Breast Cancer Manual Lymph Drainage

Breast Cancer Manual Lymph Drainage

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Breast Cancer Manual Lymph DrainageBCRL can negatively impact comfort, function, and quality of life CDT consists of MLD, compression bandaging, lymph-reducing exercises (LREs), and skin care. When MLD was added to the intensive course of compression bandaging, their swelling went down another 7.11. Thus, MLD may offer benefit when added to compression bandaging. Thus, our findings suggest that individuals with mild-to-moderate BCRL are the ones who may benefit from adding MLD to an intensive course of treatment with compression bandaging. This finding, however, needs to be confirmed by further research. Two trials measured quality of life, but neither trial presented results comparing the treatment group to the control, so findings are inconclusive. Most trials appeared to randomize participants adequately. However, in four trials the person measuring the swelling knew what treatment the participants were receiving, and this could have biased results. Compared to individuals with moderate-to-severe BCRL, those with mild-to-moderate BCRL may be the ones who benefit from adding MLD to an intensive course of treatment with compression bandaging. This finding, however, needs to be confirmed by randomized data. Research is needed to identify the most clinically meaningful volumetric measurement, to incorporate newer technologies in LE assessment, and to assess other clinically relevant outcomes such as fibrotic tissue formation. BCRL can negatively impact comfort, function, and quality of life (QoL). Manual lymphatic drainage (MLD), a type of hands-on therapy, is frequently used for BCRL and often as part of complex decongestive therapy (CDT). CDT is a fourfold conservative treatment which includes MLD, compression therapy (consisting of compression bandages, compression sleeves, or other types of compression garments), skin care, and lymph-reducing exercises (LREs). Phase 1 of CDT is to reduce swelling; Phase 2 is to maintain the reduced swelling.http://utopyainsaat.com.tr/fckfiles/brookstone-double-automatic-watch-winder-manual.xml

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Objectives: To assess the efficacy and safety of MLD in treating BCRL. Search strategy: We searched Medline, EMBASE, CENTRAL, WHO ICTRP (World Health Organization's International Clinical Trial Registry Platform), and Cochrane Breast Cancer Group's Specialised Register from root to 24 May 2013. No language restrictions were applied. Selection criteria: We included randomized controlled trials ( RCTs ) or quasi- RCTs of women with BCRL. The intervention was MLD. The primary outcomes were (1) volumetric changes, (2) adverse events. Secondary outcomes were (1) function, (2) subjective sensations, (3) QoL, (4) cost of care. Data collection and analysis: We collected data on three volumetric outcomes. (1) LE (lymphedema) volume was defined as the amount of excess fluid left in the arm after treatment, calculated as volume in mL of affected arm post-treatment minus unaffected arm post-treatment. (2) Volume reduction was defined as the amount of fluid reduction in mL from before to after treatment calculated as the pretreatment LE volume of the affected arm minus the post-treatment LE volume of the affected arm. (3) Per cent reduction was defined as the proportion of fluid reduced relative to the baseline excess volume, calculated as volume reduction divided by baseline LE volume multiplied by 100. We entered trial data into Review Manger 5.2 (RevMan), pooled data using a fixed-effect model, and analyzed continuous data as mean differences (MDs) with 95 confidence intervals (CIs). We also explored subgroups to determine whether mild BCRL compared to moderate or severe BCRL, and BCRL less than a year compared to more than a year was associated with a better response to MLD. Main results: Six trials were included. Based on similar designs, trials clustered in three categories. Subgroup analyses was significant showing that participants with mild-to-moderate BCRL were better responders to MLD than were moderate-to-severe participants.http://www.ridendo.cz/files/brookstone-egg-clock-instruction-manual.xml One of the trials compared compression sleeve plus MLD to compression sleeve plus pneumatic pump. A second trial compared compression sleeve plus MLD to compression sleeve plus self-administered simple lymphatic drainage (SLD), and was significant for MLD for LE volume ( MD -230.00 mL, 95 CI -450.84 mL to -9.16 mL; 1 RCT; 31 participants) but not for volume reduction or per cent reduction.One trial reported significant within-groups gains for both groups, but no between-groups differences. The other trial reported there were no significant within-groups gains and did not report between-groups results. One trial measured strength and reported no significant changes in either group. Overall, the sensations were significantly