Lymphedema FAQ

General questions about Lymphedema surgery and the Functional Lymphedema Operations (FLO) system are answered here. See below for specific questions about the VLNT, LVA and SAPL procedures.

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General Questions

  1. What are the goals of Dr. Granzow’s FLO system?The goals of the FLO system include:
    • reduction in the risk of dangerous infections such as cellulitis
    • reduction of excess volume
    • reduction in musculoskeletal dysfunction
    • improvement in activities of daily living
    • restoration of the ability to wear normal clothing or footwear
    • improvement in psychological well-being
    • reduction in social stigma of Lymphedema
  2. Are the Lymphedema surgeries in the FLO system safe for me? The Lymphedema surgeries that are part of Dr. Granzow’s comprehensive FLO System have standard surgical risk comparable to other surgical procedures of similar length of time. We know of no patients whose lymphedema has become worse after Dr. Granzow’s surgeries. Patients having Lymphedema surgeries as part of the FLO System have experienced significantly decreased rates of infection and cellulitis. Please note that debulking procedures, such as the Charles Procedure, are not part of Dr. Granzow’s FLO System.
  3. I’m an out of town patient. Can your office help me plan a visit?We have a large number of patients who travel to be seen and treated by Dr. Granzow and his team. Our office will be happy to assist you with planning a visit.
  4. Have you published any medical articles about Lymphedema surgeries or the FLO system?Yes, Dr. Granzow has published multiple studies in the some of the most prestigious medical journals. You can find links to these publications here.
  5. Why should I work with a trained Lymphedema therapist?Dr. Granzow’s FLO System has been successful in treating Lymphedema using a combination of effective surgical technique and integrated Lymphedema therapy that is specifically tailored to each patient. Because this combination of therapy and surgery produces the best overall outcomes, Dr. Granzow believes patients should be evaluated and treated by a trained Lymphedema therapist prior to being considered for surgery. A patient who receives proper Lymphedema therapy will experience a more successful outcome with the FLO System. Dr. Granzow believes that a patient should be treated by their own therapist in their home area both before and after surgery whenever possible.
  6. Why does Dr. Granzow believe that Lymphedema surgery is a team effort? Dr. Granzow’s philosophy in the FLO System is based on a patient-centered rather than physician-centered system of care to achieve the best results possible. The patient and every member of our care team are essential in achieving an optimum treatment plan.
  7. Why can’t a single surgery “cure” my Lymphedema? Why do I need the rest of the treatment? Lymphedema is a chronic disease process. Dr. Granzow sees patients with different stages of the disease with a wide variation of symptoms and issues. No single type of surgery or therapy is effective for all patients, and the treatment and surgery much be individualized carefully for each and every patient to achieve the maximum benefit. Many of Dr. Granzow’s patients have been able to achieve complete reductions in volume or therapy and compression. The best results have been achieved when the patient continues to maintain a relationship with their home therapist and continue to take careful Lymphedema precautions when performing activities such as flying, gardening and other at-risk activities.
  8. Why should I go to a Lymphedema surgeon who is trained and experienced with performing different types of Lymphedema surgery? There is no “one size fits all” solution for Lymphedema patients. Patients suffering from Lymphedema have varied symptoms, degrees of severity and progression of the disease. The characteristics of each patient’s lymphatic system also are different. In other words, a particular Lymphedema surgery may be suited for one patient but not another patient.
 Dr. Granzow created the comprehensive FLO System in order to optimize specific and individualized Lymphedema surgery and treatment to optimize results. A surgeon who is trained and experienced with performing different types of Lymphedema surgery is more likely to reach a better diagnosis and perform the Lymphedema surgery best suited to a particular patient.
