Good afternoon, and welcome to the on-demand session, multidisciplinary care on lymphedema. It's not just about the surgery. My name is Drew Singal. I'm a plastic surgeon, lymphatic surgeon at the Boston Lymphatic Center, and it's really my honor to moderate this session with our three incredible panelists who need no introduction in the lymphatic surgery community or plastic surgery, but I'm going to go ahead and introduce them anyway. We have Dr. Carolyn de la Cruz from University of Pittsburgh, Dr. Mark Shavarian from MD Anderson, and Dr. Minjung Cho from ASPS. Thank you very much indeed to ASPS for inviting me to talk to you today. It's an honor to be part of this panel on the very important topic of the multidisciplinary care of our lymphedema patients. My name is Mark Shavarian. I'm an associate professor at MD Anderson Cancer Center, and I'll be talking to you today on building a comprehensive lymphedema program of excellence, tying together many of the themes of this panel. I have a book, but do not accept payment or royalties. So building a new service line could often seem daunting, and where to make the first steps on what is a significant journey is often difficult to ascertain. I'm going to share with you our experience at MD Anderson Cancer Center, where we were honored to be designated as a comprehensive cancer center of excellence for our multidisciplinary care of our lymphedema patients. We published an overview of our experience and broke this down into several actionable steps to guide the development of any new service line, not specifically lymphedema, and to share our lessons learned. From a 30,000 foot perspective, it's important to have an overview of all of the components that you wish to develop within your program. In no particular order, these include prospective lymphedema surveillance as part of a lymphedema screening program. Once you determine which patients you wish to screen, is this going to be patients just undergoing lymphadenectomy or those with a sentinel lymph node biopsy that are high risk? It's important to have standardized prehabilitation and rehabilitation protocols and a patient education program to reduce the patient's risk of developing lymphedema and then to inform them of what to do if they develop it. Measurements should be standardized so that they are reliable and prospectively collected so they can later be analyzed for the same patient comparing pre-optive and longitudinal post-optive measurements. Diagnostic imaging is a very important component of lymphedema with the capacity to intervene if necessary, for example, with venous insufficiency, which is a common comorbidity comorbidity in lymphedema. It's important to have standardized treatment pathways so that different treatments can be compared. Perhaps the most important part of a lymphedema program are the lymphedema specialist physical therapists who will be treating the lymphedema alongside surgery and this may be the most important component of our outcomes for our lymphedema surgeries. These patients are managed in multidisciplinary care environments. It takes a village to manage these lymphedema patients as many of us are aware. The technology behind lymphedema imaging and surgery is constantly evolving. It is important to stay up to date with state-of-the-art developments as these progressively improve the surgeries we can perform and therefore the outcomes. And this includes the continual development towards minimally invasive surgeries such as laparoscopic and robotic flap harvest. It is now a component of many programs to have an immediate lymphatic reconstruction program, in particular as part of breast surgical oncology programs, but also now extending to inguinal immediate lymphatic reconstruction. It's important to define referral criteria, which patients do you want to see and which of those that you do not, and then to have pathways under both of those circumstances, both internal and external. It's important to continually participate in outcomes research, to participate in clinical trials, and also to develop basic science and translational research programs and contribute to national biobanks if able. The program needs to be advertised to referring physicians, lymphedema specialists, patients, and therefore all opportunities for educational activities, publications, and workshops should be taken. And it is essential to regularly re-evaluate the program, including the patient satisfaction via patient surveys to continually improve the program. As I said before, the multidisciplinary team is vital for the care of these complex patients. This includes the plastic surgeon, physical therapist, and occupational therapist, diagnostic interventional radiology, vascular surgery. Nutrition is an increasingly important component of lymphedema care, particularly with the greater access to the GLP-1 agonists. Integrative medicine is very important to manage the multifactorial issues that the lymphedema patient will have, as well as general internal medicine to manage the multiple medical comorbidities. Lymphedema can place significant psychological strain on patients, and to have psychological services such as body image is very important. And then to establish a referral base, both internal and external, is vital, and to understand that this is a reciprocal relationship between the lymphedema team and the referral network. We organized our program in defined buckets, and I wanted to go through these. The first is diagnostic evaluation and staging. These include parameter volumetric bioimpedance spectroscopy, ICG fluorescent imaging, MRL, where it is available, and lymphocentigraphy still remains an important investigation for many of our patients. Patient-reported outcome measures are also very helpful in order to better understand the patient response and outcomes from our interventions. I have combined lymphedema, specialist physical therapy, with integrative medicine, because these are both components of prehabilitation and post-habilitation, and so this includes risk reduction and surveillance, standardized treatment, involvement in a multidisciplinary clinic, which we'll go into more in just a moment, and weight optimization if this is necessary. Surgery includes many components. In particular, a high magnification operating microscope is really seen as a vital component for both therapeutic and prophylactic lymphovenous bypasses. Other adjuncts include vein images for lymphovenous bypass, ultra-high frequency ultrasound to locate both lymphatics and veins, and then power-assisted liposuction for lipectomy for patients with more advanced lymphedema. A very important component of our program has been our vascular surgeons, interventional radiologists, both for evaluating our patients through duplex imaging, CT and MR venography, and direct venography, as well as for intervention through venoplasty and stenting, which is performed prior to surgical intervention. As we discussed before, it is very important to be engaged in research. Lymphedema is a fast-developing specialty, and there are many areas that we still need to strengthen our evidence base in, and that includes clinical, basic science, and translational research, and integrating our research with national biorepositories. All opportunities for referral clinician and patient education should be taken, which includes publications, presentations, and an externally facing website. Service access and awareness is very important. That includes a patient access team that is able to manage the complexity of these referrals, both in those that are going to be suitable for consideration for surgery, and also for managing those that aren't. We do take great lengths to ensure that those patients that are not suitable candidates for surgery are triaged to the correct services that can help them. LEARN is an important body to participate in, which also can promote your lymphedema service. And also, all opportunities for publications, conference presentations, and educational events. One of the major issues with lymphedema surgery has been insurance approval, and it is important that we maintain an ongoing dialogue and interactions with our payers. A dialogue and interactions with our payers. This includes every opportunity to present to them having standardized protocols, and if possible, a dedicated team for peer-to-peer appeals, and to support national organizational efforts to standardize our CPT codes, and for more universal payer reimbursement for the procedures that we are performing. So, we'll take some of these components as examples. The first is the prospective lymphedema screening program at MD Anderson. This predominantly occurs in our breast center, whereby our patients undergo perometry pre-operatively and at standardized post-operative intervals. In the plastic surgery department, we also perform screening of our patients that undergo immediate lymphatic reconstruction, and under that circumstance, patients undergo perometer volumetric, and also by impedance spectroscopy. It's very important that we develop these programs as early identification of lymphedema, which then directs the patients to lymphedema physical therapy, reduces the likelihood that lymphedema will become chronic and established, and also means that for patients that are suitable candidates for surgery, these patients are optimized before they engage with the surgical programs. An important part of our program is standardized prehabilitation and rehabilitation protocols and patient education. This starts even before surgery. The thrust of this effort is to reduce the likelihood that a patient will develop lymphedema through regaining a range of motion after surgery, understanding the behaviors that may increase their risk and to avoid those, and also what to do if they develop limb swelling. Lymphedema physical therapy is a very important part of the program in its own right, and is also part of the surgical program. Indeed, in my opinion, physical therapy is the most important part of a successful surgical outcome. It's important that the program has lymphedema specialist physical therapists that are skilled in both reduction, which is illustrated here, including bandaging and specialized reduction garments, and also in maintenance therapy, including non-custom and custom medical garments, pneumatic compression pumps, night