Chapters Transcript Video Rebuilding, Beautifully: Microsurgical Innovations and Robotics Changing Breast Reconstruction Typically after cancer surgeries, even like in breast reconstruction or breast cancer surgeries, the lymph nodes are removed, sometimes just one, but sometimes all of them are removed from one particular part of the body, like the armpit, and this can lead to lymphedema, where the arm swells up severely, and it can be very debilitating. So one of the procedures we do at UCI Health is to connect those lymph vessels to a vein. It's called a lymphatic venous bypass. It's a lymph to vein connection, and these lymphatic vessels, by the way, are extremely small, sometimes less than 0.5 millimeter in diameter. Hi, I'm Lindsay Carrillo, director of business development at UCI Health. Hi, my name is Sunil Verma. I'm the associate Chief Medical Officer for ambulatory and an otolaryngologist here at UCI Health. Welcome to Physician Huddle by UCI Health. So today, uh, we're really honored to be joined by Dr. Gordon Lee, professor and chief of breast reconstructive surgery here at UCI Health. Welcome, Dr. Lee. Thank you. Dr. Lee, tell us a little bit about your clinical role at UCI. I'm a, as I said, a professor in chief of breast reconstruction here at UCI. Um, I'm part of the department of plastic surgery. We do the full range of reconstructive, uh, plastic and aesthetic surgery uh for our patients at UCI. A lot of what I do centers around breast cancer and breast cancer care. So, you just recently joined us, um, I think within the last year or so, but you have a breadth of experience. Maybe tell us a little bit about your former life and what brought you here to UCI. I've been here now since March of last year, so just about 1 year and 1 month. Uh, prior to this, I was at Stanford University up in Northern California and a professor of plastic surgery for 18 years. I practiced mostly breast cancer reconstruction, as well as the full range of cancer reconstruction procedures for the head and neck, for the extremity, for the body. Um, I even did things around the esophagus, not a very common procedure, but again, I, uh, tried to embody the full range of cancer reconstructions, uh, both outside the body and inside the body. So I did that for 18 years and just moved down to Southern California recently. Um, I'm from Southern California originally, born and raised in Santa Monica. Um, and so I was happy to get back closer to home, closer to my family, and of course, uh, be part of the growing healthcare system for UCI Health as it expanded to its new cancer center last year, the new hospital opening up end of this year, and of course, the acquisition of 4 hospitals. So, the growing healthcare system and the opportunity to be part of that was really, really very exciting for me. So tell us a little bit about, you know, um, let's talk about breast cancer, um, and where plastic surgery, what that means, what the involvement is, and how you team up because you're not the person that's removing the cancer, right? You're the one that's doing the reconstruction after. So what does that mean for a patient? Yes, that's correct. Breast cancer is, as you may know, is unfortunately fairly common in the United States. Approximately 1 out of every 8 women will develop breast cancer in their lifetime. So that's a, that's a pretty high number. Breast cancer care is really best approached as a multidisciplinary care. There is obviously a surgeon who removes the tumor, typically a breast surgical oncologist, and we're lucky to have 4 outstanding ones here at UCI. Um, it also involves sometimes a medical oncologist for chemotherapy, which sometimes is used to treat the breast cancers, radiation therapy, um, social workers, internal medicine, a whole host of, of, of providers, and in addition to that, plastic surgeons. We think most commonly, I think, uh, or many people do, about plastic surgeons doing cosmetic procedures, uh, Botox, liposuction, the stuff you see on TV. But uh it's also known that plastic surgeons do reconstructive surgeries, and so breast cancer reconstruction is a very common thing that we perform here at UCI Health, and this is where we are able to help restore the natural shape and size of a breast, uh, despite having a cancer removed from it. We were talking about some of the innovations that you're seeing in that field, um, some new options for patients that maybe weren't around 10 years ago. What can you tell us about that? So, breast cancer reconstruction has probably been going on for the last 50, 60 years. Um, as many of you know, breast implants are pretty, pretty well known, very popular, the silicone gel implants, the saline implants. And we've been doing that since the 1960s when they were first invented. Since that time, there have been some innovations made in breast cancer reconstruction. Um, there have been newer types of implants that are being made, uh, different kinds of shapes, different kinds of sizes, different kinds of materials. Uh, but also in using One's natural tissues. So, less commonly performed is the use of taking someone's own natural tissues and making it into a breast. And probably the most common source of that is the abdominal tissue. Many young women sometimes will have extra tissue in their tummy. Sometimes this happens with obesity or with pregnancies or what have you, but there's extra tissue there, and plastic surgeons will oftentimes remove that tissue as part of a cosmetic procedure we call a tummy tuck. That tissue is oftentimes removed and then discarded, but there is an option to take that same tissue, but rather than discard it, use