 When evaluating a surgeon to care for you, be sure to carefully investigate his or her qualifications and experience. Look up their Board Certification(s) – this can be done quickly for free at www.ABMS.org, where any Board Certification recognized by the American Board of Medical Specialties can be found. Also be sure to look into their training and experience with your specific procedure, such as Lymphedema surgery. This type of procedure is not commonly taught in residency and requires additional training and experience above and beyond standard residency training.
  9. Will insurance pay for my Lymphedema surgery?Insurance coverage for Lymphedema surgery depends on your insurance policy and your individual Lymphedema condition. Dr. Granzow’s care team is dedicated to helping patients navigate various insurance issues. We highly recommend patients to also seek assistance from their health advocates.
  10. Would my previous history of radiation therapy or lymph node dissection surgery prevent me from having success with Lymphedema surgery?Most of Dr. Granzow’s patients developed their Lymphedema symptoms following radiation therapy, lymph node dissection surgery or both. These prior operations will not prevent you from having success with Lymphedema surgery.
  11. What is the risk of infection after Lymphedema surgery?Lymphedema surgery, just like all other low-risk surgeries, carry the small risk of postoperative infection. To date, we have not seen postoperative infections from the Lymphedema surgery in the Lymphedema arms or legs of our patients. In fact, the risk of dangerous cellulitis infections dramatically decreases following Lymphedema surgery as has been described in our Lymphedema publications.
  12. What type of Lymphedema surgery is appropriate for me? Each patient’s Lymphedema course and symptoms are different and must be evaluated individually by Dr. Granzow. Patients with fluid-predominant Lymphedema tend to benefit most from Lymphedema therapy, VLNT and LVA. Patients with solid-predominant Lymphedema tend to benefit more from SAPL. Dr. Granzow will evaluate your individual case and make specific recommendations about your options at your visit.
  13. Is it too late for me to get Lymphedema surgery?Your Lymphedema symptoms, rather than the time course of the disease will most influence the course of treatment. Dr. Granzow has had tremendous success with patients even with long histories of Lymphedema.
  14. Does lymphatic fluid create adipose tissue (fat)?Lymphedema fluid is thought to cause the deposition and growth of fat through inflammation and the up-regulation of certain genes. This new fat is part of the solids present in chronic Lymphedema and is poorly treated with Lymphedema therapy or surgeries which address mainly Lymphedema fluid excess, such as VLNT or LVA. Therefore, SAPL may be a better surgical procedure in these cases.
  15. Are Lymphedema surgeries more successful in arms than legs?Due to gravity, swelling in the body tends to accumulate much more in the legs than in the arms for almost all medical conditions, including Lymphedema. Therefore, the Lymphedema swelling is typically is easier to treat in arms than in legs. However, we find excellent outcomes in patients with leg Lymphedema as well with VLNT, LVA and SAPL.
  16. Can early intervention prevent the deposition of Lymphedema fat and solids?Dr. Granzow believes that the chances of Lymphedema swelling progressing from fluid to fat and other solids can be greatly reduced or eliminated with proper early intervention such as excellent Lymphedema therapy, compression, and possibly VLNT or LVA surgery in selected patients.
  17. Do you treat patients with primary or congenital Lymphedema using the FLO system? We do offer treatment and surgery to patients with primary Lymphedema. However, we have found that treatment and surgery tend to be less effective in cases of primary rather than secondary Lymphedema. Patients with secondary Lymphedema typically have had a previously normal or near-normally function lymphatic system prior to the surgery or radiation required to effectively treat their cancer or other disease process. Patients with primary Lymphedema are much more likely to have an intrinsic defect in their lymphatic system which can make treatment more difficult.
  18. What are the treatment results for overweight or severely overweight patients with Lymphedema?Patients who are severely overweight tend to have higher surgical risks and less favorable surgical outcome with any type of surgery, including Lymphedema surgery. Excess weight also worsens and can even cause Lymphedema. In general, therefore, we do not recommend Lymphedema surgery for severely overweight patients and recommend weight loss first as the Lymphedema can tremendously improve with weight loss alone.

