedicated her physiotherapy career to helping patients with lymphoedema and secondary-to-cancer physiotherapy needs and runs her Lymph Therapy practice in Centurion.
She has been working in Cancer rehabilitation and lymphoedema clinics since 2012 and has passionately developed her skills and expertise in this field. Erika started training with LEA (Lymph Education Africa) in 2016 but has since moved to a new training school called LTA (Lymphedema Training Academy). This is the school that started FG–MLD and lymphatic mapping in 2014, initially in the UK. Erika now does training for them in South Africa, having just registered LTA: Africa together with Jane Wigg, the founder of LTA Global.
She started seeing patients requiring lymphoedema management, as a niche market. Because non-treatment of a client’s symptoms could cause major challenges, it was inevitable to start doing cancer rehabilitation as part of therapy.