Decisions

As my summer gets more and more immersed I have begun to really enjoy visiting other surgeon’s ORs. I especially enjoy the mobility that I have been allowed by the plastic surgery department. Over the course of the summer I have seen quite a few breast reconstruction cases because of this mobility. It is quite fascinating to see the different techniques each doctor uses and to see which techniques their residents and fellows have started picking up as they learn. I bring this up because last week I was able to stand in on a surgery with a different doctor than my clinician and see a surgery I have been curious about all summer. I’ve seen quite a few skin grafts and flaps, as well as breast reconstructions post mastectomy with tissue expanders, but it is the TRAM flap surgery that I was really intrigued by.

The TRAM flap, or transverse rectus abdominis myocutaneous flap, is a fairly ingenious way to aesthetically correct a traumatic surgery with a patient’s own tissue. I have had quite a bit of contact with pre-op and post-op mastectomy patients during clinic hours and have heard how difficult the decision is for the method of reconstruction. These patients basically have two choices, the choice of using a tissue expander followed by a permanent implant (silicone or saline, which unto itself is a difficult decision) or the TRAM flap procedure. Both require nipple reconstruction afterward (though a few doctors are now working on nipple saving mastectomies), but the consequences of each are hard to decide between. An implant of course is a synthetic material inside your body, but recovery time is much quicker. The TRAM flap involves taking a large portion of abdominal skin, tissue, and part of the rectus abdominis muscles (in lay terms, your abs), and fashioning a new breast out of that in place of the removed one. This is a much longer surgery, a longer recovery, a lifelong weakening of your abdominal muscles with the increased risk of a hernia and the flap does have the possibility of dying, which in term would lead right back to a tissue expander/implant surgery. Though with the TRAM flap surgery you are replacing your lost breast with your own transplanted tissue and you get a tummy tuck out of the entire process. Seriously not a decision I would want to make, ever.

As I mentioned bore, the patient was not one of Dr. Spector’s patients, but the other surgeon was quite accommodating to let me stay for the 6+ hour operation and attempted to ensure I had a view/knew what was going on. The procedure itself was not a free flap procedure, so in this case the rectus muscle wasn’t cut completely off from the blood supply before being sewn to the tissue above for relocation. This complex, known as the pedicle, was then pushed through a tunnel under the skin made from the abdomen diagonally to the affected side of the chest and sewn into place. After discussing the procedure with Dr. Spector, I found that his preference is actually to perform this as a free flap and actually remove the entire muscle and microsurgically re-establish the blood flow that was feeding the flap. Like I mentioned before, every doctor has their own established way to tackle the same problem. This is why it is important to speak to a few doctors when electing to undergo any surgery. Not every surgeon is the right fit for a patient and the ability to hear new ideas and takes on a situation is important when making an informed choice. Regardless, the surgery was immensely fascinating and seeing this shapeless mass of adipose tissue and skin suddenly come together to form a new breast was astounding. I think it is safe to say I will always be constantly amazed at what doctors have pioneered in surgery.