Vascularized Lymph Node Transfer (VLNT) Questions

  1. Do you ever use more than one lymph node donor site during the VLNT procedure?We do not use more than one donor site during a single procedure. We find that the VLNT procedure has an excellent success rate using one donor site, and prefer to leave additional donor sites untouched. This reduces overall surgical risk and preserves additional donor sites should they ever be needed in the future.
  2. I have read that, on average, lymph node transfer procedures are successful in only 30% of patients. Dr. Granzow believes that the great results achieved in his patients are the result of the FLO System, a complete system of Lymphedema treatment that includes Lymphedema therapy, surgery and compression when appropriate. While other Lymphedema treatment facilities may only offer a single procedure, such as lymph node transfer, for all patients, we offer a much larger range of surgical procedures that can effectively address the Lymphedema presentations of a much wider range of patients. This allows us to achieve an average overall reduction of excess volume of approximately 86% in legs and 111% in arms and statistically significant reductions in the needs for Lymphedema therapy and compression garment use. These results are reported in our studies using the FLO System of procedures and therapy. This is well above the average values of the medical literature when taken together as a whole.
  3. In a lymph node transfer surgery, would taking lymph nodes from a different part of the body cause Lymphedema symptoms in that part of the body? There has been fear that moving lymph nodes from one part of the body can cause Lymphedema symptoms in the donor area. Indeed, there have been reports in medical literature of Lymphedema at the donor site for multiple areas, including areas previously thought to be “safe” like the supraclavicular (neck) area. However, we know of none of our patients who have had Lymphedema symptoms occur in a donor limb. Dr. Granzow performs reverse lymphatic mapping specifically to identify those lymph nodes that are most important to drain the donor site to avoid injuring them in a surgery. Reverse lymphatic mapping and careful selection of lymph node tissue by Dr. Granzow during vascularized lymph node transfers is critical to minimize surgical risk and maximize the outcomes of the procedure.
  4. Is it possible to use lymph nodes donated from another person for lymph nodes transfers (VLNT)? Currently, Dr. Granzow uses only a patient’s own lymph nodes for vascularized lymph node transfers. Multiple issues related to rejection of transplanted organs currently make lymph nodes transfer from another individual unavailable as an option at this time.
  5. I have seen reports of vascularized lymph node transfers (VLNT) being performed to the wrist or ankle. Does Dr. Granzow perform this form of LVNT? As part of a vascularized lymph node transfer procedure (VLNT), Dr. Granzow prefers to remove and release scar tissue from areas of previous surgery and radiation treatment. This means that the surgery sites tend to be to areas such as the axilla (armpit) as a first choice, rather than the wrist.

Lymphaticovenous Anastomosis (LVA) Questions

  1. I have heard that the small connections in lymhaticovenous anastomosis surgery (LVA) may work initially but fail over time. Is that true? There has been concern that the direct connections from the lymphatic system to the veins may fail over time. However, advancement in LVA surgical techniques has shown to provide good long-term results in most patients. Dr. Granzow generally performs multiple connections during and LVA surgery whenever possible. Dr. Granzow has found that at least one or more connections appear to remain open in most patients many years after the surgery.

