During The Breast of Everything podcast, Justin Riutta, MD, director of Breast Cancer Rehabilitation and Lymphedema for Beaumont Health in Royal Oak, Michigan, sets the record straight on lymphedema, dispelling the many myths and misinformation patients are hearing and reading. For example, here are a few facts:
Thanks to improvements in surgical and radiation therapy techniques over the past decade, the incidence of lymphedema has decreased significantly. In fact, recent data shows the chance of breast cancer patients getting lymphedema has decreased from 20 percent to 10 percent over the past decade.
To learn more about lymphedema and how to manage it, listen to The Breast of Everything podcast, hosted by Comprehensive Breast Surgeons Eric Brown, MD, FACS; and Linsey Gold, DO, FACS, FACOS.
Welcome to the breast of everything podcast your trusted resource for breast health information support and encouragement. Your host today are Dr. Eric Brown and Dr. Lindsay gold of comprehensive breast care. Welcome.
DR. ERIC BROWN 0:15
Welcome to the breast of everything Podcast. I'm Dr. Eric Brown of comprehensive breast care. I'm here today with my partner, Dr. Lindsay gold and we are both very excited and happy to introduce Dr. Justin Ryuta, who has served as Director of Breast Cancer Rehabilitation and lymphedema at Beaumont Health in Royal Oak, Michigan for the past 17 years. He is also the physician lead for physical medicine and rehabilitation at Beaumont Health. Dr. Ryuta obtained his medical degree from Wayne State University in Detroit, Michigan, and completed a Cancer Rehabilitation fellowship at the University of Pennsylvania. He is chair of the Cancer Rehabilitation subspecialty organization of the American Academy of physical medicine and rehabilitation, and an associate professor at Oakland University, William Beaumont School of Medicine in Rochester, Michigan. He has authored many articles and for years he has been our go to guy for lymphedema. Welcome Justin. Welcome. Thanks for having me. We're so lucky to have you. Thank you very much for taking the time to be with us today.
Dr. Linsey Gold 15:54
affect the incidence of breast edema meaning if you put an incision in the axillary fold for your sentinel node, and you put another incision in the you know, the lateral breast it seemed to me that
they developed breast edema more often I don't maybe that was not a good observation but I changed it because of that. Yeah, the lymphatic drainage from the breast you know, if you look at it's, it's like a, it's like a spiderweb over the breast but the dominant drainage is into the infraclavicular lymph node bed. So anything that constrains drainage up into that bed right under the clavicle, which could be a high surgical incision, could be any swelling or radiation that gets higher into that area can create a little bit more risk for for breast lymphedema and in the breast Lymphedema is a little bit unique. So I'd mentioned before that sent a lymph node dissections are really not a risk for lymphedema for the arm, but you can still see rates and higher rates with breast lymphedema was sent a lymph node dissections and that's again, because of secondary impacts or radiation therapy or inflammatory processes. So just to change the topic ever so slightly, obviously, besides lymphedema, there are consequences of surgery. Maybe mastectomy more than lumpectomy but perhaps not. And, you know, Rick, and I hear a fair amount of complaints which long term. They seem not to stick around. But we do refer patients for chronic pain syndromes. What are some of the other primary physical issues that you see? So breast cancer treatment? Yeah, when you look at the data, and you look at, you know, five years removed from breast cancer treatment, regardless of intervention, the number one physical impairment or shoulder problems, and one of the things that you end up seeing is, is when patients have chest wall surgery, breast surgery, they have reconstructive surgery, they have radiation therapy, you see a significant impact to the large chest wall musculature, the pectoralis muscles, they get restricted and tight. And that creates a kind of tug of war with the back muscles in the rotator cuff interval. So one of the predominant features when I approach a patient who has had breast cancer surgery, first thing is pain control, making sure they can sleep through the night, and that they have adequate pain control. Second thing is normalizing their chest wall mobility so they can move their chest while musculature normal and then the third phase is getting strengthening up their shoulder and their shoulder blades so that they don't have any long term implications with joint restriction or paying complaints. Now, on the other side of that, you're right when patients have mastectomies and they have even lumpectomies, they can have some transient pain complaints. A small percentage of patients usually particularly with mastectomy, usually under 20%, will have pain that lasts for greater than two months. And that patient population there can be a variety of things, there can be muscle pain, there can be nerve mediated pain, and all of those have different strategies, my experiences and and I know that we do a great job, you guys just surgeons do a great job of controlling pain perioperatively The faster we get pain control in the faster patients get normal movement of their chest, long shoulder, the better off we are. And that's one of the big changes in breast cancer treatment. We don't immobilize patients for periods of time we get them moving as quickly as possible, so that they can get that range of motion back and move their arm normally.