garments, etc. We have found great value in centralizing our lymphedema care into a multidisciplinary lymphedema clinic. This way our specialists can work together, and this facilitates the patient journey, reduces the number of appointments that they need to make, and also helps us to better screen for patients who will be successful candidates for surgery, and to direct those patients that may not be ready at this point to the right care. This includes history and clinical evaluation diagnosis, imaging in the clinic setting, the ability to be evaluated and treated by lymphedema specialist physical therapy in the clinic environment, a direct referral pathway to vascular surgery or interventional radiology, the development of a non-surgical or surgical treatment plan, understanding that both are just as important, and then also the opportunity to recruit patients to research, whether that is basic or translational science, or our ongoing clinical trials. The standardized lymphedema evaluations that we perform in the clinic setting include barometer measurements of both the upper and lower extremities as indicated, bioimpedance spectroscopy, and the ability to perform ICG lymphatic fluorescent imaging in the clinic setting. It is important in our program to have a standardized lymphedema treatment algorithm. This way we can compare outcomes data between different surgeons so that we can perform research and optimize our treatment algorithms based on an evidence-based approach. Lymphedema surgery is highly technologically driven, for example here lymphedema bypass necessitates fluorescent lymphatic imaging, can be greatly aided by adjuncts such as ultra-high frequency ultrasound. Vein imaging can significantly reduce the time taken to perform therapeutic lymphedema bypasses by giving you a roadmap to add to where the lymphatic vessels have been identified to quickly identify the veins and to ensure that the valves in the veins are competent. And then also, as shown here, high-powered lymphatic specialist microscopes that include fluorescent imaging capabilities. Vascularized lymph node transfer or transplant also is greatly aided by technology and indeed our position would be that reverse lymphatic mapping such as that performed by SPECT-CT reverse lymphatic mapping is really vital where a harvest of our lymph node transplants is performed from within regional lymphatic basins such as from within the groin, axilla or neck. This allows also the capability of three-dimensional modeling which can then be used for greater fidelity within the surgery. This also allows intraoperative guidance by a neoprobe and being able to delineate between the target and those nodes which we need to preserve using fluorescent imaging. So this is a dual tracer technology. It is important that a program has the specialists necessary to be able to perform intra-abdominal flap harvest. The emmental flap, lymphatic flap has really become a vital tool in our treatment of lymphedema. Its versatility in particular to be divided into multiple flaps really stands apart from other lymphatic flap options. And we as many other departments have found that with a skilled either plastic surgeons who are dual trained in general surgery or general surgical colleagues that these can be harvested without damaging the flap through minimally invasive means that includes laparoscopic and robotic harvest measures with minimal morbidity, faster patient recovery and minimal scarring. For advanced lymphedema where the adipose component is fibrous, this cannot be removed by conventional liposuction alone and it is necessary to use a para-assisted lipectomy. This is a standard now for removing that component. There are other technologies available but we have found that para-assisted lipectomy is a really a standard tool for us for this procedure. Now most programs have engaged in immediate lymphatic reconstruction programs. We feel that this still needs to be performed under a research setting as information is still being gathered as to who this should be offered to, who stands most to benefit from it and which techniques are associated with the best outcomes. This is performed in concert with our breast surgical oncologists who perform the reverse lymphatic mapping under lymphosurine guidance. And then we perform a lymphitis bypasses. Our preferential technique is to perform standard therapeutic lymphedema techniques of intima to intima coaptation. Although there are other techniques such as lympha, which is a implantation technique. We are also extending these techniques now to our patients undergoing inguinal lymphadenectomy. As I've mentioned before, it is really vital that we engage these patients in research opportunities, clinical research, translational research, basic science research, and that we, where available, collaborate with national research biorepositories. This is going to really be vital for us to really answer some of the important clinical questions that we have, and also to aid in the development of therapeutics for lymphedema, which is really vitally needed. I thank you very much indeed for your attention. I look forward to our discussion as a panel. Hello, my name is Carolyn Dela Cruz, and it's a pleasure to join this esteemed panel discussing It's Not All About the Surgery. I'd like to thank the ASPS for the opportunity, and also Dr. Sengal for arranging and moderating this session. So let's get started. So for surgeons and patients alike, very commonly this is the motto, let's operate now. However, in lymphedema surgery, it really isn't all about the surgery. And so I'd like to congratulate the Dr. Sengal and the other speakers in this panel to discuss what might be a controversial topic. And the reason I say that is because when it comes to lymphedema care, the mainstay of treatment really for the last several hundred years has been conservative treatment with the use of therapy and adjuvant care. And it's really only been in the last recent years, namely since the late 1980s and 90s, that even the thought of surgery has entered as a proposed therapy. So surgery can be a relative newcomer in the care of these patients. Now, in reality, when a patient comes to the office, they don't wanna hear necessarily that they may require either some prehabilitation or may have to increase their lifestyle modifications. Very commonly people are frustrated from this debilitating disease that they've been suffering from. And they do in reality want a quick fix. And so sometimes I find myself in the clinic faced with patients like this that are demanding surgery. But I try to be patient and explain them that it's not all about the surgery, particularly because there's no known cure for lymphedema, and particularly because we're just continuing to understand this very complex disease. So what I'm gonna do for the next couple of minutes is share with you some of the basics of lymphedema therapy, what it means and how it can produce reliable results, and then highlight how therapists can play an integral role in care, particularly as they do in my practice. So what is lymphedema therapy? It is very commonly comprised of two phases. The first phase is decongestion, and the second phase is maintenance. First phase, the goal is to remove all the extra fluid, and that's done through a combination of manual lymphatic drainage, compression bandaging, exercise. And then patients, once they're decongested, enter the maintenance phase, where they may occasionally need additional manual lymphatic drainage, perhaps continued compression garments, exercise, and wound care and skin care. This is an example of manual lymphatic drainage, where fluid is moved from one region to the next via open channels and open anastomosis across the body and in the back, keeping in mind those that may be non-functional due to either lymph node removal or radiation, et cetera. This is an example of bandaging, which can be performed daily or over a period of weeks, which really decongests the area until patients are able to fit into a more permanent compression garment. Complete decongestive therapy alone can provide adequate results, as you can see here in this pre-op and post-op photo. It is ideal for patients who are very compliant and who are very fluid forward. And also it is ideal, perhaps, to decongest them prior to surgical intervention. This is an example of how I use ICG in conjunction with MLD to help improve patient results and how therapists can play an integral role in my practice. See a lot of patients with chest lymphedema. And as you can see, this patient who's suffering from left arm lymphedema and left chest lymphedema, the ICG can show available pathways for the therapist. In this case, the inguinal nodes below are open as well as the contralateral axillary area. This is another example for a patient who shows the absence of flow inferiorly, but continues to have flow to the contralateral axilla. Knowing that the inguinal axial pathways open in a lot of these patients can really improve the capabilities of the therapist and really in order to maximize the results. So very commonly I will communicate with the therapist prior to them beginning therapy if the patient were to have an ICG. The other way that I incorporate therapists into my practice is helping myself understand what the patient's current routine is. For example, this patient is presenting with her history of left breast cancer with left arm lymphedema. I'm really going to want to get a sense for her garment use, how often she wears it, what happens when she takes it off, whether or not she has a pump and whether or not she has done CDT and if she responded to it. Very commonly patients have inadequate CDT where they have not either completed the required MLD or even the wrapping. I do want to know if they've been seen and treated by a certified lymphedema therapist and if they've had adequate care with standard protocols. Also, I want to know if they've had an infection which can be indicative of progression of disease and may change my surgical plan. And the therapists really get a good sense for them over the course of their care. Of course, they're seeing them daily with a sense for what happens when they skip a day and whether or not they're very compliant with keeping up their care. I really lean into this idea so that I can work with the therapist and to understand the