it for breast reconstruction, it's almost like a 2 for 1, so the patient gets a tummy tuck and a breast reconstruction. The procedure is a little more complicated because we don't just take the tissue out and and stitch it in place. We have to connect the blood vessels together, the artery in the vein, to be able to restore normal circulation to the tissues. This is where we use a microscope. So the procedure is actually a microsurgical procedure where an operating microscope is used to connect the artery in the vein. So it takes a little bit longer than a tummy tuck, but again, it's for the patients. It gives them a nice result, natural, no need for implants, and a tummy tuck. Now that procedure has been going on for a number of years, but I think in terms of Orange County, uh, you know, for, for myself, I do a lot of these procedures, particularly where we save all of the muscles, because, uh, it's not uncommon that a surgeon will cut. The muscles from the abdomen, the rectus abdominus muscles, as part of the procedure. But here at UCI Health, we save all the muscles, which is better for the patients, saves their strength. And so this procedure has a particular name called the deep inferior epigastric perforator flap, or DIEP. And although it's not a new procedure, uh, coming to UCI Health, I think this is a, a nice technique that we bring here and that we do fairly commonly now. So, I mean, I can imagine, and for a patient. It's, I can only imagine, it's only one thing to be diagnosed with cancer, um, but then the surgery itself can be rather disfiguring. And so I, I imagine when you're connecting with patients, half of their mind is in, let's remove this cancer successfully, but I'm sure half is also in, what am I gonna look like afterwards? Like this is so different than other surgeries. So how do you connect with patients and how do you reflect upon that? Absolutely. One thing about breast reconstruction is it's not necessarily a vital organ per se. It's not not not a liver or heart or lung or something like that, but it's about restoring the natural form and shape of a breast, which is so important for many patients, not all patients, but many patients who want to maintain normal shape and symmetry of their breasts. Uh, which is, uh, again, for, for to mean people associated with their own self-image, uh, self-esteem, and general psychology. So, I think it's really important as a plastic surgeon to connect with their patients and really understand, you know, what their goals are. And we also have to kind of understand that a, the breast reconstruction is not a cosmetic procedure, you know, it's not meant to enhance. The breast per se, it's meant to restore normal form and size. And what I tell patients is, is that if you didn't have reconstruction, you would have, after mastectomy, a, a flat chest and a very large scar, and you'd be very asymmetric. With breast reconstruction, we can restore the normal shape and size of a breast so that it matches the other side. Um, but you won't have the same sensation to the breasts because you've had a mastectomy, and you may also require other treatment like chemo and radiation, which can also add scars and pain to the procedure. So it's important to have patients understand what the goals of reconstruction are, which are different than cosmetic surgery, and I think it's just having that mutual understanding. So, talking to patients, you really have to spend time talking to them, understanding their motivations, and helping them understand what you can do to help them. You also do a lot beyond breast reconstruction. What are some of the more complex, complicated procedures that you're able to provide to patients and that you personally have brought to UCI that weren't being done before? So, while breast reconstruction is one of the more common things that we do because that's just the nature of, of the patients that come to our practice, you're right, there's a whole host of other cancer-related procedures that we do and trauma-related procedures that we do. Um, as a microsurgeon and plastic surgeon, uh, my specialty is connecting small little blood vessels, nerves, and even lymphatics. So, one of the things that we offer here at UCI is, again, the full range of cancer reconstruction from head to toe. This includes not just the breasts, but things around the face, around the body, the arms, the legs, etc. And there's another procedure that I alluded to, which is the lymphatic surgery. So, the lymph surgery or the lymph nodes and the lymphatics that we do, uh, they are lymph all throughout our bodies. And lymph trend tends to drain. Basically, I, I try to tell patients, you know, drains the lymph fluid or the water from our body. It's not blood, it's not an artery, it's not a vein, it's a lymph. And without our lymphatic system, we would have a lot of swelling in our bodies. And so typically after cancer surgeries, even like in breast reconstruction or breast cancer surgeries, the lymph nodes are removed, sometimes just one, but sometimes all of them are removed from one particular part of the body, like the armpit, and this can lead to lymphedema, where the arm swells up severely, and it can be very debilitating. So one of the procedures we do at UCI Health is to connect those lymph vessels to a vein. It's called a lymphatico venous bypass. It's a lymph to vein connection, and these lymphatic vessels, by the way, are extremely small, sometimes less than 0.5 millimeter in diameter, in diameter, less than 0.5 millimeter. And not to mention they're difficult to manipulate. I mean, I know from head and neck surgery, you know, when you identify