Lymphatic drainage: what it is for, indications and when not to have it

Lymphatic drainage is one of the most sought-after massages, and also one of the most surrounded by promises: “reduces swelling”, “eliminates toxins”, “slims”, “gets rid of cellulite”. Some of these ideas have partial foundations, others have none.

This article explains what manual lymphatic drainage is, when the evidence supports it, what is myth and, importantly, when it should not be done.

The lymphatic system in a few words

Blood carries oxygen and nutrients to the tissues through the capillaries. Some of the fluid leaves the vessels and sits between the cells. Most of it returns to the blood, but a fraction, together with proteins, immune system cells and other particles, is collected by the lymphatic vessels. This fluid is called lymph.

Lymph passes through the lymph nodes, which filter and watch for infections, and returns to the bloodstream near the heart. Unlike blood, it has no central pump: it moves thanks to the contraction of the lymphatic vessels themselves, the contraction of muscles, breathing and movement.

When the lymphatic system is damaged or overloaded, fluid accumulates in the tissues and oedema (swelling) appears. When the cause is a failure of the lymphatic system itself, it is called lymphoedema.

What manual lymphatic drainage is

It is a massage technique developed in the 1930s by Emil and Estrid Vodder, and later adapted by other schools. It is characterised by:

• Very light pressure, which gently stretches the skin, without working the muscle.
• Slow, circular, rhythmic movements, with phases of pressure and relaxation.
• Specific sequence: it generally begins at the neck and the lymph node areas, “clearing” the path first, and only then works the swollen areas, in the direction of the nodes.
• A very relaxing sensation, almost drowsy.

It should not be confused with vigorous “body-shaping” massages or pressotherapy devices, which are different techniques. A drainage that hurts or leaves marks is not lymphatic drainage in the technical sense.

Indications: what the evidence says

Lymphoedema: the main clinical indication

Lymphoedema is a chronic swelling caused by failure of the lymphatic system. It may be primary (due to congenital changes) or secondary, mainly after surgery or radiotherapy for cancer, particularly breast cancer, with removal of lymph nodes from the armpit.

The reference treatment, according to the consensus of the International Society of Lymphology, is complex decongestive therapy: manual lymphatic drainage, compression bandages or sleeves, specific exercises and skin care, in an intensive phase followed by maintenance (International Society of Lymphology, 2020).

The role of drainage within this set is smaller than is often thought:

• A Cochrane review concluded that, when added to compression, lymphatic drainage may bring some additional benefit in reducing arm volume, but with low-quality evidence and inconsistent results (Ezzo and colleagues, 2015).
• A more recent meta-analysis found no significant benefit from drainage added to other treatments in reducing limb volume (Thompson and colleagues, 2021).
• In a large trial, lymphatic drainage carried out after breast cancer surgery, together with exercise, did not prevent lymphoedema from developing compared with exercise and guidance alone (Devoogdt and colleagues, 2011).

In other words: compression is the mainstay. Drainage can help, especially in areas that are hard to compress (trunk, head and neck), for comfort and the feeling of heaviness, but it does not replace the rest. Treatment of lymphoedema should be guided by a doctor (generally a physiatrist) and carried out by physiotherapists with specific training.

Lipoedema

Lipoedema is an abnormal, symmetrical accumulation of fat in the legs (and sometimes the arms), almost always in women, with pain and easy bruising. The most recent recommendations indicate lymphatic drainage only when there is associated oedema, in combination with compression, and stress that it does not reduce fat (German S2k guideline, 2024). See Cellulite or lipoedema: how to tell the difference.

Post-operative

After some operations, especially plastic and aesthetic surgery (for example, liposuction or abdominoplasty), drainage is often recommended to reduce swelling and discomfort. The evidence is still limited, with small studies. It should be carried out only with the surgeon's authorisation, at the time they indicate and by professionals with post-operative experience.

Mild swelling and heavy legs

Many people seek drainage because they have swollen, heavy legs at the end of the day, after many hours standing or sitting, in hot weather or on long journeys. In this context, drainage can bring temporary relief and a feeling of lightness. But what helps most, in a lasting way, is movement (the calf “pump”), raising the legs and, when indicated, compression stockings. We discuss this in detail in Heavy, tired legs: causes, what helps and when to see a doctor.

Swollen legs can also be a sign of venous, heart, kidney or liver problems or of medication effects. Persistent swelling should be assessed.

Pregnancy

Swelling of the legs and feet is common at the end of pregnancy. Gentle drainage can be comfortable, provided it is carried out by therapists with specific training and with the knowledge of the doctor or obstetric nurse. Sudden swelling of the face and hands, a severe headache or changes in vision during pregnancy require urgent assessment (it may be pre-eclampsia).

Wellbeing and relaxation

Because of its slow rhythm and gentle pressure, lymphatic drainage is very relaxing. For those who seek it for that purpose, it is a legitimate choice, provided there are no unrealistic expectations.

Summary of indications

Common myths

“Drainage eliminates toxins”

There is no evidence that lymphatic drainage “detoxifies” the body. The liver and kidneys are responsible for eliminating substances. Passing more urine after a session can happen, especially in those who had accumulated fluid and were lying down, but it is not “elimination of toxins”.

“Drainage makes you slim”

No. Drainage does not reduce fat. It can temporarily reduce the volume associated with accumulated fluid, which gives a feeling of “deflating” that is not weight loss or fat loss.

“Drainage gets rid of cellulite”

There is no evidence that lymphatic drainage treats cellulite. Cellulite results mainly from the structure of the fat and connective tissue beneath the skin, and not from “trapped fluids”. See Cellulite in slim women: why it appears and what helps.

“The harder, the better”

On the contrary. Superficial lymphatic vessels are fragile and respond to very light pressure. Strong pressure increases blood flow to the area and can increase fluid formation, as well as causing discomfort and bruising.

“It spreads cancer”

This is a common question among people who have had cancer. The available research does not show that lymphatic drainage spreads cancer, and it is used routinely in the treatment of lymphoedema after cancer. Even so, in people with active cancer or undergoing treatment, it should be carried out only with the knowledge and agreement of the oncology team.

When not to have lymphatic drainage

Absolute contraindications (do not have):

• Suspected or confirmed untreated deep vein thrombosis: a swollen, painful, warm or reddened leg, especially on one side only. See Swelling in one leg only: when it may be thrombosis and what to do.
• Acute skin infection, such as infectious cellulitis or erysipelas (red, hot, painful skin, with or without fever).
• Decompensated heart failure: mobilising fluid can overload the heart.
• Fever or generalised infection.

Precautions (only with medical assessment and authorisation):

• Active cancer or under treatment.
• Controlled heart failure, kidney failure or severe liver disease.
• Uncontrolled hypertension.
• Pregnancy (with adapted techniques).
• Uncontrolled thyroid problems.
• Severe asthma (in drainage of the trunk).
• Recent post-operative period.

In the initial assessment, the therapist should ask about your health history and medication and, if in doubt, seek medical guidance before proceeding.

Warning signs

For any questions, call SNS 24 (808 24 24 24).

At Luxmed Clinic

At Luxmed Clinic, in Algés, manual lymphatic drainage is carried out by a massage therapist, with a gentle, slow technique, after an assessment of your state of health and of contraindications. In cases of lymphoedema, the post-operative period or oncological disease, we always ask for a recommendation from your doctor.

Lymphatic drainage is a complement and does not replace medical assessment or treatment. Results vary from person to person.

Frequently asked questions