Stages of Lymphedema

Lymphedema progresses in a consistent way, and patients with lymphedema at different stages of the disease process must be treated with different techniques to achieve the best results.  We have seen multiple patients treated elsewhere in whom the surgery was not well matched to the patient’s condition.  A thorough evaluation and diagnosis by Dr. Granzow and his team will allow for the best understanding of a patient’s specific condition and determine the best course of treatment.

The Lymphedema Disease Process


Lymphoscintigraphy and ICG images can reveal decreased tracer movement and dermal retention

Stage 0 (Imaging reveals lymphedema)

  • Lymphatic drainage system damaged with deficits seen on imaging studies. Patient not experiencing visible swelling.
  • Conservative therapy (e.g. MLD, bandaging, compression) required for treatment but does not repair the lymphatic system.
  • VLNT (microsurgery) and LVA (supermicrosurgery), can repair the lymphatic system and permanently improve lymphatic function and limit further progression of lymphedema.

If Stage 0 lymphedema is not properly diagnosed and treated, inflammation will produce swelling, damage the lymphatic structures and the surrounding tissues, increase risk of infections, and cause progression to Stage 1 lymphedema.


In Stage 1 the affected arm or leg can reduce in size to approximate the opposite leg

Stage 1 (Early stage, fluid predominant)
  • Lymphatic drainage system damaged, excess lymphatic fluid accumulates. Affected arm or leg swells but does reduce in size to match the unaffected side with conservative treatment.
  • Conservative therapy (e.g. MLD, bandaging, compression) can effectively reduce volume but does not repair the lymphatic system.
  • VLNT (microsurgery) and LVA (supermicrosurgery), can repair the lymphatic system and permanently improve lymphatic function, reduce swelling and improve symptoms. This reduces the need for conservative therapies and can permanently stop disease progression.

If Stage 1 lymphedema is not properly diagnosed and treated, the excess lymphatic fluid will cause further inflammation, swelling, and damage to the surrounding tissues.  The lymphatic drainage system sustains permanent damage and fails, leading to permanent deposits of lymphedema solids including fat and proteins in the arm or leg.  The infection risk greatly increases and progression to Stage 2 lymphedema occurs.


Stage 2 lymphedema in left arm (left) right leg (right)

Stage 2 (late stage, solid-predominant)

  • Lymphedema solids and fat have permanently deposited in the affected limb. The size of the affected arm or leg never decreases to match the unaffected side.
  • Conservative therapy (e.g. MLD, bandaging, compression) reduces some volume but cannot adequately treat lymphedema symptoms.
  • SAPLSM surgery is now required to remove excess volume permanently and downstage arm or leg to Stage 1.
  • VLNT (microsurgery) and LVA (supermicrosurgery), if performed before SAPLSM, can not remove the accumulated lymphedema solids and any surgical sites used are lost for future improvement.

If left untreated, Stage 2 lymphedema can progress to Stage 3 lymphedema, the most severe form of lymphedema.  Stage 3 lymphedema is sometimes called elephantiasis.  Irreversible damage to the skin and surrounding structures occurs and standard surgical treatment methods, such as VLNT, LVA or SAPLSM are no longer effective.


Stage 3 lymphedema

Stage 3 (final stage – elephantiasis)

  • Lymphedema solids accumulate to a massive extent
  • Continued inflammation further damages surrounding structures
  • Skin thickness massively increases
  • VLNT (microsurgery) and LVA (supermicrosurgery), and SAPLSM surgery are not effective treatments. Please contact our office for more information for stage 3.

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