a lymphatic vessel, you pick it up and before you know it, it's almost in pieces. Pretty much, pretty much. It's, it's, it's really, really small and to the naked eye, it's invisible. So how do you, I mean, how do you identify these, you know, these lymphatic channels in the armpit or the head and neck? Um, what are the techniques that you're using? It is not easy. But we do some lymphatic mapping. We do things with endocyanine green, which we can inject peripherally. The. The picks it up, the lymph, the lymph system picks it up, and you can actually shine a very special light, a fluorescent, uh, angiography type of device that can show you how it transverses through the skin and the tissues. So, it's like seeing a road map, uh, probably a little more, uh, less organized than the roadmap of the freeways in, in Southern California, but you have these rivers and tributaries of lymphatic vessels that then uh join up near the armpit or the groin or the neck, and you Find these lymphatic vessels and you connect them to a neighboring vein. Uh, and again, as we said, they're very, very small, but that's how we do it. We do it with lymphatic mapping. Now, is this best done real time at the time of excision, or is this one of those things that if somebody's had surgery in the past and they're realizing that they are unfortunately suffering from lymphedema, that they can be addressed later on? Yes, both. So we do it both at the time when the tumor's being removed, but we also care for patients who have established lymphedema who are in need of this procedure. And what is the recovery from something like that? Surprisingly, these are outpatient procedures. Patients go home the same day. Uh, the connections are very, very small. We do this again in the operating room under anesthesia with a microscope. The procedure can take from anywhere from 1 to 2 or 3 hours, depending on the nature of what you're doing. Uh, but patients will go home the same day. Here at UCI Health, we have a really great anesthesia team. And so a lot of times we provide our patients different kinds of nerve blocks, which allow them to go home a lot earlier. When is this indicated? Would it be great for every patient to go through this, or what are the benefits to the patients? Well, of course, patients have to be evaluated in the clinic by a specialist who's who, who knows a lot about lymphedema. Uh there are different treatments for lymphedema. Uh, I mentioned the, the lymphatic venous anastomosis or bypass as one option. There are others, uh, believe it or not, you can actually do liposuction. For patients who have a so-called grade 4, or very severe lymphedema, or a bypass is just not suitable, we'll actually do liposuction to literally suck out the swollen tissue. And another procedure that we do is a lymph node transfer. So if a patient has lymph nodes removed, we can actually transfer healthy lymph nodes from another part of the body, again, using microvascular techniques, and transfer that to another part of the body to again try to restore that lymphatic connection and drainage. I think it's so important because it's something that patients don't often, I mean, you can discuss with a patient, hey, this could be a risk of having, you know, this cancer surgery, but it's hard to understand what that would mean and frankly would never drive a patient away from surgery, uh, but it can become rather debilitating and, and for so many years, this has been something we've said, you know, you have to wear neoprene gauze or you have to massage it out, and that's kind of the end of the story. And so for patients that have been suffering from this, this is really life changing for them, and it's, it's wonderful to hear that this is something that frankly is As minimally as minimally invasive as it can get, especially in the outpatient arena. Yeah, it's really great. Lymphedema is really, really a bad problem, and so now it's trying to find something to help patients is just so important. It's been hard because the technique is relatively new in the last 1520 years or so. So we do sometimes run into issues with insurance coverage and other kinds of barriers, but we, we do think it's a very important procedure to be able to offer our patients. Is it widespreadly, I mean, is it widely known that this is available? Do other physicians know about this, or is it more like you said, Dr. Verma, like, I don't know, just massage it out? No, it's not very well known at all. I, I just learned about it at an academic meeting last year, and my eyes sort of popped open looking at a patient before and after having had head and neck surgery plus radiation and seeing that reestablishing the lymphatic flow. I mean, I just thought of the dozens and frankly hundreds of patients we see in the office and how this could benefit them. So I didn't, I learned about it from an academic meeting and, and so I would imagine. A lot of patients don't know about or even frankly referring doctors as well. No, absolutely. The, the mainstay of lymphedema treatment has been pretty much conservative treatment, compression garments, uh, lymphatic massages. There are a variety of devices where you can actually put your leg or your arm into this device at night, and it literally pumps the fluid back into your body, and that's pretty pretty much, much it. But uh now with new techniques, new microscopes that can have super high powered magnification, uh magnet. Microscopes that can move it down to 50x, so 50 times magnification. Uh, this allows us to see those lymphatics, which are so hard to see. And then the sutures, there have been some advancements in the sutures we