Recently, important advances in microsurgery have brought patients the promise of stopping lymphedema before it ever starts, techniques that only that only a few centers in the country can offer.
In this video, Michael G. Tecce, DO , Assistant Professor in the Fox Chase Cancer Center Department of Surgery and fellowship-trained in complex reconstructive microsurgery, demonstrates a unique approach to lymphedema prevention: an advanced microsurgical procedure during breast or other cancer surgeries, known as Immediate Lymphatic Reconstruction or Immediate Lymphovenous Bypass. Tecce also reviews other types of surgery for varying stages of lymphedema.
Topics include:
The Evolution Of Microsurgery
Definitions Of Central Versus Peripheral Lymphedema
Staging Lymphedema/Surgical Concepts And Goals
Surgical Overview Including:
Lympha-Prophylactic LVA
Lymphovenous Bypass (LVB)
Vascularized Lymph Node Transfer
Debulking Procedures
Uh, first off, it's such a great, uh, honor to be here speaking with you this morning. Um, I really, really do appreciate it. I, I've really, uh, enjoyed a lot of the, um, camaraderie since, since starting here. I started here about a year and a half ago. Uh, and it's, uh, it's really been, been great being welcomed into the Fox Chase family and, um, really excited to talk to you today about surgical approach to treating lymphedema. And really it's, it's, it's quite, uh, like early in the morning, this is the topic you want to talk about, right? And everybody woke up and it was like, man, I really want a good lymphedema lecture. So hopefully, hopefully I can deliver. I gave this talk to my wife last night. She said it was really good, so hopefully we'll, we'll we'll see. Here we go. All right, so. Really, when we, uh, let's see, do I click to advance? How does this work? Click the mouse on the screen I'll wake it up. OK, click the mouse. OK. I do like that. OK, cool. All right, so. Really, um, lymphatic surgery was, was, was really born out of the evolution of microsurgery, uh, as, as time evolved and plastic surgeons were, uh, coming into the fold, people like Sir Harold Gillies and Ralph Ballard and, uh, and you look at this book here that, that was, that was written really in the, in the 50s. Uh, and we, we take a look at really the infancy of microsurgery and Trying to fix problems, right? Really, that's what plastic surgery has, has been born out of is trying to fix problems, trying to fix defects. And we think back to the, the, the early World War, uh, World War 1 and really World War 2 as well, but World War 1 was really the things that really started off how to fix, you know, defects. Using, uh, your own tissue. And you can see things like the waltzing flaps that were, we were able to take tissue. Well, they were able to take tissue, uh, from, from other areas that weren't harmed. And these are examples of tubed flaps or pedicled flaps. And even in this book, If you look at Chapter 10, there's a section on there about lymphedema, and what they used was what they called this actually a lymphatic wick. It was basically a piece of tissue that had lymphatic structures in it that they were able to leave pedicled on its original source and pedicle it to another area that needed lymphatic drainage. And so this is just a very early, you know, adaptation of some of the principles that we're going to talk about. And then you fast forward a couple of decades and really lymphatic surgery started, um, when they were trying to address, uh, problems in the groin. So patients had groin no dissections and they were having lower extremity lymphedema and This is kind of where, um, lymphatic surgery or treating lymphedema with surgery, uh, started to get not really a, a, a bad reputation, but it was kind of thought of, oh, it's not gonna work, you know, it's, it's not working. The reason is because when they started in the groin. The, the groin lymphatics are a bit, a bit larger, so they were the only ones that they could really see. They didn't have microscopes. They didn't, they weren't able to magnify 40 times. They didn't have all these different dyes that we use now to identify lymphatic channels. So they were starting in the groin and what we didn't know at that time was that the progression of the disease process in lymphedema starts. Proximal and then extends distally. So your healthier lymphatic channels are way distal in the extremity and the more diseased ones are up where the, for example, where the node, um, resection might have taken place in the groin or in the axilla. And so they were putting together these channels that really weren't competent enough and didn't have enough flow to actually be able to deliver a reasonable bypass. And so just right out of the gates, they realized, OK, this isn't working, something else needs to, needs to, um, needs to occur. And so even, even decades later, um, this was in the early 2000s, a meta-analysis look at the, looking at the different types of procedures that are done past, present, and future, and where we're going from there. And you take a look at the, the study in the top left there, vascularized growing lymph node transfer using the wrist as a recipient site. So now we're starting to catch on. As time goes on, we're starting to catch on that, OK, the less diseased vessels are in the distal part of the extremity. Maybe this would be a good area. And Min Wei Cheng was one of the pioneers of lymphatic surgery in Taiwan. He's the author of these two papers or the person behind putting these two papers together, and