plastics / plasticities

I'm done with my surgery rotation: one month of general surgery and one month of specialties (two weeks of transplant surgery and two weeks of plastic surgery). There was a lot to consider and write about in these past couple months, but there was little time and energy to do so. Ideally I'd like to start from the beginning, but starting from there and thinking about how much has to be rendered, is a little overwhelming for me even after 12 hours of catch-up sleep. So I'll start from the end, where it's freshest and easiest to retrieve.

In the two weeks of plastics, I never once saw the same procedure twice except for two or three minor removals of moles. Every day the variety and creativity made me think of it as plasticity, the capacity of our imaginations and skin to move and stretch. Plastics in general is a very broad entity. I'm sure there's a technical all-encompassing definition of what qualifies as plastic surgery, in the little guidebook they gave the students but I'm bad with defined definitions and technicalities. From my short experience I think of it as making molds and shifts, for any combination of structure, function and appearance. I find this an admirable endeavor, because it takes both art and empathy, in addition to the anatomy and science of surgery.

To be completely honest, my surgery rotation took a lot out of me and I'm still recovering. So I find it difficult to write in any other way than by a sort of list and free reflection, but maybe that's the best way in this case.

Day 1: Hand surgery. The first case consisted of carpel tunnel, trigger finger, and tenosynovitis all in one hand. These all follow similar pathologies of compressed tendons causing pain or dysfunction, and the procedures were simple releases of the respective tendons, placed in different areas of the hand. Hands have the most amazing anatomy in my opinion; they are so finely controlled. There are eight bones at the base of your hand--eight! Then four for each finger, three for your thumb. So many for such a small space. There are different tendons for each separate movement of each digit, and they extend from your forearm into the hand, and when the surgeon exposes them in the wrist, he can tug on one and make a finger move exactly as predicted. Besides the anatomical elegance, hands are so important in daily function; think of everything you need them for and how detrimental it would be for them to have pain or lose function.

In surgery they place sterile drapes on everything that's not being operated on, so in hand surgery the only thing you see is the person's hand. Sometimes there's such contrast between a person's hands and the rest of them. A face can be so rough and a hand so delicate, or vice versa, and it makes you think that there's so much to know about someone. In any case the capacity and shape of hands make them all pretty damn beautiful, and I can see why they take on so much importance in some cultures. That's where part of the uniqueness of plastics comes in; it remembers how deep aesthetics run below the surface.

Day 2: Cleft palate, eye reconstruction. I love the cleft lip and palate cases, as they're kids, and their smallness is made fuller by the small space of the mouth. Kids born with these defects return throughout their lives until adulthood, to fix the multiple problems arising from the incomplete fusion of their palates. It's interesting and touching to fix a "defect" of which they are too young to be aware. The eye reconstruction for an eye injured while ziplining consisted of molding plaster to place underneath the eyeball to lift it up and match the other eye. The person had lost much of the vision in this eye, but people need more from their eyes than to look out from them. As the surgeons looked from every angle to strive for symmetry, I realized eyes are also looked into.

Day 3: Melanoma removal. From these and the removals of moles, I was surprised that when a small area of your skin is removed, you can pull the surrounding areas together to cover it, as though we were designed with a bit of excess just for the possibility of mistakes and misfortune. Many of these occur on the face, and the surgeons cut them in a particular arrangement such that when the surrounding skin is used to close the wound, the result is very natural. There are natural creases in the face, and the surgeons cut as to conserve these; the creases that we inflict are then sewn with such care that the inevitable scars are underwhelming. Small changes are always felt by the bearer of them, and while these can never be completely eradicated, I appreciate the surgeons' sensitivity to the nuances.

Day 4: Resection of squamous cell (skin) cancer of the arm. This was a sad case, as the cancer penetrated much deeper than we anticipated. Originally, the skin was to be removed and covered with skin taken from another area of the body. But it turned out that the cancer went beyond the skin deep into the muscle; the surgeon removed what he thought was reasonable to take at that moment and the rest of the case was canceled, to further investigate the nature of her cancer. Instead of being closed with a skin graft, the area removed was left completely open, wrapped and covered with gauze. The sight of that made cancer visceral, something I felt in my throat more tightly than when I learned about cancer or interacted with cancer patients. And the weak cries of pain from the elderly woman with dementia, who couldn't express fight as even a child would by pulling away, made me feel there's a lot we can't cut away so easily. See Day 8 for a follow-up.

