Transcription:

Andrew Wilner, MD (Host): Welcome to GW Doc Pod, a peer to peer podcast for medical professionals with The George Washington University Hospital. I'm your host, Dr. Andrew Wilner.  I invite you to listen in, as we discuss advances in microvascular breast reconstruction and new techniques for the surgical treatment of lymphedema.

My guest today is Dr. Bharat Ranganath, Assistant Professor of Plastic and Reconstructive Surgery at The George Washington University School of Medicine & Health Sciences. He's affiliated with The George Washington University Hospital.

Andrew Wilner, MD (Host): . Welcome Dr. Ranganath.

Bharat Ranganath, MD (Guest): Thank you so much for having me.

Host: Yeah, well, thank you. Thanks for joining us. To get started, can you tell us a little bit about your training? I understand you're Fellowship Trained in Microsurgery.

Dr. Ranganath: Yeah, absolutely. So, microsurgery is an advanced kind of sub specialty of plastic and reconstructive surgery. So, I did my plastic surgery residency, which is a six year integrated program at Lehigh Valley Health Network in Allentown, Pennsylvania, and then I did a one-year Microvascular Fellowship in Memorial Sloan Kettering Cancer Center in New York City.

And microvascular surgery is basically a way of reconstructing different parts of the body whereby we literally transplant tissue from one part of the body, take it to an area where there's like a deficit, for example, for a breast or in the head and neck and whatnot. And we can replace that tissue. The microvascular part is that we hook up small arteries and veins in the tissue so that it gets blood flow in and out and can live. And so that's where that comes from. So it can be arteries and veins that were hooking up, it could be nerves. It could be lymphatic channels and those kinds of things.

Host: Well, so this is kind of sounds like precision you know, watchmaker work. Are you using a microscope?

Dr. Ranganath: Yeah, absolutely. So, we'll use high powered microscopes and really fine needles and small instruments that we use. So for example, like some of the what we would call forceps, but the pickups that we use are called jeweler's forceps, very similar to what an actual jeweler uses under their magnifying glass and the sutures we use are about a couple of microns, a hundred microns big. So they're thinner than a human hair.

Host: I'm thinking this is tedious. It sounds really, really precise and difficult. Is it?

Dr. Ranganath: Well, there are parts of it that go fast and there's parts of it certainly, that go slow. I mean, the procedures have evolved significantly over the last 30 or 40 years from the first microvascular surgery was done in about the fifties or sixties. And the cases took 24 hours. And now we do them in like approximately four hours, six hours, something like that.

So it depends on the case. There's fast parts and there's slower parts. But you know, when it comes down to it, in order to be successful, we're sewing blood vessels or lymphatic channels that are, one millimeter, two millimeters. And so you have to be quite precise during those portions of the case.

Host: Now, I would think it would be difficult to attach, now this is a neurologist speaking, so you're gonna have to help me, blood vessels to each other while the blood is sort of zooming by. Do you have to stop the flow to do your repair or do you just do it, you know, you'd you clamp off these little vessels and then sew them together or how does that work?

Dr. Ranganath: Yeah, it's a good question. So, usually we'll find a blood vessel, you know, named blood vessels, arteries and nerves within the wound or deficit that we're working. Usually these aren't critical vessels, so it's not like the aorta or the subclavian or anything like that, but maybe a branch off of the internal mammary or one of those more peripheral vessels. And then there are temporary clamps yeah, that we put on that are partially occlusive. They're on for maybe 15 -20 minutes at a time. And then we take them off.

Host: All right. So let's move on to microvascular breast reconstruction. How is that different from traditional methods?

Dr. Ranganath: Yeah. So, kind of the most common, I would say simplest method of reconstructing the breast has always been to put in an implant. So, these are foreign bodies, usually silicone that are placed to kind of form the shape of the breast. And implant-based reconstruction while it has a lot of uses and is very common, comes with all the caveats of having silicone implants.

So, high risk of infection, wound breakdown, pain, discomfort, and scarring and contracture that can happen around the implant. In addition, implant-based reconstruction tends to be less durable. Requires a lot more maintenance over the course of their life and is not thought to be a lifelong durable reconstruction.

