Areas of Expertise:
Dr. Jay Granzow is an internationally respected lymphedema surgeon. He serves as Professor of Surgery in the Division of Plastic Surgery at the UCLA David Geffen School of Medicine, and Assistant Chief of Plastic Surgery at Harbor-UCLA Medical Center. He is Board Certified both in Plastic Surgery and Head and Neck Surgery.
A pioneer in lymphedema surgery, Dr. Granzow successfully integrated lymphedema therapy with three types of lymphedema surgery including vascularized lymph node transfer (VLNT), lymphaticovenous anastomosis (LVA) and suction assisted protein lipectomy (SAPL). He has published major scientific articles on lymphedema surgery in leading medical journals. Dr. Granzow is a frequent lecturer at U.S. and international conferences, educating patients, therapists and physicians on the latest advances in lymphedema surgery. Dr. Granzow provides lymphedema treatment for patients in his private medical practice located in the Los Angeles area.
I had mastectomy, DIEP flap reconstruction and 17 nodes removed on left arm in 2014. Now I was diagnosed with calcific tendonitis on my left shoulder. Which one of these treatments will have less lymphedema risk on my affected arm? Lavage will involve injections while shockwave therapy may increase blood.Thanks.
Unfortunately, there is no medical study or literature of which I am aware covering the procedures you discuss. Generally, minimizing trauma and needle sticks etc. to any affected area tends to decrease lymphedema risk.
will I have to continue to use compression pumps (flexitouch) after SAPL surgery? Also--I understand I will have to wear compression garments for 23 hours out of 24 hours for 6 months after surgery? after 6 months, how long do I need to be in compression?
SAPL surgery is the first part of my comprehensive lymphedema treatment program for patients with advanced, solid-predominant, chronic and severe stage 2 lymphedema. These patients already have severely damaged lymphatic systems and permanent pathologic deposits of material such fat and proteins. They already require compression 23 hours per day even before surgery.
SAPL surgery is crucial for such patients by removing the inflammatory and toxic deposits caused by lymphedema. If these deposits are not removed, they continue to cause increasing inflammation which deteriorate the patients’ already damaged lymphatic system and surrounding tissues. Without SAPL surgery, their lymphedema tends to worsen, and they often face increasing cellulitis infections and deteriorating quality of life because of the inflammatory and toxic deposits.
Some people inexperienced with SAPL surgery believe that SAPL surgery somehow causes the need for new or additional compression after surgery. However, SAPL surgery itself does not increase the need for compression after surgery. In our extensive experience, the need for compression either remains the same or decreases to some extent. In fact, tremendous clinical improvement occurs in almost all cases when the surgery is performed by an experienced surgeon and proper protocols are followed. Imaging studies and clinical outcomes seen at various centers have consistently shown that the lymphatic drainage system is not damaged by the removal of pathologic solids and usually improves following the surgery.
Overall, the amount of compression that a patient will need will largely depend on the severity of their lymphedema. After SAPL surgery, patients must maintain consistent compression garment wear to allow their severely damaged lymphatic system to heal and rebuild. Because significant recovery occurs after SAPL, most of my patients decrease or eliminate the use of their compression pumps after the surgery.
When a patient completely heals from SAPL surgery, they may be suitable for the second part of my treatment program, which consists of lymphatic reconstructive surgeries such as lymphaticovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT), which repair and improve the lymphatic system. These procedures can further significantly decrease inflammation and decrease the need for compression, pumps and therapy.
The ultimate goal of my lymphedema treatment program is for patients to have a better quality of life. For most patients, a better quality of life means their affected arm or leg look and feel more normal, to better participate in their hobbies and sports again, and to enjoy more time with their family and friends (less time spent on conservative therapies and compression garments).
What is your experience with patients recovering from SAPL and how long post operation the patient has to wrap their leg before returning to custom compressions?
After SAPL surgery we typically bandage the patient’s arm or leg for about 2 to 8 days before placing the arm or leg into a new, much smaller, set of custom compression garments. The length of time for bandaging depends on the patient’s individual situation and the complexity of his/her lymphedema disease process.