you can see more and more. Innovation is starting to really flood the field of plastic and reconstructive surgery as it pertains to lymphedema. Uh, and he's one of the people that pioneered endocyanine green lymphography, which we'll talk about as well. Um, it's important to get an understanding of the different types of lymphedema, right? So you have central lymphedema and peripheral lymphedema. So central, you're thinking of Kotthorax, uh, Kyloocis, plastic bronchitis, things like that. And a lot of times these are occurring because of a dysfunction at the thoracic duct. So, As we remember all from, from medical school and actually it's kind of crazy to think about. We really didn't learn much about the lymphatic system in med school, right? Like we, we learned certain things and really a lot of it was unknown. So, um, our lymphatic system. Terminates, right at the thoracic duct, dumps into the subclavian vein and your central disorders are gonna really be affecting that really central portion, that, that thoracic duct. Peripheral lymphedema, however, There's really a problem with the external or more the, the, the, the peripheral sources of either lymph nodes or lymphatic channels. And so this in the box, here's what we're going to focus on today, the, the primary, but really the secondary, uh, types of, of, of lymphedema. And so we can have early onset, which is, is, uh, as early as 2 months. After having lymph nodes eradicated and then late, which can be as many as 20 months, and I've seen patients that have come in up to 4 years after having their lymph nodes removed, and they'll have some kind of a trauma or some kind of an inciting event, you know, somebody's gardening, they get pricked with a thorn bush or something like that and suddenly sets off this inflammatory cascade. And it affects the vessels. So by the numbers, lymphedema affects up to 250 people, a million worldwide. So we'll get through some of the number stuff and then we'll get into some of the more exciting, you know, photos and cases and stuff like that. In the West, approximately 99% of individuals with lymphedema have secondary disease. So worldwide, the number one cause of lymphedema is filiaresis, and it's a primary lymphedema. In the, in the, in the US, the number one cause is cancer or not eradication. So in the US, up to 10 million people are affected by lymphedema. There's approximately 200,000 new cases diagnosed every year. Some of the questions I get asked a lot, you know, you know, and make sure to tell patients do is that, you know, the published rates are up to 30 to 40% incidence of lymphedema after an axillary node dissection. And that approximately 75% of cases occur within the first year of surgery and again, as I indicated before, that that remaining 25% can really happen at any time point after surgery. Uh, when I see a lymphatic patient, we, one of the first things we do is figure out what stage of lymphedema they are. And this goes beyond even figuring out is it actually lymphedema, because as a society, I feel like the lymphedema community first of all is, is really kind of. Served they don't have a home per se, right? I mean, if you're a cancer patient, you have cancer, you're going to see a surgical oncologist, you're going to see a medical oncologist. People who have ownership of your disease with lymphedema, we're trying to figure out like who really owns this disease process, and oftentimes patients are Either misdiagnosed or mismanaged, not because of any wrongdoing, just because we don't have the infrastructure yet. We don't know what exactly is going on and who's going to be the right person to help this patient. Is it lymphedema therapy? Is it, you know, a medical source? Is it surgical? So we have a staging system and this is from the International Society of, of, of Lymphedema. So this is stage 0 through stage 3. So in stage 0, The patient is starting to have some symptoms, right? They don't have any, and you can see in that stage 0 photo, they don't have any visible signs of limb swelling, you know, they look pretty much the same. They don't have any pitting, but they're starting to say, hey, you know what, my, my arm feels a little heavy. I get occasional numbing and tingling. What's going on? Stage one, you start to have an actual difference in the limb volume discrepancy, and you can see in the photo that the person's left arm is larger than the right arm, and here they may or may not have pitting edema. Um, but they certainly have the symptoms and they certainly have the size discrepancy. In stage 2, now you're going to have pitting edema. The symptoms still remain. You have an enlargement of the arm, and then in stage 3, the skin starts to become affected. And really it's in the conversion of stage 2 to 3 where the limb actually shifts from being a fluid dominant disease to being a fat or fibrosis dominant disease, and it's that photo on the left that the patient is starting to have skin changes. They may not even be pitting anymore because by now the lymphatic channels of all sclerosis and their limb is just full of fiber fatty deposition, which is caused by the inflammatory cascade that happens as lymphedema evolves. Our composition of lymphatic fluid, it's, it's, it's mainly water, about 4% solids and proteins, and if you look at the fluid hemostasis and what our body is actually responsible for, so if you have interstitial egress of 20 L per day, your capillaries are reabsorbing 17 of it. That means your lymphatic system is responsible for the management