Week 7: C'mon, get flappy

This past week, we saw two flap cases in the OR. First was a mandible reconstruction with free fibula flap, a procedure we had seen in our first day of surgery. This time around though, we had much more context. Having seen the surgical planning meeting a few weeks ago, I entered the OR feeling confident in my knowledge of what was going to happen and with greater appreciation for the entire process. The room was swarming with people as soon as we entered, but in little time formed into a number of teams clad largely in blue. At least one OR tech was scrubbed and ready to assist each team. Oral surgery started by removing any teeth from the length of the mandible that would be cut out. At the same time, the plastics team was locating the vessels that supply the fibula flap, and cutting through several layers of tissue to isolate the fibula. ENT (ear, nose, throat) removed the mandible tumor from an incision below the jawline. In great contrast to last week, it was during this procedure that I was able to truly appreciate the efficiency of an OR in which everyone knows what is happening and how to perform their role appropriately. The anesthesiologists were very responsive to the surgeons’ requests to raise/lower the patient’s blood pressure (although I don't recall seeing an issue with anesthesia in the cases I’ve observed so far), the OR techs and circulating nurses knew what tools were needed and where to find them, and the correct microscope was ready to go when Dr. Spector needed it. We were even able to connect the video camera attached to the scope to the monitors in the OR so that everyone could watch the microsurgical anastomosis. With everything running smoothly, this case was completed hours sooner than our first mandible reconstruction had. This patient even received titanium implants in the fibula flap (posts onto which custom dental implants may be placed), which had not been done for the first one.

The next day, we saw a buccal tumor resection and reconstruction with radial forearm free flap. This was unique compared to cases we had seen before because the vasculature is much closer to the surface of the flap, and the flap was to be used to patch the defect in the patient’s inner cheek. ENT was involved in this case to remove the tumor, and to locate potential vessels at the recipient site. The vascular pedicle extended from the patient’s wrist to about halfway down the forearm, since the vessels would be tunneled from the patient's cheek down to the neck, where the flap would be anastomosed. Aside from navigating another crowded room, the main issue we encountered in this case was poor temperature regulation in the OR. Although we had set the thermostat to a low temperature, the room only seemed to be warming over time. After several calls to the engineering team, someone came with an IR gun to check the vents in the room. It turned out that one thermostat controlled multiple rooms, but there was a leak in the thermostat, causing it to sense cooler-than-actual air coming from our OR. We were all relieved to feel the temperature dropping once this was fixed. The most amazing part about all this was how the surgical team was able to continue working (i.e. do microsurgery) in these conditions; despite their discomfort and complaints, everyone was still able to do their jobs and ensure a successful procedure.