Hrev_master Veins and Lymphatics 2017; volume 6:6634 [Veins and Lymphatics 2017; 6:6634] [page 25] Medical interest of 3D reconstructed limb to build a customized multicomponent bandage for the treatment of a lower limb lymphedema with partially amputated calf: a case report Frédéric Pastouret Compression Therapy Research Unit, Papignies, Belgium Introduction Multicomponent bandage (MCB) is an essential method in the treatment of lower leg lymphedemas.1,2 However, 2 layers bandages applying methods proposed by manufacturers do not result in selected pres- sures nor in a digressive pressure gradient and the proposed methods are not adapted for each type of case. For some particular lymphedema’s patients, the therapist has to find a bandage applying method to obtain specific therapeutic criteria as the final stiff- ness of the assembled bandage, the expect- ed pressure and a specific pressure gradient. Objective The aim of this study is to build a cus- tomized multicomponent bandage with selected pressures and a digressive pressure gradient for a patient with lymphedema and partially amputated calf (Figure 1). The patient underwent a lymphatic system infection of her right lower limb with partial inguinal node dissection, aggravated by a sepsis and a calf subcutaneous tissue infec- tion. She cannot stand high-pressure levels on her limb, usually used during multicom- ponent bandage treatment for lymphoedema patient. Materials and Methods This experiment was conducted in 2 phases; first, on the 3D reconstructed lower limb and second on the patient herself. - From the simulated limb, a very light foam prosthesis of the partial amputated right calf was customized in order to fill in the loss of the calf tissue under the future bandage. A 2 mm thickness custom silicone pad (medi® silicone for custom made lin- ers, density A-5) was designed to be the protective skin interface layer of the pros- thesis (Figure 2).3,4 Pressure sensors were applied at 10 dif- ferent selected points (Figure 2). Multicomponent bandage consists on a first layer of tubular cotton jersey put directly on the skin, a second single layer of Mobiderm® (minimal overlap, no tension) and a last single layer of Biplast®. Biplast® overlap method was adapted with a constant band tension to obtain 20-25 mmHg at dor- sal face of the foot (100% of pressure) and a digressive pressure gradient on the rest of the limb (2/3 overlap at the foot, calf and knee distal part; ½ overlap at the tight) (Figure 3). The foam prosthesis was placed on the silicone pad which was directly applied on the simulated limb under the multicomponent bandage. - Bandage applying method was finally tested on the patient (Figure 3). Pressures were assessed in the same 10 locations on the patient’s own right limb in standing position and during walking. Dynamic vari- ation pressure indexes (DVPI) were calcu- lated at each selected points (difference between maximal pressures and minimal pressures during walking), which represent the local massage effect or pump effect under bandage. Results On the 3D reconstructed member and on the patient, selected pressures at dorsal face of the foot was respectively 20 mmHg and 23 mmHg. Global internal and external digressive pressure gradients (Int PG, Ext PG) were also obtained with the selected applying method (Figure 4). On the patient, DVPI (mmHg) demon- strated high massage/pump effects at the dorsal foot face (16), above the malleoli (8- 6) and under the prosthesis (16), due to the final resistance of the assembled bandage. The customized multicomponent bandage was well tolerated by the patient during experiment. Discussion Patient was previously treated by anoth- er therapist with multicomponent bandage including high pressures. It was a failure because she did not support high pressures (or common pressures used for a lym- phoedema patient) especially at the thigh level due to the skin graft. For this reason, the higher tolerated pressure was evaluated on her foot during the first appointment. This low pressure was selected as the pres- sure reference at the dorsal foot face for her customized multicomponent bandage. Having a previous satisfactory experience concerning multicomponent bandages applied with very low pressures and global digressive pressure gradient for lymphoede- ma patients (Leduc’s method), those two pressure paramaters were the solution to build a tolerated bandage for the patient. Those pressures were possible to obtain due to the selected applying method, the global conic shape and the circular section all along the limb. In this case, recorded DVPI during walking were not only due to the final stiff- ness of the assembled bandage, but also to the limb volume change. The patient walk- ing difficulties (inability to bend the knee) and the amputated calf explain the poor” Correspondence: Frédéric