of 3 L of fluid per day. And if you look at the anatomy of, of a of a lymphangian, you can see that the lymphatic channel is really a hybrid of an artery in a vein. So like an artery, lymphatic channel has smooth muscle and it's able to propel fluid and, and push it up the channel, but like a vein, it also has valves. So over time as the channel widens and gets weaker, that smooth muscle dilates, the channel widens, the valves no longer become competent, and you get a retrograde backflow of the fluid. The way it gets into the channels to begin with is through these anchoring filaments and little openings that are in the cells, and they push fluid into the channel and then it goes up through the mechanism that I just described. And this this image shows you. What, um, what the lymphatic vessel is, is like over time and and what it looks like in a healthy versus a disease state. So as a lymph node is removed, as you shift from left to right, um, you get, you know, an incompetency of the valve, you get increased pressure and a lot of this really is, is, is, um, explaining to patients what's going on because Patients will come in and they say, you know, I, I have no idea why this is happening. Like, can you explain what's going on? And the easiest way I found it to, to Um, related patients is to think of it as like a system of water pipes, right? So if you think of it in that setting, it's pretty easy to understand. If you have a system of water pipes and suddenly you've removed the water pump, now that water's just sitting in the pipe, and as the pressure builds, the water in the pipe is going to increase in pressure. It's going to widen, it's going to crack, it's going to get weaker and as that happens, the fluid is leaking out of these channels and into the periphery of the tissues, and that's how the swelling occurs. Seems to make, make, make sense a lot for them and it kind of hits home. Um. And you can see here what happens to those channels as the lymphedema progresses. So in normal, so if you were to correlate it with the stage of disease, in normal you see that there's a nice wide open channel, you know, it's not dilated, it's nice and round, and then as the pressure builds, you move into the Actasia stage step which is. Stage 1 and you wind up having a widening of the channel in stage 2. Now the damage to the channel has been done so much that it starts to lay down scar tissue. And so you have a contraction type where the, the channel's actually contracting because the walls are getting thicker and it progresses to a sclerosis type in step 3. And this was a great study which showed us. Uh, what the, what the channels actually look like as the disease progresses. Our surgical concepts for this, right? So it makes sense. If we have a bunch of fluid in the limb, we're going to look at shunting this fluid. We've got to get rid of it somehow, right? So excess fluid shunting, excess adipose tissue removal in the later stages, right, and then skin removal, and it's only fitting that those concepts should fit with our goals of surgery. So the main goals of surgery in patients with lymphedema. After an aggressive workup and figuring out, do you have lymphedema or not, and can we help you in some way, is decrease lymph circumference, reduce cellulitis attacks, decrease heaviness, decrease garment dependence, um, which really is, is something that, that can be very, um, uh, Very impactful for a patient to go through, um, you know, and if you think about it and you spend time with any of these lymphedema patients, you realize what they, what they go through and it's, it's intense. I mean, they, they, they wake up, the first thing they think about is their limb swelling and how they're going to manage it for the day. They spend hours either with trying to put garments on or wrapping them. Some patients can't even get a garment on, so they have to wrap their limbs. So just imagine like every day you have to sit there and wrap your, wrap your arm every day, change the bandage in the middle of the day. So, It's quite a lot that they go through and all of that leads into our desire to help them to increase their quality of life, increase their function, get them back to doing the things that they want to do. So when all of this was, you know, being figured out over the past decade, even in terms of, OK, which procedures are going to fit which patients better, we realized as a society that there were a lot of people doing different procedures in the same patient, and we didn't have really a good consensus on what is the right. Procedure for which patient and how to do it and when to do it. And so in 2019, uh, a number of, of leaders in the field got together for A consensus and they performed a systematic review meta-analysis and came up with recommendations based on the different types of um uh procedures that are out there to help with lymphedema. So the first one you see up there is Lympha, which is an acronym that we'll talk about in a second, and that came out in 2009. And this is basically saying, OK, maybe we can put these channels together to even stop lymphedema from occurring. And then of course the ones we're probably more familiar with lymphovenous bypass and vascularized lymph node transfer, and then And those are physiologic procedures, right? So that you can kind of think of lymphedema surgery as two separate areas. One is physiologic procedures, the other is ablative, getting rid of the tissue in general that is diseased, and that fits into the debulking area where you're