I'm 21 years old and had lymphedema since I was about 8 years old. I have a 1 inch difference in my ankle and foot but everything else is even. Is it safe if I have lipo in my stomach or a boob job
Thank you for the question. Unfortunately, I cannot provide specific guidance regarding your specific medical condition given that I have not seen you in-person for a consultation. There are no studies in the medical literature speaking specifically to your question. It is unclear to me whether it would be safe for you to have liposuction in your abdomen area. In patients that I have seen, I am not aware of any patient that had leg lymphedema worsen after a breast augmentation. A few patients have reported to me that their lymphedema symptoms worsened after liposuction, but those patients have had either more severe presentations of lymphedema or they had very aggressive liposuction or laser liposuction.
after 22 years my right arm start swelling after the removal of lympnode I had the compression sleeve who did not help also the exercises just on June 19th 2020 my vascular doctor here in Tennessee said I needed a stent to help with drainage but decided not to
It sounds like you are worried that the swelling is an indication you have lymphedema. Unfortunately, I cannot provide any feedback about the stent issue since I am not a vascular surgeon. For patients who believe they have lymphedema, we recommend that they seek consultation with a lymphedema surgeon who would determine whether the symptoms are consistent with lymphedema. In addition, the lymphedema surgeon would likely recommend imaging studies to confirm the lymphedema diagnosis.
Hi Im using conservative treatment on my leg and feel i'm doing everything i can however my leg is continuing to progress . if i have sapl surgery and continue to wear compression and look after my leg what will stop it from progressing again. Thanks
Unfortunately, I cannot provide specific guidance regarding your specific medical condition given that I have not seen you in-person for a consultation. I have found Suction Assisted Protein Lipectomy (“SAPL”) to be extremely effective for patients that I have treated. My personal experience is that after SAPL lymphedema surgery, patients’ lymphedema no longer progresses if they continue with conservative therapy and custom compression. Patients report that their therapy and compression usually is less than before SAPL surgery. This is due to the decreased swelling and inflammation after healing from SAPL is complete. My patients also typically have had their arm or leg after SAPL lymphedema surgery reduce to be closer to or about the same size as their unaffected arm or leg.
I am 57 year old who developed lymphedema after gynecological cancer treatment (surgery no radiation). I have early stage lymphedema and mild venous insufficiency equal in both legs. Is it possible to avoid the need for compression garments after successful lymphovenous bypass?
Thank you for your question. I don’t know the specifics of your particular case so I am unable to make a direct recommendation.
In general, the presence of lymphedema means that the natural drainage in of lymphatic fluid, called lymph, is impaired. Conservative treatments, such as compression, manual lymphatic drainage, etc., will help drain the fluid.
Surgeries, such as lymphaticovenous anastomosis (LVA), sometimes called lymphaticovenous bypass, and Vascularized lymph node transfer (VLNT), can also help to drain the excess lymph and reduce the amount of conservative treatments needed. The amount of improvement from surgery depends both on the patient’s condition and the surgeons training, experience, and ability to match the correct surgery for the patient’s specific condition.
I just had a panictalectomy to remove my lymphedema in my lower abdomen. Can it return? My BMI is high because I’m obese. Will weight loss help make sure it Doesn’t come back again? Thank you!
In general, obesity and especially morbid obesity have been shown to increase the risk of lymphedema and worsen lymphedema that is already present. In fact, losing weight in a safe way overall will have one of the most positive impacts on almost anyone with excess fat or swelling in the abdomen.
I recently had a lumpectomy with 4 lymph nodes removed (1 month) I have not started treatment yet but am taking a flight and confused as to whether a fitted compression sleeve will reduce likelihood of Lymphedema as I have seen conflicting views.
Although there are conflicting opinions regarding flying and the development of lymphedema after lymph node removal, wearing a compression garment properly fitted by a certified lymphedema therapists during your flight is likely to reduce the onset or progression of lymphedema and unlikely to worsen any disease progression.
I don't wear bandages or garments at night. Lack of compression during sleep does not adversely affect leg condition Will compression at night be necessary after SAPL? In the past my leg got blue after pulling off my stockings, now it's gone. Can it come back after SAPL?
Thank you for the question.
Unfortunately, I cannot provide specific recommendation about your condition since I have not seen you in-person for a consultation and so I do not know whether you would benefit from SAPL surgery given your situation. The following information is general in nature.
There is a misconception that SAPL surgery itself causes patients to require compression after surgery that they would otherwise not need if they did not have SAPL surgery. This is not true. In my experience, the compression needed after SAPL surgery typically does not change and sometimes decreases slightly.
