by Safi Ali-Khan
This is the third piece in a series dedicated to exploring the nuances of plastic surgery through interviews with resident and attending surgeons.
This piece includes contributions from Dr. Alexes Hazen, Dr. Roberto L. Flores, Dr. Vishal Thanik, and Dr. Rachel Bluebond-Langner, all of whom are faculty members of the Hansjörg Wyss Department of Plastic Surgery at NYU Langone Health.
As Dr. Flores and Dr. Hazen were also members of the team that performed the historic complete face transplant at NYU Langone Health in August of 2015, a special question is directed towards them regarding this operation. All interview excerpts have been edited for brevity and clarity.
Why plastic surgery?
AH: In medical school I kept on thinking I was going to do something like international health, public health related, so I was thinking about internal medicine and I just ended up loving surgery. I thought surgery was the coolest thing ever. I’d never thought about it before, but the one thing I did always have was a connection to plastic surgery because I got burned as a child. I was very badly burned when I was two — third degree on my neck and shoulder, second degree on my entire face — and then I had multiple surgeries, skin grafts on my shoulder and neck…I was an inpatient at Cornell for two months… so that’s a huge deal obviously. And then I always went back to the plastic surgeon, you know, what could they do, could they make it any better…so I always knew that plastic surgeons do real stuff….and then when I was in med school and doing surgery I really, really liked orthopedic surgery, vascular surgery, and then I saw a plastic surgery case of a breast reconstruction using a TRAM flap and I thought that was the coolest thing I had ever seen. So then I started doing research, and there was no looking back. And why, I think it’s the same things everybody says, it’s so that you can be creative, so that it’s not the same thing every day, it’s problem solving, thinking outside of the box…and also you’re generally not dealing with chronic disease, you’re dealing with a problem, you fix it, you go on your merry way and the patient’s happy and you’re happy.
RLF: I always wanted to be a doctor. I was always interested in medicine, even from a very young age…when I got into medical school I had a strong interest in surgery, partly because of the influence of my father who is a vascular surgeon, and I had interest in many different surgical fields. I did research in cardiac surgery…and the lab I was working in shared laboratory space with Michael Longaker, and at the time the people in his lab were Babak Mehrara and Jason Spector, and a bunch of other people who they themselves have become leaders, but I was interested in heart surgery, and they were doing this bone stuff and I didn’t really care. I thought okay these are nice guys, whatever. And from cardiac surgery I started taking a big interest in neurosurgery and I thought I was going to be a neurosurgeon, but as a medical student during my surgery rotation I was assigned subspecialties and one of my subspecialties was plastic surgery, and so I just went in and said ‘Okay, this is my rotation.’ So I went into the room and I was assigned to this surgeon who was this very cooky guy who was clearly incredibly smart, but he was one of these kind of gifted, but almost a little crazy kind of guys. Super nice, and he actually did a cleft lip repair. I didn’t know that that was a component of plastic surgery and I saw this transformation, and with that one surgery that kind of changed everything. What I didn’t know was that the person who was doing that operation was this world famous surgeon named Court Cutting, but that one surgery started me on the path. I started spending more time with the unit, attending grand rounds, really thinking about it more…I felt like it was surgery at the highest level possible because it had no rules, it had principles but it didn’t have rules necessarily and you could surpass the rules, and I’ve always been a bit of a nonconformist. I’ve always been someone who would savor in the new and the challenging and going into the unknown, and I felt like a lot of plastic surgery was that by taking something that is for all intents and purposes normal — you could say it’s deformed but it’s not a disease or a diseased part — and deconstructing it and taking things completely apart and putting it together to make it look better or function better. It’s actually a very daring thing to do. If you’re going to put a knife to someone’s face and say ‘You’re going to look better from this,’ that’s a daring thing to do and being skilled enough to be able to do that was something that resonated with me. Being skilled enough to do a surgery that you couldn’t hide in the abdomen or in the chest — in particular if you’re doing surgery on the face everyone sees it, the patient will see it every day — and so your performance level needs to be at the highest level it can be consistently, that pathway was intriguing to me.
What made you choose your fellowship and certain patient populations?
