David Chang, M.D., Chief, Section of Reconstructive Surgery Prof., Uni. of Chicago Medicine

As a world-renowned plastic and reconstructive surgeon, can you reflect on your reasons and motivations that pushed you to apply to medical school and pursue a career in medicine? After entering med school, was there a pivotal moment in your education or training that cemented your decision to specialize in plastic surgery?

This may sound like a cliché, but I wanted to have a career helping others. After my family and I immigrated to the US when I was 12, I thought about becoming a physician, specifically a medical missionary.

I wanted to be a surgeon but was not sure what kind. During GS [general surgery] residency, I became exposed to PS [plastic surgery] and how PS reconstructed patients, and then I knew right away that is what I wanted to do. I was intrigued by PS because many people view plastic surgery as simple cosmetic alterations, but in fact it requires imagination for problem solving, repairing things, and reconstructing defects to restore patients’ function and appearance. Every case is unique and different, and we work all over the body from head to toe. I liked the variety in PS and how it was not limited to one particular anatomic area. I also found it incredibly fun to repair and solve problems for patients and for our physicians as well. So, after the GS residency, I did PS residency and then a fellowship in Microsurgery.

How common is lymphedema, and what problems does it cause patients? As a pioneer in lymphedema microsurgery, can you explain in more detail the innovative procedures you helped in developing and promoting such as lymphovenous bypass and vascularized lymph node transfers? Why are these surgical procedures so complex and important and in what way do they significantly improve the quality of life for lymphedema patients?

Lymphedema is more common than people realize. Over 250 million people worldwide suffer from it. Common causes are parasites/cancer/congenital. Lymphedema causes pain, discomfort, infection, an inability to wear proper clothes, and physical disfigurement. It can have a significant impact on quality of life as it can interfere with work, social and daily personal activities.

Lymphovenous bypass (LVB) is a procedure in which an obstructed or damaged lymphatic system is diverted to an open venous system, allowing trapped lymphatic fluid to be drained. VLNT [vascularized lymph node transfer] is transplanting a patient’s own healthy, functioning lymph nodes to a site of lymphedema to promote generation of new lymphatic vessels to reestablish lymphatic function.

Lymphatic vessels are very small, usually much smaller than 1 mm. So, they are very difficult to identify and then suture together, even under the microscope. Compared to other systems in our body, the lymphatic anatomy and physiology have not been well studied and understood.

The procedures we perform do not cure lymphedema, but have been shown to help reduce the severity of the lymphedema, reduce the incidence of infection, and improve quality of life for the patients. Also, they help reduce the progression of lymphedema, an important benefit, as the natural history of lymphedema is that it usually becomes worse over time.

As an innovator in various areas of plastic surgery such as breast reconstruction and microsurgical treatment of lymphedema, what are some of the current major innovations and growing trends in reconstructive surgery? How do you see the field of reconstructive surgery advancing in the next few years and what are some changes in practice you would like to see happen?

The utilization of microsurgery for cancer reconstruction has become standard world-wide, so it’s no longer limited to only a few selected centers. It is a tool that allows us to reconstruct almost any defect, anywhere in the body, whether it be soft tissue, bone, nerve, or lymphatics. In addition, these advances in reconstruction allow our oncologic surgeons to perform more definitive ablative surgery, facilitating chemotherapy and radiation therapy which can perhaps lead to better survival of these patients.

And our approach to reconstruction continues to improve, with creation of more innovative techniques, the incorporation of new technology, and a better understanding of our bodies. Rather than just reconstructing the defect, there’s growing emphasis on better functional restoration and better aesthetic outcomes.

This field is already evolving rapidly with incorporation of new and state-of-the-art technology. For example, we are now incorporating advanced imaging systems to help plan for safer and more efficient surgery. We also have better equipment and instruments, including robotics to facilitate surgery. We have already seen advances in face and hand transplants, and this progress will expand to other parts of the body. We will see advances in tissue engineering that will allow us to grow various tissues which we can use for reconstruction. I envision advances in robotics and AI that may alter how we do reconstructive surgery. The future of reconstructive surgery is very exciting and we will be on the forefront of these new innovations.