Yes, we give patients you know, some, I think American Cancer Society make simple basically exercises, right post, post surgical exercises and tell them you know, right at the first post op visit, go ahead and start doing these. I tell every patient it's exceptionally important to make sure that you get your complete range of motion back prior to initiating radiation and then continue to do those exercises during radiation. Is that good advice? The other tips Yeah, that's That's great advice and and to be honest with you the awareness around this in making it and normalizing that type of behavior is really important because you know there
Justin Riutta 20:00
Used to be patients who had come to see me and they'd be afraid that they're going to split their skin if they stretch because they were going through radiation because they had our an expander in and there used to be all these concerns and, and the point being is, the faster we get patients moving, the better off they do. And that's that really is is a paradigm shift in thinking and we've seen it in all realms of surgery, as you know, we're getting patients out faster and moving them faster after surgery now, because the outcomes are better, and that certainly is applicable to our breast cancer population. So our patients are exceptionally lucky to have you evaluate and treat them and we feel lucky and blessed. But why aren't there more of you? You're kind of few and far between? Well, it's it's interesting. You know, I'm a physical medicine and rehab doctor by trade. So as you guys know, we spend time rehabilitating patients who have strokes and spinal cord injuries, we take care of musculoskeletal problems when I was a resident.
Back in 2003, a long time ago, I gathered an interest in cancer patients, I felt like they were a nice group of people who had physical needs that weren't being addressed. And so I did a cancer rehab fellowship at the University of Pennsylvania in 2003. I was the first fellow in the United States and Cancer Rehabilitation suppose the first one who ever took her fellowship ever Oh my goodness. So it is a field that has expanded and there's a lot more need. And in there are programs now even University Michigan as a program, so hopefully there'll be more people coming out. Unfortunately, it seems that the focus for Cancer Rehabilitation is really a lot on injections. And as you guys know, with my patients, I focus on the evolution of cancer treatments, which has been great because of survivorship is I focus on really their global wellness, you know, their sleep, their diet, their exercise their pain, control what they can do I get questions, questions, just baseline questions, like when can I go back to work? When can I go back to doing Pilates? When can I do that? And those are, that is a different approach they have than some of the other cancer rehab places. Excellent. That's super, super helpful actually in in if we can, let's kind of segue talk a little bit about just that diet, exercise and maybe how it might impact lymphedema. We know that obesity certainly does play a role. What about salt intake? Is that something significant? In salt intake really primarily affects the venous compartment and it affects the blood compartment to the great to the greatest extent. Now. You can and I do hear patients frequently who will say yeah, my lymphedema got a little bit worse when I when I had a greater salt intake, but there's no clear evidence that salt intake really impacts the lymphatic compartment. To a great degree, the lymphatic systems a funny bugger in it kind of paradoxically, one of the things that helps the lymphatic system is actually being well hydrated because it flushes the system. When I tell patients about lymphedema, I tell them everybody thinks it's fluid, but it's actually it's like wet paper towel with oatmeal in it. And all the oatmeal is like this debris in particular, like large proteins and fat levels. And what would you want to do you want to flesh that out or squeegee it out to get rid of it. So I tell patients being hydrated and being very physically active are the two primary factors that really help to reduce lymphedema risks. On the flip side of that patients who have really significant fluid fluctuations because of diabetes, or patients who have obstruction, because they gain weight, or they they get really heavy, those are independent risk factors that we end up seeing. So we do counsel patients regarding weight maintenance as an independent risk factor for lymphedema. So it is important and it all falls back to the same vein we want patients to to be I always tell people, we want them to be lean and mean we want them to be to be to exercise to have their weight maintained, and I want them to build their lean body mass, I want them to be strong. And those are some of the proponents the some of the components of the physical management for patients with breast cancer. Wow. Yeah, I typically will tell patients, you know, you got this cancer that was completely out of your control. But now with exercise equipment available at every corner, diet and monitoring your caloric intake, you can put that in your control. And there is very good data on exercise and lowering the risk of recurrence and maintaining a healthy diet in the same. How important do you think it is for patients to go maybe to the next level and see a dietician or exercise and wellness counselor after their therapy because you know, a lot of women they're mad, you know, they're healthy, they do the right thing and there they are on your doorstep with breast cancer. And they're constantly asking us what did I do and what can I do? Yeah, I think it's I think it's really important in a couple of respects when I talk to patients
