week 4

I was so surprised that this week was already our fourth week of summer immersion. However, what made me more astonished were surgeries that I observed during last week.

Last week, fortunately I had a great chance to witness astonishing cases in plastic surgery and neurosurgery. First of all, there were two big plastic surgeries. One was skin free flap to the throat of the oral cancer patient and the other one was soft tissue free flap for patient who had a large size of tumor in the right maxillary region with deformity of ethmoid bone. For the first surgery, the patient was 44 years old women having a chunk of tumor on the area of pharynx. Thus, her neck was dissected and mental protuberance which is the part of jawbone right below the lip was cut to access to the lesion. When neck was dissected, the dissected line was also significantly important. The straight dissected line can cause a lot of contraction of the neck muscle when they are sutured and move. However, if neck was dissected along curved neck line, it will not result in contraction and tension. Lateral jawbone below the right ear was also excised to totally open neck and the half of face under eyes. After tumor was excised, the empty space where tumor was used to be had to be filled. There are several reasons beyond but one of the main reason is the empty space can cause improper movement of tongue. Also, blood supply is essential as well. Thus, about 15 cm of skin and soft tissue on the arm with radial artery and vein was cut and translocated to the empty space. Since there are two arteries on the arm one of which is radial and the other of which is ulnar artery, it is okay to facilitate one artery. Blood can perfuse to the other artery after taking out one artery. Radial artery and vein of skin on the donor site and artery and vein on pharynx were connected under microscope. A coupler was used to connect veins but artery had to be firmly sutured since artery is covered by thick muscle and have higher blood flow and pressure. It was 16 hour long surgery so I was exhausted by the time when I left. However, it was a really astonishing and instructive case since I was able to learn head and neck anatomy and some of principle beyond surgery for oral cancer. The second case was similar as the first case but the difference was where tumor was formed. The patient was 26 year old, young female and a large size of tumor was blocking her nasal cavity since tumor was sprawling from the right side of ethmoid bone to the maxillary region. She had a severe congestion and higher pressure on her right eye, which brought her to hospital and unexpectedly found out the tumor. One of the interesting things was she could not find out until the tumor grew as big as a fist. This was not because she was insensitive but because generally people cannot feel anything growing underneath ethmoid bone until they become noticeably enormous.

In addition to plastic surgeries, I was able to explore neurosurgeries such as endoscopic tumor resection and craniotomy for tumor resection. The first case is endoscopic resection for bilateral tumor which was totally different from what I have seen since most of cases that I have seen in plastic surgeries were open-surgery which means dissecting and totally opening the certain area to debride or get access to the lesion. The patient had 4cm macroadenoma on the pituitary gland and the pituitary macroadenoma can cause hypopituitarism (decrease of hormonal secretion from pituitary gland) and higher pressure within skull and thus compress brain. Through nasalectomy with endoscopic tools, Dr. Schwartz was able to reach the lesion in the pituitary gland and then excised tumor. Subsequently, nasal septum flap had to be followed to protect from leaking cerebrospinal fluid to the outside of brain. Thus, nasal septum was flapped over to the excision part of pituitary gland. Also one of the amazing things was being able to find the specific area in the brain using MRI picture and ‘brain GPS’. While surgery was in progress, we were able to watch how tumor was excised and nasal septum flap was done through screen connected to endoscope and brain GPS. The other surgery was craniotomy for Meningioma resection which was totally opened surgery through drilling skull. The problem of this patient was shifting right side of brain to the left as well as higher pressure within the skull. Shifting one side of brain to the other side can cause malfunction of brain since each side of brain has different functions and characteristics. Once it is compressed and shifted to the other side, the unique functions that each side of brain has will be ruined. One of the interesting parts in this case was that the excised part was not sutured but just covered with soft tissue and a lot of gel type of cream called “Dura Seal”. The soft tissue will not have any role in brain but play a role as filler to the empty space. Also, saline will help compressed brain by tumor come back to the normal shape and location. From the cases that I observed, I could learn how engineering technique is used specifically as well as more about brain and nose, neck anatomy. Also, I really thank a couple of medical school students attending in those cases together for good and detailed explanation which helped me a lot.

Next week, I will try to see more diverse areas and work on my project which will be being a trial patient for liposuction and appreciating how it works for me.