talking about suction assisted lipectomy or the Charles procedure, which I will say, I mean, I, I, I think I've maybe seen one Charles procedure in training and fortunately because of the advent of, of innovation in the field and what we're doing, I don't think Charles procedure is even on the, on the map anymore. It's not even, not even in the algorithm and that was borne out out of this conference that That really, and I can, you know, just distill it quite quickly here for an early stage lymphedema, lymphoenous bypass has been shown to be more efficacious because the fluid, it's still a fluid dominant disease and so offloading that fluid is, is, is advantageous. However, in a late stage lymphedema when the The disease process has already taken over to the point that it's become fibrotic that a fluid procedure like a lympho venous bypass is not going to really be efficacious as much as a lymph node transplant would. And then they also, um, it was at that time a little bit too early and studies hadn't come out enough to fully support, um, uh, uh, prophylactic bypass. However, we've seen a huge shift in that in the past few years alone. Uh, so the workup, and I can't underscore this enough in terms of the workup for a patient with lymphedema. This honestly is the most important part. Um, sure, the surgery can be technically challenging. It's, you know, uh, these vessels are less than 1 millimeter in diameter. Uh, we're using 11, sometimes 120 suture, um, that you can't even barely even see if it's on your hand. It's, it's super, super tiny and like all that is challenging, but the real challenge is, is, is the workup. So. Patients ideally have a BMI of less than 30 to 35. They have the absence of venous disease, which is important because if we're doing a bypass and we're going from an area of a certain, um, pressure system in the lymphatic and we're bypassing it into the vein, if there is a high level of pressure in the venous system, it's just going to backflow right into the lymphatic and now you've arguably made the patient even worse. So, The absence of venous disease is important. No major medical issues, and then compliance. Like we need to see a patient that is compliant with their preoperative regimen in order to be assured that they're going to be compliant with their postoperative regimen. And and being realistic is important too. Like, these are, these are, um, you know, procedures that don't work in everybody and so it only further underscores the importance of getting the person who we think it might work best in, um, and managing expectations. So these injection points, so I prefer to work these patients up in the clinic because you can do it with an ICG injection right in the clinic. You don't have to go to the OR to do it. In some cases we have to go to the OR because of, you know, technology or whatever, but the injection points are the 1st and 3rd web space of the hand and the lower part of the wrist for the upper extremity, for the lower extremity, same thing, the web spaces 1 and 3rd, and then the medial malleolus. And you, it's, it's a 0.1 cc injection of ICG and I'll show you what this looks like. So, In the first image here, all the way up on the left, see if I can find the mouse here we go all the way on the left, this is what A normal extremity would look like. So you have these, you do the injection and you use your camera and you're able to see the lymphatic channels. You see how linear they are. They're not congested. They're just nice linear channels going up into the axilla, and that's what we see in a normal functioning lymphatic channel. And the camera that we use is either a spy machine or a PDE Gen 3, which is the, the version of the spy machine that was created by one of the companies that makes the microscope that we use. Now if we contrast that that linear pattern to somebody who has lymphedema, take a look at this. Very different, right? You see these cross channels, these are, these are all channels that were developed by the body to try and offload the fluid. But basically, these are roads to nowhere. They're not going anywhere, right? They're not these like linear channels that are going up into the axle and have some level of outflow into the venous system. These are channels that are just sitting in the, in the limb and there's a A variety of different patterns called splash, or starburst or dermal backflow. So in the beginning here, you see more splash patterns. You see that the channels aren't, they're just kind of going into a starburst right there and then up at the top, you see dermal backflow. And this is a patient who's progressing really into stage 3 lymphedema now. And so, Because they they have the absence of any linear channels, they might not be a patient that's going to be suitable for a bypass, and that's really the crux of it. You want to find a nice linear channel with flow that you can bypass. And so it's so fitting to be talking about this in Philadelphia and be from Philadelphia and being a guy who's dealing with an obstruction because I feel like I lived with it my whole life. I spent like 10 years on City Avenue between education and like, you know, college, med school, all that stuff and so like everybody knows that. 76 is probably one of the worst highways in America, and I love it when I see that MLK Drive sign because it means I can get off of the highway, and that's what we're doing with a bypass. We're going into an area of obstruction saying the hell with this, I'm getting off the road and we're going into