about wellness. And I really talk about the three elements of wellness and now get to the dietary component, but their sleep, diet and exercise are the three elements of wellness. And the one thing that we see in our society and we see in, you're going to start to see more data about this being an independent risk factor is going to be the lack of sleep. And I know that doctors aren't great at this, and they certainly am trying to get better at this. But the lack of functional sleep and restorative sleep is a factor in all of this. The second component is with diet. I really, I initially, the one thing I'm very cautious about is about, you know, medical visit fatigue that occurs with cancer treatments. So I try to counsel patients regarding having a balanced diet with some preponderance of protein in their diet, because the one thing that cancer treatment does, even breast cancer treatment, patients may gain weight, even with breast cancer treatment, but they they lose predominantly their lean body mass from cancer and cancer treatment. And that's their muscle mass. So in order to rebuild that, you need to have protein intake. So I counsel patients regarding adequate protein intake, and then doing lean body mass training. I certainly do utilize dieticians and I recommend them for patients who have additional questions or need really specific guidance in regards to that. And then the exercise programs are threefold. There's, you know, conditioning, flexibility and strength training. And I tell patients that each of those have to be an element. And I try to, and I'll be honest with you of the, you know, two or 3000 patients a year who have breast cancer that I follow where I see everybody's different regarding their exercise capacity. So we tried to individualize it, but we really want them to focus on those on those metrics. And again, getting yourself involved in an exercise program is not going to increase your risk of getting lymphedema, even doing curls and push ups, especially in the era of sentinel node biopsy fair to say, that is an excellent statement. And that's one of a huge paradigm shift. You know, years ago, they used to tell people not to use the affected arm because it could cause lymphedema. And that that was really turned over on its head when they started doing analysis of the dragon boat drivers, these people who were rowing boats, and they never developed lymphedema. And they said, Hold on, why are they and then when you understand lymphedema, you circulate lymphatic fluid through muscle pumping and through activity. And so you'd really want to augment that movement of fluid. And so, yes, we recommend lightweight training, we recommend high repetitions, the things to be to be aware of with weight training is you don't want to number one, overload the musculature to the point of soreness because that can break down muscle and can create its own issues. The second thing is you want to be very protective of the chest wall, particularly if it's had a mastectomy or reconstruction or radiation that would require some modified activity. But generally, and this is one of the biggest misnomers out there for lymphedema is that they'll tell people you can't lift more than 10 pounds or 13 pounds or eight pounds. That's absolute. There's absolutely no foundation for that whatsoever. It's based on your tolerance. And I tell patients, I want you to be lean and strong and be able to lift and do whatever you need to do. So there's no physical restriction with a physical activity related to lymphedema risk at all.
DR. ERIC BROWN 28:07
It's funny half the half of our job is dispelling the myths that are out there, isn't it? Yep. Yeah. We're in a society of misinformation. That's one of the things that we really and people hang on to things that they hear. And and so yeah, it is very, and that's one of the one of the beauties of being a cancer rehab doctor is taking these patients who are fearful and watching them get back to their regular daily activities and enjoying I had a patient who she had been under the impression that she couldn't lift more than four pounds, and she had gone eight or 10 years after breast cancer diagnosis. And she had waterskiing and I told her, I was like that's you can water ski, you're fine. So we got her condition strong and she water skied and she was fine. And she was very happy and she had spent eight years of her life not waterskiing because she was afraid of getting lymphedema. So those are examples.
Dr. Linsey Gold 28:55
Well, I love waterskiing. That's a great story. I love that. And I'm in trouble from the sleep diet and exercise. But that's a whole
tribal thing. So watch us today. All right. Well, Justin, if somebody wants to learn more about you and your work, where's the best place to find this information? Well, a couple of things. I do a sharing and caring lecture through Beaumont, which is done. I do a bunch of different types of lecture on neuropathies and shoulder problems and lymphedema and I do those throughout the year and that can be obtained through the sharing and caring website. I have my own data and information that I put out. The National lymphedema network and the American Cancer Society has good information regarding lymphedema. If anybody wants to be assessed or has any specific questions, they can just call my office at any point I'm happy to discuss with them over the phone. I do free phone insights to patients on many occasions. It's not a big deal. Ah, that is wonderful. Well, Dr. Ryota, thank you so much for joining us today. I think I can speak for Rick as well. We both learned a lot today. So absolutely.
