Dr. Russell Ashinoff, co-director of the Program for Lymphedema Surgery at The Institute for Advanced Reconstruction, is a double board certified plastic surgeon with expertise in reconstructive microsurgery, particularly for breast cancer reconstruction and traumatic injuries. He completed his medical degree at the SUNY Upstate Medical University in Syracuse, NY. He was chosen to continue his training in general surgery at the renowned New York University and Bellevue Hospital program in Manhattan. He completed his training with a fellowship in Plastic and Reconstructive Surgery at Emory University in Atlanta.
Lymphedema Procedure Shows Promise for Sufferers of the Condition
Dr. Lisa Schneider, co-director of the Program for Lymphedema Surgery at The Institute for Advanced Reconstruction, specializes in plastic surgery with an expertise in microsurgical reconstruction of all areas of the body, including innovative techniques in breast reconstruction. As an undergraduate, she attended Yale University, and completed her medical degree at Columbia University. While training at the Institute for Reconstructive Surgery at NYU, Dr. Schneider was one of an elite group chosen for a directed six year program that combined general and plastic surgery, the most selective residency category in the United States. Dr. Schneider is certified in plastic and reconstructive surgery by the American Board of Plastic Surgery.
Dr. Russell Ashinoff and Dr. Lisa Schneider of The Institute for Advanced Reconstruction are among the few physicians to offer a number of pioneering surgical treatments for lymphedema. These procedures, known as vascularized lymph node transfer (VLNTx) and lymphaticovenous anastomosis (LVA), have shown promise in treating lymphedema.
Q & A with Our Specialists
Q: Lymphedema can be a result of breast cancer surgery. As a breast surgeon, what have been your observations of lymphedema?
Lymphedema is something unexpected that can go on for years, even after the cancer has been treated and cured. It can be very debilitating for patients. They often feel uncomfortable and embarrassed. The compression garments, which apply pressure to the affected limb in order to keep the lymph fluid flowing in the proper direction, have to be worn full time, even in the summer. Adding insult to injury, wearing a compression garment on the arm (where lymphedema can occur following breast cancer surgery) presents further challenges than the leg. It’s like wearing a long pair of gloves to do all of your everyday tasks. It’s very difficult.
Q: What are the different types of lymphedema and which do you treat?
There are two types of lymphedema: primary lymphedema, the cause of which is largely unknown, but it relates to inherited problems with the lymph vessels; and secondary lymphedema, which is caused by procedures, such as surgery, that result in damage to the lymph nodes or lymph vessels.
Secondary lymphedema can occur in the arms when lymph nodes from the underarm, called axillary lymph nodes, are damaged or removed. Secondary lymphedema can also occur in the legs as a result of surgery for melanoma. This surgery may include removal or damage of lymph nodes in the groin, called inguinal lymph nodes.
We treat all kinds of lymphedema. In fact, it is only relatively recently that people have understood there are surgeries we can do that can help this disease.
Q: What types of surgery are offered at The Institute for Advanced Reconstruction?
To date, although there is no consensus on surgical procedures and protocol, refinements in microsurgical techniques and improved methods have led to the establishment of a standard surgical treatment for lymphedema.
Dr. Ashinoff and I work as a team, and we perform the surgeries together. We offer three types of procedures. The simplest is liposuction to reduce the weight and circumference of the affected limb. Liposuction can also be done in conjunction with the other procedures (discussed below) to further augment the results. However, with liposuction alone, people still have to wear the garment afterwards.
Lymphaticovenous Anastomosis (LVA) is a procedure done in order to improve the fluid drainage. In this procedure, the distal lymphatics are anastomosed or connected to small superficial veins, creating a “bypass” for the lymphatic fluid into the venous system.
The other procedure is free lymph node transfer, also known as Vascularized Lymph Node Transfer (ULVTx). In this procedure, lymph nodes from the groin or chest wall are isolated with their blood supply and microsurgically transferred to the arm or groin, where the lymph nodes are not functioning.
We do all of these procedures as needed. Sometimes, LVA and lymph node transfer can be done together. These two procedures can be combined with breast reconstruction surgery. Obviously, every patient is unique, so each person is individually assessed. We take each through a detailed evaluation to determine which procedure is best. The choice depends on a number of factors, including the patient’s medical history, his/her lymphatic anatomy and what makes sense for his/her life and lifestyle.
Q: What has been your general outcome for these surgeries?
I think the overall patient satisfaction speaks for itself. It is very high. These procedures have been done for at least 15 years. Now, there’s a better understanding of getting the surgeries more consistently successful.
Q: Often in your practice, you get the frustrated patients who have long heard the medical community tell them “just live with it” about various conditions. Why is it important not to take this as the only option with lymphedema?
No cure for lymphedema currently exists, so people can feel hopeless. It can be very moving for patients to realize there is something they can do about this problem once deemed unsolvable. This is revolutionary for them.
In addition, the financial impact of lymphedema is considerable. A recent study demonstrated significantly higher medical costs within a two-year period in patients with breast cancer-related lymphedema compared with patients who had breast cancer alone. These costs are likely underestimates given that these patients were only evaluated for two years, and lymphedema is typically a lifelong condition.
Q: Who makes a good candidate for this surgery, and how should a potential candidate go about being evaluated?
Someone has to be a good candidate for surgery in general. Significant medical problems would prevent lymphedema surgery. Otherwise, we carefully review patients on a case-by-case basis.
Essentially, our approach to the patient with lymphedema begins with a highly individualized analysis that combines advanced diagnostics with an array of treatment options. First, we typically spend up to an hour with the patient during this initial consultation taking a detailed history, performing a physical exam with limb circumference measurements and photographs. The choice for the particular surgical option depends on both the patient’s anatomy and his or her treatment goals. In terms of being evaluated, if someone lives outside the area, initially we can speak over the phone. Ideally, however, it is best for people to make an appointment so we can see them in person.
Q: What is in the future/on the horizon for lymphedema surgery?
Dr. Ashinoff and I are doing research to look into procedures to prevent lymphedema for patients who undergo cancer surgery.