an area where there's no obstruction, which in this case is the Venus system. So this is a patient actually coming up in a, I think like a month or so. So I worked her up preoperatively and you'll see. The lymphatic vessel here pushing that fluid and you see that fluid in this nice channel going right into that area of obstruction. And coincidentally, right, or, you know, uh, from an acceptable standpoint, like that's where she has her symptoms, right where the obstruction. She says it hurts right here. And then I, I aspire. I see all of this obstruction. Well, OK, we have, we have the answer. This is why it hurts right here. So. Um, there's different types of anastomosis that we can do. There's an end to end anastomosis, so the blue being the vein, the gray being the lymphatic channel. There's side to side, and then there's end to side. And more recently, what has been popularized is a side to end technique. And the reason for this actually makes a ton of sense because in some cases we're not sure which flow the lymphatic fluid is actually. Going in. Because if your channels have widened and your valves are no longer competent, then you just have fluid sitting in the channel. And so you don't, you're not really totally sure if you're taking the right direction of the fluid because it's not pulsing the way an artery would. The lymphatic channel pulses about 2 to 3 times per minute and it's a low, and it's a low flow state. So it's not as aggressive as, oh, I'm just going to like cut the artery, let it go and boom, I know which way the flow is going. Uh, so this is a little bit different. So the side to end technique is very interesting in the fact that you're able to kind of get the flow bidirectionally. And I'll show you an example of a congested lymphatic here. So on the left side of the screen here you can see that the lymphatic channel is the green one. It's filled with, it's not green in situ obviously you guys know that, but we use the dye, we use fluorescene dye, and this really helps us to, it's very excitable by the filter that we use. So it's really helpful to find these lymphatic channels as it's, it's literally almost finding a needle in a haystack because they're so small. So the, so the green dye helps us and we can find this lymphatic channel. And you watch what happens when I cut it, there is just diffuse. Fluid just kind of pouring out and that needs somewhere to go, right? And so that place that we're able to put it into is the vein and if you look at this right side photo here, you see these boxes, these boxes are 1 millimeter by 1 millimeter. So our lymphatic channel is submillimeter and usually it's, it's usually it's about 0.5 millimeter in diameter, and this, this really Uh, you know, promulgated the advent of super microsurgeries. So we have microsurgery, you know, free flaps and the vessels diameters are generally about 1.5 to about 3 millimeters. Uh, but once you get into the sub-millimeter, generally the super microsurgery they've pointed is uh 0.3 to 0.8 millimeters. And so that's, that's the what we're dealing with there, um. So, and that's the bypass. So now what about a a lymph node transfer? So this study at the University of Chicago at the time, um, looked at, and this was an ASA, ASA paper as well, um, looked at the advantage of doing a lymph node transplant with With a venous bypass at the same time. So this was a review of prospective data. They had 204 patients. They had follow-ups at 3 months, 6 months, 12 months, and then annually for the patient groups. And overall they found that in the both upper and lower extremity. The patients who underwent lymph node transplant, 80% of them in the upper extremity group and 60% in the lower extremity group had a significant reduction in volume differential of their affected limb during at least one time point postoperatively. So what that means is pre-op, you get a measurement, you measure the affected limb and the non-affected limb, and you get your, your, your, your volume differential. And then post-op you do the same thing. And so what they were realizing is that they were having significantly different um improvements in volume differential. And then in the upper and lower extremity patients you have 86%, 75% respectively, improvement of life and quality of life scores. And you fast forward a little bit to another study that came out of MSK around a similar time, and this was a prospective study, and one of one of the reasons I really like this study is because it's quite clean in the sense that they kind of stacked the cards against themselves in terms of mitigating post-op compression, or actually I should say pre-op compression as a confounding factor. Um, so what they did was they said, OK, well, how do we know when the right time point is to catch a patient in terms of their swelling preoperatively? How do we know that we're actually starting from ground zero, right? And so what they figure, and this is true for lymphedema. I see lymphedema patients sometimes they come in and say, hey, you know what, it's not that bad today. I really compressed it a lot. So how do you Know on the day that you're measuring the patient, if they're having a good day or if they're having a bad day and they're like, Hey, you know, I slept on a funny or whatever. My arm is huge this morning, right? So what they did in this, in this case was they did what's called limb optimization where we wanted to optimize the limb, get as much fluid out of there as possible, and then do your recording and then get your