So, over the past 20 or 30 years, what we've really been able to do as a field in plastic surgery and microsurgery is find a way to use the patient's own tissue, where they may have some excess, transplant that based on certain blood vessels to the chest after a mastectomy, find the small blood vessels, basically internal mammaries and use a hookup the blood vessels from there to the flap of tissue that we transferred and use that to reconstruct the breast.

So that's microvascular breast reconstruction. Kind of the gold standard or the most common way to do this is using the lower abdominal tissue. Something called the diep flap or D-I-E-P flap. That's where we use excess skin fat that a woman may have below her belly button. Basically what would be removed if you would've had a tummy tuck. We'll trace the blood vessels that supply that tissue through the abdominal wall, detach it, bring it up to the chest, hook it up to under the microscope, to vessels in the chest. So, we use that skin and fat to kind of create a mold, a molded natural kind of soft, durable, long lasting, kind of more natural feeling, natural looking breast. And the abdomen is closed similar to if the patient had a tummy tuck. So they get kind of a flatter contour there and almost get a tummy tuck scar out of that as well. So, that's the way that surgery is done. I think it's a very advantageous way of getting a long, durable, natural, less invasive reconstruction that is less reliant on foreign bodies and will last, over time, I would say.

Host: What about sensation? Because you mentioned you're going to remove this excess tissue, reconnect the blood vessels to new blood vessels or blood vessels that in the breast area, not in the stomach here. And then so we've severed the little tiny nerves. Are you able to find any nerves to connect that tissue to, or is that not important because this isn't skin or what's going on there?

Dr. Ranganath: Yeah, that's a great question, actually. So, the baseline for forever has always been, if you get a mastectomy, your chest and your reconstructed breast would be numb because all the nerves that supply that area go through the breast tissue and they all get cut or removed, when the mastectomy is done. Nowadays, we can actually perform neurotization or neurotized flaps. So, when we transfer this flap of tissue, we can also find the nerve that goes into that tissue. And we can find one of the cut nerves in the chest, and we can actually reconnect those with a small cadaveric nerve graft. And that has the potential to regain sensation within the reconstructed breast.

Now it's not promised right now. It's certainly not proven. But it's been done for the last, I would say five to eight years and still being studied. And overall, the early data is showing pretty good return of some sensation to the breasts. Now it's not, never back to a hundred percent normal, but I think it is a meaningful way of at least offering a woman the opportunity to have a sensate reconstructed breast as well. Whereas the baseline has always been to have a numb chest.

Host: Okay. Thanks for explaining that. Then the other part is I'm just having a lot of trouble visualizing how you can take well, let's call it a chunk of tissue from the abdomen and how that's going to end up looking like a breast.

Dr. Ranganath: Yeah, well, let's call it a flap because that's usually what we call it, but it's a flap of skin. You can think about it if you kind of, I'm not sure what your body habitus is Dr. Wilner, but if you think about kind of your lower abdomen, you can kind of grab a, you could say a chunk or a flap of skin and fat there and usually pinch it closed. So, you can think if we take that, transfer it up to the chest that fat and skin can be molded to fill the envelope of skin that's left behind by the breast surgeon. And basically fill that tissue, and very well match it, the shape and the hang and kind of the natural teardrop appearance of a breast. And so it's basically like filling the hole, that's left behind with soft, warm, natural tissue.

Host: I know for surgical outcomes, it's always patient selection is key. You gotta get the right patient, if you want a good outcome. There are some patients who, for one reason or another, they're not the ones to have that particular surgery. So who are the optimal patients and who are the ones where you're a little reluctant to try this microvascular surgery?

Dr. Ranganath: Yeah. So, I think the main thing to keep in mind is almost anyone is a candidate for microvascular breast reconstruction, as long as they have some tissue in certain parts of their body to give. So, most patients, you know, as they're in their forties, thirties, fifties have some excess tissue in either the lower abdomen or the thigh.