Suction Assisted Protein Lipectomy (SAPL) Questions

  1. What kind of volume reduction can I expect to experience after SAPL? Our goal is to achieve a volume reduction in the patient’s Lymphedema arm or leg so that the size approaches the opposite, unaffected side. While each patient is different and no guarantee can be made as to a particular percentage of reduction, we have found an average overall reduction of excess volume of approximately 86% in legs and 111% in arms in our published medical studies.
  2. Why do you prefer flat knit compression garments rather than adjustable bandaging devices or bandaging?While it is possible to use adjustable bandaging devices or bandaging, we have found that custom-fit, flat knit, compression garments are easier to use and better tolerated than bandaging over the long term. As the size of the arm or leg decreases after SAPL surgery, the comfort and effectiveness of custom flat knit compression garments continues to improve.
  3. Can Lymphedema swelling return after the SAPL surgery?We prevent the reaccumulation of the Lymphedema fluid after SAPL surgery with a specialized course of Lymphedema therapy and compression garment use. These garments are specially fit for each patient and reduced in size by the Lymphedema therapist as the swelling in the arm or leg decreases. The continuous use of custom fit, flat knit compression garments is mandatory after the SAPL procedure to prevent recurrence of the Lymphedema fluid and swelling. The requirement for continuous compression can be reduced significantly with a carefully planned VLNT or possibly LVA procedure performed after the arm or leg has healed and the swelling has stabilized following SAPL. We have described this in our published medical studies.
  4. Can fat reaccumulate in the arm or legs after SAPL?As described above, it is thought that the excess fat found in Lymphedema accumulates as a result of inflammation and gene up-regulation caused by Lymphedema fluid. Proper control of the Lymphedema fluid after surgery with therapy, compression and possibly VLNT or LVA surgery will prevent the reaccumulation of the fat.
  5. How do you minimize the risk of damaging the lymphatic vessels during a SAPL procedure?Specialized training and careful technique reduce the risk of damage to lymphatics during SAPL. In fact, Dr. Granzow’s published medical studies have shown that the lymphatics are not further damaged by SAPL. In our experience, lymphatic function actually appears to have improved after the reduction of the excess pathologic fat and proteinaceous solids that are removed by SAPL. In fact, the risk of cellulitis and infection decreases significantly after specialized lymphatic liposuction. Blood flow to the skin of the affected arm or leg has also been shown to improve after surgery.
  6. Can you treat lipedema (lipoedema) or lipo-Lymphedema with the SAPL procedure? The SAPL procedure may be used together with Lymphedema therapy and compression for Lipoedema and Lipo-Lymphedema. The type of surgery and requirement for therapy will vary among individual patients.
  7. What happens to my skin after excess volumes of Lymphedema solids have been removed? We have found that the excess skin has contracted remarkably well in our patients. Please see our patient photos for some examples.
  1. Are Lymphedema surgeries safe for patients?The Lymphedema surgeries that are part of Dr. Granzow’s comprehensive FLO System (which stands for Functional Lympedema Operations) have an excellent safety record. These surgeries have the standard surgical risk comparable to other surgical procedures of similar length of time. We know of no patients whose Lymphedema has become worse after these surgeries. Patients having Lymphedema surgeries as part of Dr. Granzow’s FLO System have experienced significantly decreased rates of infection and cellulitis. Please note that debulking procedures, such as the Charles Procedure, are not part of Dr. Granzow’s FLO System.
  2. Does specialized Suction Assisted Protein Lipectomy (SAPL) damage a patient’s lymphatics or make Lymphedema worse?No evidence has been found that specialized Suction Assisted Protein Lipectomy (SAPL) results in any damage to the lymphatics or make Lymphedema worse. Specialized Suction Assisted Protein Lipectomy (SAPL) can provide significant and long-term volume reduction for arms or legs with chronic Lymphedema. This surgical procedure has been studied extensively and found to be safe for patients. In fact, the risk of cellulitis and infection decreases significantly after specialized Suction Assisted Protein Lipectomy (SAPL). Blood flow to the skin of the affected arm or leg has also been shown to improve after surgery.
  3. Why is it important for a patient to work with a trained Lymphedema therapist and to receive proper Lymphedema therapy to ensure a successful outcome with Lymphedema surgery?Dr. Granzow’s comprehensive FLO System has been successful in treating Lymphedema through a combination of effective surgical technique and integrated Lymphedema therapy that is tailored to each patient. Because this combination of therapy and surgery produces the best overall outcomes, we feel that patients must be evaluated and treated by a trained Lymphedema therapist prior to being considered for surgery. Dr. Granzow believes that a patient should be treated by her own therapist in her area both before and after surgery whenever possible.
  4. Why should a Lymphedema surgeon be trained and experienced with performing different types of Lymphedema surgery?Any particular type of Lymphedema surgery is not a “one size fits all” solution for all Lymphedema patients. Patients suffering from Lymphedema have varied symptoms, degrees of severity and progression of the disease. In addition, the characteristics of each patient’s lymphatic system are different. Dr. Granzow believes that Lymphedema surgery must be individually tailored to address each patient’s specific conditions. In other words, a particular Lymphedema surgery may be suited for one patient but not another patient.Dr. Granzow created the comprehensive FLO System in order to tailor specific and individualized Lymphedema surgery and treatment to optimize results. We feel that a surgeon who is trained and experienced with performing different types of Lymphedema surgery can reach a better diagnosis and perform the Lymphedema surgery best suited to a particular patient.

