HAND SURGERY
Upper Extremity Lymphedema Index
A Simple Method for Severity Evaluation of Upper Extremity Lymphedema
Takumi Yamamoto, MD, Nana Yamamoto, MD, Hisako Hara, MD, Makoto Mihara, MD,
Mitsunaga Narushima, MD, and Isao Koshima, MD
Abstract: Measurement of the circumference is the most commonly employed
method for evaluating extremity lymphedema. However, comparison between
different patients is difficult with this measurement. To resolve this problem, we
have formulated a new index, upper extremity lymphedema (UEL) index,
which can be easily obtained from measurements of the body. We evaluated
correlation between UEL index and clinical stage in patients with UEL. The
UEL indices were significantly correlated with clinical stages and could be used
as a severity scale. The lower extremity lymphedema index makes objective
assessment of the severity of lymphedema through a numerical rating, re-
gardless of the body type. This numerical rating makes the index useful for
evaluation of lymphedema severities between different cases.
Key Words: upper extremity lymphedema, breast cancer, severity scale,
circumference, body mass index
(Ann Plast Surg 2013;70: 47Y49)
A wide variety of tests, such as lymphoscintigraphy, indocyanine
green (ICG) lymphography, and volumetry based on computed
tomography, magnetic resonance imaging, and water displacement
method, exist as evaluation methods for lymphedema. The measure-
ment of the circumference of the extremities is the easiest and most
fundamental method among them.1Y7 Circumference measurement,
however, has its set of disadvantages. First, comparison between
different cases is not possible due to the difference in individuals.
Second, we cannot evaluate through absolute values.6Y8
To overcome these drawbacks, we formulated new severity
scaling systems which enabled the evaluation by absolute values,
regardless of body types and comparison between different cases with
upper extremity lymphedema (UEL).
PATIENTS AND METHODS
The UEL indices were calculated using figures obtained from
physical examinations (body height, body weight, and circumfer-
ence of upper extremities) conducted on 42 limbs from 21 female
UEL patients from June 2009 to March 2010. The UEL index was
calculated from the circumference and body mass index (BMI) after
upper extremity circumference measurements at the olecranon, 5-cm
above and below the olecranon, the wrist, and the dorsum of the
hand. The UEL index was calculated using the formula shown in
Figure 1. The clinical stages used the Campisi clinical stages.9 Severity
stratification was established based on the UEL index through com-
Received April 3, 2011, and accepted for publication, after revision, June 1, 2011.
From the Department of Plastic and Reconstructive Surgery, Graduate School of
Medicine, the University of Tokyo, 7Y3-1 Hongo, Bunkyo-ku, Tokyo 113Y8655,
Japan.
Conflicts of interest and sources of funding: none declared.
Reprints: Takumi Yamamoto, MD, Department of Plastic and Reconstructive Sur-
gery, Graduate School of Medicine, the University of Tokyo, 7Y3-1 Hongo,
Bunkyo-ku, Tokyo 113Y8655, Japan. E-mail: tyamamoto-tky)umin.ac.jp.
Copyright * 2012 by Lippincott Williams & Wilkins
ISSN: 0148-7043/13/7001-0047
DOI: 10.1097/SAP.0b013e3182275d23
Annals of Plastic Surgery & Volume 70, Number 1, January 2013
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
parison of the UEL indices with corresponding clinical stages. The
Spearman rank correlation coefficient was used for statistical analysis.
Continuous, quantitative data are expressed as means T standard devia-
tions. A P value G0.05 was defined as statistical significance. Formal
approval by the institutional review board was obtained.
RESULTS
Data obtained from this study are shown in Table 1. The mean
UEL index of 21 unaffected limbs of 21 UEL patients was 102 T 7. The
mean UEL indices of 21 affected limbs of the patients were 110 T 8 in
Campisi stage 1 (n = 4), 125 T 15 in stage 2, 150 T 11 in stage 3, and
169 T 9 in stage 4. With progression of the clinical stages, the UEL
indices increased linearly as described by the line y = 20.4x + 87.3
(Spearman rank correlation coefficient, rs = 0.904; P G 0.001; Fig. 2).
From these results, we were able to formulate a new quantitative staging
system, UEL stage, as a clinical stratification: UEL index G130 cor-
responded to UEL stage I, 130 to 150 corresponded to UEL stage II, 150
to 170 corresponded to UEL stage III, and 9170 corresponded to UEL
stage IV (Table 2).
DISCUSSION
Among a number of methods for evaluating lymphedema,
circumference measurement of the extremities is the simplest and
most fundamental method.1Y7 Although circumference measurement
is useful for follow-up of UEL patients and comparing with the
unaffected extremity in unilateral cases, it has its own set of dis-
advantages.6Y8 First, in patients with bilateral UEL, comparison with
the unaffected side cannot be made. Although UEL usually develops
as unilateral UEL unlike lower extremity lymphedema (LEL), com-
paring different UEL cases is not possible due to variability of indi-
viduals. Furthermore, since edema entails volumetric increase, it may
not be appropriate to evaluate the condition with mere measurements
of the circumferences. These disadvantages of arm circumference
measurements are the same of leg circumference measurements. To
resolve these problems in LEL, we have formulated a new index for
LEL evaluation, LEL index, and demonstrated its clinical utility in
severity scaling and in determining treatment efficacy.10
As the LEL index had been developed, we established a new
index for UEL evaluation with the introduction of 3 concepts to re-
solve these problems. The first is the institution of an areal evaluation,
which used a higher dimensional, cross-sectional area measurement
using a circular model of the extremities. The second concept is cor-
rections by the body type for an index that takes BMI into consider-
ation. The third involves an evaluation by absolute values that allow
mutual evaluation between different cases and in cases with bilateral
UEL. In calculating the index, we first added cross-sectional areas
of the extremities in 5 parts where circumferences were measured,
making an approximation that the cross-sections are perfect circles
(Fig. 3). We made use of the summation of the cross-sectional area’s
property of being proportional to the summation of the square of
the circumference to simplify the calculation of the formula. Finally,
the number was divided by BMI to make corrections for the body
type, and the obtained value was defined as the UEL index (Fig. 4).
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Yamamoto et al Annals of Plastic Surgery & Volume 70, Number 1, January 2013