Absolutely, yeah. Really, really appreciate it. We should probably attend some of your lectures just saying no doubt. No. I appreciate you guys. Thank you. So is there any any other messages you'd like to share? I just want to say one of the best things in healthcare delivery of when when when healthcare providers collaborate and working with you guys in the surgeons and everybody, we've created a great way of managing these issues for patients. So I appreciate you guys. We appreciate you. So listeners, we also appreciate you and thank you so much for listening to the breast of everything podcast. I'm your host, Dr. Lindsay gold with my partner, Dr. Eric Brown of comprehensive breast care. As always, we do want to hear from you. If you have a topic you would like us to talk about. We welcome your suggestions you can send them to comp breast care.com That's compbreastcare.com Be well. Till next time.
You've been listening to the breast of everything podcast with your host and board certified breast surgeon, Dr. Eric Brown and Dr. Lindsay gold of comprehensive breast care.
If you have a subject you would like the surgeons to discuss, please email your suggestions online at comp Breast Care. com. That's co MP breastcare.com The doctors want to hear from you. The views thoughts and opinions shared in this podcast are intended for general education and informational purposes only and should not be substituted for medical advice, treatment or care from your physician or healthcare provider. Always consult your healthcare provider first.
DR. ERIC BROWN 1:31
Oh, you're welcome. You know, I tell you, Justin as a part of consultations that we've done for over a decade, two decades, a very, very common theme to some of the surgical discussion involves the risk of lymphedema. And I'm sure you've heard a lot about lymphedema know way more than we know about lymphedema. Can we first start by just talking about what actually is lymphedema in what is the Paramount cause.
Unknown Speaker 2:02
So Lymphedema is a disorder of swelling and how I convey this is that there's two fluid systems in the body. There's the blood system and the lymphatic system and the lymphatic system is, you know, to put it in layman's terms is kind of the garbage can for the blood. It removes debris in particular, it circulates the debris in particular to regional lymph nodes. And in the United States, the most common cause that we see for lymphedema in our cancer population is when they've had involvement of their lymph nodes with cancer, either they've had surgery with cancer removal or spread of cancer to lymph nodes, or that they have had radiation therapy that has impacted the lymph nodes. And generally what happens is in the area where the lymph nodes are impacted, specifically that region the body, patients can have backup of lymphatic fluid into an extremity or breast for that matter, and it results in swelling underneath the skin.
DR. ERIC BROWN 2:58
And I know it well, my grandmother actually had a radical mastectomy in the late 70s and had lymphedema for as long as I can remember. So it's it's fairly debilitating and early on, there really wasn't anything we could do. But that's changed, hasn't it?
Unknown Speaker 3:16
Yeah, it certainly has. I think a few really relevant points for lymphedema number one in what's really evolved since I started my clinical practice is the more selective lymph node removal for surgery. Obviously, the less lymph nodes are removed, the less likely you are to develop lymphedema. The secondary elements is that we become very proactive about prevention strategies. And those include getting patients more active and more mobile immediately after surgery, having patients focusing on pain control and activity levels and then giving education to patients so they understand what the do's and don'ts are, are with lymphedema. So certainly lymphedema does still exist, but it's at a much lower frequency in in circumstances where we have really savvy surgeons like yourself and Dr. Gold, the earlier that the patients are sent the the better we are able to manage them.
