Terence and I spent a good portion of this week standing out in a sea of blue scrubs at HSS. Dr. Spector operated on two patients with exposed orthopedic implants, both of whom required muscle to be pulled over their hardware. Since these are reconstructive surgeries that orthopedic surgeons do not specialize in, Dr. Spector’s expertise was called upon. As infection is a common problem for orthopedic devices, the exposed surfaces were thoroughly rinsed and cultures were taken before vascularized muscle tissue was laid on them. The presence of the muscle in these cases increases a patient’s ability to fight infection, as the vasculature provides a means of transporting antibiotics directly to the implant surface. For our patient with spine implants, the approach was relatively straightforward, as surrounding muscle could be stretched out and pulled over before closing the patient. However, our patient who had exposed hardware just above their ankle required a more complicated approach: a reverse flap with skin graft. Dr. Spector rotated a muscle flap from the patient’s lower leg to cover the implant, and then took a skin graft from the upper thigh to cover the muscle flap. In the days following, we rounded on these patients to observe their recovery, and also included a “social” round on one particular BME professor who had the misfortune of being (re)admitted to HSS.
Back at the familiar NYP, we also saw a variety of debridement, cosmetic, and reconstructive cases. For patients with large open wounds, debridement is a process used to remove necrotic and other tissue that may impair the healing process. I was amazed at the ability of the surgical team to stomach these cases, because they can involve unpleasant smells, plenty of blood, and chunks of tissue that may fly off the table and land within inches of your feet. (Terence and I lost our appetite for red meat after seeing one too many of these cases. Luckily it was just for one night.) Among the other cases we saw were breast reduction, revision of a previous maxilla/cheek reconstruction, external auditory canal reconstruction, and nasal/upper lip reconstruction with composite graft (cartilage and skin) from the ear.
The most interesting part of the week happened outside of the OR and clinic: we saw an online meeting that Dr. Spector took part in to plan a patient’s upcoming mandible reconstruction with free fibula flap. As described in my previous post, there is a company that specializes in computer-assisted surgical planning, which involves taking the patient’s 3D scan data to virtually plan the locations of cuts to the mandible and fibula (http://www.medicalmodeling.com/solutions-for-surgeons/vsp-technology/vsp-reconstruction). During the meeting, the company took input from Dr. Spector and two other surgeons (oral and head & neck), and in real time, we were able to visualize how the fibula flaps might fit the mandible defect. Several factors were considered in the process, including whether to do a “straight shot” reconstruction (one piece of fibula) or to use two cuts of the fibula to better recapitulate the native mandible geometry, as well as how placement of titanium implants (to be used later to anchor dental implants) within the fibula flap might compromise the ability to screw (orthogonal to implants) and fix the mandible plate in place (see website link above for a better idea of what I mean). I find it amazing that we have the 3D visualization tools to do this for each patient, and that this company is able to create patient-specific cutting templates and customized mandible plates that save time in the OR and result in better outcomes. I will be looking forward to seeing this surgical case in July. In contrast to our previous mandible reconstruction case, this patient will be receiving titanium implants, which, as I mentioned, further complicated the planning process. I am curious to see how the concerns that were brought up during the meeting might present themselves in the OR, and how the surgical teams will handle them in the moment.
Lastly, I am getting a handle on some of the lab work that I will be doing for the next six weeks. The Spector Lab has developed a microvasculature platform that has potential to be used for in vitro tumorigenesis and metastasis studies. I will be considering ways that the platform can be used to systematically study these processes, ideally in the context of breast cancer bone metastasis, which I am researching in the Fischbach Lab. I am excited to see where this goes, because it could have a great impact on the direction of my research back in Ithaca. This coming week will be more lab-focused, so I will be sure to update more on this aspect of immersion as it happens.
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