reduced in both groups over baseline, but with no between-groups differences. No trials reported cost of care. Most trials appeared to randomize participants adequately. However, in four trials the person measuring the swelling knew what treatment the participants were receiving, and this could have biased results. OK More information. This article has been cited by other articles in PMC. Abstract Background This retrospective cohort study evaluated whether manual lymphatic drainage (MLD) therapy increases the risk of recurrence of breast cancer. All patients were monitored until October 2013 to determine whether breast cancer recurrence developed, including local or regional recurrence and distant metastasis. Patients who developed cancer recurrence prior to MLD therapy were excluded from analysis. Risk factors associated with cancer recurrence were evaluated using Cox proportional hazards models. Factors protecting against recurrence were positive progesterone receptor status and receiving radiation therapy. Exercise increases lymph flow through muscle contraction around the lymphatics. MLD applies light strokes to mimic the pumping action of lymphatic vessels and directs lymph flow from blocked to open lymphatics.http://www.bosport.be/newsletter/3g3pv-manual 10 MLD is a gentle massage technique that follows the anatomic lymphatic pathways of the body. The technique is administered in a descending manner and produces a pressure of 11 A lymphoscintigraphic study showed that MLD produces movement of lymph fluid in the ipsilateral and contralateral lymphatics, indicating the effectiveness of the technique in stimulating accessory routes useful for resolution of lymphedema. 12 MLD has been widely used in managing BCRL; however, the potential risk of cancer metastasis because of MLD has received little attention in previous research. Invasion of tumor cells into lymphatic vessels is a critical step in the metastasis of breast cancer. Although MLD facilitates lymphatic drainage, it may increase the opportunity for tumor spread through the lymphatics, thereby increasing the risk of recurrence of breast cancer. This study investigated whether patients with breast cancer who developed BCRL and then received MLD therapy had a higher risk of breast cancer recurrence at follow-up compared with those who received no MLD therapy. Materials and methods Data source We conducted a retrospective cohort analysis based on cancer registry data from Chi-Mei Medical Center (CMMC). This registry has prospectively collected and followed up cancer patients diagnosed at CMMC since 2002 and the center’s Liou-Ying branch since 2006. The demographics, diagnoses, and clinical characteristics of cancers, types of cancer treatment (operation, chemotherapy, or radiation), responsiveness to treatment (remission, recurrence, or metastasis), and outcome (survival or death) were recorded. Additional clinical information not included in the registry was obtained retrospectively from medical charts. The CMMC institutional review board reviewed the medical ethics and approved this study before its commencement. A total of 1,122 women fulfilled our inclusion criteria during the study period.http://adams-tool.com/images/breadmaster-bread-machine-manual.pdf After exclusion of 16 patients who were lost to follow-up by day 180, the remaining 1,106 patients qualified as our study population, and were monitored until October 31, 2013 to determine whether breast cancer recurred. To determine if MLD therapy contributed to recurrence of breast cancer, the patients were divided into two groups: group A, in which patients received no MLD therapy during the study period, including patients with no BCRL and patients who developed BCRL after surgery but refused to receive MLD; and group B, in which patients received MLD therapy because they developed BCRL during the study period. The decision whether to receive MLD therapy is based on the discretion of patients. All of the patients in each group who developed BCRL were evaluated to ensure that BCRL was not a result of cancer recurrence, and the severity of lymphedema (stage 1, 2, or 3) was rated based on the criteria defined by the International Society of Lymphology. 13 MLD as a rehabilitation intervention A specialized physiotherapist administered MLD based on the Casley-Smith method to breast cancer patients who developed BCRL. 14 An MLD session was initiated at the center of the neck and trunk to clear the main lymphatic pathways, followed by massage of the upper limb to facilitate lymphatic flow from an affected limb to an unaffected area. 15 Each MLD session lasted for 30 minutes and was administered twice a week on an outpatient basis. The total number of MLD sessions varied depending on the clinical condition of the individual patient. Outcome The outcome of this study was the recurrence of breast cancer confirmed by pathological, radiological, or clinical evaluation between the date of surgery and October 31, 