This week started at 7am in the conference room on the 7th floor of Payson Pavillion. The guest surgeon, a former dentist and renowned plastic surgeon sought out by the wealthy and often previously botched patient, confirmed what I’d already suspected --- plastic surgery is one of the broadest , most complicated, intense and now sought after specialties in medicine. “You will never be bored being a plastic surgeon,” he exclaimed, “ you can change your practice every 5 or so years.” And it’s true. Plastics surgeons do everything. You can focus on the more cosmetic kind of surgeries or trauma type surgeries. You can pick what area of the body you’d like to focus on, if you’d like. Or can simply do it all. Monday’s conference focused on lip and chin surgeries. I learned that the mentalis muscle is a very important muscle in the face. It allows you to pout and close your mouth and must be carefully regarded in chin and lip surgeries. A plastic surgeon must pay very close attention to anatomy, so that when he is finished his surgery the patient may go about performing his everyday tasks as he did previously. If a mentalis muscle is pushed too far down or severed, the patients won’t be able to play wind instruments, tell if they are dripping food from the lower part of their mouth or even put lipstick on without looking in the mirror.
The rest of the day and week were filled with patient visits and some really great surgeries. After seeing the insertion of a tissue sizer and breast implants, I was really interested to see a TRAM flap. A TRAM, transverse rectus abdominus myocutaneous, surgery was a breast reconstruction in which the post – mastectomy breast was reconstructed from the tissue, fat and muscle of the abdomen , essentially providing the patient with a tummy tuck as well as autologous breast reconstruction. The tissue from the abdomen was moved through a pedicle flap or tunnel up to chest to create the new breast. The nipple and areola would later be reconstructed in another surgery if the patient decided that was something she wanted.
Another surgery I found really interesting was a jaw reconstruction after a tumor the size of three golf balls was removed from the patient’s jaw. This surgery began around 8am and lasted until 7:30pm. Oral and ENT were there in the morning removing the tumor from the patient’s jaw, while plastics simultaneously removed a portion of the patient’s fibula, as it is a non weight bearing portion of the leg, and could be used to recreate the patient’s jaw. The extraction of 16mm of the patient’s fibula along with the surrounding tissue skin and major blood supplies was a long delicate process. Doppler was used to mark the major vessels and the piece was extracted and then further cut to the specifications of the patient’s jaw. Prior to surgery a 3-D reconstruction of the patient’s jaw and tumor were made from CT images. A 3-D model was given to the surgeons and titanium constructs with multiple holes, where screws could be placed, were made to match the portion of the jaw that was being removed. These constructs were then used as a guide as to how the extracted fibula should be further sectioned. The bones were then screwed onto the titanium constructs and the patient’s leg was sewn up and skin grafted. While a plastics fellow and resident worked on the closing of the patient’s leg, the attending and another resident moved up to the jaw where they sewed together the extracted blood vessels, attached to the skin, and tissue excised from the leg, to the severed blood vessels, left after oral removed the tumor. This was done under a scope with two eye pieces that allowed them both to work at the same time. The jaw was screwed in place and face closed up after flow was heard under the Doppler. This was one of my favorite surgeries, as I’ve always studied soft tissue biomechanics and have never really been interest in orthopedics. I was really impressed by the technology and creativity used in this surgery. It opened my eyes to more areas of biomedical engineering that I might want to become involved with.
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