VT: Hand combines a lot of the things that I really like plastic surgery. Obviously it’s micro heavy and it’s difficult micro which I really like, and I really enjoy the fact that most of it is functional surgery…Hand surgery literally gives people function and I think that’s where the real core of it is. I’m really interested in operations that I think have the ability to let people move on or get on with their lives, and do the things that they want to do. That’s really the sort of thing that I like about hand. And I like the biomechanics, it’s a real cerebral corner of plastic surgery.
AH: About 9 years ago one of the breast surgeons asked if I was willing to see a transgender patient who had a family history of breast cancer and wanted a mastectomy but then didn’t want female reconstruction, and wanted male chest wall reconstruction. And so the surgeon asked if I would do it and I said, “Well, I haven’t done it before, but… sure,” you know. So it was just serendipitous, and the patient population somehow I really connected to. Very grateful patients, very informed patients, very happy, easy. And you really change their lives. And it’s been such a positive thing for me. It was really that one patient, and there’s such a network that patients tell each other. I don’t think it’s even on my website, but it’s all word of mouth for me. Some people promote it, but for me it’s really just the patient’s who promote it.
RBL: My practice has shifted towards doing primarily gender affirming surgery…I do think that gender affirming surgery is sort of the embodiment of plastic surgery, the illustration of form and function, the opportunity to improve someone’s quality of life, and you use a variety of skill sets from craniofacial surgery to microsurgery to general principles of tissue rearrangement and even aesthetics.
RF: There is a certain place you go when you operate on somebody’s face…When you operate on somebody’s face there is a certain area that you touch with a patient, the very personal private and public part of them, and if you’re privileged enough to earn a patient’s confidence whereby they will let you in and alter that on themselves and on their own children, that is a very unique and very special relationship and duty that you have. It makes the craft that much more meaningful.
What drew you towards academic medicine?
VT: A lot of people talk about academic medicine because they say oh I love teaching and I love students and residents, and that is absolutely true. I think one of the obvious appeals of being in academics is having residents and fellows and being able to teach and learn from them, but one of the other parts of it is research, and when people talk about being an academic just meaning teaching residents and fellows that’s not academic…research and academic curiosity and trying to advance the field and innovate, that is the keystone of what it means to be an academic. And if you have research ideas and academic interests then residents and fellows are super valuable in developing and executing projects and pushing things forward, so that collaborative thing between you and your residents and fellows and students is a huge part of it, but it’s not just the teaching part of it, it’s the research part and the curiosity part. To me that’s the biggest difference in academics versus being in private I would say…I hope that we’re more curious and trying to push the boundaries and push the envelope and approach things in novel ways more because we have a little more freedom to do that compared to the grind of being in practice…I love doing cases and I love operating but if we’re not doing novel and interesting things or trying to do new things I think I would be less happy.
RLF: I was interested in craniofacial surgery and you cannot do that in a private practice, so I knew that I would have to be in an academic setting to really do the surgery the way I wanted to do it. And from an early point in my interest in plastic surgery, from even before medical school, I had an interest in research. At one point I was considering a PhD and not going to medical school, and I continued my interest in research, more clinical research, when I started forming bonds with the plastic surgery unit at NYU, and as I matured in my training my mentors ended up being people who were very academic and I really enjoyed the intellectual process, the creativity, the organizational skills, the competition of research. It’s at this point where it’s just as much a part of my identity as my clinical practice…it’s the other exciting part, and when you think about the impact you can have it’s where you really make a difference.
What was missing from your training, or what does modern training lack?
VT: I do think that one of blind spots of modern training is the business aspect of medicine…I’ve really thought that it should be a real part of the curriculum where we have people come in and talk about the nature of insurance, the nature of working for a health care system, the way people are being hired, they way they are being incentivized to work – this is really important stuff, and people don’t have intrinsic knowledge. There aren’t a lot of great ways to learn about it, and the problem is that when we don’t teach ourselves we are intrinsic losers in the system. The system is structured through really sophisticated and savvy entities, which are insurance companies and hospital systems, who have enormous resources to dedicate and we are really disadvantaged in that system both because of a lack of knowledge, and because we’re not allowed to organize, and that’s why the system is so asymmetric. I really think that’s why physicians are in this real period where many, many people are really unhappy because it’s a stacked system against them. We don’t have much say in the system, we’re not large enough stakeholders, and we don’t have the ability to organize, and so I do think that I wish I knew more, I wish we did better in training our residents and our fellows in being savvy within the system, and that’s something I think we could make an impact in. There are ways to structure a curriculum where you have people come in – hospital administrators, insurance executives, healthcare policy people – just to teach people about the system that they’re getting themselves into and where they see it going because I think that is a huge blind spot for most people…it should be part of the curriculum and it’s surprising that it’s not, even on the ACGME level.