SAPL surgery that I perform is to treat patients with solid predominant, stage 2 lymphedema. These patients have advanced disease in which the affected arm or leg never can be reduced in size to the approximate the size of an unaffected arm or leg. These patients already require ongoing compression and other conservative treatment to prevent further progression of their disease.
I perform SAPL surgery to remove the excess solids and inflammation and to normalize the size of the arm or leg. The procedure is very different from cosmetic liposuction and requires a specialized compression therapy regimen during and after the surgery to be successful. After healing is complete, the expected result is that the affected arm or leg approximates the size of an otherwise unaffected arm or leg.
For my patients who undergo SAPL surgery, the amount of time of compression wear does not change from the amount of compression that I recommend prior to their SAPL surgery. However, since SAPL greatly decreases inflammation and infections, effective compression may be easier to achieve after the SAPL surgery.
Once healing from SAPL surgery is complete, the size of the treated arm or leg will approximate the unaffected arm or leg and the lymphedema inflammation will be greatly reduced. At this point, I often recommend other lymphedema surgeries for further treatment to maintain the reduction. Such surgeries include lymphaticovenous anastomoses (LVA) and vascularized lymph node transfer (VLNT). These surgeries can reduce the amount of compression needed long-term. These surgeries generally are not effective if performed on an arm or leg with chronic, solid predominant stage 2 lymphedema which should be treated with SAPL instead.
I have breast lymphedema and lymphedema in my arm All is on the left side I have an expander on my left side I finished radiation at the end of October I plan on getting a prophylactic mastectomy on my right Will the DEIP surgery hurt my lymphedema?
Typically, breast reconstructions using your own tissue, such as DIEP flap reconstructions tend to improve the surrounding tissue and are unlikely to cause lymphedema by themselves. In addition, your procedure will be on the opposite, right side, and is unlikely to affect your current left side lymphedema.
Hi I recently took a lymphoscintigraphy scan to rule out lymphedema.. the scan came out negative.. but I remember walking 5 miles leading up to the scan.. question is could the walking i did prior to the scan had an effect on the outcome?? I was never diagnosed with lymphedema
Thank you for the question.
Lymphoscintigraphy is an excellent test of lymphatic flow in the arms and legs. Since I don’t know your specific case, I am unable to provide a specific recommendation for you. However, I do not believe that walking for distances such as 5 miles would change the results of a lymphoscintigraphy, and I’m not aware of any medical studies which would speak to that point.
My mother has been living with stage III lymphedema (severe) in her legs for 10 years. Shes tried therapy, massage, & compression wraps to try and control the swelling. This just pushed the fluid up into these large fluid sacks behind her knees. Would she be a candidate for surgery?
Thank you for the inquiry. Your mother would need to be evaluated in-person by a lymphedema surgeon to determine whether she is a candidate for surgery. The surgeon would take into consideration many aspects before recommendation surgery, such as her specific symptoms, physical condition, other medical condition(s) and overall health.
I believe in a team based integrated approach to both evaluation and treatment of lymphedema. These are the kinds of questions that the surgeon should consider: 1) Can the underlying cause of her lymphedema be addressed first? 2) What kinds of therapy have been tried, and for how long? 3) Are there any other underlying medical conditions which could affect her outcome? The surgeon should consider these factors with a thorough history and physical examination in order to offer appropriate surgical options.
Does liposuction damage lymphatic or vascular pathways
Thank you for the inquiry. Lymphatic liposuction or suction assisted protein lipectomy surgery to treat stage 2 lymphedema has been studied extensively in medical literature and found not to damage the lymphatic pathways. This has been well known for over 20 years and is consistently supported by surgeons who perform this procedure.
In fact, a medical article was published by Brorson et. al. in 1998 which found that lymphatic liposuction does not damage lymphatic pathways. More recently, medical investigations using indocyanine green (ICG) laser imaging have confirmed that the lymphatic pathways actually appear to recover and improve after properly performed lymphatic liposuction surgery used to treat lymphedema.
The inflammation in the affected areas is reduced after lymphatic liposuction surgery, which allows the soft tissues, including the lymphatics, to recover and heal significantly. Even ICG images taken immediately after lymphatic liposuction surgery consistently show that any lymphatic structures seen before surgery remain intact even immediately after surgery.
