Plastic Surgery Perspectives, Part V: Microsurgery
Plastic Surgery Perspectives is a recurring series of posts on the PRS Resident Chronicles blog led by Stav Brown, MD, Plastic and Reconstructive Surgery Research Fellow in the Department of Surgery at Memorial Sloan Kettering Cancer Center, New York. In the fifth and final part of this series featuring leaders in microsurgery, Dr. Brown interviews Joseph Dayan, MD. – Rod J. Rohrich, MD, Editor Emeritus, Plastic and Reconstructive Surgery
Interview by Stav Brown, MD
Research Fellow, Memorial Sloan Kettering Cancer Center
Joseph Dayan, MD
Co-director of the Lymphatic Surgery and Research Program at Memorial Sloan Kettering Cancer Center, New York, and president of the American Society for Lymphatic Surgery.
PSR: Why did you choose plastic surgery – and microsurgery in particular?
Dr. Dayan: I've always wanted to be a cardiothoracic surgeon and I liked that in general surgery, you can operate anywhere on the body and have an in-depth understanding of the human anatomy, which is beautiful, fascinating and mysterious. But I didn't want to be limited. The frontiers and innovations of microsurgery offer an endless variety of things you can do to provide a better outcome for a patient. I love the microscopic world and vascular anatomy, nerve anatomy, lymphatic anatomy – this amazing, sophisticated network delivering everything exactly where it needs to be and in exact proportion, and when it's off in just a little bit, it ceases to exist. You take a piece of tissue, you cut it out of the body, it's dead, and then you transplant it somewhere else. You resurrect it, but now it serves a function and transforms into something more useful than it was before – you take the belly fat and make it a nice-looking breast; you take a fibula, which has a purpose and a use, but it has more of a use in becoming a mandible. You're viewing structures in the body with more utility, meaning and purpose than which they were originally intended. A large frontier in plastic surgery is microsurgery, which allows us to touch the frontline of the amazing and miraculous creation of the human body and is a natural and major tool in progress and innovation for better outcomes.
PSR: How has microsurgery changed since you started?
Dr. Dayan: Microsurgery has become more approachable and demystified. It's still a technically demanding procedure, but the stress level surrounding a micro case and the duration of cases have changed dramatically. It's become streamlined and recovery has become much better with regional blocks and anti-inflammatories. It has gone from a big scary operation into a reasonable, approachable operation – not only for the surgeon but also for the patient. Being open to change has altered the culture of microsurgery. Fixating on something because it was taught to you a certain way leaves things unchangeable and realizing that has been one of my biggest developments in my personal learning curve. During my time at Chang Gung Memorial Hospital (CGMH) in Taiwan, I was exposed to an amazing microsurgery culture. Free flaps were done in a very relaxed atmosphere. We had regular O.R. banter during cases, and it totally blew my mind.
PSR: What are your main interests within microsurgery?
Dr. Dayan: From a clinical perspective, my interests center around facial nerve, lymphedema and breast reconstruction. From a research perspective, I'm interested in improving the standard of care for patients who are undergoing parotidectomy with facial nerve sacrifice and radiation. Those patients get a wide variety of procedures and outcomes from nothing to nerve grafts, multiple nerve transfers and a free flap. Facial paralysis is devastating; there's a limited window to keep those facial muscles alive and once they're gone, it's very difficult to restore. My current research interests include a protocol for multiple, targeted nerve transfers, and nerve grafts for facial reanimations after complete facial nerve sacrifice in parotidectomy patients. I'm also interested in augmented reality, using nanoparticles to identify nerve and nerve structures that are critical in surgery. On the lymphedema front, I'm interested in assessing the effectiveness of lymph node transfer and in whom it's most effective; lymphovenous bypass; immediate lymphatic reconstruction; and immediate axillary reconstruction. I'm also interested in imaging of the lymphatic system, particularly with ICG and other particles. I'm interested in measuring lymphatic transport as well as drug discovery for lymphedema. For breast reconstruction, my research interests include breast sensation and neurotization, as well as axillary reconstruction.
PSR: Which clinical case or aspect has most influenced you?
Dr. Dayan: In my first lymph node transplant after I came back from Taiwan, I had a patient who had been admitted to the hospital three times for recurrent severe cellulitis. She ran a sizable business and had to fly multiple times a week, but her life became dominated by wrapping her limb all day, every day. Her life has basically stopped – not because of her breast cancer but because of the treatment for the breast cancer. We did a lymph node transplant from the groin to the limb, and it worked. She doesn't wear a daily sleeve anymore, her arm is smaller and in the past 10 years she had only one case of cellulitis treated with oral antibiotics. She had imaging both in lymphosyntigraphy, ICG and MR and we had clear evidence of improvement. That case cemented in my mind that while lymph node transplant is certainly not always successful – and there are risks and disappointing results along the way – there are also many successes that transform these patients' lives. She lives her life fully again. That case made me believe that this is worth trying to figure out.
PSR: What excites you most about the future of microsurgery?
Dr. Dayan: I'm extremely attracted to the newest technology – not just new flaps but also new drugs and devices, augmented reality platforms and robotic surgery. These are going to transform our lives and give patients outcomes we've never dreamed. We're on a constant journey to find a better standard of care for technology and innovation. Much of my interest lies in industry, where most of the new technology becomes real. We still go into the O.R. and use our own eyes to see just like we've done for the past 4,000 years. What is surgery going to look like in 20, 30 or 50 years from now?
It would be great to go into the O.R. and see right through the skin; to see the tumor, the margins and critical structures that you might accidently cut or buzz, just like a Tesla. It's hard to get into a car accident driving a Tesla. All of us know how to drive cars, but sooner or later, most of us will be in a car accident – some of them really bad. So, what is the Tesla version of surgery? How do we make surgery more consistent around the world so that standards of care are reached and elevated? Through technology.
PSR: What's your advice for a resident interested in a microsurgical fellowship?
Dr. Dayan: True learning takes place when you see how an experienced doctor manages a large volume of complex cases and problems, and how that doctor makes clinical decisions when things are grey. When you're exposed to a variety of perspectives, it's eye-opening. Great mentorship is probably the most important thing – having somebody who feels like they want to give back and takes a particular interest in you to really guide you. That's really a rare gift.
The ideal microsurgery Fellow has fire in their belly and is talented, inquisitive, intelligent and wants to work hard. It's someone who sees the volume of work as an opportunity to actually develop, who's open-minded and is a pleasure to be around. Microsurgery is demanding – the days are long and we'd like to be with people we're actually looking forward to seeing.