2013. In this study, recurrence included local, regional, and locoregional recurrence as well as distant metastasis. Local recurrence was defined as the reappearance of cancer in an ipsilateral preserved breast.https://www.geosuiteonline.de/wp-content/plugins/formcraft/file-upload/server/content/files/16285a1cda3933---bytecc-bt-300-manual.pdf Regional recurrence referred to a tumor involving the ipsilateral regional LNs, including the ipsilateral axillary, supraclavicular, infraclavicular, and internal mammary LN groups. Locoregional recurrence indicated a recurrence in either the breast or regional nodal basin. Distant metastasis implied that a tumor has spread to distant body parts. Variables of interest The variables of interest in this study were categorized as patient-related, disease-related, and treatment-related. Patient-related variables were age at diagnosis of breast cancer, body mass index, smoking and alcohol consumption history, and menstrual status. Treatment-related variables were type of surgery (breast-conserving surgery, mastectomy, modified radical mastectomy) and receiving adjuvant treatment (radiation therapy, chemotherapy, hormonal therapy). TNM staging was based on the 6th edition of the American Joint Committee on Cancer Staging Manual, 16 and histological grading was based on the Nottingham Score for breast cancer. 17 Statistical analysis Patient-related, disease-related, and treatment-related variables were summarized using descriptive statistics. Continuous variables were expressed as the mean and standard deviation or the median with interquartile range when appropriate. We analyzed the categorical variables using Pearson’s chi-squared test or Fisher’s exact test and the log-rank test. Univariate and multivariate Cox proportional hazards regression models were used to evaluate the relative prognostic significance of the variables in predicting recurrence of breast cancer. Based on one-year steps, the entry time was the date of breast cancer surgery, and the exit time was the date of cancer recurrence during follow-up. All of the variables in the univariate analysis were included in the multivariate analysis.www.cjacksonlaw.com/ckfinder/userfiles/files/787-fluke-user-manual.pdf The results of the multivariate analysis were adjusted for all of the aforementioned variables and are presented as hazard ratios (HRs) and 95 confidence intervals (CIs). Table 1 presents the patient demographics and clinical characteristics. Most of the demographic and clinical features did not differ between the groups, except that a higher percentage of patients in group B received radiation therapy ( Table 1 ). A univariate analysis was conducted to investigate the relationship between breast cancer recurrence and predictive factors ( Table 3 ). Several predictive factors were identified; however, receiving MLD was neither a risk factor for nor a protective factor against cancer recurrence. Notes: Group A includes patients who did not receive manual lymphatic drainage and group B includes patients who received manual lymphatic drainage due to breast cancer-related lymphedema. Because a higher percentage of patients in group B received radiation therapy ( Table 1 ), this therapy could be a confounder with regard to cancer recurrence. Therefore, we conducted a stratified analysis ( Table 4 ). Discussion In this study, we analyzed two groups of breast cancer patients in remission after treatment for the disease. Group A comprised patients who received no MLD therapy, including patients with and without BCRL, and group B consisted of patients who developed BCRL during the monitoring period and thus received MLD therapy. Compared with group A, group B contained more patients receiving radiation therapy, which is known to contribute to lymphedema and accounts for why these women developed BCRL. We observed no difference in the rate of cancer recurrence between group A and group B (15.5 versus 10.9, Table 2 ). Multivariate analysis identified several risk factors and protective factors; the risk factors were those associated with tumor invasiveness and protective factors were those related to cancer treatment.http://www.abaco-engineering.it/wp-content/plugins/formcraft/file-upload/server/content/files/16285a1cdc557c---Bytecc-duplicator-manual.pdf These factors were consistent with those reported in the literature. 4, 5 In contrast, MLD was neither a risk factor nor a protective factor for recurrence. The clinical relevance of this finding is discussed in the following subsections. Mechanisms of cancer invasion and spreading Hypoxia is a critical feature of the tumor microenvironment that promotes invasion and metastasis of solid tumors as well as resistance to treatment. Low oxygen tension inside the tumor core activates hypoxia-inducible factors, which activate the transcription of numerous other factors, including vascular endothelial growth factor. These factors are proangiogenic, forming new vasculature with an abnormal structure and high permeability, which facilitates the intravasation of tumor cells into the circulation. 