Surgery related questions Answers from a panel of experts
More of your questions from the 2015 National Lymphedema Conference
By C.Moffatt, A.Towers, D.Keast, J.Granzow, P.von der Weid, J.Macdonald and M.McNeelyQAre there physicians in Canada doing similar surgeries to the ones described by Dr. Granzow? (article in Winter 2016 issue of Pathways)
Granzow: It’s hard to say. Everyone will approach the procedure differently as there is no “central clearing house” for physicians. Some will just do lymph node transfer ovalbumin (OVA), very few will do the suctioning as well. In short, yes I think there are some physicians in Canada who will do the surgeries, but like I said it will not be an identical procedure to the one I perform in California.
Keast: In my local area of London, Ontario, I’m not aware of anyone that is doing any of these types of surgeries. There are some physicians in Toronto who I have heard are doing them, but I don’t know all that much about them. Additionally, in Toronto it is not a common procedure and it is still very experimental. There isn’t a dedicated practice for lymphedema patients at this time.
the surgery here. While they are available in the United States, I would still like to see more long term results from the U.S. before recommending surgery to my patients at all.
McNeely:
Calgary and Edmonton as well who are looking at starting these programs.
Macdonald:
“I would never recommend surgery to a patient where I know we can’t attain the desired results.”
Dr. Granzow
Towers: While it is experimental in Toronto, I am not aware of any surgeon in Canada performing these surgeries. For that reason, I would not recommend my patients get
skilled surgeon. But when you see these surgeries you have to be careful. As we’ve learned from Dr. Brorson in Sweden, these procedures are very difficult to duplicate. be very careful about it because there could be many complications and problems. I sometimes call this “Niagara Falls Surgery,” because one man can take a tightrope and walk across the Falls and it is very impressive, but just because it has been done doesn’t mean it can be done by everyone. It’s really great that younger surgeons are working on perfecting this procedure, but you also have to keep in mind that the photos (and examples) you saw were not of severe cases of lymphedema. For now, Complete Decongestive Therapy is still
Granzow: There are an increasing number of surgeons around the world, who are able to reproduce Dr. Brorson’s results, but it is a matter of surgeons taking the time off work to go to Sweden and learn the procedures and unfortunately a lot of physicians are still unwilling to do that. We do our procedures in a very, very specific way with properly selected patients in order to see the results in these surgeries, because surgery is not an option yet for all patients. I unfortunately can’t operate on a patient that has really thick skin and a massive fold in the leg, because the surgery will not produce the desired results. I would never recommend surgery to a patient where I know we can’t attain the desired results.
Panel of Experts was a popular session featured at the National Lymphedema Conference in Calgary, Alberta in the fall of 2015. The above questions and answers are just a selection from the transcribed session and featured Dr. Christine Moffatt (England), Dr. Anna Towers (Quebec), Dr. David Keast (Ontario), Dr. Jay Granzow (California), Prof. Pierre von der Weid (Alberta), Dr. John Macdonald (Florida) and Prof. Margie McNeely (Alberta).
QHave you performed this surgery on Canadians who have financial coverage by their health care systems?
Granzow: I don’t understand much of how financial coverage works, my office generally deals with that end of things, but we have had patients from Canada and internationally. The vast majority of our patients, however, are from the U.S. or out of state. There, the coverage varies from case to case, but what we’ve found is that Medicare (federal health insurance program for US citizens over 65) does not cover the procedure. With private insurance, we are often able to get all or at least most of it covered, but it is getting harder and harder to do. The bottom line is that it is different from case to case, but I would imagine that the Canadian insurance doesn’t match it.
QIs surgical intervention possible for lobules formed as a result of a formerly obese patient who practices lymphedema reduction practices?
Granzow: As long as the fluid is addressed first, it is possible to remove or excise a lobule. You don’t want to excise a lobule if there is a lot of fluid present, because it will weep and the lymphatic fluid can cause wound healing issues and possible infections.
Lymphedema and lipedema are entirely different disease processes... and need to be treated differently.
Mof fatt: I’m always cautious about this one because with lobules, the skin is very damaged. So, it is very hyper-keratotic, there are a lot of papilloma. You have to be really careful because the risk of infection post operatively is very high. The surgery is not impossible but you have to treat these patients very carefully.
QIs solid lymphedema the same as lipedema?
Granzow: I’m going to politely disagree with that treatment protocol. I think that especially in Germany, and a doctor in Arizona, liposuction for lipedema is looked at more cosmetically and you tend not to need the compression for as long afterward. It actually seems to relieve symptoms, especially if the patients are really sore and swollen on the insides of their legs. A gain, the cosmetic procedure is a smaller procedure with different recovery and we’re finding that symptomatically they get better. Are we fixing the underlying issue with this surgery? No, but the pathologic issue seems to get better, and the patient is afforded a tremendous amount of relief.
ADDENDUM
Keast: I’m sure it varies from province to province, but just to give you an idea, in Ontario if the procedure is not performed in Canada, you have a much higher chance of getting it covered if you go state side to get it done. That said, it is still a very lengthy process (for reimbursement) and the only thing that will be covered is the cost of the procedure, no travel or accommodation costs will be covered.
QIs joint surgery safe for lymphedema patients?
Towers: The orthopaedic surgeon’s job is to balance risks. There is the risk of reduced mobility from joint problems, which shortens life expectancy, versus the risk of cellulitis or post-operative infection that can be treated. You need to trust your orthopaedic surgeon’s advice on whether the procedure should be done, but in general, if you can’t walk it is bad news both for lymphedema and life expectancy.
Granzow: No. Lymphedema and lipedema are entirely different disease processes. Lymphedema is a disorder of the lymphatic system; clinically it presents differently. For example, a limb affected with lymphedema is never the same size as it’s opposite, while limbs with lipedema tend to be symmetrical, and they tend to have painful, sore, rice-grainy fat. So no, they are very different and need to be treated differently.
QIs there a specialist in Canada with knowledge of lipedema and surgical treatment protocol?
Towers: In general, you should avoid surgery if you have lipedema. At this point, it is a poorly understood metabolic disorder. So, if you go for surgery, it doesn’t cure the metabolic disorder and the fat will just come back
Towers: I am aware of a surgeon in Germany who performs specialized liposuction procedures on highly selected lipedema patients who have no lymphedema and who are not markedly overweight. I understand from his published series that carefully selected cases patients may benefit. To my knowledge there are no surgeons in Canada who perform these highly specialized procedures. They require very specific skills and careful patient selection. We also need more objective, long-term data regarding results. LP
Reference: W. Schmeller, M. Hueppe* and I. Meier-Vollrath. Tumescent liposuction in lipoedema yields good long-term results. 2011 British Association of Dermatologists 2012 166, pp161–168
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