Dr. Linsey Gold 4:10
Yes, that leads me to my next question is when patients present at the time of surgery, there's a lot of discussion right in just the pre op area of what you can and can't do with the arm that is having the lymph nodes removed. Right. So nurses frequently put a bracelet on the patient you know, do not do blood pressures anesthesia won't start the IV are they're very specific things, either activities or things we should or shouldn't tell our patients to do to maybe prevent lymphedema or decrease
Unknown Speaker 4:47
the risk? Sure. Great question. You know that first we need to stratify the patients first if patients have had a true sentinel lymph node dissection, three or less lymph nodes removed, the risk for lymphedema is really negligible. To the extent of the last 30,000 patients I've seen for lymphedema, only one or two of them develop transient swelling after a true sentinel lymph node dissection. But for patients who have had a full actually lymph node dissection, there certainly are appropriate prevention strategies. Certainly, we want to avoid any stimuli to the arm or any trauma to the arm. So that's why we try to avoid blood draws in the affected arm. We also try to avoid blood pressure assessments though again, I've never had a patient develop lymphedema from having their blood pressure checked in there. But some more specific recommendations are number one avoidance a couple of things that we really need to be stringent about avoiding with lymphedema risk are hot tubs and saunas. The extreme heat from those environments really promotes lymphatic fluid production and can cause acute swelling in the extremity. The other component that we talked about is skin protection. So we don't want people to get burns or skin infections, so you need to protect the skin from sunburns and cooking burns and things of that sort. And the final thing for patients who are higher risk for lymphedema we've had a full actually lymph node dissection. It is still a standard recommendation for patients to use sleeves for air travel to avoid swelling that can occur from the changes in barometric pressure from air travel.
Dr. Linsey Gold 6:16
Oh, thank you. I really just learned something. I did not know that about skin protection. That is so interesting. And hot tubs and saunas. Rick, did you know that? I did not know that. As you heard.
DR. ERIC BROWN 6:29
I didn't actually I had seen some data on the hot tub and sauna and the air travel. You know I I have if I can follow up on that. So sleeves for air travel. Does it have to be measured prescription sleeve or as I'm sure you've seen there's a website lympha diva.com. That has themselves decorative sleeves if you will. Is there anything in particular when there's air travel?
Unknown Speaker 7:04
Yeah, it's technically if you want a sleeve that provides adequate what you're doing with this is essentially we when you swell with lymphedema, you swell directly underneath the skin. And in when you go on an airplane, the same thing that makes your airs air your ears pop will shift fluid into that space underneath the skin. So just gentle external compression from a sleeve can reduce that risk. And the sleeves that are that are typically utilized. You know, I tell patients you can't buy these at CVS or Rite Aid. Those are a low grade venous insufficiency type of sleeve or stacking, they usually need to get them from a medical supply store. They're typically a compression class grade sleeve which would be 18 to 30 millimeter mercury sleeve. The lympha diva sleeves are in that class also. So you could get one from lymphedema as long as they're a compression class one or graded compression for lymphedema. A
DR. ERIC BROWN 7:58
question I had in regards to just the pure risk of lymphedema involves the change in surgical management of the axilla. So now we're doing a primarily sentinel lymph node biopsy. And although the risk isn't zero, I'm sure you've seen a significant change in the number of women since the implementation of that surgical management of the lymph nodes. Have you seen that a lot? Just
Unknown Speaker 8:28
no question. When I was first in practice, the full actually lymph node dissection was quite common with patients who had any active disease and then it's less so with the reduction in the number of lymph nodes being removed, you essentially have seen a substantial reduction in the rates of lymphedema. And since the most correlate fact correlate to factor with developing lymphedema is how many lymph nodes you have removed, it makes sense the less you remove the better. My own, you know, the anecdotal experience from some of the studies have been done as they range that seven to 16% of patients will develop lymphedema and those are patients who develop some swelling but it lymphedema to me has other Hallmark features like skin thickening and some more chronicity of swelling. And I'll and I'll be candid with you in my 18 years of practice now. I have not seen a patient develop overt lymphedema with a true sentinel lymph node dissection. It's exceedingly rare.
Dr. Linsey Gold 9:23
Oh, that's good news. Yeah, absolutely. Is there a benefit to sort of getting baseline measurement is or what how am I? Right? Help me out. I get your measurement of a patient and then follow things serially, because we usually we'd send them to you after the fact
Unknown Speaker 9:46
if the measurements are done by the same person. They do have validity but for example, Dr. Gold if I if you measured a patient and I measured a patient, the intra rater reliability is only about 60% But if I measure again And then I measure the patient, it's about 90 to 95%. So if it's the same person it can have some benefit certainly would not be necessary in somebody with a sentinel lymph node dissection. But if I had somebody who had pretty extensive disease, and they were going to have significant risk, preoperative measurements, can humps kind of have some value. The other part about it is, you know, if I measured both your arms, everybody has a little bit of an asymmetry in the size of their arm that that you want to account for before surgery if need be. And so I think there is some value it's a data point. But most of the time my diagnosis of lymphedema is really based on clinical findings of swelling, skin integrity, some of the hallmark features that you can see with patients who develop lymphedema, they all you'll see blunting they won't be able to see their veins on the extremity, they won't be able to see their tendons or their bony prominences on the extremity that they have lymphedema. It's it's kind of a hallmark feature of that. So I use a lot of the clinical guides and use the measurements to support either the extent of lymphedema or how effective management's been. Excellent.