AH: I think what is missing is in taking care of yourself. I think there is no component of wellness — we don’t talk about it, we don’t address it, and I think that we need to. We’re doctors, we know how to take care of ourselves, we take care of everybody else, but we don’t take care of ourselves. And you see it. Look at the attendings, most of them are tired and look older than stated age and are not going to yoga classes, so I think that we have to figure that out so that we’re not killing ourselves in the process of taking care of everybody else. My training was awesome, wonderful people, but my personal well being and personal life suffered, as does everyone’s. You make huge sacrifices, and I don’t want to interfere with the level of training — you need to operate and you need to do all of these things — but there are things that could be done better.
RBL: I think there’s no perfect residency, because the field is so diverse and there are so many subspecialties within the field. It’s really difficult to become a master of all of them, and I think it’s really important that you spend time operating and honing your skills so that you have a strong surgical foundation upon which you can build and learn additional techniques or additional procedures. I trained in a high volume place and I think it’s important to be in a high volume place where you have a lot of hands-on experience and you manage both simple, straightforward as well as complex cases. So you want to see a range, but there will always be an area that you see less of.
RLF: One can say, well I didn’t learn this technique, I didn’t learn that technique, what have you. My training was extremely well rounded, but I can name a bunch of techniques that I didn’t learn in residency just like anyone else can do. What I really learned in residency and particularly in fellowship, was how to think. How to make a diagnosis and how to systematically come up with a reconstructive solution that included your A plan, B plan, C plan, D plan, and how to get out of trouble. That’s really the most valuable thing that you can get from your training, because the techniques are going to continue to evolve, as will the patient demand and patient need, and you have to be able to adjust to those things. I don’t think I was necessarily lacking in anything.
What are some of the difference you notice between today’s residents and previous generations?
RLF: I think the quality of the residents just continues to improve. I have a lot of pride in my class and the people of my generation, but what I see in the residents that I’m exposed to here, where I am, is that their performance level is consistently very, very high. It makes coming to work that much more fun and that much more stimulating. I think that there is a greater reliance on digital media, which I think has its benefits but has its detriments. I think there is a benefit to reading a textbook cover to cover, and being in a world where you just look something up is convenient, but it’s unclear to me if the residents are reading the entire body of work. I don’t know. With the reliance on digital media the residents are going to resources that are, for lack of a better word, unknown to us. They are unknown resources, they could be made by experts, who knows. They’re looking at videos on YouTube by some yahoo who’s just trying to promote his practice, and they won’t be following standard of care practices in plastic surgery. You asked me before, what we’re not doing, or what’s lacking in the training — one of the things that’s very lacking, that will hurt us and it is hurting us now, is that we as a society and as educators have to populate the internet with vetted resources made by experts, made by the leaders, that the residents will go to, and we’re just, just starting to do that on a grand scale. I’ve been involved with some of it. But it really has to happen because the residents are not picking up textbooks. We are really going to lose them if we don’t create these resources for them.
VT: One of the biggest challenges as we go forth is the compression of training…I think it has to be compressed, that is the modern era, but it is more difficult for people to learn everything that they need to learn in the time that they have. There are more blind spots. The trainee that comes out now is much savvier and much more well educated in many aspects of plastic surgery, but they’re also much more focused, and their broad knowledge of surgery is less. What the value of that is, I’m not sure, it’s hard to quantify. But I do think it is a bit of a loss. We have to be vigilant and make sure that people get the exposure that they need when they train…This is like an old man sort of thing, but people of this generation are more hyper focused on the things that they are doing. We have less generalists, and more people who are hyper focused on what they’re doing. And this crosses every industry, it’s a generational thing in which people knew what they sort of wanted to do, moved to it quickly, took less time to wander around, and so they just don’t have as much exposure. I don’t know the solution. I do think that it’s great to not be in your late 30s when you’re starting your first job, and there are real advantages to being focused, but I do think that having people understand a wide swath is important. I definitely think it helps with innovation, the more you know, you can draw from different reservoirs, so we need to figure out ways in which people who are training get exposed and maintain curiosity outside of things they’re actively doing.