18 In addition, vascular endothelial growth factor stimulates intratumoral lymphangiogenesis. These local lymphatics are immature and dysfunctional, leading to sequestration of interstitial fluid within tumors and an increase in intratumoral interstitial fluid pressure. These pathological changes place mechanical stress on the surrounding extracellular matrix and promote peritumoral lymphangiogenesis, which facilitates the dissemination of shed tumor cells from a primary tumor into locally draining (sentinel) LNs. 19 Obstruction of lymphatic flow at the sentinel LNs by tumor cells further stimulates LN lymphangiogenesis. These newly formed lymphatic vessels serve as additional routes for circulating cancer cells for distant LN metastasis. 20 Because hypoxia is a mediator of the metastasis cascade, treatments that “normalize” or improve the circulatory and metabolic profile of a tumor microenvironment may stabilize the tumor structure and reduce tumor cell shedding and invasion. 21 In addition, improvement in a tumor microenvironment can increase the efficacy of cancer therapy and that of effector immune cells.https://penoplex24.ru/wp-content/plugins/formcraft/file-upload/server/content/files/16285a1ddb3c61---Bytecc-sata-drive-mate-manual.pdf 21, 22 Risks and benefits of MLD The potential risk of cancer cell spreading because of MLD remains controversial. Mechanical manipulation, such as MLD, has been hypothesized to compress tumors and increase cancer cell shedding. Consistent with this theory, an animal study involving real-time lymphatic imaging demonstrated that the number of tumor cell fragments, cells, and emboli in the lymphatics increased significantly when heavy pressure was applied to the tumor. 23 However, no compelling clinical evidence has suggested that light pressures, such as those generated by MLD ( 24 Other debates regarding MLD include whether it facilitates spread of cancer by opening of lymphatic routes and whether it increases the success rate of implantation by pushing and lodging cancer cells inside capillaries or lymphatics. Even if these statements were true, the circulating cancer cells may not survive. For example, most shed tumor cells are nonviable, apoptotic, and nonclonogenic. 25 The conduit size of capillary bed or lymphatic vessels trap the tumor cells, 26 and this confined environment offers no survival advantages. 27, 28 In addition, MLD has other functional benefits, including favorable tissue circulation and oxygenation as well as an improvement in lymphatic contractile function. 29 As mentioned, better tissue oxygenation can improve the tumor microenvironment and increase the efficacy of anticancer treatment. An improvement in lymphatic drainage can facilitate the immune response 30 and thereby increase exposure of tumor cells to the host immune system. These benefits may compensate for the potential disadvantages of MLD. After weighing all of the pros and cons of MLD, we consider that MLD is “neutral” with regard to cancer recurrence and metastasis. Metastatic potential is governed primarily by the biological nature of the cancer cells rather than a passive mechanism. Therefore, clinicians and patients should not hesitate to select MLD when BCRL develops.chicken-cage.com/d/files/787-fluke-manual.pdf Additional studies are required to demonstrate how to optimize the benefits of MLD and avoid potential harm to the cancer patient. Limitations Our study had several limitations. First, the case number in group B was much smaller than in group A; therefore, type II errors could not be avoided when analyzing the risk factors for cancer recurrence. In addition, the number of confounders that can be adjusted in Cox proportional hazards analysis depends on the sample size. 31 Second, this was a retrospective study based on a hospital sample. Extrapolating our results to all breast cancer patients would be challenging. Third, the cancer registry may not have included all variables associated with breast cancer recurrence; therefore, estimates from multivariate analysis are subject to confounding bias. To reduce this bias, we endeavored to incorporate most clinically critical variables in our analyses by reviewing medical charts. Fourth, we could not access information at other hospitals, so could not exclude the possibility that patients in group A received treatment in lymphedema control programs outside our hospital. Finally, patients in groups A and B were similar at baseline except that more patients in group B received adjuvant radiation therapy. Because radiation therapy could reduce the risk of breast cancer recurrence, any adverse effect of MLD on cancer recurrence in group B, if present, might be mitigated by this treatment. However, the stratified analysis ( Table 4 ) indicated that the baseline difference between the groups did not substantially affect the outcome. Conclusion MLD therapy is a safe procedure that does not increase the risk of disease recurrence in breast cancer survivors who developed BCRL after surgery, axillary LN dissection, and adjuvant therapy. Footnotes Disclosure The authors report no conflicts of interest in this work. References 1. Jemal A, Bray F, Center MM, et al. Global cancer statistics. Cancer Registry Annual Report. Available from:. 