Balls and Walnuts
more than you ever wanted to know
Balls of steel, or suspension of disbelief?
Today’s schedule presented me with a skin cancer extravaganza. The worst one left me (or, I should say, my patient — but I’m the one who has to fix it) with a 1.4 cm diameter circular defect in the lateral surface of the nose, all the way down to cartilage.
I used Zitelli’s modification of a bilobed flap (if you’re not too squeamish, click here for a description with photos and diagrams). In short, I elevated a fan-shaped flap of skin with two lobes. The first lobe consisted of a round area equal to my defect, the second a leaf-shaped lobe equal to half the defect. The whole thing rotates down and, if I’ve done everything right, closes like a charm.
And damn, but it did.
You need to understand something about this operation in particular and plasties* in general. Midway through a typical plasty, it looks like a small bomb has gone off in the middle of the surgical field. The worst such operation is breast reduction mammoplasty. Once the cuts have been made and the excess tissue has been removed, the inexperienced viewer (such as me, when I was a medical student) gazes on in horror, thinking (A) how could that possibly come back together? and (B) but she had a perfectly decent triple F cup — oh, the humanity!**
The Zitelli bilobed flap isn’t quite that bad, but it’s close. I had to undermine most of the soft tissue of the nose before I could bring everything back together. At one point, my scrub nurse said, “My God, Dr. Hoffman, what are you doing?”
That’s when it occurred to me that for a short time, I have to forget my usual state of nutlessness. I’m not the kind of guy who can filet someone’s face and bring it back together prettily — that’s not me. Yet I suspend my personal disbelief one more time and do what has to be done.
Of course, I know that many surgeons who came before me did it, made it work, and published their results. I have colleagues whom I trust who have told me, “Yeah, go for it. You’ll be surprised how well this works.” But it all comes down to me. I’m the one who creates this mess. I’m the one who has to dig himself (and the patient) out of it. And each time I do something like this, when I get to the midpoint, I quake a little.
It’s really true: I have to forget that I don’t have balls of steel. If I stopped and thought about it, I’d be paralyzed.
This is not to say that I do every case that comes my way. I send lots of things out of town to docs with honest-to-God titanium testes. Judgment is key. Back when I taught medical students and junior residents, I used to quote Dirty Harry to them ad nauseum: A man’s gotta know his limitations.
I hope you’re beginning to sense what a weird business medicine is. It doesn’t come naturally to take this much responsibility for another person’s life. Even the initial baby-steps of this process are a challenge, at least at first; I suspect most health care workers remember the first time they touched a stranger in a manner which would, in any other circumstance, get them arrested.
Medical school, residency, and even post-residency practice: it’s a ladder, and with each step, we ask ourselves, What the hell am I doing? Is this really me?
D.
*’-Plasty’ gets tacked on to an operation when the surgeon is changing the shape or appearance of something. Hence, rhinoplasty (the nose), blepharoplasty (the lids) and so forth. **When I said as much to my OR team, my circulator said, “Yeah, well, you’re not the one carrying it around all day.”
I am recovering from Blepharoptosis repair surgery due to Graves disease. The surgery was successful so you can imagine my joy at this moment. I so admire the talents of my surgeon. He is awesome and I will forever be thankful for his artistry with my eyelids.
On those TV documentaries, cosmetic surgeons get all the air time, have you ever noticed? But my vote is for docs like yours, who solve obnoxious medical problems with finesse. Great news, Lucie!
I don’t get it! I’ve looked at the pictures, and it looks so neat and tidy. If you rotate the flaps, the big one covers the defect, the second covers half of the mess left from the first flap — but half the tissue under the original site of the first flap should still be exposed,and all the tissue under the original site of the smaller flap. What’s going on here?
What you are not taking into account is the stretchability of skin. (Is that even a word? We say ‘plasticity’.) You’re borrowing skin from a place where the skin is highly mobile (the upper lateral portion of the nose) and transferring it to an area where the skin has little or no give (the lower third of the nose). Skin is amazing stuff in that regard.
Wow, Doug. Congrats on the successful procedure.
I knew my limitations early in life which is why I did not follow my father and brother into medicine. Dad was a top notch surgeon. He developed some cervical procedure and published, almost 40 years ago, but damned if I remember now what it was.
I cannot cut a straight line, even with a guide. My construction paper turkey in 4th grade was so mishapen, it looked more like an ink blot and the teacher wouldn’t display it with the work of my classmates.
I’m only marginally more adept with scissors and knives today. That I can julienne veggies and dice stuff without lopping off my own fingers is a miracle.
For some reason, I’m now inclined to be extra generous with the sunblock every day. 🙂
These sorts of procedures have been done for hundreds of years. I believe there’s documentation for being done in India way back when. It’s so amazing.
And thank god(s) for doctors with cojones! My retinal surgeon did a couple of membrane peels on my retinas, and described the consistency of the retina as being similar to wet tissue paper. After it all was said and done, I could see so much better than before it was done. That man walks on water as far as I’m concerned.
M’kay, I’m squeamish – but OMHigherBeing!! That was COOL! I’m much impressed! 🙂
Can Dr’s have groupies? LOL