measurements. So the primary outcome was was quality of life, and then you have a whole list of secondary outcomes as you see there. Uh, the inclusion criteria again, secondary lymphedema, uh, BMI less than 30, and they had 89 patients, 73% of which underwent an omentum transplant for their donor site. And one of the reasons that Omentum is so great is because there is no risk of donor site lymphedema. So with any of the other sites, whether it be supralavicular groin, you have a risk of donor site lymphedema because, you know, you're basically robbing Peter to pay Paul. So what they found was significant improvement in 2 years post-op. 75% of patients had an improved quality of life. 50% of patients had a reduction in limb volume, 93% cellulitis, and that should say no longer wearing compression garments, so 34% of patients, which is a significant improvement for those patients. Um, this just shows the, the, the omentum that that we use for a vascularized lymph node transplant. Uh, I certainly don't need to go into how to get momentum to this group. Um, and then that brings us to Lympha, which is the prophylactic bypass. So as I said earlier, in 2009, this study came out, um, and it looked at the Um, the possibility and the efficacy of, of taking those channels, those lymphatic channels at the time that the lymph nodes are removed and performing a bypass. And there have been a number of studies that have come out since then looking at this, but probably one of, one of the, one of the cleanest and one of the ones that I'm really excited for to see the final results is this, this study right here where they just this past year published their preliminary results of an RCT, and what they found was that they had 72 patients in their surgical arms, 72 patients in the control arm, and The incidence of lymphedema was reduced, so 32% in the control group. This is a 2 year follow up, and 9.5% in the immediate lymphatic reconstruction group or the lymph group, which is the prophylactic group. So this study I really like to because again it's very clean. These patients were randomized at the time of putting the vessels together. So you would do the axonal dissection. You would find the lymphatic channels, find a vein. If you weren't able to find a lymphatic channel or weren't able to find a vein, the patient was no longer enrolled in the study. So we literally got all the way up to, we have the microscope, we're looking at the vessels, we're ready to sew them in, and now we're going to call the research people and say, hey, Is this, is Mrs. Smith getting her bypass or not? That's how they were randomized. Um, and so, uh, just again, very, very, very clean study. They try to really, um, minimize any, any number of, of biases that, that could, uh, that could be addressed. And so this is an example of one of our patients who underwent an immediate lymphatic reconstruction at the same time as a breast reconstruction she was having a direct implant on the, on the right breast, and then you see here, and this was kind of fun. I got these pictures because I wanted to like kind of underscore the size of what we're dealing with here and some of the anatomy, and you can see as you zoom in, you see the thoraco dorsal vessels right there and you see our, our, our, you know, lymphatic branch going into what is the vena comitants off of the dorsal. Uh, and you can see here there's two lymphatic channels to the left that are telescoped into the recipient vein, uh, on the right there. And then if we turn our fluoresce on, we can see that the lymphatic channel is patent. And really that, that's, that's part of the workup here, and that's not the workup, that's part of the surgery. This is part of the important part of the surgery is to make sure that not only when you're putting these vessels together, because your needle is often almost the same diameter as the vessel, it's, it's kind of crazy how. All these things are, but you need to make sure that your nastomosis is patent, right? Cause you could put these things together and so it and be like, oh, it looks good. Like, see it, but you don't know if the thing is actually open. So a way to know that it's open is, do you see actually that the vessel in this case, it turns green. Now in a thicker vessel, you won't be able to see it because if the vein is too thick, then it won't turn green, but you can use ICG and you can see the, the, the, the forward flow of the, of the lymphatic as it goes into the recipient vein. So end to side is another way to do it, and we talked about this a second ago. I just think this is a really cool picture, so I wanted to put this in there. This is just the two lymphatic channels going into end to side into into a vein for an immediate lymphatic recount. Uh, end to side telescoping technique, uh, again, same kind of a concept. Instead of doing two, you have one. If you have a size mismatch, then you can still do a small emphatic vessel into a large vein. You can put that in and then just sew down the size of a vein, uh, and and and that works, works perfectly fine. And then the TD to the Va Coons. Um, so this I haven't really seen um written up yet, so maybe it's something that we'll put together. So I see some of my, some of our plastic surgery fellows in the room will kind of add this to the list potentially. But this is kind of a game and this, like, honestly, the surgery is actually quite fun. It's technically challenging and like, it takes a little bit of time and it's, it's, it can be tedious and frustrating, but it's