I have Primary Lymphedema for 42 years. I developed a non-cancerous lump or cyst on the toe of my lymphatic right foot that was removed but came back again. Are there any treatment options for this type of malformation.
Thank you for the inquiry. More information would be needed here since the treatment would be dictated by the diagnosis or type of lump or cyst present. I would recommend that you see the surgeon who removed the previous lump or cyst for a follow-up.
Lymphoceles, which are collections of lymphatic fluid, are rare in patients with lymphedema. For lymphoceles, excision with ligation of the feeding lymphatic may be an option.
I'm stage 3 lymphedema, diagnosed 2.5 years ago. This happened after ablation surgery both legs for venous insufficiency a few months before. Doctors want to do further ablation surgery. Would this improve lymphedema or make it worse?
Regarding your venous ablation procedures, I would recommend that you seek advice from a vascular surgeon who has expertise in treating the venous system and who is also knowledgeable regarding your lymphedema condition. The overall goal here should be to decrease the venous pressure in the legs, which would then likely improve lymphatic outflow and improve lymphedema. Increased venous pressure in the legs can cause or worsen leg edema, especially in conditions such as May-Thurner Syndrome.
I had Lipo of abdomen and flanks 16 months ago. It was a slow recovery - slower than advertised. Is it possible that I am still swelling from that ? My abdomen becomes much larger after being up all day. My mons pubis still seems ‘fleshy’ to me. I hadMLDrightaftersurgery.
Thank you for your question. For your questions I assume you had cosmetic liposuction, as opposed to SAPL surgery for lymphedema which is very different.
Swelling from liposuction surgery usually tends to resolve by 3-6 months, and swelling that still persists after 16 months is very unusual but has been described. Prolonged swelling can occur especially after liposuction which uses laser or ultrasound as part of the procedure. I would recommend that you follow up with the surgeon who performed the surgery, who can both perform an exam and better guide you.
I had total reverse shoulder arthoplasty and Dr missed I had lymphedema until it was stage 2 I want to find out if I am a candidate for lymph transfer?
Thank you for your question. Unfortunately, it is not uncommon that physicians fail to notice the signs and symptoms of lymphedema. Many medical schools devote around 1 hour or less of the entire 4-year curriculum to the study of lymphedema.
A thorough evaluation by an experienced lymphedema surgeon and lymphedema therapist is recommended to evaluate for the possibility of a vascularized lymph node transfer (VLNT) or other lymphedema surgery. Your comment that the arm is stage 2 implies that the lymphedema is more advanced and has a significant solid component present. This means that the affected arm does not reduce in size to the size of the opposite, unaffected arm even when proper lymphedema therapy, compression and other conservative (non-surgical) therapy is used to remove the excess lymphedema fluid present. In such cases, VLNT surgery, a procedure which also is designed to remove lymphedema fluid, if used by itself, would not be successful in reducing the volume of the arm to the size of the unaffected arm, although minor improvements in volume and and improvements in symptoms may occur.
Instead, for lymphedema with significant solid component present, suction assisted protein lipectomy (SAPL) surgery would first remove the excess lymphedema solids and allow the arm to reduce to the size of the opposite arm. SAPL surgery does not increase or reduce the need for compression garment use. Once healing is complete, VLNT and/or lymphaticovenous anastomosis (LVA) surgeries could be prescribed to further reduce symptoms and the need for compression use and lymphedema therapy.
Can you please let me know what are sucess rates for LVA (lymphaticovenous anastomosis) in case of Primary Lymphedema (1st manifested at the age of 23) in right arm? Do you perform such a surgery? If not, can you please refer me to someone who does. Thanks.
Thank you for your question. Since 2005, I have successfully performed lymphaticovenous anastomosis (LVA) lymphedema surgery in either primary or secondary lymphedema patients.
In my experience, patients overwhelmingly see improvements in lymphedema symptoms and see significant decreases in the amount of compression and therapy needed after LVA surgeries. The exact amount of improvement will vary from patient to patient. Patients with congenital/primary lymphedema often show tremendous improvements after LVA, often similar as patients with secondary lymphedema. LVA surgeries also are generally the least invasive and have the quickest recoveries compared to other lymphedema surgeries.