patient's needs. As well, it's very important to understand if they respond to CDT. It does give me some idea if the patient has fluid versus fat versus fibrosis. I do not routinely order an MRI but several other surgeons do to determine if they're fluid or fat-based. However, it is helpful to know if they've responded to decompression which indicates that they may have more of a fatty or a fluid component. Or for those patients who don't respond at all, they may have more fibrosis. This is a case of pre and post-liposuction lower extremity who in this patient was primarily fatty in nature with minimal fibrosis with a good response. However, it may change my planning to offer patients a physiologic procedure versus a debulking procedure. Another way that I incorporate therapists into my practice is in pre-habbing them to define whether or not they're a good surgical candidate. For example, this patient who presented to the clinic, there has a clear cardiac component to this lymphedema. This patient has significant mobility issues and is a wheelchair bound, has a component of venous insufficiency as well, which will need to be managed, has significant obesity and really the therapist can help answer the question of whether or not they're maximally, maximally conservatively managed. And they can help you maybe convert patients to be better surgical candidates. Speaking of surgery, I would like to talk about post-op for those of you out there that may be beginning a surgical practice, may be entertaining lymphatic surgery. So I'd like just to give you some idea of how I incorporate therapists into each particular procedure. So we can start with surgical excision, which typically for the mainstay, maybe as some sort of debulking procedure for cases of liposuction, I use the therapist to do on-table wrapping post-op. I think it's critical to get good compression post-op with Comprilon standard lymphedema wrapping. And that begins on table. They come to the surgery, the patient's wrapped on the table. We do have a protocol for daily wrapping for a week until which their custom garment is ready. It's great for the therapist to see the result on table and have some idea about perhaps areas of skin thinning or really just to get to see the on-table post-op result to have some idea of how it can be maintained. And then also they are there to provide measurements for the transition. This is an example of a patient who had debulking procedure and had very significant tight wrapping in her hand. We don't, very commonly do not debulk the hand. And in this case, a graded compression was not applied with too much pressure in the hand. The patient had a skimming of her hand and had to undergo a release of her arm in her compartments. And she did go on to do well. This is just one reminder that in the same way that therapists rely upon us and we can rely upon them, communication is the key. Another surgical intervention that we do quite often is lymphovenous bypass. And the therapists have an active role in this as well in a similar way. Very commonly, the patients can have some swelling post-op. I do not wrap them like I would for debulking procedure. And often I put a loose lace, sorry, loose ace wrap on their arm for at least the first week. There are surgeons that do encourage patients to wear their garment to increase lymphatic flow. But I find that sometimes the garment can cut into them, especially because patients can have increased post-operative swelling. And so you really need a good therapist to monitor for these changes, to make sure the patient's not having a lot of swelling and bring in the garment when they're ready. Very commonly too, the patient's hand can swell, particularly if they don't have a gauntlet portion of it. So a good therapist will be available just to wrap the hand for patients that may have transient swelling as a result of surgery. For larger procedures, such as a lymph node transplant or a flap with lymph nodes, therapists are key. They can provide a creative wrapping and garments that are gonna avoid pressure over these flap areas. Very commonly, the rest of the arm may need to have some garments, but they can create custom garments for the compression for the extremity, but not have areas of compromise over the flap. In addition, they are very good at doing serial measurements and can detect even small changes in volume. So for example, this patient had an ALT flap and had some transient swelling in his leg from the donor site. And in this case, the therapists were key to getting him into a garment and controlling the swelling and resolve it without incident. As many of you know, donor site lymphedema after harvest can be an issue for a number of different flaps. So a good therapist will really be able to partner with you when identifying this problem early. Patients also that may present for breast reconstruction who may have arm lymphedema with or without, who are seeking reconstruction with or without lymph node transplant may have a significant arm swelling post-op. So they as well may need a therapist to know the best timing to bring back their garment. Very commonly, they are subject to long surgery and may have post-op swelling, as well as the need for specialized bandaging in special areas. This patient underwent a skip flap to her upper arm. You can see her pre and post-op. And however, she needed an offloading device so that she wouldn't have any pressure on her arm. However, we had to be cognizant of her abdominal donor site. And so you can see here, we had a special splint fabricated to offload pressure on the flap and still allow her to have some elevation. This could not have been achieved without a really good therapist working side-by-side. Perhaps the most critical role for lymphedema therapists is in the lymph population. As many of you know, immediate lymphatic reconstruction is meant to be purely prophylactic for those patients who may require axillary node dissection or maybe who may be at high risk to develop lymphedema. But as we know, anatomy can be very different. And patients even with one or two nodes may undergo the development of lymphedema. So predicting who will go on to get lymphedema still remains a challenge. And so I have a very aggressive surveillance clinic where the lymphedema therapists provide post-op teaching and monitoring and risk assessment. And they can answer the nuanced questions for patients on whether or not they need a garment, even if they don't have any signs of lymphedema. Because this can be challenging for patients who are trying to avoid the diagnosis at all. Patients do spend a lot of time on the internet. There's a lot of fear about getting lymphedema and I think rightfully so. And a good therapist can help answer these questions in addition to the surgeon to sway the patient's fears, but also give them a reasonable expectations and most appropriately a plan. I am grateful to my team of experts and my therapists who play an integral role in the care of my patients. And I'm grateful for their expert skills and their excellent care. I think from a microsurgical perspective is challenging to say that it's not all about the surgery, but sometimes despite wanting to offer everyone a surgical approach, I think it is important every now and then to zoom out and remember that we are part of a big team. And I think it's important to understand everyone's role in being able to maximize everyone's care. So thank you for joining this session. And we look forward to the discussion in our follow-up panel. Thank you very much. Hi, everyone. My name is Minjeong Cho. I'm a microsurgeon from the Ohio State University. And I would like to thank ASPS and Dr. Singhal for inviting me to discuss imaging and lymphedema surgery 101, the basics for your practice. I have no disclosures. So becoming proficient in using different types of imaging modalities in lymphedema surgery is critical as they play multiple roles during the phases of lymphedema treatment. They help us with diagnosis of lymphedema, identifying and determining the severity of the disease, preoperative planning for lymphatic surgery, and also post-operatively evaluating the success of your surgery. So therefore, the goal of this session is to become familiar with different types of imaging modalities that are available and also learn how to use them effectively to maximize the success of a surgery. So the question is, what will be your weapon of choice given that there's so many different types that are available? So first to start off is the lymphocentigraphy. In the lymphocentigraphy procedure, the radioactive tracers are injected to web spaces of hand or foot depending on the location of extremity. And then the tracers are used to identify the pathways of lymphatic systems. So here on this PowerPoint, this is my patient with a primary lymphedema. So you could see here on the left side, the patient has normal lymphatic because you could see the linear lymphatic pathway. However, on the right side, you could see that there are actually no identified lymphatics are visualized in this imaging. As you could see that the dyes are kind of spreading by the dermal backflow and there's no linear lymphatic pattern. So therefore, the lymphocentigraphy is great at usually for diagnosis and also in some cases, post-operatively evaluating the success of your surgery. The other type of lymphatic imaging is MR lymphangiography. So in this case, also similarly, the dye is injected to the web spaces of hand here, and then it's used to identify the veins and the lymphatics. So here, typically the veins are linear. You could see it here. And also on, however, the lymphatics are usually tortuous. So you could see that on here, the lymphatics and the veins are visualized. These are usually for diagnosis as well of the lymphedema and also a preoperative planning and also post-operative monitoring to determine whether the lymphovenous bypass procedure you have done has been successful or potential lymphangiogenesis after the lymph node transfer. The pros cons of MR lymphangiography, the advantages is that no radiation. It provides a detailed anatomical information and also you could evaluate the soft tissue. So the previous panelists have discussed, you know, the fibrosis and soft tissue edema. So here in MR lymphangiography, you could visualize that. However, the disadvantages that obviously