4. Cheng L, Swartz MD, Zhao H, et al. An overview of prognostic factors for long-term survivors of breast cancer. Stubblefield MD, O’Dell MW. Cancer Rehabilitation Principles and Practice. Ferrandez JC, Laroche JP, Serin D, Felix-Faure C, Vinot JM. American Joint Committee on Cancer. Galea MH, Blamey RW, Elston CE, Ellis IO. The Nottingham Prognostic Index in primary breast cancer. Achen MG, Stacker SA. Molecular control of lymphatic metastasis. Harrell MI, Iritani BM, Ruddell A. Tumor-induced sentinel lymph node lymphangiogenesis and increased lymph flow precede melanoma metastasis. Goel S, Duda DG, Xu L, et al. Normalization of the vasculature for treatment of cancer and other diseases. Stylianopoulos T, Martin JD, Chauhan VP, et al. Causes, consequences, and remedies for growth-induced solid stress in murine and human tumors. Hayashi K, Jiang P, Yamauchi K, et al. Fornvik D, Andersson I, Dustler M, et al. No evidence for shedding of circulating tumor cells to the peripheral venous blood as a result of mammographic breast compression. Racila E, Euhus D, Weiss AJ, et al. Detection and characterization of carcinoma cells in the blood. Bockhorn M, Jain RK, Munn LL. Active versus passive mechanisms in metastasis: do cancer cells crawl into vessels, or are they pushed. Tan IC, Maus EA, Rasmussen JC, et al. Assessment of lymphatic contractile function after manual lymphatic drainage using near-infrared fluorescence imaging. Schander A, Padro D, King HH, Downey HF, Hodge LM. Author manuscript; available in PMC 2016 Jul 29. Published in final edited form as: Cochrane Database Syst Rev. 2015; (5): CD003475. Abstract Background More than one in five patients who undergo treatment for breast cancer will develop breast cancer-related lymphedema (BCRL). BCRL can negatively impact comfort, function, and quality of life (QoL). Objectives To assess the efficacy and safety of MLD in treating BCRL. Search methods We searched Medline, EMBASE, CENTRAL, WHO ICTRP (World Health Organization’s International Clinical Trial Registry Platform), and Cochrane Breast Cancer Group’s Specialised Register from root to 24 May 2013. Selection criteria We included randomized controlled trials (RCTs) or quasi-RCTs of women with BCRL. Data collection and analysis We collected data on three volumetric outcomes. (1) LE (lymphedema) volume was defined as the amount of excess fluid left in the arm after treatment, calculated as volume in mL of affected arm post-treatment minus unaffected arm post-treatment. (2) Volume reduction was defined as the amount of fluid reduction in mL from before to after treatment calculated as the pretreatment LE volume of the affected arm minus the post-treatment LE volume of the affected arm. (3) Per cent reduction was defined as the proportion of fluid reduced relative to the baseline excess volume, calculated as volume reduction divided by baseline LE volume multiplied by 100. Main results Six trials were included. One of the trials compared compression sleeve plus MLD to compression sleeve plus pneumatic pump.Two trials measured function as range of motion with conflicting results. One trial reported significant within-groups gains for both groups, but no between-groups differences. One trial measured strength and reported no significant changes in either group. Two trials measured QoL, but results were not usable because one trial did not report any results, and the other trial did not report between-groups results. Four trials measured sensations such as pain and heaviness. Overall, the sensations were significantly reduced in both groups over baseline, but with no between-groups differences. No trials reported cost of care. Trials were small ranging from 24 to 45 participants. Most trials appeared to randomize participants adequately. However, in four trials the person measuring the swelling knew what treatment the participants were receiving, and this could have biased results. Authors’ conclusions MLD is safe and may offer additional benefit to compression bandaging for swelling reduction. Compared to individuals with moderate-to-severe BCRL, those with mild-to-moderate BCRL may be the ones who benefit from adding MLD to an intensive course of treatment with compression bandaging. This finding, however, needs to be confirmed by randomized data. In trials where MLD and sleeve were compared with a nonMLD treatment and sleeve, volumetric outcomes were inconsistent within the same trial. Research is needed to identify the most clinically meaningful volumetric measurement, to incorporate newer technologies in LE assessment, and to