Joachim Zuther, Lymphedema Specialist. 
Although lymphedema can be reduced to a normal or near normal size using proper treatment techniques, the lymphatic vessels are never normal again after lymphedema was present. In addition, once lymphedema has been reduced, skin elasticity may never be regained completely since the elastic fibers in the skin are damaged from the swelling present in lymphedema.
External support is therefore an essential component of lymphedema
Loss of skin elasticity following successful reduction of lymphedema
management following successful reduction of the swelling. The primary goal of compression garments is to maintain the reduction achieved during the intensive phase of Complete Decongestive Therapy (CDT); it is imperative to understand that compression garments are not designed to further reduce lymphedema.
Patients are fitted for garments directly following the intensive phase of CDT by someone who is experienced, or even better, certified in taking measurements for compression garments.
The measurements should be taken in the morning when the limb is smallest; it is highly recommended to measure directly following the removal of the padded compression bandages, which are used until the garments are ready to be worn.
Selecting an appropriate compression garment is a challenging task, and many important factors, such as mobility and activity level, age, coverage area, general shape of the limb/body part, compression class, material, appearance, cost, skin sensitivity/integrity, possible presence of arterial diseases and donning/doffing issues need to be considered. Some of these factors play a major role in the process to determine if a custom-made or ready-made compression garment would be the better choice for the individual.
What is the difference between custom-made and ready-made garments?
The major difference between a higher quality compression garment and a garment of lesser quality (OTC, or over-the-counter products) is the presence of an inlay thread (red yarn in picture left), generally made of Lycra or rubber, which provides a high level of compression consistency. Both custom and ready-made garments used in lymphedema therapy contain this thread, which is woven into the material in a continuous manner. The different compression levels are achieved by adjusting the tension of this inlay thread.
Knee-high ready-made stocking with silicone border
Ready-made or off-the-shelf garments are made from relatively thin and sheer fabrics that are continually knitted in a circular fashion on a cylinder and thus have no seam; varying stitch height and yarn tension create the appropriate shape and size. Generally, these garments tend to be more cosmetic (no seam) and lighter in weight.
Ready-made garments are less expensive, easier to replace and quicker to obtain than custom-made garments and come in a variety of girths, lengths, fabrics and compression classes (please refer to an earlier entry: The Role of Compression Garments in the Treatment of Lymphedema).
Disadvantages of ready-made garments are that they may not provide enough support and are not as precise in fit as a garment, which is custom-made to the individuals’ exact measurements. They also have a tendency to roll at the top if a silicone border is not added on the inside of the upper part.
Custom-made stocking with toe cap
Custom-made compression garments are generally made from thicker (but breathable) materials and knitted row by row as a flat piece, which is shaped and produced by adding or removing needles during the production process, according to the exact measurements of the patient; the flat piece is then joined by a seam to form the garment. Custom garments can be made to fit any shape, and are available in all four compression classes.
The heavier knit materials provide greater stiffness resulting in greater resistance and better containment of the swelling than ready-made garments (so-called stiffness factor).
Factors that determine the choice between a Custom and Ready-made garment:
Shape – although ready-made garments are available in a wide variety of sizes from most manufacturers, they are generally made for a limb of
Custom-made compression pantyhose
average proportion and length. Although some ready-made garments allow for an extra-wide calf/elbow and thigh/upper arm, a patient with a distorted or disproportionate limb will generally require a custom-made garment. Even if the individual circumferential measurements fall within the range of a specific ready-made garment size, some patients may have a disproportionate large calf, with measurements at the top end of the range and a relatively thin ankle with measurements on the low end of the range. The result would be a looser fit around the ankle area, which could result in a “ballooning” effect with fluid accumulating in the ankle area.
For very obese patients, custom-made garments are often the only available option; however, some ready-made pregnancy garments, which can be obtained at a much lower cost, may accommodate the measurements of these individuals.
Compression classes – the level of compression within the different classes is determined by the value of pressure the garments produce on the skin (please refer to an earlier entry on compression levels: The Role of Compression Garments in the Treatment of Lymphedema).
Ready-made garments are available in compression classes I through III, custom garments are available in all four compression levels. The highest level, compression class IV is reserved for the more severe and challenging cases of lymphedema.
