The Plastics People

20 06 2012

My current assigned surgical service is not, as I expected, general surgery.  Instead, I’m working with a very small team that deals primarily with burns, wounds, and plastic surgery.  I’ll be honest, I didn’t have the highest respect level from plastic surgeons.  The societal preconception is that they are superficial and super wealthy; really, I can’t think of a single beneficent plastic surgeon featured in the media, save for the generic ads in magazines to sponsor a child in a developing country to have a cleft lip or palate surgery.  The whole subspecialty just sounded like a group of snobby doctors who made patients believe that they were flawed and then charged exorbitant amounts of money to fix those flaws.  Who hasn’t seen or heard grotesque descriptions of facelifts or liposuction procedures?

But the plastic surgeons I work with now are caring, compassionate physicians.  Possibly the fact that they chose to spend the bulk of their careers grafting burn scars, covering the worst pressure sores with flaps of skin, and reconstructing breasts and other areas marred by cancer is a testament to this.  It is not the kindness of the physicians that has taken me by surprise, but the sheer complexity of plastic surgery.

All of the procedures involved in plastics (except perhaps for skin grafts) are so geometrically and anatomically complex that it has taken me a while to wrap my head around the visual mathematics involved.  In order to do any sort of tissue reconstruction, these plastic surgeons have to take into account not only the tension lines of the original skin, but also how best to re-orient those lines during a reconstruction, all the while taking into consideration how the skin stretches with the patient’s natural movements, the patterns of tissue regrowth as the surgical site heals, how best to suture the wounds closed, how to leave underlying structures (like the nipple of a breast) intact, and the method of surgery that will be least invasive to the patient.

The most basic example of this is probably the Z-plasty.  This is used for very thick, inflexible scars, the purpose being to restore mobility to the area (particularly if it’s over a highly mobile area, like a finger joint).  As my attending would tell you, “it’s turning a metal rod into a spring—you lengthen and coil it.”  The diagrammatic representation is below.

Cool, right?

They also have a 4-flap z-plasty for scars of the thumb web and a more complicated “jumping man” z-plasty that they use a lot for eye surgeries involving the epicanthal folds.  Pictures below:

 

Easily, the procedure that has most blown my mind was the breast reduction, so I’m going to talk about it.  If that sort of thing bothers you, feel free to redirect your attention elsewhere.

Part of the reason why I was so amazed by the process was, admittedly, because I was more or less pulled into the surgery and didn’t have time to research the procedure beforehand (which is a giant no-no as a surgical med student).  The theory is as follows:

Now, I didn’t know what was happening, so I was a little surprised when the surgeon’s first move was to cut the areola and nipple area free from the rest of the breast (using a tool that they literally call the ‘cookie cutter,’ and it works in exactly the same way).  The plastics resident I was working with also didn’t make a keyhole, it was more of a W, and when he started dissecting out all of the skin of the breast that wasn’t part of the W, well, I spent a decent chunk of time wondering how the tiny amount of remaining skin would cover even the reduced breast.

After the requisite amount of breast tissue was removed, the surgeon threaded a thick length of suture through each of the bottom points of the W as well as through the skin in the middle of the bra line, and when he gave it a good tug, all three points came together and it was a breast again!  Then he let me help with the subcuticular (read: tiny and precise) stitches—which I botched a little for about the first centimeter before they started to come together and lie flat—until the edges were sewn together.  Then he used the cookie cutter again and pulled the nipple and areola back out through the new hole, sutured that in place, and voila!  The woman who was getting breast cancer treatment not only had symmetrical breasts (the other was received an implant; the reduction was just for symmetry), but had received a bit of a “breast lift” in the process.

And that’s just breast reduction.  The options for breast reconstruction (after a partial mastectomy, for example) are numerous, and each seems more intricately creative than the next.  The minutiae are mind-blowing for someone new to the specialty (like me).

Overall, I’m quite impressed by the knowledge and skill of plastic surgeons.  I personally am not destined for that career—partially because I don’t like general surgery enough to tolerate the residency, partly because I’m tired and don’t want to spend that many years still training—but if I had to do surgery, that’s the branch I would choose.

The chitlins just aren’t my thing.

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