I have Stage 3 lymphedema in my right leg with serious leaking, pain, mobility issues and near constant cellulitis infections. Amputation seems to offer a better quality of life. Is it a viable solution to amputate the affected limb?
Stage 3 lymphedema as you describe can be extremely debilitating, cause serious health issues and be very difficult to live with.
Amputation would present a very extreme treatment. It may not alleviate all symptoms of lymphedema and my not improve overall quality of life. After amputation, lymphedema may still persist in the remaining part of the leg may and may contribute to significant healing issues after amputation. In addition, the physical functional losses associated with an amputation, especially an above-the-knee amputation, are also significant.
Therefore, I would strongly recommend pursuing all conservative and surgical options before considering this extreme approach to treatment.
I have edema around my breast implant from reconstruction. Could this be made worse if I had them removed or replaced? Could it be caused from the implant itself? I only had one node removed in my mastectomy surgery. The swelling gets worse with weather changes, air pressure.Thank you.
It sounds like you are describing edema or swelling in the skin and soft tissues immediately next to the breast implant, such as the skin and fat of the breast and chest wall rather than having fluid in the implant pocket itself.
Edema may occur in the treated chest wall skin after surgery, especially if the skin and chest wall soft tissues have been treated with radiation therapy need for cancer treatment. In fact, in my experience, previous radiation therapy will be much more likely than lymph node surgery to worsen chest wall swelling and symptoms.
Additional swelling will always occur to some extent after additional surgery, such as removal and replacement of implants. Most of this swelling will resolve over time.
Unfortunately, it is impossible to predict how this swelling will behave. Lymph node removal can increase the chances of worsening swelling over time.
My husband has had lymphedema in both legs for 8 yrs. Developed after back surgery. He weighed 210 lbs .. He is now 410 lbs. What are the courses of action we should take to get weight off him. Should bariatric surgery be a consideration. Thank you
Thank you for your question.
For your husband, the weight issue is separate from the lymphedema issue. For our patients with similar situations we have recommended treatment by a team of caregivers who specialize in treating severely overweight patients. This team will typically include a surgeon specializing in bariatric (weight loss) procedures. The final decision on whether or not to recommend and/or pursue surgery weight loss will rest with the team and the patient.
We have found that increasing patient weight often makes lymphedema symptoms worse and the lymphedema more difficult to treat. Conversely, lymphedema often becomes easier to treat when patients safely decreases a large amount of weight.
I had a body lift with dehiscence complications, I packed Wet to dry for 7 weeks! I have huge abdomen , thighs , buttocks that grows throughout day and horribly uncomfortable. Who or type of doctor do I go to for diagnsis? Is this possible to be in those areas
It sounds like you are describing issues that can occur after “body lift” types of surgery, even when surgery is properly performed. Wound dehiscences can be extensive due in part to the very long incisions and large surface areas involved. This type of swelling swelling is unlikely related to lymphedema.
You would be best served by continuing care with the surgeon who performed the body lift, who should be familiar with such issues.
Hi DR Granzow As vascular surgeon ,I met in my clinic children below 5 years and complaining from different forms of primary lymphedema ( localized to the feet or leg ,sometimes involve whole limb,).my questions are : 1- what is the best investigation tool ( e.g.NIRFLI,MRI ...)? 2-do you prefer certain age for intervention i.e. postpone surgery untill growing up? 3- what are kind of surgery do these children need( e.g.SAPL,VLNT)&are these surgeries different from those in Adult? Thanks in advance A.SAWABY
The patients that I treat are primarily adult patients but I have come across children and teenagers who have primary lymphedema. I would consider MRI of the affected extremity and adjacent torso to better characterize the limb and also rule out proximal pathology that may be contributing to the swelling.
An indocyanine green imaging study in both the affected limb and the unaffected side would also be very helpful. I would recommend having this study also performed with the child under anesthesia, as the injections can be difficult to tolerate.
I was recently diagnosed with RT leg lymphedema after a single SLNB in my groin. I am learning to manage with daily compression use and the flexitouch, but am only 34 and expect to need surgical and/or other therapeutic treatment in the future due to the progressive nature of the condition and duration. As many patients do I seek tips, tricks, and community through other lymphedema patients on social media. A patient recently posted that she is having VLNT and surgeons do not want you to use the compression pump before or after. Is that accurate? If so, immediately before surgery or ever? Can you explain why? Thank you.
