Week 3 - Improving the Quality of Life via Surgery

On Thursday, I accompanied Brooke to see a breast reduction procedure conducted by her mentor, Dr. Grant, at Columbia. We got there early and had the opportunity to read through some articles in the latest editions of the Plastic and Reconstructive Surgery Journal of the American Society of Plastic Surgeons. It was very interesting to me to read papers based on clinical studies and the results of actual operations. For example, one of the articles I read was about skin-sparing mastectomies in which the natural areolar tissue is preserved during surgery, and used to immediately reconstruct the nipple. The primary benefit of this technique is that most of the breast reconstruction occurs in one step (with the exception of when tissue expanders are used). The goal is to achieve more natural appearing results. This article interested me because I was able to compare the techniques used to the techniques used by my surgeon which I have observed over the past few weeks. Additionally, I read another article that was more experimentally-based, in which endothelial cell explants were isolated from intramuscular venous malformations and cultured in vitro. The growth and migratory behavior of these cells was analyzed, as was the expression of matrix metalloproteinases in an attempt to understand the invasive behavior of these cells. This article was interesting to me because the experiments mirrored some that I have performed in Ithaca, and the cells showed behavior similar to that of some cancer cell lines I have used.

Meeting Dr. Grant was a real pleasure. He was very enthusiastic about having another student to teach, and in the brief time I was there, I listened to him and Brooke discussing many different patients and procedures. I am amazed at the variety of different procedures he performs – a big change from the more specialized practice of my surgeon. Additionally, as chief of plastic surgery he is in charge of hiring new surgical fellows, and he took the time to explain to us how the process works. They take on only 3 new surgical fellows every year, chosen from hundreds of applicants, a process he appeared to really enjoy.

After meeting Dr. Grant and having time to read some papers in his office, we went down to meet with the patient pre-op, where Dr. Grant marked lines on her body of where he would cut, explaining to the patient what he would do in the OR. The patient was a woman in her sixties, who was more than ready for this procedure. She explained to us how in her twenties, her breasts were a D cup, and then they progressively kept growing until they reached a G cup. It was clear that they were very problematic to her, causing her quite a bit of unnecessary pain.

For the actual procedure, a cookie-cutter type ring was used to outline a new areola, which would be more proportional to her new breast size. The new areola was cut out, and a flap of skin was removed above the areola, where Dr. Grant and his surgical fellow went in and began removing tissue. It was a truly amazing process to work, because in the process, additional incisions were made, until it literally looked like the breast was “exploded”. The tissue that was removed was placed into buckets – one for each breast, and the buckets were subsequently weighed in order to quantify how much tissue had been removed from each side. The goal was to make the breasts as even as possible. Dr. Grant worked on one breast, and the fellow worked on the other breast, so it was amazing to me that they tissue each removed was quite comparable. After they had removed quite a bit of tissue, they temporarily stapled the breast together and sat the patient up on the table, in order to visually check that the breasts were hanging at the same level, and looked even. The table was laid back down, and more tissue was removed from each side. The total tissue removed weighed well over 1 kg. Then came what seemed like the longest part of the surgery – stitching the breast back together. Delicate stitches were used to stitch the areola back to the breast, and the rest of the incisions were closed as well. A medical student who was also present was able to help by cutting the stitching where Dr. Grant and the fellow requested. Dr. Grant stressed the importance of a smooth stitch, because regardless of how good of a job they do, the patient is left with the scars that remain after the stitching, and the smoother the stitch is, the less noticeable the scar will be.

The entire procedure was much shorter than I thought it would be. I think total the operation took about 2.5-3 hours. Additionally, I was shocked that this was an outpatient procedure – the patient would only be in the hospital for a few hours for monitoring, and then would be able to go home. Remembering how the patient’s breasts had looked in the middle of the procedure and realizing that she would be able to go home the same day, I was absolutely amazed by the resilience of the human body. The best part of the procedure was realizing how much this procedure was going to improve the patient’s quality of life. Her breasts will look more proportional to her body size and, more importantly, she will feel so much better without having that extra weight to carry around, putting pressure on her whole body. Such a short procedure, and it would have a huge impact on her life. It was really an amazing procedure to have witnessed.