Day 5: Breast reconstruction. Most of the breast reconstructions I've seen here are for mastectomies for breast cancer. One consisted of making an entirely new nipple, by raising existing breast tissue. I did not expect to be impressed by this at all, but I was. It isn't until you see something being made from scratch that you realize how much structure it contains. With my own limited capabilities I've tried to craft things, and know it's much easier in theory than in practice to make something you make resemble something natural (which is probably why most of my Halloween costumes are abstract). It also feels important, this attempt to give back something a woman has lost that she's probably never anticipated losing. Regaining a breast is a slow process, that often requires gradually expanding the space underneath the tissue you've injured by removing the cancer, before you can place implants or other means of reconstructing the breast. In one case I watched the surgeon transfer fat from the belly to the breast--how malleable we are, how much can flow from one space to another if we only think of it. I also saw a breast reduction, which was the bloodiest surgery I've seen thus far; who knew that space encased so much red?

Day 6: I can't remember...

Day 7: Skin flap, which means taking the skin and muscle of one area of the body to cover another. This was a long day, with the surgery ending at 9:30 at night. The patient had basal cell cancer, another skin cancer that doesn't spread to other parts of the body but does invade local areas pretty aggressively. It takes years and years to do this, so sometimes people ignore it until it gets to be quite a large area. In this case, it had gotten so out of hand that the ear nose throat surgeons had to remove her ear, facial bones, and most of the left side of her face including the nerves. I didn't enter the surgery until much of this had been taken, and I couldn't recognize anything to orient me to what exactly we were working on; it wasn't until I saw her exposed neck (her jugular vein and carotid artery were completely out in the open) that I could somewhat tell. To cover this large area, the plastic surgeons took a large flap from her thigh. It took quite a bit of effort to use the thigh's surrounding skin to close this new wound, and even more to contour the flap to suit its new location on the face. In the end, it looked like a face, her face.

Day 8: Resection of skin cancer from Day 4. They decided that they could take out her entire tumor; they'd go back and take out the muscle that it had invaded. They planned to take the skin and muscle from a muscle on your side called the latissimus. They cut away at one edge of the cancer while I pulled on the other edge, and at one point they'd made enough progress that as I pulled the entire thing came away from her body. I felt then that we were doing something. Later they moved to under her arm, where the cancer had spread, and found that the cancer had wrapped itself around the vessels supplying the latissimus muscle. If we wanted to get rid of the cancer, we'd have to sacrifice the vessels, and thus sacrifice the muscle that was to replace the gaping hole the cancer left in her already fragile arm. And so that's what happened. Though her arm skin was loose enough to be able to be pulled over the wound, the inability to replace the removed muscle left her arm thinner and without much function. This was disappointing to everyone, and harder than I imagined, to see her be twice cut away...the cancer removed but likely to recur, her body and function progressively lessening in character. It made concrete the idea of fighting cancer, something that had previously seemed to mean a conceptual and mental battle but that I now know is also a physical struggle that is fully felt by the person.

Day 9: Skin graft. In this case, only the skin of an area is removed to replace another damaged area; no muscle is taken as with a skin flap. This elderly patient suffered a stroke and fell onto a heater that burned her back and knee quite badly. The surgeon razed a thin layer of skin from her thighs, and ran the skin through a little machine that places little holes into it to make a mesh with more surface area. This was originally invented for burn victims, who lost more skin than they could replace with the skin they still had. It's procedures like this that make for terms like "donor" and "recipient," both of which refer to the same person. One part gives to another, and I felt lucky to have seen this connectedness, to see things come together that I hadn't even realized had been apart.

Day 10: Nasal fracture, mandibular fracture. These reminded me of having my wisdom teeth taken out, fully awake--I didn't feel anything, but the noises of cracking and screwing together bone terrified me. The first person had broken his nose in a fight, and the other had broken both sides of his mandible and I don't know how. In addition to moving things around, plastic surgeons are good at putting things back in place, but I hope I never have anything in me knocked out of its origin.

Over the course of two weeks of seeing things rearranged and created to make things of value for people, I find myself glad that people require so many views to see them. I'm not personally equipped to do what these surgeons do, and so I feel lucky to have at the least seen a small part of their work. Sometimes it's painful to know how easily we can be damaged, but I think the plasticity that makes that true is also what makes repair possible.

ellipse

We removed a mole from the scalp of a sweet little boy today (it has a low potential to become cancerous). They incised an ellipse around the area to be removed. A circular wound doesn't work, because when you bring the edges together to sew into what will be his scar, there will be areas that don't meet and cause a bump. To render it smooth, you make an ellipse instead (three times as long as it is wide). And with your hand, you have to stretch all the surrounding skin under the scalp, to release the tension. Tension doesn't bode well for stitching the wound.

For all the pains of surgery, it's pushed me to stretch farther than I imagined. And at the least and most, I've had many experiences, which is what I came here for. I'm looking forward to processing and stitching them up, into a scar whose pain is past but whose presence is palpable.