it is a time consuming and difficulty with distinguishing lymphatic and vein. There's some filters that you could use to kind of offset the signals. So however, sometimes the lymphatic and then the vein could be very similar looking. So it is hard to determine the difference and also potential allergic reactions to contrast medium. The other types, which is most lymphatic surgeons are familiar with endocyanin-grain lymphangiography. There are different kinds of machines available here. You could see that the SPI, Hamamatsu, VisionSense, and CarSource. Most of the surgical centers have certain kind of ICG lymphangiography. So that you could be used to map out the lymphatic system. So here is a patient with upper extremity lymphedema. And then those patients also similarly, we will inject the web spaces as well of the hand and also around the wrist, the dorsal, and then the volar site. And it could be used for diagnosis, planning, and staging and post-operative evaluate. So here is, this is a Hamamatsu. And then you could see it here. The ICG has been injected into the web spaces. And here you could see, we're starting from the hand and then you could see the normal lymphatic pathway. And then this area is a dermal backflow. And then also you could see it, the drawing of the lymphatic system, juxtaposed on the top of the normal skin on the left side. There are different kinds of stages that are available for the ICG. So typically the linear pattern of the lymphatic system is a normal pattern. And as the disease progresses, there are different kinds of dermal backflow patterns, which is splash, stardust, and then diffuse as the disease progresses. Depending on the different kinds of the lymphatic system imaging available for the staging, we in our Ohio State University, we use MD Anderson Cancer Center ICG lymphatic system staging. So here in the stage zero, you could see that there are multiple patent lymphatic vessels and there are no dermal backflow. So this is a patient with a normal lymphatic. And stage one and two are typically considered early stage lymphedema, where you start to see a few patches of dermal backflow and then it's starting to progress. And then stage three, you could see that it's advanced stage lymphedema where you could see significant dermal backflow and not too many patent lymphatic vessels. And stage four is a diffuse pattern. And stage five is typically for patients with primary lymphedema, where you inject the dye into the web spaces and no dye is moving. This is another patient with a lower extremity lymphedema. Similarly, as upper extremity lymphedema, we inject the dye into the web spaces of the foot and also around the lateral and medial malleolus as well. So this is ICG with a lower extremity lymphedema. So you could see that, again, the linear patterns of the lymphatic vessels going up and then you could follow this and until there's a dermal backflow happening. So the good thing about this system is that you could see what you're marking. Sometimes it could be difficult as you know, to do the ICG, you have to turn the room light off and then also determine where the dye is going. So sometimes it's difficult to identify where your marker is. However, sometimes when the imagings are juxtaposed on the other side, you could see what you're marking and also confirm that what you have marked, it is the correctly marked on the skin and reflects what you're seeing on the ICG. So the pros and cons of ICG lymphangiography is advantages is no radiation and also you could use it intraoperatively and it's operator dependent. So MRL, lymphocentigraphy, you depend on a radiologist and it's not a real time imaging. However, here you can use it for preoperative use to determine the stages of the patients and also take him to the intraoperatively and then do the ICG intraoperatively and then mark the lymphatic pathways and it provides a detailed anatomical information. However, the disadvantage is that it's only penetrates usually one to two centimeter and difficulty with evaluating deep lymphatics. So the patients with significant skin fibrosis or significant edema, the dye do disperse at the skin level. So sometimes you may have a lymphatic, patent lymphatic channels that are underneath that dye spread. However, you cannot identify because of the low penetration. So, and then also the questions that were the veins. Sometimes, you know, you are trying to find the lymphatic vessels and then you have beautiful lymphatic vessels that you identified on ICG intraoperatively, then you make an incision in that area. And the question is, where are the veins? It's almost like sometimes you're finding the wall though, because you have this beautiful veins that are ready to be bypassed and then you cannot find a really good size veins. Or sometimes you find the veins that's significantly much bigger with a backflow which is not an ideal candidate for the bypass. So for us at Ohio State, we use ultrasound guided lymphatic and vein mapping, which is a real-time imaging. You could visualize and measure and assess the patient anatomy and it increases the degree of freedom. And then there are different kinds of ultrasounds that are available for mostly, I think a lot of us are familiar with the butterfly, which a lot of anesthesia carries. The good thing about the butterfly is that it is a portable, you could connect it to your cell phone or iPads or however it is a low frequency and which with a low frequency, it does provide low resolution, however, increased depth. And then the higher frequency it is, there's a higher resolution, however, it's a decreased depth. For high-frequency ultrasound, typically here's an image where you could see that the lymphatic vessels and then the veins are visualized here. So instead of making an incision where the ICG has a dermal backflow, you could identify the veins and the kind of tailored tour where you would think find the vein and the lymphatic. And this is the ultra high-frequency ultrasound and I'm gonna play the video. So here, which you could see the two yellows are showing that open lymphatic vessels and then they're moving and that they're combined. And then you could see it's continued to travel and then there's another lymphatic vessels coming in and then suddenly it's gone. So then you could see that that's the area of location here. We're gonna play this video again, your yellow vessels, a yellow line, and you could see that they're coming together and then suddenly they're gone. So that's the location where the sclerosis is happening. And then the red arrow indicates where the vein is. So here you could literally find where the lymphatic is and then here's the vein coming in. You could see that there, it's a great place to do make an osmosis because they're on top of each other. And then you could see the caliber, which is a great match for the lymphatic and the vein. And then you're doing it at the location of the sclerosis. So the pros and cons of ultrasound guided lymphatic imaging. Is it non-invasive? It provides very detailed real-time anatomical information. You could see the sclerosis around the lymphatic. You could measure the caliber of the vein, the flow of the vein, and the ability to validate the status of lymphatic and identifying vein is huge plus because a lot of us, if you are, do a lot of lymphatic surgeries that many times you will have beautiful lymphatic, but your vein has a significant backflow or is much bigger, then there's a huge mismatch. But however, you could see it on the images that have shown that you could really identify nice caliber vein and lymphatics just next to each other. However, disadvantages that it does have high learning curve and then also is very operator dependent. So, you may have beautiful vein and lymphatic and just a little bit more pressure than when you need to make collapse those channels. And then it is a high initial cost special for also high-frequency ultrasound because it's contrast to a lot of high-frequency or lower-frequency ultrasound. They're usually readily available in your surgery suits because ultrasound is typically used for IV placement by the anesthesia. Ultra-high-frequency ultrasound, it is one of the device that you do have to kind of invest in. So, the question is, which one? There's so many different types available. What are you gonna use? We did comparative analysis of preoperative high-frequency color double ultrasound versus MR lymphangiography and ICG. And then we found that, this is a kind of rundown of the paper which shows that the invasiveness, MRL and ICG and imaging speed, obviously MR lymphangiography takes much longer. And however, high-frequency ultrasound has a significant learning curve. But it is operative dependent and then something that you could do it pre-op, intra-op, in a clinic, in a surgery. It's not like a order that you have to do it and wait for radiologists to complete. And then the cost-wise, obviously MRL, you have to order it through radiology and then ICG because of the dye cost. However, once your machine is bought for your ultrasound, you don't have, there's no extra cost except your time. For vein mapping, it's great. You saw it on the video that you could find the vein really well with the high-frequency ultrasound. MRL would show you where your vein's located, but then you cannot put it side by side when you're actually operating in the OR. It's hard to determine where that vein was exactly visualized. And then the study showed the accuracy of the lymphatic and vein imaging using these types of imaging modalities. And then the treatment option. So now you have identified whether you have identified the diagnosis of lymphedema, identified the severity of the disease, and now what do you do with it? Any kind of treatment for lymphedema, your first line of treatment is complex decongestant therapy, which you have to, it's a multidisciplinary care. As we discussed, the topic of this panel is multidisciplinary care. Lymphedema is not just surgery. So we have a really significant and strong relationship with oncologic rehab. All of our physical therapists are lymphedema-certified physical therapists, which any patients who have overload of volume, we start them with a decongestant therapy. So all the patients who are going to surgery needs to be decongested and also in a maintenance and optimized phase. So they would