by Stav Brown, BS1
1 Sackler School of Medicine at Tel Aviv University, Tel Aviv, Israel
Through interviews with leaders in the field, we present here the second piece in the series “Plastic Surgery Perspectives” dedicated to providing residents and medical students a perspective on future career options and possible fellowships within the field.
This piece includes contributions from Dr. Babak J. Mehrara
Why did you choose this specific field?
When I first started at Sloan Kettering, I actually didn’t know the scope of the problem, but after a few years in practice I saw how many of my patients came in with lymphedema and that is what brought me to choose this field.
How has this field changed since you started?
Tremendously. Understanding the pathophysiology of lymphedema has changed a lot and having a basic understanding of what the pathophysiology of the disease is can then help us develop rationale and targeted interventions that can be helpful. So, if you don’t know what’s causing a disease, it’s magical—you sort of come up with different solutions that may or may not work, but if you actually understand what’s the pathway that regulates that disease, then you understand how you can make an impact. It also opens up the possibility of looking at other fields that have a similar pathophysiology and translating that into our process. There has been a tremendous increase in the interest that people are showing in treatment of lymphedema and part of that is because we currently have a much better understanding of what that disease process is and that translates into better patient outcomes.
We now know that lymphedema is a disease that is on the spectrum of other fibroproliferative diseases, so if you wait until so much function has been lost then physiologic procedures may not work anymore. When we first started doing lymphedema surgery, we would offer it to patients who failed all their treatments and a result we would often select out patients who had a very advanced, late stage disease and didn’t get much benefit from these physiologic procedures. Mostly, since they didn’t have much lymphatic function for us to restore. As we learned more about the process, we started intervening earlier and earlier. In fact, in some patients we intervene at the time of the axillary lymph node dissection. That has been a major change in the surgical management—not reserving surgical treatment for end-stage disease but rather identifying patients in an early stage and intervening in that stage.
What are your main interests in your field?
I think the most important thing is combining surgical treatment with medical treatment to optimize surgical treatments. This is a common scenario that we do as surgeons—the best treatment for tumors is resection but an adjunct treatment is chemotherapy, and I think the same thing is going to happen with lymphedema. The clinical research that we do tries to identify the best surgical approaches that we have for restoring lymphatic function. The basic science that we do tries to identify the pathophysiology of lymphedema and develop pharmaceutical interventions that can help lymphatic functions regenerate lymphatic function better.
Tell us about a clinical case/aspect that has shaped the vision of the field for you.
We all have patients that teach us more than we do for them. I had one patient who came to me and was very severely affected by her early stage lymphedema. She had 5% difference in her arm volumes, and by any clinical measures her lymphedema was mild and fairly well controlled by her garments. However, she was very active—she was a ballerina and wanted to continue to do what she loved—so she pushed us for surgical intervention. That was one of the first cases where we did lymph node transplantation for a patient with a normal arm volume. She had a great result and ended up having no changes in her arm volume, her quality of life improved significantly and she stopped wearing her garments. That patient really helped me getting over the idea that we need to reserve lymph node transplantation for patients who have end-stage disease.
What role does technology play in your field of research?
The most important role of technology is to identify and quantify lymphatic function. Right now, the diagnosis of lymphedema is based purely on physical examination and there is no quantifiable measure of lymphatic function. That is problematic because if you look at any other organ system, we have very good and robust methods of quantifying function in patients. If you have a patient with heart failure and you know their ejection fraction, you know their blood pressure, you know their cardiac output and all those numbers are calculated and you can look at the effect of your treatments on those measures. We don’t have anything like that for lymphedema. I think that’s the biggest problem we have that we can’t solve. It’s just a matter of figuring out how to solve it best and non-invasively. All the standard measures we have today measure secondary effects. We need to be able to measure the ability of lymphatics to transport macro-molecules out of the limb and the ability of lymphatic vessels to transport immune cells out of the limb. There’s a good hope that ICG would be able to do that in the future or other fluorescent agents that can be used to identify lymphatic vessels.
What most excites you when you anticipate the future of the field?
The convergence of medical and surgical treatment is an exciting field. We can definitely improve our surgical outcomes by improving lymphangiogenesis and lymphatic function. Another area that’s exciting is getting people interested in the lymphatic system and getting people from other fields to help us solve some of these problems like measuring lymphatic function. As we do more of these basic science research projects, different areas such as radiology, vascular surgery and pharmaceutical companies are becoming more interested. Plastic surgeons have always been the innovators in this field and I think we should continue that. As we learn more about the disease process, standardize the procedures and figure out the best ways to do the surgeries that knowledge can be distributed more evenly. For example, 25 years ago, back when I was a resident, a free TRAM or a muscle sparing TRAM flap was a big operation. Nowadays, doing a DIEP flap is the standard and a technique that’s available to every plastic surgery resident. I see that in the future for lymphatic surgery, we’re probably a decade away.
For a resident interest in incorporating basic science into their clinical career, what advice do you have?
I think we need to remember that surgeons are not just technicians, but we’re also scientists. Every surgical resident has to have a basic understanding of a study design, a basic understanding of how to interpret study results, how to identify weaknesses and strengths of a study, how to be smart about new things and developments. A common scenario in plastic surgery and other fields is that we tend to jump on bandwagons, not really do the necessary work to make sure that what we’re doing is efficacious or safe. Does everyone need to do basic science research? No. But everyone needs to be able to understand and interpret basic science research findings? Absolutely. And more importantly, people need to be able to understand and interpret clinical findings. Residents interested in incorporating basic science into their career need to take dedicated time to do research. Surgical training requires hands-on experience and learning how to do research also requires teaching. If you’re interested in an academic career it’s no longer enough, in my opinion, to simply do a residency and then a fellowship. I think you need to do additional training in research design since we don’t have it innately in us and you need to learn these skills. As for timing, there’s definitely an argument to be made that earlier in your career is better since it allows you to interpret things as you get more surgically mature and there’s also an argument to do it later in your career when you’ve had the surgical training to be able to understand the clinical problem more accurately. The timing of it is less important for me. Be curious, resilient, innately motivated to do things and capable of coming up with your own questions.