Given the high compression of these garments, it is important that the ankle-brachial index (ABI) of the individual is tested by a health care professional. The ABI compares the blood pressure of the ankle to that of the arm, and is used to determine if peripheral arterial disease (PAD) is present. While an ABI index of less than 0.5 presents a general contraindication for compression therapy, the ABI should be greater than 0.8 if a compression class IV garment is prescribed.
A normal resting ankle-brachial index ranges between 0.9 and 1.3, which means that the blood pressure in the ankle area is the same or greater than the pressure in the arm.
Donning issues - some patients may have difficulty in donning a garment, especially a compression class IV garment (age, mobility). In these
Layering of two compression garments
cases it is possible to layer two garments of lesser compression – for example, two compression class I garments on top of each other can be used to achieve up to 40 millimeters of mercury (mm/Hg) pressure. With the first garment applying 20-30 mm/Hg, the second garment will add about two thirds of the pressure applied by the first garment. Layering of two compression garments also increases the stiffness factor, which results in greater resistance and better containment.
A second, less desirable option, would be the addition of a zipper to aid donning of compression garments. The disadvantages of zippers are that they are difficult to close once the garment is in place; they make the garment more bulky and the cosmetic results are less desirable. Another important issue is wearability of a zippered garment – zippers do not stretch which makes these compression garments less comfortable to wear.
Skin integrity – if wounds or other skin conditions are present, it may be better to go with a more breathable custom garment. In some cases it may be necessary to apply an under-stocking (silk, cotton) to avoid slippage of 
wound dressings while donning the garment. Compression garments containing silver may present a very good option; silver threads woven into the garment have naturally antimicrobial properties, prevent odor and are commonly used in the treatment of wounds.
In some cases, a zipper option may be considered if wounds are present.
Cosmetics – appearance of a garment is very important for many patients. In some cases it may be necessary to choose a less desirable option (no seam, garment color issues, less bulky garment) to further patient compliance. It is important to understand that there is no therapeutic value in a compression garment, which is not worn by the patient for cosmetic reasons.
Stay tuned for more on compression garments in upcoming postings, such as care of compression garments and tips on donning and doffing and how to hold garments and bandages in place in challenging cases.
Additional Resources:
Compression Hosiery in Lymphedema
Join Lymphedema Guru, a Facebook page solely dedicated to inform about all things related to lymphedema – news, support groups, treatment centers, and much more
I have been wearing Juzo full foot panty hose 40-50mmhg daily for 3 years now. They are costly and I was wondering if there is any way to get Medicare to help with the cost. Thank you
Did you know that when you get a rip or tear in your stocking you can mend it? Use regular thread & hand sew the run or hole. The co. that makes the stockings began making them sheer on the bottom, where they get the most wear so they will wear out more quickly. Nice! One stocking got a hole in it after just 2 wearings. $600 a month in stockings is unaffordable, so something had to be done.
I have been using a custom garment on my right arm for 9 months. I also have a REED sleeve that I use at night. My day garment has the silver thread in it and it is controling my arm fairly well. I have had lymphademis for 6 years now following breast cancer.
Deb,
Some Medicare beneficiaries are receiving payment for their compression garments. But you have to appeal every denial and then have your case heard by an Administrative Law Judge. The process does not cost anything, but may take two years to receive your reimbursement. Contact LymphActivist@aol.com for help in filing your appeal.
Bob Weiss has been great in handling the appeal for my custom garment. If appeals are not filed again and again, these garments will never be covered.
I am a PT, CHT. Do you have any references for evidence based efficacy of neck/head garments? This would be useful in cases of insurance denial. Thanks!
Dolores – I will research and get back with you
This was very interesting – I didn’t understand how custom garments were made.
How often do you suggest that custom garments be replaced? What are the characteristics of garments that need to be replaced? Also, does washing them by hand (as opposed to “handwash cycle” by washing machine) allow them to last longer?
Thank you again for donig this blog.
Dear Nancy:
The elastic fibers of a compression garment will break down with wear. While proper care will increase the lifespan of garments, they will need to replaced about every six months or when the garment shows signs of wear that could adversely affect the compressive properties of the garment. As a general rule, if the garment no longer returns to its original shape after washing, has runs or holes in the material, no longer feels compressive, and if the garment becomes easy to put on, it probably needs to be replaced.
Garments may be machine or hand washed, depending on the preference of the user. Daily washing is recommended, especially if lotions or creams are being used (moisturizing lotion can break down the fibers in compression garments and should be applied only at night when the garment is removed). When washing garments in a machine it is recommended to place the garment in a mesh laundry bag in order to protect the fabric during the washing cycle (the gentle cycle should be utilized).