use because we really, we literally stitch it with needle and thread with our hands. And, uh, and, um, and having new instrumentation specifically for these really, really small little tiny vessels has been really helpful in the last several years. So, I know when I under operate under the microscope on the vocal folds. I know if I, I don't drink coffee on those mornings, so I can't imagine, you know, the amount of focus you have to have, especially with a 50X. I think mine goes to like 15 or 20, 20X. So I can't imagine the stable hands you must have need to have to accomplish these complex surgeries. Well, you're absolutely right, no coffee, no caffeine, no Celsius that morning. No SAA that morning. No, no, you know, Red Bulls or Jolt or anything like that. No, but I think that, uh, you know, uh, speaking about things that are new in plastic surgery, uh, one of the things that's coming out there is that robotic microsurgery, you know. And so, um, there are a variety of different companies that have developed robots. That will actually do the suturing. Now, the user, the physician still has to control the devices, but now there's no tremor. The robot takes that tremor out of your hands. It's very smooth, and um so it's being used now by certain centers in the US for what we're talking about doing, so. And certainly we're considering that possibility here at UCI Health. I think, you know, um, I, I've not necessarily used a robot before on a patient. I'm so used to doing it with my hands, but I can see how a robot can be very helpful. So, then you could drink your coffee and Red Bull the night before and then still beer it the next day with a robot. You might even use it in laryngology. It's in the future. Yeah, you know, we've talked about it in our field and it's, you know, when I was approached about this 15 years ago, the instruments just weren't small enough and, and the, the use case scenario wasn't quite there. But as it gets smaller and smaller and the devices can articulate better, you can take them down smaller channels and be able to, to apply it and take some of those, apply more consistency to those routine tasks that we perform in the operating room, uh, hopefully to create some improved outcomes. So we're talking about technology, robotic surgery, been a hot topic for a long time, and, you know, those continue to come out, get better. What other technologies are you seeing that are, you think are going to be the future coming on the horizon? Well, we're all talking about AI. And I have no doubt, I have no doubt that AI is going to be a much bigger part of our future. I mean, we're already using this now in our clinics, where you have a device on your phone that can listen to your office visits, you and the patient discussing things. But the AI just doesn't record and transcribe. It listens to your conversation. It takes out the, hey, how are you? How are the kids? How's the family? Nice weather today, and it basically distills it into a scientific, medical, legal document of a progress note that documents the conversation, the risks and benefits of the procedure, etc. So AI is already there. Um, AI is gonna look through all of our charts in the future. So, when I see a patient that comes from another hospital, rather than me sifting through thousands of pages of charting, AI is gonna do that for us, and just pull out what I need to know. Um, AI is gonna come to the operating room. So, when I do a surgery, I'm gonna put on some glasses, and we've actually experimented with this in the past, but, you know, glasses that can augment reality. So now I can be doing some surgery and the AI can say to me, whoa, whoa, whoa, that's a blood vessel, that's a nerve, that's a bone, don't cut that. And in the future, I mean, it sounds like science fiction, but in the future, there'll be robots and AIs doing part of the surgery, maybe even the entire surgery itself, to remove a gallbladder or something like that. I mean, that technology in some ways does exist, you know, if you can, if you can build a car, you know, with robots and manufacturers on the assembly line, at some point that technology translates to medicine. Still be a physician, I think, who needs to be there, you know, to make sure if anything goes wrong, someone's there to take care of it. But I do think that's gonna be the future. Is it gonna be in the next 5, 10 years? I don't know. Uh, I think it's gonna take a lot longer to go through a lot of safety, you know, evaluations before we trust a robot to do that completely, but we're getting there. I mean, we're already letting robots go on the road and drive by themselves. What's next? I'm thinking to the Uber ride I had last week to Dodger Stadium, and that was with a human, and it was terrible. Like this guy was, he was going illegally in side roads and going left and right, and I thought, man, if I just had had a waymo for that one, it would have been a lot safer. So there's definitely, uh, some, some benefits to having a robots, uh, assisting us. Yeah, maybe they can program it to ask you awkward conversations, make you feel really human, you know, exactly. Uh, so we're talking about trends in plastic surgery, and I think, yeah, as you mentioned before, a lot of people have this idea about plastic surgery that it's mostly cosmetic or, you know, mostly kind of that skin deep, and, you know, people always looking for that fountain of youth. What innovations do you actually think will be worthwhile and coming, you know, when we're talking about the aging trends and wanting to look youthful. What isn't beneficial, what isn't worth people's time, and what do you think actually