DR. ERIC BROWN 11:05
Yeah, usually as patients, if I notice a little bit of what I perceive to be swelling, if their jewelry is fitting tighter if their ring is a little bit harder to get on and off, as a clue. But if I could just jump back to that kind of pre operative assessment, is it worthwhile? There's, you know, in our literature, and certainly within some of our colleagues nationally, there's been a little bit of a push to doing some preoperative or pre habilitation, if you will, our measurements and, you know, some of the companies have devices that you can bring patients back every three to six months, over the ensuing few years, so that you have a little bit earlier detection of lymphedema, do you find that that's significant, or if you just go based on clinical assessment, you have just as good a chance of controlling and potentially eliminating that,
Unknown Speaker 12:04
why there are a couple a couple of different variables that occur with that, you know, prehabilitation, when we talk about management or assessment of patients before surgery, and before intervention is very important. For those patients. I talked to them about what exercise and activity they should be doing, maximizing their chest long shoulder mobility before any chest wall or axillary surgery, and then taking some preoperative measurements. Now, when you get into a phase of monitoring, there's a couple of different forms of monitoring. There are devices that monitor flow, meaning how lymphatic flow occurs. And there are devices that manage that measure volume. And when you look at the flow devices, the problems with those is that let's say that I have a 20% reduction in lymphatic flow in my arm after I have my lymph nodes roped Well, that doesn't necessarily mean you're going to develop lymphedema, it just means that your arm is slower at draining than then otherwise. So I think the volumetric component in combat combination with the clinical assessment really has the most value. Because by the same token that we want to catch patients early we also don't want to treat patients unnecessarily or be over aggressive with treatment if it's not necessary, because, again, lymphedema is rare. You look at this probably the old dead is at 20% of patients develop lymphedema after breast cancer treatment, it's probably down in the 10% range right now. So to do a lot of really aggressive treatment for a small subset of the population is probably is might be a little too much. But I will say the earlier that we catch lymphedema, the better the outcomes are when we did our data in 2007. We put we took new onset lymphedema patients, not patients with more chronic thickened skin and fibrotic changes. And we had them in decongestive therapy, they had 100% reduction in volume if we caught them early enough. So there's value in knowing that patients are having some signs of swelling and there's value in getting it taken care of rapidly.
DR. ERIC BROWN 13:59
So what we commonly hear of lymphedema patients are very focused on the arm. But we actually see not a small number of patients that actually get lymphedema of the breast. Can you tell our listeners a little bit about what that is and how that's managed?
Unknown Speaker 14:19
Yeah, lymphedema, Nebraska is it used to see it in less proportion than you do from from lymphedema the arm. The features of that is usually what happens with that is you get an inflammatory process that affects the chest wall or the breast you'll get a radiation dermatitis or potentially an infection or something along those lines that creates this large volume of fluid in that area in the problem with with breast swelling is that the breast becomes almost like a water balloon because there's not outer covering of the breast. There's just skin and the musculature is underneath it. So the fluid tends to sit in that area. And we manage that number one we try to turn the speaker As I say to patients and try to reduce the inflammatory process, whatever that may be. The second component is we start with lymphatic drainage techniques with massage techniques from the chest wall on the breast. And then we use external compression with a device called a swell spot, which is a foam piece that we put on the breast that the patients can wear under their bra. And in certain circumstances will actually wrap the chest wall with that foam to circulate the fluid up into the intact lymph node beds. The good news is, is once you get rid of the breast cancer once you get the fluid out of the breast, usually it's not a persistent problem after that, but it's it's another factor that you want to jump on early so that you don't get some of the thickening of the skin and the fibrotic changes.
Dr. Linsey Gold 15:42
I've changed some of my surgical practice because where we place incisions seemed just in my anecdotal experience to
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