Was wondering what you think about the Solaris custom garments to replace night time bandaging. How effective are they, approx. cost, etc. thanks
Dear Diana: We had excellent experience with the Solaris Caresia products – you can view them here: http://solarismed.com/store/cart.php?m=product_detail&p=5
I have worn a Jobst custom support garment for the last 21 years for lymthdema in my leg do to having melemona. I wear the highest compression since I do work full time and I stand on my feet for the whole 8 hour day. I may have been one of the lucky ones because I haven’t had any problems with my leg and the sock and over night garment does work wonders.
[...] the quality of your compression garment. If you have more than one garment, take the extra one with you as a back up. If your destination [...]
I have been wearing Profore dressings for almost 5 years and would kill to be able to wear stockings and shoes. I have a natural bracelet around my right ankle and short legs. Four years ago I was deemed ready for compression knee-high stockings. Although the original prescription was for the highest compression level we tried several levels and I also asked about custom-made. In every case within less than an hour the stocking material had gathered in my ankle resulting in a white foot with no palpable pulse. The only suggestion the fitter had was to don my neon blue gloves every 15 minutes and remove and replace the left stocking. I work in a busy ICU – there is no way I can do that! Do you have any suggestions?
Jan,
Have u considered getting pockets made around the ankle so you can insert foam/pad to make the area around the ankle to have more weight so it will pull away from your skin rather than it cutting into the creases. Mediven (pockets/liner) and Jobst(pockets and profile for their Elvarex stockings
Im a certified garment fitter and their are many options available .
Judy
I have worn compression stockings for about 7 years and recently, Juzo Varin is now Juzo Dynamic 30-40mm. HAs anyone else noticed a difference of quality? Anyone know where I can find a “thicker” material that the varin used to be? Thanks and good luck to everyone!
@Nick, I thought I was the only one. I’ve been wearing Juzo stockings for about 18 years with no problem but recently got a new pair and they are different. Not as effective. I called Juzo and they told me they changed the machines they use to make the stockings. If you know of a better stocking please let me know. Summer is the worst season not to have the best compression.
I have been diagnosed with Lipedema alone. Best we can figure I came about it genetically and then expedited it after my gastric bypass by having extensive skin removed from my thighs with a thigh lift, along with 2 rounds of traditional liposuction, and bilateral knee replacements. I am currently considering CDT and my massage therapist told me that for LIPEDEMA, i should not expect much, if any decrease in the size of my legs as I would if I had LYPMHEDEMA. That raised a concern in me. If that is in fact the case, than while I can still see the benefit of MLD (Vodder) massage itself, and of keeping compression on after a session, wouldnt I be able to consider something like your Solaris Readyware after the massage instead of paying to be bandaged everyday? Since my legs wont decrease much and the readywear has ~a 15mm velcro adjustable range, with a 50% overlap with graduated compression, so I can keep the fluid from returning between sessions and at the end of the month. Consider too that after the Vodder massage I will be responsible for my doing self MLD, compression thigh highs by day, decongestive exercises, deep breathing, and wearing a garment to sleep like the readywear anyway, do I still need to be bandaged daily? Why not put on the ready wear after the massage and measure at the end of the treatment it to see if perhaps I sized into a smaller daily garment? It isnt likely that I would size into a different readywear. In fact, wouldn’t I also be better off taking off the readywear to get into my therapy pool to exercise everyday and then putting them back on considering the exercise would probably enhance the MLD by further stimulating the lymph system? Anyone have advice for me on this one?
[...] achieved during treatment with Complete Decongestive Therapy (CDT). To select the correct garment (ready-made or custom made), compression level, and, if necessary, fastening systems, the patients age, physical abilities [...]
I am wondering if night time custome made garments stick to bed linens ? I am in thearapy right now & using coban 2 for the maintancene phase until custom garments arrive. So far it’s not going well as i am sticking to the bed sheets & I like to roll around in bed . thanks
I would like to know the manufacturer of the stocking and toe cap that is photographed in this article. I have two pieces for my leg and foot, but Mediven includes seams in both the foot cap and the end of the stocking around my foot that cause discomfort and areas of constriction. I like the lack of seams in the garments that are pictured.
BSN – Jobst