Given the complexity of cancer reconstructive surgery, can you describe the process of coming up with personalized treatment plans for a diverse set of cancer patients? How do you work with each patient to develop the optimal reconstructive surgical plan for her particular needs and are there any personal philosophies and principles that you incorporate into your patient care?

Every patient is different. Each has a different body type and shape, and different medical conditions, lifestyle, expectations etc. Thus, it is critical that in offering reconstructive options we customize our approach to meet each patient’s needs. One size does not fit all. Foremost, communication and patient education is critical. Patients need to know what the options are, what the pros and cons of each option are, what to expect after the surgery, so that they can make educated, informed decisions about the type of reconstruction to accept. Also, their expectations of what the surgery will be like and what types of outcomes they can expect are very important. In most cases, patients may have several options, so they need to make the decision that is best for them.

Having published more than 175 peer-reviewed research articles and serving as a principal investigator on several clinical research studies, can you describe some of your key research projects and their findings? How important has research been in your career and why do you find it important in the field of reconstructive surgery? How do you find the right balance between patient care and research?

I have been fortunate to work in leading academic centers such as at the MD Anderson Cancer Center and now at the University of Chicago. And it is exciting that I have had opportunities to do research to advance our field. Research is essential in making improvements and coming up with new, better ideas that can help our patients. Research is not only done within the lab setting but also in the clinical setting. We can critically evaluate our data outcomes to evaluate which approach works best. We need to continue to make investments in research that can lead to innovations and advances in caring for our patients. We cannot improve, innovate, and advance without research.

I am currently conducting an NIH clinical trial that is studying a new collagen-based medical device that is inserted under the skin during a lymph node transplant. It acts as a scaffold to promote the growth of lymph nodes. It’s an ongoing study that will require another 3-4 years for outcomes.

Finding balance between patient care and research does not need to be difficult because, for clinical research, they compliment each other. For example, critically analyzing outcomes data from our own patient care is essential for us to continue to find ways to provide better and improved patient care. Also, it is critical that we collaborate with experts from other areas to work as a team to do research. In my mind, research can be done most effectively when we collaborate with others.

Can you explain to our readers what microsurgery entails and why it is important in the field of plastic and reconstructive surgery?

In microsurgery, surgeons use microscopes to operate on small structures that are difficult to see and manipulate because they are so tiny, such as little blood vessels, nerves, and lymphatics. A common application of microsurgery is transplantation of tissues. Large organs such as the kidney, liver and heart have larger vessels, so microscopes are not necessary. Other tissues, however, such as muscle, skin, fat, bone etc. have blood vessels that are 1-2 mm or even smaller and require the use of a microscope. Microsurgery is a very useful tool that allows surgeons to transplant virtually any type of tissue from a patient's own body to another location of defect or damage, allowing reconstruction and restoration of virtually any defects, whether caused by such factors as cancer resection, or trauma, or in even in cases of congenital defects. These transplants can be done anywhere in the body: the scalp, nose, jaw, tongue, throat, breasts, arms, hand, genitals, legs, etc.

What are some final remarks and advice you would like to leave for aspiring physicians and plastic surgeons? Are there any key characteristics/qualities that you believe all medical professionals should possess or activities that all should engage in?

In one word, passion. You need to love what you do. It is hard work, and the training is long and rigorous. But if you love what you do and if you are passionate about your work, then it is not work. I am very grateful that I found a profession that I love. It continues to be a huge privilege and a joy to help reconstruct patients’ lives for better.

February 6, 2023

David W. Chang, M.D., F.A.C.S.

• Chief, Section of Plastic and Reconstructive Surgery Professor, University of Chicago Medicine

David W. Chang, MD, specializes in complex microsurgical reconstructive surgery in cancer patients, and has an international reputation as a pioneer and an innovator in the field of breast reconstruction, head and neck reconstruction, extremity reconstruction and microsurgical treatment of lymphedema. Dr. Chang has published more than 175 peer-reviewed research articles in high-impact journals as well as numerous book chapters. Dr. Chang is the Chief of Plastic Surgery and the program director of the prestigious UChicago Medicine Microsurgery Fellowship. He previously served as the president of the American Society for Reconstructive Microsurgery and the vice president of the World Society for Reconstructive Microsurgery.