assess other clinically relevant outcomes such as fibrotic tissue formation. Findings were contradictory for function (range of motion), and inconclusive for quality of life. For symptoms such as pain and heaviness, 60 to 80 of participants reported feeling better regardless of which treatment they received. One-year follow-up suggests that once swelling had been reduced, participants were likely to keep their swelling down if they continued to use a custom-made sleeve. PLAIN LANGUAGE SUMMARY Manual lymphatic drainage for lymphedema following breast cancer treatment Background More than one in five of breast cancer patients will develop breast cancer-related lymphedema (BCRL). BCRL can negatively impact comfort, function, and quality of life Manual lymphatic drainage (MLD) is a hands-on therapy that is commonly used for BCRL and often as part of complex decongestive therapy (CDT). CDT consists of MLD, compression bandaging, lymph-reducing exercises (LREs), and skin care. The Review Questions Is MLD safe and effective in treating BCRL. Study Characteristics We found six trials published through May, 2013, totaling 208 participants. Key Results When women were treated with a course of intensive compression bandaging, their swelling went down about 30 to 37. When MLD was added to the intensive course of compression bandaging, their swelling went down another 7.11. Thus, MLD may offer benefit when added to compression bandaging. Examining this finding more closely showed that this significant reduction benefit was observed in people with mild-to-moderate lymphedema when compared to participants with moderate-to-severe lymphedema. Thus, our findings suggest that individuals with mild-to-moderate BCRL are the ones who may benefit from adding MLD to an intensive course of treatment with compression bandaging. This finding, however, needs to be confirmed by further research. When women were given a standard elastic compression sleeve plus MLD and compared to women who received a standard compression sleeve plus a nonMLD treatment, results were mixed (sometimes favoring MLD and sometimes favoring neither treatment.) One-year follow-up suggests that once swelling had been reduced, participants were likely to keep their swelling down if they continued to use a custom-made sleeve. MLD is safe and well tolerated. Findings were contradictory for function (range of motion), with one trial showing benefit and the other not. Two trials measured quality of life, but neither trial presented results comparing the treatment group to the control, so findings are inconclusive. No trial measured cost of care. Quality of the Evidence Trials were small ranging from 24 to 45 participants. BACKGROUND Description of the condition More than one in five women with breast cancer will develop breast cancer-related lymphedema (BCRL) ( DiSipio 2013; Paskett 2012 ). Breast cancer surgery can cause lymphedema through several mechanisms: surgical removal of lymphatic structures such as nodes and vessels can impair lymph carrying capacity. Surgical removal or damage of muscle tissue can diminish the muscle’s compressive force on the lymph vessels and impair the “muscle pump” ( Ridner 2013 ). Although recent changes in diagnosis and treatment of breast cancer (such as sentinel node biopsy, changes in radiation therapy, and less invasive surgical techniques due to earlier diagnosis) have reduced the risk of BCRL, BCRL remains a major problem for women with breast cancer. Six-month prevalence rates, for any six months within a three-year window, have been estimated at 23 to 29 ( Paskett 2007 ). Prospective incidence rates of BCRL range between 20 to 40 for the first three years following breast cancer surgery ( Armer 2009; Clark 2005; Geller 2003 ). Incidence rates vary according to the type of breast cancer treatment received, with women who receive both axillary radiation and axillary lymph node resection showing the highest incidence ( Shah 2012 ). Risk factors for BCRL include higher stage of breast cancer, higher number of lymph nodes removed, obesity, poorer performance status, receipt of adjuvant chemotherapy or radiation therapy ( Helyer 2010; Miaskowski 2013 ) and certain genes ( Miaskowski 2013 ). Exercise such as strength training has been associated with lower risk of BCRL ( Park 2008; Swenson 2009 ). BCRL can affect the arm, hand, fingers, wrist, elbow, shoulder, neck, breast, chest or any combination of these areas. Arm BCRL is the most widely studied and is classified according to the excess volume of the affected arm compared to the unaffected arm. A common arm classification is mild ( 40 excess volume) ( Partsch 2010 ). Arm BCRL is often not diagnosed until the patient, herself, notices subtle signs of swelling such as the inability to wear rings or watches, or has symptoms such as discomfort, heaviness or tightness in the limb or region. In some cases the skin may appear shiny, veins may be less visible, and tissue may feel firmer than normal.