Oct 11, 2018
Lymphedema can cause painful, uncomfortable arm swelling for people who have been treated for breast cancer. Dr. David Song discusses how we can reduce or eliminate these symptoms with advanced surgery.
TRANSCRIPT
Intro: MedStar Washington Hospital Center presents Medical Intel where our healthcare team shares health and wellness insights and gives you the inside story on advances in medicine. In today’s episode, we talk to Dr. David Song, Regional Chief for MedStar Plastic Surgery and a nationally recognized specialist in treating people who have lymphedema. Lymphedema is a condition in which fluid accumulates in the body causing pain and swelling in the areas where the fluid builds up. About 20 percent of patients diagnosed with breast cancer will develop lymphedema. Compression garments, physical therapy and massage techniques used to be the only treatment options for lymphedema symptoms. Now we can treat the root cause with surgery, and Dr. Song is one of the only doctors in Washington D.C. and the east coast who offers these advanced surgeries.
Host: Thanks for joining us.
Dr. David Song: Thanks for having me.
Host: So today we’re talking about lymphedema surgery. Lymphedema surgery is actually fairly new.
Dr. Song: That’s right.
Host: And what does that mean—fairly new?
Dr. Song: So probably within the last decade it’s become more of an explosive sub-arena of plastic surgery and microsurgery, where we’re able to see long term results now—five, ten year results and the impact that we’re having on patients with lymphedema can be very profound in a positive way, and it can really change their lives around. So, it’s something that’s very exciting. I’ve been doing it for several years now.
Host: And how many hospitals in the D.C. area perform this?
Dr. Song: So, as of now, my understanding is I’m the only one in the greater D.C. area that does this. There’s not many people that do this in the country, so it’s a new field, it’s in its infancy and there’s just not a lot of people that do this.
Host: And who are some of the patients that do get lymphedema surgery?
Dr. Song: So primarily they’re patients after breast cancer surgery. So, a mastectomy, radiation or lumpectomy with lymph node biopsy and radiation—those are the patients that can develop lymphedema. Approximately 20 percent of all patients with breast cancer that get mastectomy and radiation and lymph node biopsies can develop lymphedema, so it’s a disease that’s not uncommon and it can be rather debilitating. It can limit one’s function, motion, quality of life. So, if you think about, you know, the tens of thousands of women that get breast cancer a year, that get mastectomy and radiation, and 20 percent of those every year can develop lymphedema, you’re talking about, again, tens of thousands of women that are walking around with lymphedema.
Host: How do you help patients understand if the surgery is a good option for them?
Dr. Song: Yeah, so surgery, a surgery, one of these options is good for virtually everybody. Uh, so it’s a matter of consultation, it’s a matter of having frank discussions about what patients are willing to undergo, optimizing their nutritional status, their body weight status prior to surgery, stopping smoking—all the things that can help our success rate. So, it’s a lengthy discussion with a patient, and so that’s the way to find the best individualized treatment plan for each and every patient that we see.
Host: So what types of lymphedema surgery do you offer and how do they work?
Dr. Song: So, the whole gamut, starting from lymphovenous bypasses, which are actually rerouting the lymphatic channels to the veins in the extremities. And that requires a technique called super-microsurgery. These vessels are beyond paper-thin and they’re, on average, less than .8 millimeters in diameter, down to as small as .3 millimeters in diameter. So, the suture that we use is exceptionally small and thin. It’s a specialty ordered suture. So, rerouting the lymphatics into the veins helps to drain the entire arm and it bypasses the blocked pathways that patients with lymphedema have. So that’s one. The other option is to transplant lymph nodes from an area in the body that there’s a redundancy of lymph nodes, like your back or the inguinal region where you pick the right lymph nodes, sparing the important ones—and there’s a technique to do that—then transplant them into the arm or leg that’s affected by lymphedema. That acts as a natural pump. So, combining those two techniques, lymph node transplantation with lymphaticovenous or lymphovenous bypass, seems to be the preferred method of choice with the longest outcomes of success. There are other aspects of lymphedema surgery that we can go into, as well. For those that are severely affected - years and decades they get more like an elephantiasis-type of outcome, where the skin is thickened and changed. Those patients are more amenable to what’s called the Charles’ Procedure - it’s an old procedure where we’re actually removing all the subcutaneous tissue, the fat around the affected leg or arm and then regrafting it with skin grafts. It’s a pretty radical procedure, but that’s really reserved for the very advanced patient with lymphedema.
Host: And how long will it take to actually see results?
Dr. Song: So, we can see results right away because of the scar release that we get. And the lymphaticovenous bypass works right away. But, the lymph node transplantation, it takes a while for the lymph nodes to grow and to start pumping again, and so that sometimes takes upwards of six to nine months to see some results from a lymph node transplantation. But you can see immediate results from the lymphaticovenous bypass and liposuction and the methods can be tailored to each and every patient.
Host: And recovery time is how long?
Dr. Song: Typically, for a lymphaticovenous bypass, it’s sometimes an outpatient procedure. When you add a lymph node transplantation, we usually like to keep patients for 2 days, sometimes 3, depending on their pain level. So, it’s a one to two-day, possibly three-day admission, and the recovery time back to work is, you know, maybe a week or so thereafter. So, it’s a very short period of recovery.
Host: And, once they leave, they have to wear a compression garment?
Dr. Song: That’s right. So, this is not a panacea for all lymphedema. It is an adjunct. Occasionally we get complete resolution, but most of our patients see improvement, sometimes dramatic, but they still have to keep up with their lymphedema therapy, their manual lymphatic drainage and their sleeves, especially when they fly.
Host: What else can we share about it? Is there anything else we didn’t discuss already that people should be aware of?
Dr. Song: I just think the answer for patients with lymphedema, that’s present now, is something that I hope everyone at least hears about and knows that there’s an option for them. You know, ten years ago this was rather new—it was a concept—and I’m hoping that with efforts like this to get the word out with patient advocacy efforts, insurance companies will start to recognize this as something that’s proven and that’s, not, no longer experimental, because it clearly isn’t.
Host: Well, thank you so much for joining us.
Dr. Song: Absolutely. Thank you for having me.
Conclusion: Thanks for listening to Medical Intel with MedStar Washington Hospital Center. Find more podcasts from our healthcare team by visiting medstarwashington.org/podcast or subscribing in iTunes or iHeartRadio.