have to go into compression therapy, self-management, and also manual lymphatic drainage prior to any surgery. And whenever they are maximized and optimized for the surgical treatment, whether the patients have early or late stage, and then we'll determine different treatment options for them using the MD Anderson Cancer ICG staging. So for patients with early stages, which is stage one and stage two, early stage lymphedema, we use MRL or ICGL for lymphatic mapping. And for late stage lymphedema, traditionally those studies show that you don't do lymphovenous bypass in this patient because you cannot find lymphatic vessels and also there might be disease. However, with ultra-high-frequency, ultrasound-guided lymphovenous bypass, we do do this procedure in patients with stage three. As you could see here, the patient on the right side, patient had lymphedema, and this is where you could see that patient has significant decrease in the size of the edema she has on the right side. Here, this is why I think this is a patient, actually, this video is a patient with stage three. You could see it on here, the white area is the thickness of her skin, and then how much of disease use she has is that with ICG, I think it would have been really difficult to visualize it. However, with ultrasound, you're able to visualize the lymphatic and then also identify where the sclerosis is. And we also did other study where we looked at the utility of lymphovenous asthmosis and advanced stage lower extreme lymphedema, which does show that the patients who were traditionally thought to be not to be a candidate for lymphovenous bypass are candidates and it is effective. So with the use of ultra high-frequency ultrasound, it has changed our treatment algorithm where in patients who have advanced stage lymphedema, we will attempt to do the lymphovenous bypass. And patients who have done the lymphovenous bypass and it has not had effect or the disease is so severe, like in stage four, even we are really difficult to identify the channels where the disease is so severe then we'll do lymph node transfer and lymphovenous bypass, if we are able to find the lymphatic channels intraoperatively. So in our center, we typically use omentum or jejunum lymph node transfer for the vascular lymph node transfer, given that yes, it does require laparotomy and an additional donor site. However, typically in intra-abdominal area, there are abundant lymph nodes available. The risk for iatrogenic lymphedema is quite low. So in a jejunum lymph node transfer, you use a transillumination of your jejunum to identify lymph nodes. So here you could see the close-up view that there are a couple of small lymph nodes here and you could see the size of the jejunum lymph node transfer is quite small. So typically in case of breast cancer-related lymphedema with upper extreme lymphedema, omentum will be used for axillary, usually axillary scarrings. And then, so you will place the omentum because of the size of the tissue and then vascularized lymph node transfer from jejunum will be used for distal area, such as around the wrist or around your popliteal fossa, like a little bit distal to popliteal fossa where patients have a lot of edema in the ebola area, which, because it has a smaller size. So in summary, a combined approach utilizing each imaging modalities during different perioperative stages is very critical and there are different kinds of imaging modalities available. So then you could use it during different phases of lymphedema care to effectively help your patients. And patients with advanced-stage lymphedema may warrant use of all of this imaging, ICG, MRI, and ultrasound to maximize the success of LVA. And a lot of patients are hesitant to go to a lymph node transfer sometimes because it does require hospitalization and flood monitoring. So some patients are more inclined to go to lymphovenous bypass first before committing to lymph node transfer. And this is a photo of our OSU lymphedema team. As you can see, it's a very multidisciplinary care which involves oncologic rehab, nutrition, intervention, radiology, vascular medicine, and then plastic surgery. And I think it's a key because it is a, it's a very multidisciplinary care and you can't really do this without, it takes a village to provide the care for the patient. So I think, you know, becoming familiar with, as we, you know, the talk of the session is that imaging, becoming familiar with using the imaging modalities and then also working with a physical therapist will be the key to maximizing and also, you know, the success of the surgery and then helping the patients. Thank you for listening and I'll take any questions and then if you have any questions, please email me on my email. All right, thank you. Good afternoon and welcome to the on-demand session, Multidisciplinary Care and Lymphedema. It's not just about the surgery. My name is Drew Singal. I'm a plastic surgeon, lymphatic surgeon at the Boston Lymphatic Center and it's really my honor to moderate this session with our three incredible panelists who need no introduction in the lymphatic surgery community or plastic surgery, but I'm going to go ahead and introduce them anyway. We have Dr. Carolyn de la Cruz from University of Pittsburgh, Dr. Mark Shavarian from MD Anderson and Dr. Minjung Cho from Ohio State. So welcome to our panelists and I just got to say before we start, wow, great talks. I actually love it when they ask me to moderate because it forces me to sit down and listen to the talks and I'm always agreeing. So thank you so much. I really enjoyed it and what we'd like to do here is just have about a 30-minute conversation. We'll have some questions from your talks and we'll go from there. So Mark, I want to start off with you. Really incredible work, not only at MD Anderson in terms of building your center of excellence, but also in terms of sharing with the rest of us how you did it, tips and tricks, and you went over some of that in your talk and then obviously laid out the entire program. A question for you is a question that a lot of the questions they ask originated from questions I get. And, you know, we're thinking about early lymphatic surgeons. We're thinking about starting programs. They're just starting. And they're looking to us to help provide some guidance. What's the hardest part in your opinion on the program, in building the program that you did so successfully at MD Anderson? So great question and thanks, Drew, for putting this together. The hardest part is probably the most important part and that's the physical therapy side of it. So, you know, often entering into historical practices that may be some distance from contemporary practices and also where they relate to surgery because there is a knowledge gulf between physical therapy and surgery that many of us are actively trying to bridge. And so the most important part was, you know, engaging the physical therapists and really having physical therapy as a linchpin of the service. I always say that physical therapy is 75% of the outcome, right, of surgery. And it is probably more important to have a robust, modern, comprehensive physical therapy service, perhaps, than it is to have a surgical service because many patients can be treated very adequately by physical therapy. And without physical therapy, we cannot do prehab or post-hab and our surgeries are only moderately effective. And so really, physical therapy has greatly expanded what we are able to achieve. And so the hardest part is getting physical therapy, you know, to the table in a very, you know, constructive, team-building way in order to fully engage, make them feel valued, really integrate them as part of the program. And, you know, as I say, physical therapy has a very central role in our department. We have physical therapy embedded in our clinic, specifically, so we have point-of-care, you know, lymphedema care delivery, which has been really revolutionized what we do. You know, I completely agree with you. And I actually heard that in the other talks, too, on how physical therapy kind of was the engine room of the program. You know, I think about it similarly in terms of the hardest part. I answered a little differently, but I think we're saying the same thing. For me, it's culture change, you know, getting people to think about lymphatics as a service line and so that we're not working as independent practitioners. Awesome. All right. Carolyn, again, awesome talk on the importance of therapy coming off the topic that, you know, Mark took that first question to. And I really loved your talk, really after the almost, I love the entire talk, but after like the 11-minute mark where you went surgery by surgery, and you said, look, this is what my therapists do for these patients. That was super educational for me. ICT guided MLT, really a unique modality we've started exploring a couple of years ago. We sent part of our team to the alert team with Louise Kohlmeyer to learn about how to do this. And it's a really cool way to bring physical therapy and surgery in the same room in the clinic space and come up with a plan for a patient. But I don't think many people know about ICT guided MLT. Can you talk a little bit about, can you go into greater depth about who do you do this on? You know, do you do this for rehab, like before patients go to surgery, or is this an alternate to surgery? Talk me through how ICT guided MLT works in your program. Sure. Thank you. And thanks for, you know, the title, the concept of this panel, which is it's not just about surgery, which I think really just speaks to your own understanding of the process. And really like your integrity, because a lot of people may just say that this could be cured surgically. So congratulations on that. And also congratulations for making it 11 minutes into my talk. Anyway. So, yeah, so I would like to say that, you know, some people don't even know what MLT is. Some people don't even know what MLT stands for. Just, you know, zooming out, people don't even really know what CDT stands for actually, which is partly why, you know, on a broader stroke, I myself became, you know, certified lymphedema therapist so I could understand it. And I think that because just to understand the role, like Mark was saying, I completely agree with that, obviously. And then also just to communicate and understand the