Thank you for the inquiry.  I can’t comment specifically on your case since I have not seen you in our office and you are not our patient.

Generally, I have not seen patients with lipedema in the abdomen but not in the legs.  There are no set BMI cutoffs for treatment of lipedema fat, although different BMI values can significantly change treatment options.  Abnormal skin may be removed after Lipisuction if needed as a patient’s particular situation dictates.

I’m providing you some feedback from our insurance appeals team: “Your daughter would need to file a formal appeal with her insurance company.  It is important for her to review her health plan certificate of coverage/plan document regarding the following relevant information: 1) how many appeals are available; 2) what are the time frames for filing appeals; 3) what information are required in the appeal package; and 4) definition of medical necessity and what is considered cosmetic surgery.  Your daughter should also search her health insurance portal for possible applicable medical policies that could apply here.  The denial letter should contain information as to what medical policy(s) were relied upon to deny her surgery.  Your daughter should get a medical necessity letter from her surgeon as to why her surgery is medically necessary and not cosmetic and seek assistance from her surgeon’s office regarding the appeal.”  Best of luck!

Regarding lymphedema staging, generally I think of the staging as Stage I – arm or leg has normal size on best day or with control but has symptoms of swelling etc.  Stage II – permanent solids have now accumulated between skin and deep tissues such as muscle fascia and size no longer matches opposite unaffected size.  Stage III – very advanced with larger lobules, permanent skin changes and significant solids deposited.

I feel strongly that LVA really should be reserved for patients with Stage I disease.  SAPL is required for Stage II disease (and LVA may be possible after Stage II treated with SAPL and healing has occurred).  Stage 3 would require even more involved treatment.  I couldn’t provide treatment guidelines for him since I haven’t seen him in my office.  I’m not good with insurance but I do know that unfortunately my office does not take Medicare.

The laser red light therapy is something that my lymphedema therapists have used in the past and could be beneficial on a case by case basis.  Keep in mind this would be an additional therapy provided as part of the overall lymphedema therapy and surgery treatment program and should not be used instead of properly administered therapy, compression and possible surgery.  I would encourage you to speak with your certified lymphedema therapist (CLT) or surgeon about this option.

I would recommend that you contact your surgeon regarding possible medical journal articles that support the type of lymphedema surgery that your surgeon has prescribed. Your surgeon will have access to medical journal articles that he or she believes to support the safety and efficacy of your surgery.

Thank you for the question.  To answer your question properly, I would need to see you in my office with my team and evaluate your situation carefully.  I would not be able to make recommendations without such an evaluation.  I would need to accurately assess where you are in the lymphedema disease process and then determine where the previous surgeries fit in and which additional surgery, if any, is appropriate for your specific situation.  For example, the surgeries you describe address the fluid component of lymphedema swelling only, and would not be very effective in reducing the size of your arm if you have a solid-predominant, Stage 2 lymphedema.

In my experience, lymphaticovenous anastomosis surgery (LVA) has been very effective at improving the symptoms and quality of life of patients that I have treated.  This is a consistent result and these positive results are confirmed overwhelmingly in the medical literature.

I am sorry that this is frustrating to you, but unfortunately as a surgeon, I don’t have the expertise in insurance issues to answer your question. My understanding is that large medical centers are more likely to accept Medicare insurance.  If a lymphedema surgeon who you are researching is a part of a large medical center, then I believe it is more likely that your Medicare insurance would be accepted.

The situation you describe must be very frustrating.  It is impossible to be able to provide an answer for your specific situation without having seen you in the office together with my team first.  In general, LVA surgeries are the least risky or invasive lymphedema surgeries.  When applied properly in the correct patient, they can be very effective at improving overall lymphatic drainage in and around the areas in which they are performed.

Thank you for you question.  At present, I know of no studies that indicate that lymphaticovenous anastomosis (LVA) surgeries increase the risk of cancer metastasis above and beyond any baseline cancer risk caused by the cancer itself.  Also, since most LVA connections are made further away from the center of the body than cancer locations such spread is theoretically very unlikely.

Unfortunately, I cannot advise you regarding surgery you had with another surgeon.  I would recommend that you follow up with your surgeon regarding postoperative instructions and care.

Thank you for the inquiry.  I do not recommend LVA and SAPL at the same time in the same areas.  In my experience patients have the best outcomes if SAPL is performed first in the affected area and the patient is allowed to heal and improve their underlying inflammation.  LVA is then performed at a later date to help reconstruct the lymphatic system and better improve drainage.

The outcome of all surgical procedures is significantly impacted by many factors such as the selection and timing of surgery, other treatments performed before and after surgery, postoperative care and treatment protocol and the specifics of a patient’s lymphedema disease.  The amount of training and experience of the surgeon impacts the success of the surgery in a significant way as well.  Unfortunately, I cannot provide specific surgical options for you given these reasons.

I have successfully treated many patients who had prior LVA surgeries, even when they had been told that their LVA sites showed significant scarring.  I believe that the success of LVA surgery is highly dependent on the expertise of the surgeon and the surgeon’s ability to overcome the difficulties and challenges of a patient’s lymphatic vessels.  Over the last 15 years, my technique in performing LVA surgery has evolved considerably, increasing the success rate of long-term success for my patients.  I have found ways to make successful LVA connections even in scarred areas, and can approach multiple different areas as needed in each patient’s unique circumstance.

It is very important to note that LVA surgery will only work to reduce the fluid excess caused by lymphedema.  LVA surgery will not work to address the pathologic solids found in stage 2, solid predominant (late stage) lymphedema disease.  In stage 2 lymphedema, the affected arm or leg never reduces in size to match the size of an unaffected arm or leg.

For patients with previous LVA surgeries performed, they require a thorough evaluation by our team so that we can recommend additional surgical or non-surgical treatment.

Thank you for your question.  In general, it is not possible to assign specific percentages to risk for patients regarding any given surgery.  For my patients, I would be able to provide an understanding of types of risks after an opportunity to evaluate that patient, diagnosing the type of lipedema and other medical circumstances about a patient’s specific condition or the specific surgery that patient would need for treatment.

I often recommend LipisuctionSM surgery for patients with lipedema.  This surgery allows for a controlled removal of the pathologic fat while preserving the lymphatic pathways and minimizing risk.  LipisuctionSM surgery generally carries a low risk profile when compared to other surgeries performed routinely in the surgery center or hospital.  In my experience with this surgery, I have had few complications, all of them minor. 

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.

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). 

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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. 

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. 

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.

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.

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. 

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.

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.

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.

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.

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.

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.