    When evaluating a surgeon to care for you, be sure to carefully investigate his or her qualifications and experience. Look up their Board Certification(s) – this can be done quickly for free at www.ABMS.org, where any Board Certification recognized by the American Board of Medical Specialties can be found. Also be sure to look into their training and experience with your specific procedure, such as Lymphedema surgery. This type of procedure is not commonly taught in residency and requires additional training and experience above and beyond standard residency training.

  5. Who should perform my Lymphedema surgery?It is critical for the safety and success of any Lymphedema surgery that the surgery is performed by a Lymphedema surgeon who is not only an experienced microsurgeon and familiar both with technical aspects of the surgery, but also with the overall care and treatment of Lymphedema patients. For instance, Suction Assisted Protein Lipectomy (SAPL) is entirely different than cosmetic liposuction. In addition, Lymphedema surgery (a type of microsurgery) is very different than other types of reconstructive microsurgery. A successful outcome relies on a qualified Lymphedema surgeon who not only masters the unique technical aspects of the surgeries but also properly integrates Lymphedema therapy before and after the procedures.
  6. In a lymph node transfer surgery, would taking lymph nodes from a different part of the body cause Lymphedema symptoms in that part of the body?There has been fear that moving lymph nodes from one part of the body can cause Lymphedema symptoms in the donor area. However, we know of no patients who have had Lymphedema symptoms occur in a donor limb. Careful selection of lymph node tissue by Dr. Granzow during vascularized lymph node transfers is critical to minimize surgical risk and maximize the outcomes of the procedure. Dr. Granzow has worked with leaders in the field and has personally performed many successful vascularized lymph nodes transfers.
  7. What kind of volume reduction can I expect to see after specialized Suction Assisted Protein Lipectomy (SAPL)?We have seen consistent positive results after Suction Assisted Protein Lipectomy (SAPL). Our goal is to achieve a volume reduction in the patient’s Lymphedema arm or leg so that the size approaches or even becomes smaller than the opposite, unaffected side.
  8. Are there any preliminary tests that should take place prior to an evaluation in person with Dr. Granzow?Dr. Granzow uses specialized studies, such as lymphoscintigraphy, to help him assess the function of a patient’s lymphatic system. Having the results from lymphoscintigraphy prior to the in-person evaluation is highly beneficial for Dr. Granzow to evaluate a patient’s specific Lymphedema condition. Also, Dr. Granzow may require a patient to obtain a complete evaluation by a qualified vascular surgeon to rule out any venous problems or other vascular causes of arm or leg swelling. Our dedicated staff will assist with coordination efforts according to Dr. Granzow’s recommendations based on your specific condition.
  9. I have heard that the small connections in lymhaticovenous anastomosis surgery (LVA) may work initially but fail over time. Can you please explain this possibility?There has been concern that the direct connections from the lymphatic system to the veins may fail over time. However, advancement in LVA surgical techniques has shown to provide good long-term results in most patients. Dr. Granzow generally performs multiple connections during and LVA surgery whenever possible. Dr. Granzow has found that at least one or more connections appear to remain open in most patients many years after the surgery.
  10. Is it possible to use lymph nodes donated from another person for lymph nodes transfers (VLNT)?Currently, Dr. Granzow uses only a patient’s own lymph nodes for vascularized lymph node transfers. Multiple issues related to rejection of transplanted organs currently make lymph nodes transfer from another individual unavailable as an option at this time.
  11. I have seen reports of vascularized lymph node transfers (VLNT) being performed to the wrist or ankle. Does Dr. Granzow perform this form of LVNT?As part of a vascularized lymph node transfer procedure (VLNT), Dr. Granzow prefers to remove and release scar tissue from areas of previous surgery and radiation treatment. This means that the surgery sites tend to be to areas such as the axilla (armpit) as a first choice, rather than the wrist.