disease. So drilling down to just MLD and what the role is in my practice at using ICG for it, I think, number one, there are a lot of, so if you think about the history of manual lymphatic drainage, when and how it was devised, it was created by therapists, right? And they were actually working off these patterns of flow. They were working historically and a lot of these were clinical, clinical people working in the, like the front lines, taking care of patients, moving fluid from one spot to another. A lot of the surgeries were probably lumpectomy at that time, to be honest with you. They weren't all mastectomies. Maybe, I don't know what the degree of radiation was, but, you know, this was a device very, like 50 years ago in like the, or whatever, in the late, a while back. Enough time has passed that we know a lot more. And now with the use of ICG, we actually can understand what these pathways are. And so rather than assuming that anastomosis are open across lymphosomes, we can actually see them. Rather than understanding that the axial inguinal pathway may be open, we can visualize it. And now we can target a therapy that is otherwise being done blindly. And so for patients, you know, they complain of, I have swelling in my back, you know, instead of saying, oh, yeah, yeah, yeah. You can say, let's look at your ICG. And furthermore, as you do, as I'm sure, you know, well, this is a real benefit to doing it in the office, right? You can show the patient, look, this fluid that's, if you're doing, say, the breast, this fluid is stuck here, it's stuck here. And then you can communicate effectively, and you have a way to apply a therapy that is going to be effective and targeted, and not just based upon guesswork. So I'll take, I show it, you know, we do it in the office, I'll show the patient, we have pictures, and then we'll communicate to the therapist, this pathway is open, this pathway is not. And also we're understanding, obviously, it could apply for the lower extremity, and it can apply for, it can apply to any specialty, which may have, you know, urology, we're doing it with melanoma. So it's applicable in every circumstance. In your presentation, I think the case you showed was a breast lymphedema, I believe. Sure, sure. That's traditionally how we use it as well, because that, I've done a lymph node transplant to the breast, I've done all the bypasses to the breast, but to be honest, I don't have that much to offer for breast lymphedema. So that's an avenue where I've found ICG-guided MLD to be something useful. Are there other uses? You're mentioning extremity, are you using, are you prescribing ICG-guided MLD for upper or lower extremity as well? Right. So, you know, any, you know, there's a lot, it's amazing, right? Because just the more you sort of understand, the more you, and the therapists are great because they may come in and say, I have a patient with genital lymphedema, right? Scrotal lymphedema. I've had a lot of, now, referrals from urology, from prostate cancer, and now they get, they have pathways that are poorly understood. And so now we're sort of rolling that out as well. We did a case yesterday where, you know, patient had a previous Charles procedure and we were understanding what, you know, what was going where for the therapist, which is very challenging in terms of wrapping and scar tissue. Because, so to answer your question, it can be applied in a wide variety of areas. I don't think it is currently being done, like mainstay, you know, but I think that there is a role for it. And in order to provide more effective MLD as well, because a lot of people may not believe that MLD actually works. And now we know that it's not going to work if you're going to drainage patterns that aren't open. If you're going in directions that are actually, sometimes we see it's going in the opposite direction to get where it needs to go. So I agree. It will work effectively, more effectively, and people may then use it more often. So. Beautiful. And it's really cool to see this string occurring where, you know, Mark talks about centers of excellence. He talks about physical therapy being the workhorse. Carolyn, your talk was on physical therapy and surgery, and you're linking in that imaging, and that is a great lead-in to Min-Jung and her talk, where Min-Jung, you did awesome. It was really clear, thoughtful, lymphatic imaging kind of laying the landscape. And it's true, right? As surgeons, if we can't see it, we can't address it. Like, if we can't draw it, you probably can't do it. So very nice talk. Portion for you, and this is a question I get, not this exact question, but some flavor of this question. It's true, if I'm starting a lymphatic surgery program, what do I need? From an imaging standpoint, Min-Jung, what do you think a new lymphatic surgeon who's going to the hospital, who's fresh, who's, you know, they have to now go up and fight for something. They only had to fight for one or two or three things. What are they fighting for? And what maybe is already on premise that they can repurpose to assist them in lymphatic imaging? Well, thank you so much for your question, and thank you, Drew, for moderating this important panel. And, I mean, Carolyn described what it is, your answer, so your question is essentially ICG lymphangiography. It helps with your diagnosis and also kind of help patients understand, like you said, you know, there are areas with the backflow or areas that we are having swelling, and it actually helps patients understand why you're offering the treatment that you're offering, why this kind of surgery will benefit you better. And then also, it helps with the manual lymphatic drainage as well, where patients could see it themselves. And I'm more of a fan of operator-dependent imaging techniques, which is ICG lymphangiography. MR lymphangiography, lymphocentrography is done in a radiology suit, so then, you know, you kind of have to wait for it, and it's, you know, you're dependent on the radiologist's schedule or, you know, or the insurance approval. So, ICG, we, in our clinic, heavily, similarly, we're with physical therapists in the same floor, and then we're connected. And then also, we do ICG in office with patients, so then we could show it to the patient, this is, these are the areas that are blocked, or these are the areas that we need improvement, or the treatment. And then also, it is actually very relatively, we discussed it before, relatively common technology in a lot of hospitals, like Carolyn mentioned, urology, gynecology, they use it all the time. And it's funny that we're discussing it now, because there's actually a shortage of that dye around the nation right now, and then everyone's like, that they thought it was just us using it, and they're like, funny, they're like, I need it, you need it, esophagectomy, you know, like hysterectomy, all that. So, it's very readily available technology. So then, whenever you're requesting for it, it's guaranteed that hospital has some kind of technology that uses ICG. The question becomes whether it is good for the lymphedema surgery. I think there are various, various different kinds, which I showed on the PowerPoint that you could use. And a lot of, without saying the company name is, I don't know, there are certain kind of machines that a lot of hospitals use, I think they do become frequent with it during residency and fellowship. So it's not so much of learning curve that you have used it before. But ever since I have come to Ohio, so there are different kinds of ICG that I use for the lymphedema case, and then they do vary. So sometimes I think some hospitals do have different types of machines available. But I think if I were to pick one for starting lymphatic surgery, it would be ICG. Fantastic. And, you know, there are probably other modalities that are already on site, for example, the MRI. But I agree, ICG is the workhorse. I'm going to give you a follow-up question on that one. Because you said something, you'd rather have it in the surgeon's hands than the radiologist's hands. Right. And I wonder if there's a middle ground here. Let me tell you why. Because when I started, you know, I was doing all the ICGs myself. And I was staying here late at night. And I don't think it's humanly possible to have a high volume center with a lymphatic surgeon doing all of it. And so the way we've gone around that is I now have a dedicated nurse practitioner who's really taking this on. She's getting a doctorate. She's taking on breast lymphedema. And so identifying somebody in your team who can really almost act as your surrogate. They're part of the surgical team, but they're almost your surrogate. Have you gone a similar way? Or how do you get around that time suck that a lot of these studies do? Right. I completely agree with you. So in our practice, we have a lymphedema PA. We have one, but we're going to get to essentially, like you said, we'll do the ICG. And then most of the time, they do put the ICG lymphangiography on the days that the surgeons who do lymphatic surgery is available. So then like Tuesdays and in the Mondays, whatever. And then they will do the imaging and then they will quickly call you to the room and like, is there any other options? Or most of the time, they will, you know, just go over the options based on the imaging finding. But if it's like a repeat, or a complicated patient, then it's really easy to hop on with imaging. And what we started to do is that they take photos of the lymphatic mapping. So then you could refer to that because it is the downside of the operator dependent imaging is that what your lymphedema, you know, person who have gotten it might not you might not necessarily get it on the day of surgery. So it is helpful that they take photos. And then you also it helps with the discussion that my patient when they show up and then going for bypass lymph node transfer, I'm like I before even opening the imaging with them, I'll be like, where are you having most, you know, pressure or like a tightness or swelling. And then I confirm with them, okay, it is the same size that that was found on ICG lymphangiography. But then if it's not, then the then the discussion becomes more like, what will we do? But it has been really helpful. I completely agree because it's impossible to ICG lymphangiography perform that on every patient that you