Pastouret, Compression Therapy Research Unit, Papignies, Belgium. E-mail: compressiontherapy.researchunit@out- look.com This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright F. Pastouret, 2017 Licensee PAGEPress, Italy Veins and Lymphatics 2017; 6:6634 doi:10.4081/vl.2017.6634 Figure 1. View of the patient lower limbs (left), her partially amputated calf and her thigh and her inguinal node dissection scar. No n c om me rci al us e o nly Conference presentation [page 26] [Veins and Lymphatics 2017; 6:6634] DVPI at the tight level. Silicone pad was selected as a safety protective interface between skin graft and the prosthesis to reduce local mechanical stress on the calf skin scars (medical propri- ety used during scar management)4 but also for two other technical reasons (washable and reusable). The association between Mobiderm® (stiff layer) and Biplast® (adhesive layer) leads to an adhesive short stretch (inelastic) final assembled multicomponent bandage. Mainly, Mobiderm® band is used in associ- ation with a non-adhesive short stretch band in lymphoedema treatment.5 Our kind of adhesive MCB completes the tools range (non-cohesive or cohesive MCB) at the dis- posal of the therapist. For this patient, staying in the same standing position or walking during a long time was very difficult. Working on 3d reconstructed limb was the solution to build a customized multicomponent bandage and offered the possibilities to practice multiple tests (products choice, best applying method). It was like having the patient in our lab. Conclusions The use of simulated limb in compres- sion therapy in vitro experiment to assess related pressure parameters is common.6-9 Working on 3D reconstructed limb to pre- pare a customized multicomponent bandage for a specific patient is a new concept in compression therapy that allowed decreas- ing the patient time’s investment. Custom prosthesis with the silicone interface enabled to normalize the leg’s shape, to protect the skin scars and to obtain a high massage/pump effect on the skin graft, which is a very important skin care benefit during the treatment. Final pressure, pressure gradients, DVPI and final resist- ance of assembled bandage are very satisfy- ing and are leading to an optimal bandage tolerance by the patient. References 1. International Society of Lymphology. The diagnosis and treatment of periph- eral lymphedema: 2013 Consensus Document of the International Society of Lymphology. Lymphology 2013;46:1-11. 2. Partsch H, Flour M, Smith PC. Indications for compression therapy in venous and lymphatic disease consen- sus based on experimental data and sci- entific evidence. Under the auspices of the IUP. Int Angiol 2008;27:193-219. 3. Ehrler SC, Eveno D. Résultats d’une étude multicentrique française concer- nant la mise en place d’un manchon Post opératoire en silicone chez 211 patients amputés du membre inférieur. J Orthoped 2009;10:1432-4. 4. Monstrey S, Middelkoop E, Vranckx JJ, et al. Updated scar management practi- cal guidelines: non-invasive and inva- sive measures. J Plastic Reconstr Aesth Surg 2014;67:1017-25. 5. Quere I, Presles E, Coupe M, et al. Prospective multicentre observational study of lymphedema therapy: POLIT Figure 3. Multicomponent bandage applying method on the 3D reconstructed limb (left) and on the patient (right). First layer of tubular cotton jersey (A). Second single layer of Mobiderm®, minimal overlap, no tension (B). last single layer of Biplast ®. Biplast®, digressive overlap and constant band tension (C). Figure 4. Recorded pressures (mmHg or %), internal and external pressure gradients (%) and DVPI during walking, according the sensors location. Figure 2. Pressure sensors locations on the 3D reconstructed limb. C5 is located under the silicone and the prosthesis. C6 on the prosthesis; Silicone pad: Medi® silicone for custom made liners, density A-5 (blue arrow); Light foam prosthesis of the partial ampu- tated right calf (F). No n c om me rci al us e o nly Conference presentation [Veins and Lymphatics 2017; 6:6634] [page 27] study. J Malad Vasc 2014;39:256-63. 6. Stolk R, Wegen van der-Franken CP, Neumann HA. A method for measuring the dynamic behavior of medical com- pression hosiery during walking. Dermatol Surg 2004;30:729-36; discus- sion 36. 7. Partsch H, Partsch B, Braun W. Interface pressure and stiffness of ready made compression stockings: compari- son of in vivo and in vitro measure- ments. J Vasc Surg 2006;44:809-14. 8. Gaied I, Drapier S, Lun B. Experimental assessment and analytical 2D predictions of the stocking pressures induced on a model leg by Medical Compressive Stockings. J Biomechan 2006;36:3017-25. 9. Pastouret F. Pressures exerted by circu- lar or flat knitted arm sleeves during simulated muscular contractions. 42nd ESL Congress, Mulhouse, France; 2016. p 67. No n c om me rci al us e o nly