Plastic Surgery Perspectives: Part II
"Plastic Surgery Perspectives" is a recurring series of posts on the PRS Resident Chronicles blog led by Stav Brown, MD, at the Sackler School of Medicine in Tel Aviv University, and Plastic and Reconstructive Surgery Research Fellow in the Department of Surgery at Memorial Sloan Kettering Cancer Center, New York.
In the second part of this series featuring leaders in microsurgery, Dr. Brown interviews Phillip Blondeel, MD, PhD
PSR: Why did you choose the field of plastic surgery – and microsurgery in particular?
Dr. Blondeel: I didn't choose the field; the field chose me. I've always been good with my hands, so I went into general surgery – and during PGY-1, I did a rotation in plastic surgery and felt motivated to pursue this field. My professor gave me many opportunities; I was allowed to perform 25 free flaps in my first year of residency. It might have been a little risky back then, but I did pretty well and it gave me a great head start. I went to Plastic Surgery The Meeting as a PGY-5 resident, and there I saw Rob Allen, MD, and Claudio Angrigiani, MD, talk about perforator flaps. We figured that we needed to get good proof through evidence-based medicine to demonstrate the role of perforator flaps in reconstructive surgery. I earned my PhD, and we wrote a book and started the International Course of Perforator Flaps. It was genuinely a natural flow. I like a good challenge, and microsurgery has definitely been one, dealing with very small dimensions and instruments.
PSR: How has microsurgery changed since you started?
Dr. Blondeel: The greatest change has been moving from myocutaneous flaps to perforator flaps. Besides the flap itself, we used to perform very rudimentary reconstructions with very poor aesthetic results at the recipient and donor sites. Using perforator flaps, we've refined the donor site – not only the functional part, but also the aesthetic part. For example, a DIEP flap isn't only about taking the flap but also taking care of the "dog ears," making the umbilicus look nice and achieving perfect proportions. For the recipient site, we've established a way, with my publications on the three-step principle, to analyze the aesthetic problems of a breast and offer a treatment plan from a more engineering point of view and a more refined way of looking at aesthetics. With supermicrosurgery, we can now operate in smaller dimensions – and this has definitely expanded the array of pathologies we're able to treat. For instance, lymphatic surgery has been added to our scope of treatment and understanding of lymphatic problems, and its patient-selection criteria is an evolving field.
PSR: What are your main interests within this subspecialty?
Dr. Blondeel: Clinically, I'm striving for personalized medicine with significant patient participation. It's important to master all the tools in a certain surgical plan. For example, a breast reconstruction surgeon must be able to offer implants, lipofilling, lymphatic surgery and free flaps. You're not a good surgeon if you only know two of the four options for your patient. Doing autologous reconstruction when possible is always better than implant surgery; however, to provide the most-effective patient care, you need to offer the patient the full array of options and perform all the available techniques.
From a research perspective, we're heavily pursuing 3D bioprinting – we're recruiting funding and working with other faculties in chemistry, engineering, bioengineering and so on, to build a multidisciplinary approach. If you stay within the walls of your own specialty, you end up being very limited and unable to evolve. You must be able to look at the other side of the wall to see other parts of the whole picture. This leads to innovation and discovery.
PSR: Was there a particular clinical case that influenced you?
Dr. Blondeel: One of the milestones in my career has been the face transplant we performed. (Editor's note: This facial transplantation was Belgium's first and the 19th worldwide, and transpired over 20 hours in late 2011.) It has changed a lot in our view of craniofacial surgery and aesthetic facial surgery. I remember how difficult it was explaining preoperatively to the patient and his family that we were going to do a major surgery that we'd never before attempted. We successfully completed the surgery and the patient is doing extremely well. It also brought us back to the anatomy lab, which made me look at a facelift in a totally different way. You suddenly can go from imitating somebody else's technique to being creative, due to a deep understanding of facial anatomy.
Another experience that has influenced my perspective as a surgeon was being a patient myself. I underwent a neck operation since I had a C6-C7 fusion as a result of years of performing microsurgery. Aside from teaching me the importance of spending time on ergonomics, being a patient is a real eye-opener. I'm in the field – and it's taken me a long time to find the right surgeon. Surgeons have the tools to look for a surgeon: We review literature and evaluate outcomes, but it's still been an extremely difficult process. The experience taught me how patients feel and how difficult it is to make decisions – and this has made me a better doctor.
PSR: What role does technology play in microsurgery?
Dr. Blondeel: One of the major things we've done over the past 25 years is improve the safety of perforator flaps through technology: CTA, MRI, dermo scans, ICG and so on. It's all about looking for that golden vessel – the major dominant perforator – and imaging has a significant role in that process.
PSR: What most excited you when you anticipate the future of microsurgery?
Dr. Blondeel: Tissue engineering is definitely the future, and I'm excited to go back to the basics of cells and biology. It's very complex, which is discouraging and exciting at the same time, because there's so much room for innovation and discovery. Looking at the history of flap surgery, we've gone from bigger, deeper vessels to more-superficial, smaller vessels. However, there's a certain limit to what we can put together in terms of the sizes of vessels, and I think we've reached that limit in flap surgery. That's one of the main reasons why I'm currently not investing much of my time and effort in clinical research of flaps. I'm instead spending more time exploring tissue engineering. We'd be able to get rid of scarring and foreign bodies such as implants or perform these repetitive surgeries as we do with lipofilling. Surgeries will be done in one "go," using a super-elegant technique. I see a very bright future for tissue engineering. We'll have to walk away from being full-time surgeons and become part-time surgeons and part-time tissue engineers.
PSR: For a resident interested in a microsurgery Fellowship, what advice to you have?
Dr. Blondeel: Come to us! I love teaching Fellows because not only do the Fellows benefit from that, but so do their future patients – so I'm helping a much wider scope of people. If you're able to develop a technique – for example, perforator flaps or maybe in the future, tissue engineering – even people you haven't taught directly will adopt that technique, make it a part of their armamentarium and use it to help their patients. Suddenly, you'll have a pyramid where you progress from the one-on-one patient-surgeon relationship to massive amounts of people – and now you're making a difference and improving medicine on a global scale.
As for my ideal candidate for a Fellowship, we're looking for someone who is curious and involved. A great example is one of the best Fellows I've ever had: John Hijjawi, MD, who wrote the papers on the three-step principle with me. He was constantly asking questions, trying to figure out my surgical moves and techniques, and to deeply understand the rationale behind them. He kept pushing, insisting to have everything explained clearly. I realized that although I constantly got things right and had great results, I didn't know how to translate my techniques into a written text. It took us weeks to structure and solidify it to three simple steps – and finally the paper came out as a series of four parts. This is an example of a great Fellow: one who initiates interaction with you, doesn't take "no" for an answer, thinks with you, brings new ideas and pushes you to your limits.