see. Carolyn, Mark, you guys as well, how do you, do you perform your own ICGs? Or how do you get around this? Is it it takes a long time? I can have a stab at that. So I we don't image every patient that comes to us in clinic. We image every patient that goes to the OR. We will image if as Caroline has gone into, you know, great depths into if we need to elucidate, you know, pathways for patients, you know, that are challenging for MLD. But really, we're using it to make specific surgical decisions. And so for me, I need to be there to see the imaging, because sometimes it can be very subtle, you know, such as, you know, you know, are these pathways that are visualized to be obstructed? Are they in an anatomical area that I can get to ergonomically to bypass, right? That's going to be a very important question. And then choosing between, you know, bypasses and lymph node transplant, that is a something that comes with a lot of experience. And, you know, you can look at static images, you can look at video feeds. But you know, I really want to be there, I want to be there from the immediate time the injection is put in, you know, to sometime afterwards, I really want to see what evolves. And that helps me to make decisions on function. And again, there's all the nuances of, you know, as you do more and more of these cases, you know, you start to correlate what you're seeing with outcomes. I completely agree with Ming Zhang, I find that what I see on ICG, on the majority of patients is what I can find, what corresponds to, you know, detailed clinical examination. So it's often to make surgical decision-making for me. I find that patients can, you know, if the diagnosis is lymphedema, they can very accurately localize where the problems are. They correspond very closely to lymphatic imaging. And so, like I said, it, for me, although every patient gets imaged at some point, typically in the OR, I'm using it for decision-making between the different surgical modalities or if a patient is even, you know, a surgical candidate. So, you know, particularly those that present with, you know, have symptoms. And so I'm actually ruling out lymphedema as the diagnosis. A patient can get great relief from knowing that their problem isn't lymphedema, but then obviously that starts a whole new pathway of what is it, right? So. Yeah, we've all been there. All right, cool. Oh, can I make a comment? Yeah, go. Yeah, so I transitioned from doing it in the OR, which obviously is a waste of OR time. And I would pair it with procedures, you know, and obviously other procedures, you know, sort of for screening purposes, et cetera. But I transitioned to doing in my office. I will say, so I can see both sides of the coin. Like Mark commented, there are nuances and a little splash, you know, that you might have had a target of a leaking lymphatic will be gone, you know, in 20 minutes and it'll be full dermal backflow. So there are opportunities for like an intervention that somebody might be a candidate that'll be gone, you know, without someone, you know, carefully doing that, which does take more time, perhaps even, you know, injection, you know, points with visualization. So it's a longer process than just the injections and then just looking. I also will say that the patients that had lymphocentogram before used to complain, they would say, I mean, these are people, tough survivor warrior people that are like, you know, went through, you know, hours of surgery and pain. And then they say, the most, you guys know what I'm gonna say, the most painful thing was that radiologist that stuck me. And now, and that's like the worst person ever because, you know, you're lucky to get, you know, you say like, this is gonna be, you know, whatever, six injections. Sometimes you can only get, you know, two or three in because they want to stop. So it is more painful. It does take more time. There are some, some probably nuances that were missing, but I would love if I had someone just doing it. So I'll tell you a little trick for the pain on the ICGs that I found and Takumi Yamamoto taught me this when I went to visit him, it's D5W. Putting D5 into the mix really cuts down the pain significantly. And I've actually had my nurse practitioner inject me with it before and after. And it's a night and day difference. Really? All right. Send me your recipe. Thanks. The panel, the 30 minutes is worth just that for me. That's right. That's what I do too. I listen to his talk and he gives you different, he makes sure that you have use and that D5 is the one that works. Yeah. Yeah, I completely agree. All right. Let me ask another question that I often get asked. And you know, this is about like getting these programs started and the different aspects of it, whether it's therapy, imaging, or whatever you need for a comprehensive center is, you know, you need resources, right? You need to go to the hospital and say, look, I need, I need these things. And, and then the hospital often says, well, you're doing a surgery that most insurances deem investigational. What's the strategy that you have all used to make successful programs such as you have and that young lymphatic surgeons or new to the practice can, you know, learn from? And I'll just randomly start. And Jung, you, you, if you don't mind, oh, I'm sorry. Yeah. If you don't mind starting. I think it's really challenging. Like you said, a lot of times it's lymphedema, even like insurance companies will be like, this is experimental. And then you have a patient literally sitting in your office. It's like after the bypass, like I used to not able to climb up the stairs. Now I could climb up the stairs. One of my patients would be like, I walk and I do marathon. And it's completely night and day. And it's really challenging to fight for those patients. And then for me, I do work at the cancer center. So then it's just not the patients who, you know, are like referred to you as these patients themselves that get, nowadays they're actually all the cancer therapy are going into more like kind of non-surgical like radiation, especially axilla. You know, there's some studies that's like, don't even go for axilla lymphoid dissection, just go for radiation. Then you are seeing more patients with increased survival that are showing with now this is not just lymphedema, one-time thing is actually they live longer and the long-term commitment. And then, so that's what we try to advocate for the patients that a lot of patients who are gynecological, they, now their patients are, they're more increased patients with this problem. Like, it's just not like, oh, just one specific population who are born with it. And then it's just that the thing about cancer treatment is that I see tons of patients just being referred. So that's why I try to advocate to the hospital that, look, you're doing all this treatment and all this radiation and then, you know, treatments and these are the patients that we're seeing because of them. So then we try to incorporate as a part of a cancer care, like a survivorship more so, not like a different problem. This is a continuation of a cancer care. Yeah, I have thoughts on that, but I want to give everyone a chance to share their secret recipe. Mark? Yeah, so it's, it's obviously that, you know, our perspective as surgeons and lymphoedema surgeons is that, you know, we're looking at this from a perspective specifically from surgery, right? But I view lymphoedema care as being, you know, a comprehensive package of treatment. So the surgery is one part of that. We spoke about the physical therapy. You know, there are many other components to this, the integrative medicine, the physical medicine and rehabilitation, you know, the long going chronic, you know, physical therapy needs, management of other comorbidities, and many patients will actually choose to move all of their cancer care to the institution that's offering, you know, these packages. And so whilst, yes, we have the same challenges as everybody else, that sometimes these surgeries, you know, don't get approved, the way that we see this as the surgery is just one part of this, you know, very robust package of care that we offer. And so, you know, by doing that, if we don't get a patient into surgery, you know, for example, or it's delayed, at least we are offering active treatment, you know, multimodality active treatment to improve the quality of life of the patient. So, you know, whilst, you know, we obviously endeavor to try and get the patients to surgery who are suitable candidates, you know, I feel we can offer something to everybody, you know, even those that we ultimately cannot get to surgery. So, you know, so I think we're getting consensus. Okay, I'll see if you have anything to add, but I completely agree. I mean, this is the approach to get resources is exactly what you tell the hospital. First of all, this is good patient care. Okay, but second of all, along with these patients coming, seeking the surgery, there is a lot more going on in the center that is bringing in resources. And, you know, lymphatics needs to get some credit for that. I think that's a very, very strong argument. It's worked for me here. And it sounds like you both use a similar strategy. Carolyn, do you agree? Any other thoughts? Yeah, sure. I mean, I obviously agree with everyone and what they said. I will just add that there is an advantage to being in a major academic center because we, as academic plastic surgeons, have a commitment to innovation. Obviously, we have a commitment to taking complete comprehensive care of our patients. And so any, like was said before, any expansion of service lines, you know, will be sort of music to their ears, expanding care, innovation, bringing new ideas, right, to sort of lead the way in this area and breaking down the barriers. Like Ming-Jung said, it's just as straight up as saying, hey, look at these patients, right? Show them the patient, show them how that we can change their lives. Quality of care is what we do. And it's really that it's our responsibility and commitment to advocate for the patients and actually expand people's understanding of the disease because people can't even spell it, let alone say it, let alone give us millions of dollars to care for it. And so that's what we're doing, right? We pound the pavement. Every single meeting I go to, every conference I go to, every