is, you know, gonna improve? There have been so many devices over the last 2030 years, you know, if you asked me years ago, it was the newest lasers. What laser is gonna come out and make the wrinkles go away. Then it was into a radio frequency and other kinds of devices that tighten the skin and change the collagen. And then, you know, obviously there was Botox back in the 90s and, and fillers that began to make us look fuller, youthful. Uh, gosh, that continues to happen. There's still more new fillers coming out. There's still more toxins coming out, things that last longer, less painful. Um, there's still more lasers that are coming out, uh, microneedling. Other ways that we can kind of help the skin, uh, cool sculpting, if you're familiar with that technology to help suck the fat, but not, not liposuction, but simply a device that attaches to your body, and under certain thermal conditions, uh, basically melts the fat by cooling it. And with variable results, sometimes it works, sometimes it doesn't. And I think that's, that's, that's been that way in plastic surgery for so many years. There will continue to be new devices, um, that we will have to just try on patients to see if it works. Hopefully nothing that's gonna be, you know, permanently harmful, um, but all these devices do have potential side effects, and sometimes these devices and these treatments are costly, and patients have to go back again and again to see their, their doctor to do these things, but I mean, Golly Ge Willacers, if, you know, wouldn't we all want something that was like minimally invasive that we could put in our skin, a cream, a lotion, something that could keep us young again. I mean, I'd be the first one to sign up. So, for now, we have so many different devices, and I think we're still trying to figure out what is the best way to fight aging. So let's say like in the 90s or maybe 10 years ago, like what was the thing that everyone thought was going to be great and maybe hasn't really panned out and what do you think has actually proven to have some benefit and you see some improvements in, in what the patients want? Well, you know, back in the 90s there was collagen, just simple collagen, and it did, you know, it filled things around the face and wrinkles and things that made things look right, but it didn't last. And so, and there was Botox, which would paralyze your muscles and make wrinkles go away, but again, it, it lasted for a few months and went away. I think now we see Botox that lasts longer, different kinds of formulations of that, and we have fillers, hyaluronic acid, other variations that last longer, and believe me, they're still working on things that hopefully can be, can be permanent. Um, so Botox, uh, you know, again, I, I think fillers and, and toxins still are nice because people can kind of go in, get it done over lunchtime, and then go back out and see a result almost immediately. Um, but yeah, I don't know, I don't know what's gonna be for the future. I think there's someone out there who's developing a new laser, a new, a new Botox, a new filler. Well, it's been a, it's been a real pleasure to have you here. Tell, you know, as we conclude, um, reflect on, uh, what you, you know, you've been in the practice now for almost 20 years, um, maybe reflect a little bit upon Those that are younger in training or, or how, how you advise your residents and fellows, um, what's made you successful? You've been at a couple, you know, obviously very prominent institutions. What makes this place special and, and what advice do you give to people in terms of starting a practice and, uh, what drives you? Well, uh, I always tell the trainees, I says, there's got to be a better way. You know, the way we do things now, I mean, I can teach them what I think is the best way, but there's got to be a better way, and I learned that from my teachers too, uh, back when I was a resident. And so with when it comes to the to the residents now and the trainees, I tell them, you know, pay attention to the details, understand the principles of what we do, the techniques and the equipment will change in the future, you know, but how the body heals and all that has, has been pretty much the same and well established. So if you understand the principles, then you have the opportunity to innovate. You know, so I always tell trainees, you know, I don't train you to be as good as me, I train you to be better than me, and I don't want you to just do what I do now. If you're doing what I'm doing now, 2030 years from now, I'm gonna be, I wanna feel, I'm gonna feel like a failure. I want you to find a better way to do it, and uh that's the challenge to them. And we have a great group of, of young learners here at UCI who want to do better. And so I, I like that spirit of kind of just innovation. It uh follows my roots back from Silicon Valley up north, but uh if a resident or trainee comes to me and says, hey, Doctor Lee, what about doing it this way, you know, my first thought is, I think about it and I go, why not? You know, maybe there's a better way to do this, and I think that that's how we grow and we learn. So, I really like to instill that kind of uh inspiration to some of our younger, young folks. Thank you both so much for being with us today. Great conversation. This has been Physician Huddle by UCI Health. Thank you. This was an episode of the Physician Huddle podcast by UCI Health, produced by Brett Shahen, Angelica Yugubi, and Victor Ting. For more episodes, information on clinical trials at UCI Health, or to refer a patient, view the show notes or visit clinical connection. UCIhealth.org. Created by