And so we're able use this tissue to help reconstruct a breast. In the case of a very thin patient who has essentially no tissue excess, implants are going to be the really only option for them. But for everyone else, this is something to consider. The only caveat meaning is that you have to be able to tolerate a little bit longer surgery.

So these surgeries, whereas an implant-based reconstruction may take two to four hours, these are taking more like four to six hours for one side, maybe six to eight hours, if we're doing both breasts. So, you have to be generally healthy enough to undergo longer general anesthesia. And to be able to tolerate that from a cardiopulmonary standpoint. But for the most part, most women are getting breast cancer in their forties and fifties and otherwise relatively healthy. And so we generally offer this to almost everyone who has some excess tissue and wants this type of reconstruction.

Host: Are there any issues with healing?

Dr. Ranganath: Not particularly. Again, you know, generally you'll have scar from wherever we take the tissue from, most commonly the lower abdomen, but it could be the thigh as well. So, it's another surgical site and that has to heal. But it usually heals relatively well with minimal complications, except for in the same patients who would have complications otherwise. So obesity, uncontrolled diabetics, those kinds of things. Other than that, risks at the donor side are pretty minimal. They're always going to be kind of wound healing related issues, but other than that, you know, major complications are pretty rare.

Host: You had mentioned earlier about reconnecting lymph ducts. I know there can be a problem of a lymphedema associated with breast cancer. How do you approach that?

Dr. Ranganath: Yeah, it's a good question. So lymphedema can be a very debilitating problem for women who've had axillary lymphadenectomy, so lymph nodes that were positive for cancer that had to be excised. And lymphedema rates are 20 to 40% or higher for those types of patients. And lymphedema can be very debilitating. In the past 20 years or so, we've developed kind of newer techniques to see if we can bypass lymphatic channels into the venous system to try to help drain out the arm after lymphedema develops. So, this is called a lymphovenous anastomosis, where if a patient comes to see us with kind of moderate lymphedema, we can do some imaging tests to try to find these little sub millimeter lymphatic channels.

And in the appropriate patient, we can actually find these channels under a microscope and use these even smaller sutures than usual to hook them up to veins in the area, to try to reestablish lymphatic drainage in the limb. That is for more mild lymphedema. For more severe lymphedema, what we can do now, something called a lymph node transplant. Which is literally instead of taking lymph nodes from someone who is deceased like a kidney transplant, we can actually take lymph nodes from a different part of your body, your own body, and transplant them to usually it's the axilla in this case, and hook them up to blood vessels and lymphatic channels in the axilla to see if that can help restore lymphatic flow as well.

These are all treatment models and are still being studied, but are in the right patient is actually quite effective. And we can also talk about maybe some preventative options that we have coming up as well.

Host: Well, that's really interesting. I don't think I would have thought of that lymph node transplant. That's, I give kudos to whoever came up with that one. That sounds like a very novel and potentially effective idea. Well Dr. Ranganath this has been a great discussion of surgical microsurgical approaches to breast cancer. Is there anything else you'd like to add?

Dr. Ranganath: No, I just like to say I, you know, I think for patients that, you know, we know that breast cancer affects one in eight women. It's very common. And to a T, we know that women who are offered options for breast reconstruction generally report much higher on quality of life scales and sense of self-being and sense of self-worth and those kinds of things.

So, you know, breast reconstruction should be offered in some way to every patient. And I think microvascular reconstruction is a really good way of getting a patient, a natural kind of durable reconstruction.

That concludes this episode of GW Doc Pod, a peer to peer podcast for medical professionals with The George Washington University Hospital. To refer your patient please call 1-888-4GW-DOCS. If you have a question for one of our specialists please email physicianrelations@gwu-hospital.com 

Disclaimer: Physicians are independent practitioners who are not employees or agents of The George Washington University Hospital. The hospital shall not be liable for actions or treatments provided by physicians.

Individual results may vary. There are risks associated with any surgical procedure. Speak with your physician about these risks to find out if minimally invasive surgery is right for you. Individual results may vary. There are risks associated with any surgical procedure. Talk with your doctor about these risks to find out if minimally invasive surgery is right for you.