TABLE 2. UEL Index and UEL Stage

UEL Stage UEL Index

FIGURE 1. Calculation of upper extremity lymphedema Stage I G130

(UEL) index. The index is calculated by taking the sum of the Stage II 130Y150
squares of the circumference (cm) in 5 areas (C1Y5) of an Stage III 150Y170
upper extremity and dividing it by body mass index (BMI). Stage IV 9170
C1 denotes circumference at 5-cm above the olecranon, C2 UEL indicates upper extremity lymphoedema.
circumference at the olecranon, C3 circumference at 5-cm
below the olecranon, C3 circumference at the wrist, and C5
circumference at the dorsum of the hand.

TABLE 1. Patient Characteristics

21 Upper Limbs of 21 Upper Extremity Lymphoedema Patients
Age (y) 35Y80 (average, 56.8)
BMI 18Y30 (average, 22.7)
Latency period (y) 0Y32 (average, 4.4)
Duration of edema (y) 0.5Y44 (average, 6.6)
Radiotherapy 14/21 (66.7%)
Cellulitis episodes 13/21 (61.9%)
Clinical stage 1Y4 (average, 2.5)
BMI indicates body mass index.

FIGURE 3. Calculation of the sum of the cross-sectional area

with the circular model. The sum of the cross-sectional area is
proportional to the square of the sum of the circumference
when measurement of a given area of the upper extremity
circumference is rendered as a circle.

FIGURE 2. Clinical stages and the upper extremity

lymphedema (UEL) indices. With progression of the clinical
stage, the UEL index increases linearly described as the line
y = 20.4x + 87.3 (rs = 0.904, P G 0.001).

Dividing the sum by BMI corrected the index according to the body
type because in cases with the same severity of edema, larger physique
and greater BMI lead to increase in circumferences.11
As the UEL index can be easily calculated from physical
examinations, and it significantly correlates with the clinical stages, it
is postulated that it will prove useful in evaluating the severity of the
lymphedema condition. Similar evaluations of severity as the con-
ventional clinical stages will be made possible owing to the rough
classification of the UEL index into UEL stages (Fig. 5). The index has
a potentially wide range of applications, including comparison of the
severity between different cases and evaluation of the efficacy of
treatment over time due to the digitalization of severity level to an
FIGURE 4. Correction for the body type with body mass
index (BMI). An obtained index, upper extremity lymphedema
(UEL) index, enables the evaluation of swelling in an upper
extremity regardless of the body type by dividing with BMI.
absolute value. By using UEL index, more appropriate evaluation of
conditions and efficacy of treatment will become possible since the
comparison of severity of conditions between different cases, even
those with vastly different body types, becomes possible.
The UEL index is calculated using cross-sectional area, but for
more appropriate evaluation, a more precise approximation with a
cylindrical model may be adopted. In addition, with the UEL index, it

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Annals of Plastic Surgery & Volume 70, Number 1, January 2013
is not possible to evaluate each part of an upper extremity since the
index gives a comprehensive assessment of an upper extremity. For
this reason, UEL index is not suitable for evaluation of patients with
regional edema, as in primary lymphedema.12,13 Although the UEL
index may be simple and useful severity scale systems, further review
is necessary for its use in routine medical practice.
CONCLUSIONS
The UEL index, which can be easily obtained from physical
examinations, is established as a new method for evaluating UEL. The
UEL index correlates well with the conventional clinical stages and
can be useful in determining the severity of a condition or efficacy of
treatment, allowing evaluation between different cases regardless of
the body type by means of absolute values.
ACKNOWLEDGMENTS
The authors thank Riko, Dr. Hidehiko Yoshimatsu, and all
members of our department for their kind support to this study.
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* 2012 Lippincott Williams & Wilkins
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
UEL Index for Arm Lymphedema Evaluation
FIGURE 5. Upper extremity
lymphedema (UEL) stages and
clinical cases. A UEL index of G130
corresponds to UEL stage I (upper
left), 130Y150 corresponds to UEL
stage II (upper right), 150Y170
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