Week 5: Bawk to basics

With new residents starting and current ones increasing in rank, the plastics team is taking this month to cover the core concepts in plastic and reconstructive surgery during Monday morning conference. This week the material covered the basics of flaps and grafts, which Terence and I have been learning little by little throughout this term, but I found nice to see formally presented. Amazingly, skin grafts have been performed for about 3000 years, first documented in India. We discussed the timeline of the healing process in a skin graft: appearance of circulating erythrocytes (within 24 hours), osmosis and fibrin keeping the graft in place (first two days), capillary bud growth (2-3 days), and revascularization (5-7 days). We also learned about Dr. Ian Taylor’s landmark publication The Angiosome Concept, which describes regions of composite tissue supplied by an artery and vein (3D vascular territories), many of which are used in flap procedures today. The maximum ischemic time  of different tissue types (based on metabolic demand) was also discussed, with intestine being most sensitive to ischemia and skin/bone being most resistant.

On Monday evening, Terence and I also had the opportunity to attend plastic surgery’s monthly morbidity and mortality (M&M) meeting, during which the residents and fellows present select complications from the prior month’s cases. Following M&M, we joined the team for journal club at Uva. The dinner was sponsored by Medtronic, allowing the plastics team to review articles from the most recent release of Plastic and Reconstructive Surgery  in a nice setting over dinner in exchange for a short sales pitch. I actually found the Medtronic demo most interesting, probably because we engineers are typically drawn to building the devices that are implemented in the OR. The sales reps introduced one of Medtronic’s newest products, an electrocauterizing device with a few advantages compared to the traditional Bovie device used by surgeons. Using a specialized generator, the device could perform the same cutting and coagulation functions as the Bovie with less damage to the surrounding tissue, all while vacuuming any fumes up to clear the room of the burning flesh smell that some of us are all too familiar with. The reps brought a raw chicken breast for demonstration purposes, and for the first time this summer, I was able to use a surgical instrument! The residents asked the reps many questions and provided design feedback, all of which I hope the company considers in the next iteration of the product. After all, if the needs of the surgeons are not met and the incentives are great enough to switch to a new, unfamiliar device, the entire product will lead to losses for Medtronic.

In clinic, we saw our first nerve-related consult. The patient was over half a year post-tumor resection from a facial bone, and was experiencing loss of facial nerve function unilaterally (e.g. could not smile with one side of face). Dr. Spector discussed several options to restore motion beyond a static sling (pulling the corner of the mouth up and fixing it in a smiley form). One possibility was to do a cross-facial nerve “jump”, which would connect the contralateral facial nerves (through a tunnel beneath the upper lip) in an attempt to achieve symmetry in facial movement. Another would be to take a nerve graft from the inner leg and simply bridge the gap. However, because the nerves have been out of commission for so much time, Dr. Spector warned the patient that any of these procedures may be limited in their success, and full symmetry in motion may never be restored. After a thorough discussion of the potential benefits and limitations for each option, the patient left clinic asking for more time to decide on a procedure. After hearing all of this, I wonder if there would be a way to discuss preservation of nerve function sooner after such resections, or a way to predict the success of a nerve grafting procedure. I have doubt about the latter, since aligning a bundle of nerves does not ensure direct connection between individual axons, but maybe conduits could be placed at the time of resection to encourage growth and prevent degeneration.