single opportunity I have in any meeting, I mention lymphedema. Like, you know, I could be on like a meeting for like, I mean, I don't even know, like anything. And I'm just like, oh, well, what about lymphedema? And they're like, this is like, you know, the cafeteria talking about wellness food. I'm like, yeah, but what about people that have lymphedema? And they're like, what? So understanding people's knowledge, understanding there's a role for it in academic surgery and providing the resources is our responsibility. Yeah, okay. So as I always find that time is flying, we're gonna have time for one more question. Then I do wanna give each of you a chance for any last comments you might have about, you know, it's not just about the surgery, but I'll ask one more question. We're gonna get a little bit in the weeds here, less about high-level programs, but maybe a little more about the surgery is, Carolyn, I saw in your talk, you talked about doing breast reconstruction with lymph node transplant and implicit in that. And in some of the, I think one or two slides that you showed, you're transplanting it into the axillary. I'm gonna bring up an age-old debate. I just wanna see where everyone is at in 2024, proximal versus distal transfers. Do you have a standard? Is it patient-specific? If it's patient-specific and you wanna go that route, I'm fine, but you gotta give me a little more. What is it that you're looking at that's gonna get you proximal or distal? Anybody wanna, whoever takes this first can get last on the last word. How about that? So anybody wanna take this? I don't want the last word. I don't definitely want the last. I think Mark is, we're gonna sign Mark up for the last word. I mean, I don't know, but I'll just say, I do mostly proximal. I'm not a distal girl, and most of what I'm doing would be probably related to breast, probably in conjunction with reconstruction, which works proximal for me. But I would love to, I love controversy, so I'd love to hear someone that's 100% distal. Well, let me just ask you why proximal. I'm 100% distal, so. But you tell me why proximal. Well, oftentimes, so in my practice, if I'm combining it, say, with a deep flap, it's just a little bit more convenient. And that's, in my experience, just what I have the bulk of experience in doing. But if you can convince me that there's better to go distal, I'm happy to hear it. If you can show me some evidence. You think I'm a moderator and I don't have to do that? No, I'm kidding, I'm kidding, I'm kidding. I will give you my thoughts in a second. Enjoy. Okay. I was like, I'm gonna go get my popcorn. So I have to, I'm actually, you know hate, you know when someone asks your mom or dad and they say both, and I'm gonna be that person? Because I actually hit the dual level this week. So this is actually a patient that had like X-ray tightening, and then they actually kind of talked about kind of breast, truncal lymphedema, and she had an infection in the axilla before. And then also she complained of a forearm swelling that I've done bypass before, and she hasn't improved. So I actually took her out for the distal and proximal. And for me, and then I think I would speak for our lymphedema practice as well, we actually do target it based on whether it's a more proximal or distal. And most of the time, I think majority of us do dual just because it might not be just proximal and distal. So I'm gonna be that bad person where they say, yes, I do love mom and dad. Fair enough. Mark. Yeah, this could be a whole panel of insight. I know, I know. Okay, so just to cut to the weeds, right? So we use the imaging, right? The ICG imaging to determine, you know, in concert with clinical examination and really duration of disease, right? And, you know, what patient has done so far to care for it and infections, right? Can give me a real pointer, particularly where the infection actually began can be pointers to where the disease actually is within the limb. But, you know, in essence, I regard the elbow as being a watershed. So patients with, you know, advanced ICG disease, you know, in the wrist and in the hand, you know, you're gonna be, it's few of those that are gonna be successfully managed by, you know, simple orthotopic transfer. And so, you know, we will look to do either dual level, you know, or distal transfer in those patients. Those patients that are, whether it's a longitudinal nature of the disease, early lymphedema begins as a proximal disease, proximal to the elbow. And so those patients are very well cared for by a proximal transfer. You know, these patients can derive an enormous benefit from that axillary scar release, you know, helping them with their range of motion and that, you know, painful tethering of the scar tissue. And that's why, you know, like Ming Zhong, I'm very much, I very much favor a dual level if I'm going distal. And I think what we're acknowledging is that, you know, there are multiple pathways affected in these more, you know, chronic situations. You know, we have, you know, the upper arm, you know, we have the volar forearm and the dorsal on the forearm, essentially are separate components. And that's been shown on, you know, Hiroswami's, you know, lymphangiosome studies. And so, you know, I think you have to, you know, acknowledge that with our techniques, we are able, you know, potentially to manage all of those. And we certainly, if we are doing proximal transfer on an early lymphedema, where there is, you know, some general vector in the forearm, we will do lymphvenous bypass at the same time to treat those focal areas. And that can be a very effective pathway of treatment for those early patients. But, you know, again, there are many, many nuances within that, just kind of a broad brush as to how I think about this. I love it. And I'll say I'm very similar to you in that you go to the imaging and we get MRI images on all of our patients. And let's just take the upper extremity, for example. I have never seen, after hundreds, not over a thousand of these, an upper extremity lymphedema, upper arm lymphedema, without lower arm lymphedema. I just haven't seen it. I have seen it in the lower extremity on rare occasions, but not on the upper. And, you know, Hong-Chi Chen was one of my mentors, and he always said, look, ask the patients where it's the worst. And almost universally, they'll grab their forearm. And so for me, that's my rationale for going this door, because if we think the lymph node transplants the sump pump with the sump pump where the flood is, the flood is this. Now, if you think it's a bridge, but it rocks, as has been mentioned. So again, I think this is an ongoing controversy, and it'll be fun to see where this goes in the coming years. All right, so we are over time, but that said, I do want to give everyone a last word. So Carolyn, you voted Mark to do the last, last word. So I'm going to vote you to do the first word, and then we'll go Min-Jung, then we'll go Mark, and we'll close it up. Yeah, I mean, I just, it's so good to see everyone on the panel. It's so good to hear everyone's practices, and I learned a lot. So I had a great time. And I think that, you know, it's interesting to see what will happen to the future of lymphatic surgery. Hopefully we'll have some of these questions answered, but I'm sure if we redo this panel in five years, we'll probably have some more questions. So, you know, it's only beginning. This is just the beginning. And I'm happy to be a part of it. I echo you, and it's really, thank you very much for having organized this panel. And I think it's like the fact that there are controversies and there are like different areas, that's why there's an area for innovation and also research as well that, and I think the theme is like the multidisciplinary, how it is, and that it is, it takes a village to, you know, raise a baby. And I think of that for lymphedema patients, you know, surgeons, physical therapists, and nutritionists, you know, IR, everyone is involved. And then I think it's a great field that we're in a great time to discuss this. Beautiful, love it. Thank you. Yeah, and I think it's, you know, really kind of shows where we are in the specialty that, you know, ASPS has dedicated the entire panel, you know, to essentially the non-surgical management or the surgical augmentation. How far we've come from, you know, panels of just a few years ago that were very directed to the technical nuances of surgery. And like Carolyn, I'm very excited about the future. You know, lymphedema is a unique disease whereby, you know, surgery is still the mainstay. We don't have any pharmacological treatments and that stands us unique to other disease types. And so I think the, I'm fascinated to see what this panel can, five or 10 years time, but I think, you know, definitely the anti-fibrotics, anti-inflammatory medication to really sort of change the landscape of this disease and can't come soon enough. I couldn't agree more. And you see all the funding in that, that's now going into lymphatics, right? With the CDRMP, ARPA just announced another lymphatic program, so to light and glide. So I think the future is incredibly bright. I think my only thought, maybe additional to what everyone said, and everyone said it beautifully is, you know, it's not just about the surgery. And as a lymphatic surgeon going into this, implicit in that, and thankfully, I think we're all natural leaders. You have to be a leader in this. So when, if you go into this, you have to be a leader in your institution for lymphatics, whether you're meeting with dietitians about wellness in the cafeteria, you mentioned lymphedema, you really have to be a leader to do this and you will lead your team. And that will be the key to the success, will be the success of the team. So again, thanks, Mark, Minjung, Carolyn. Awesome talks, awesome discussion. I know all of us are looking forward to seeing everyone at the meeting. Thanks everyone. Thank you.

Lymphatic System

surgical intervention

Collaborative Care Models

non surgical

Chronic Condition Management

Lymphedema

Multidisciplinary care

Collaboration

Surgical interventions

Physical therapy

Diagnostic imaging

Patient education

Manual lymphatic drainage

Complete decongestive therapy

Imaging modalities

Interdisciplinary approach

Innovative techniques

Institutional leadership

Insurance companies