The compression pump can be effective for some patients in moving lymphedema fluid and helping manage the fluid part of the lymphedema volume excess. Other modalities that also move fluid are manual lymphatic drainage (MLD), compression garments, and microsurgery such as vascularized lymph node transfer (VLNT) or lymphaticovenous anastomosis (LVA).
For my patients, I have no issue with compression pump use before surgery. For VLNT surgery, I typically allow my patients to use their compression pump again 6 weeks or so after surgery.
Please keep in mind that treatments I mentioned above (MLD, VLNT and LVA surgeries) are not be effective in reducing the permanent solid portion of lymphedema swelling. Such solid swelling has also been described as “non-pitting”. This solid excess is best treated with SAPL lymphedema surgery, prior to repairing the defect in your lymphatic system using microsurgeries such as VLNT or LVA surgeries.
DEAR Dr.Jay I am interested in lymphedema surgery. If you allow me to ask you about SAPL technique : 1_Which cannula type you prefer for liposuction ? 2_What is your solution for humping of forefoot (long lasting CDT or liposuction)? 3_what is the max. amount of liposuction per limb? 4_in st.II lymphedema,when you decide to liposuc? Thanks in advance A.Sawaby
Thank you for the interest in SAPL surgery. I believe a bit of background will give more insight into the answers.
Lymphedema swelling comes in 2 forms – fluid swelling and solid swelling. Fluid swelling occurs first, and is caused by accumulation of the inflammatory lymph fluid. This can be treated with modalities that move fluid and include conservative treatments such as compression garments, manual lymphatic drainage and compression pumps. This fluid in most people tends to collect more in the feet, ankles and lower legs due to the effects of gravity. Swelling in the foot tends to be fluid, and typically is best addressed in this way. Microsurgery procedures such as LVA or VLNT also are effective in moving fluid.
Over time, the inflammation caused by this fluid leads to damage of the surrounding structures and permanent deposits of solids. These can be quite thick, and cannot be removed with conservative treatments or LVA/VLNT surgery.
I find that an integrated approach to lymphedema treatment consistently yields the best results. Therefore I prefer initially to use proper lymphedema therapy to reduce the fluid volume excess first, and then use SAPL surgery to remove the remaining solids to allow the limb to approximate its normal size. My experience is that few patients have sufficient excess solid present in the foot and ankle to require SAPL surgery in these areas.
SAPL surgery can be used for solids that have been present for both short or very long times. I have successfully treated patients whose lymphedema solids were present for almost 50 years. To remove the solids, a blunt, custom-made cannula that is much larger and longer than average is used. While the maximum amount of solids that can be removed varies from person to person, in almost all cases I have been able to treat an entire leg in one surgery.
It is important to note that SAPL surgery is very different from cosmetic liposuction. This is due to significant differences in the technique used, such as the use of a tourniquet during SAPL, which can greatly increase safety and also the amounts of volume that can be removed when properly applied.
How do I go about finding a doctor to diagnose and support me in my struggle with lipedema or lymphedema? My primary care said she read some articles and thought it was Lymphedema. She referred me to two different vascular surgeons, both found insufficient veins and seemed gleefully happy that I would qualify for surgery...however neither led me to believe this would be anything more than short-term relief and neither made me feel this would result in significant improvement. Instead I went to an OT who has helped me a great deal. Her therapy combined with compression stockings that were made specifically for me has helped somewhat. Looking long-term, I would love to find a knowledgeable physician to guide me and support me in making decisions to support my journey. What type of specialist would this be? Are there any in New England? Thank you,
This is a question often asked by patients with lipedema or lymphedema. Unfortunately, many health providers are not familiar with these conditions to provide adequate guidance to patients. In fact, most physicians receive little to no teaching about lymphedema during their entire 4-year medical education. Patients often report that they feel they have more knowledge than their primary care physicians about their condition.
We find that patients who are successful in managing their conditions have a team of knowledgeable medical professionals who care for them. For instance, this team could be comprised of a primary care physician who is open-minded and want to learn about lymphedema or lipedema, a certified lymphedema therapist (CLT) who provides ongoing therapy for the patient, and perhaps a surgeon who has expertise in lymphedema or lipedema.