actually quite fun. So you kind of like play a game like where's the lymphatic? So you look at this picture and you're like, all right, like where's the lymphatic channel? Um, and then you put your filter on and you see this kind of that green streak right there. It kind of clues you into where the lymphatic might be, um, and then you take your filter off and the green remains. And there there's right there your lymphatic channel. So you're gonna, you're gonna find it pretty easily. Now, if even if we find channels, right, and this this honestly. would not be possible without um excellent surgeons like we have here performing the axillary dissections and actually being cognizant of leaving length on the lymphatic channels and leaving length on any veins that are found. Super important, can't underscore it enough like how important that is. And fortunately, we have, we have our team that does that. In some cases though, the disease burden in the axilla doesn't leave us any options in the area to actually find a vein to put the lymphatic channel into if we can find it. And so what I found is that we could dissect the vena comitants off of the thoracco dorsal, which actually gives you a good amount of length. It's a smaller caliber vein. It's about a 1 to 2 millimeter caliber, so you can sometimes get two vessels in there, but sometimes only one. So but if you dissect this off enough, and the great thing about it too is it has valves. You can see that valve right there. So you're not going to have backflow of venous pressure onto the lymphatic. And so we're able to take that via comitants, dissect it distally to proximately, swing it around, and put it into the lymphatic channel, and you know, hopefully save this patient from getting lymphedema. Uh, so what about the patients that aren't that aren't going to be candidates for lymphovenous bypass, aren't going to have a no transplant, uh, and didn't have prophylactic reconstruction at the time? Well, there are candidates for debulking in many, in many cases. Um, and this study recently came out looking at liposuction. This is a five-year follow-up study out of Australia, actually quite well done, um. Looking at liposuction for advanced stage lymphedema. So this is prospective 59 patients with unilateral, primary or secondary lymphedema. You see the split in the lower extremity versus upper extremity again advanced stage, and what they found was a medium volume reduction again in that volume differential we talked about pre-op versus 1 year, 5 years, and you guys can see the, the volume differentials, as time goes on. So liposuction here, this is one of our patients. Um, she came to me. She had a right upper extremity, very advanced stage lymphedema, uh, and it's funny like how much we, I guess maybe it's just because I'm early in practice and I'm appreciating it so much is the stories that patients tell us, like how much we actually remember when we're, you know, treating problems and, and, and dealing with these things. So. She, she was the one who was like, honestly, like, I just wish I could brush my hair, you know, and she couldn't really bend at the elbow much because of all the fibrosis that she had. And so we were able to perform liposuction on her and you can see the, the volume difference, uh, post-op 2 weeks, post-op 5 months. And really for her it was function. She was able to, to really, um, improve, um, her, her daily living. Uh, and she also said, Like I said, like it's kind of funny what patients will tell you, and you remember, she said, my hands, she said, my hands are the biggest difference. She said, I, I just, it feels so different. I can actually like flex and extend my, my digits. And if you look at the pre-op, look at how swollen her hand is versus the, the post-op, it actually um is, is pretty significant for her. So, um, you know, we, we went through a whole bunch of things. I mean, you could do, you know, there's entire, um, you know, conferences just on the stuff that we just talked about. Um, so it is a lot, but I think as time goes on, and I think as we've seen from all the support that we get, you know, with Fox Chase and how much interest there is in the community that This provides us really an opportunity on a number of levels. It gives us an opportunity to grow and it gives us an opportunity to educate, teach not only patients, but trainees. It helps us to, to, you know, educate our colleagues in the community to identify lymphedema and, and really help to, um, redirect patients to their, the, the right level of care that they deserve. Uh, and it gives us an opportunity to help those patients. Research in this area is booming right now because again, we don't know a ton and there's so much left to do. Research in primary lymphedema, head and neck, even looking at GLP ones. So, you know, as, as Dr. Patel indicated, you know, I, I, I did my training at Sloane, and, you know, I'm so grateful to the training I got there, um, and one of my, my closest mentors, uh, Joe Diane, he's, he found, you know, a possible. correlation between GLP ones and could they have an impact on lymphedema that, you know, that that he's written up. So again, another area to explore uh facial lymphedema and barriers to implementation, you know, right, right now with the current landscape in medicine in terms of reimbursements and things like that, there's so many, so, so many areas of investigation, things that we could do to to help. So I really thank you for for your time this morning and attention. Really do appreciate it.