What most excites you as you anticipate the future of plastic surgery?
VT: I think that tissue engineering and some breakthrough in tissue engineering is the most potentially interesting thing that could happen in plastic surgery. The idea now of always having to borrow from something that has a cost or a loss in order to reconstruct something is a concept that is based out of scarcity, so scarcity of resources leads us to take from one to give to another, and it’s an equation where there’s always a negative. So the prospect of tissue engineering combined with techniques that we have allows you to be additive without the negative.
RLF: Many people would agree that right now that there’s a competition, between regenerative medicine (stem cell research), composite tissue transplantation — and robotics. By robotics I mean limb or other types of organ replacement, not robotic surgery. Each one will have its place somewhere, but we don’t know where quite yet because they’re all in the very early phases. I have an interest in regenerative medicine, and I see myself pursuing that for as long as I can. I think that the use of computer technology, 3D printing and robotics for surgery will continue to increase. I do have concern on the additional financial burden that those innovations can place on the healthcare system, as those will come into conflict at some point.
What are some of the ways in which you have observed plastic surgery making a positive impact on patients’ sense of identity?
AH: I think there are different ways of thinking about this. When you want to change something, if it’s a change related to aging you really just want to turn back the clock and there are a lot of ways to do that such that you still look natural and normal, so that’s always my goal with cosmetic age related stuff…so you’re still the same person, but you’re just maybe the person you were 10 years ago. Or, I think what happens to people, and certainly it’s happening to me, is that you have this image of yourself as what you looked like at 20 or 25, and then you see a picture of yourself you’re like, “Who is that person?” And for a lot of people they just want to stop the clock a little bit and I think that’s reasonable. I think what’s not reasonable is to want to look like something completely different. And people do that. And then there are certain, I don’t want to call them deformities, but things that are God-given that may always bother a person and that you want to change, and then there are accidents that change things and then you may want to change that…so for a lot of people if they have big ears or if your nose doesn’t fit with your face it seems reasonable to change that. And for women actually there was a recent study that showed that breast augmentation increased people’s confidence in a huge way, and I was really surprised that it would have such a difference because it doesn’t seem like that big a deal to me, but it’s a big deal to people. So I think that things that basically enhance who you are, make you feel more confident, make you feel more at ease navigating the world, those are things I’m in favor of. And if you think of all the populations we operate on — craniofacial kids, transgender patients — they just want to feel at ease and they don’t want to be binding their chest to put on the clothes that they want to wear. And for patients who have an aging face and they still want to be working and performing, they don’t want that to stand in the way of their navigation of the world…And I think for people who have craniofacial difference, they just want you to see beyond that so that you listen to them. It’s not about even beauty, it’s just about getting to a place where you see beyond their face or whatever it is.
VT: I think that’s one of the most interesting things about it. So much of our ability to do things that we want to do are really intricately tied into our hands, and that can happen in two ways: people who have defined injuries that cause loss of function, obviously the restoration of function back to normal is a big thing, but also people who have injuries that cause long term pain or just diminished capacity, they have really pervasive effects on people’s lives, which is interesting. If you have constant pain or loss of ability, dexterity, or whatever, that manifests itself in lots of things and it really affects what people can do in terms of their work, their family life, their hobbies, all of those things. So it’s really nice when you can get people back.
Reflections on performing the historic face transplantation in August of 2015, under the leadership of Dr. Eduardo D. Rodriguez:
AH: We spent so much time prepping, and we went to a facility and got the timing down, and the point of no return down and the stumbling points worked out, and so we got it so we pretty much knew how long it was going to take and the two teams had done it so many times they were probably dreaming of it in their sleep. My role was really documenting everything and coordinating between the two teams and making sure everybody was on track and knew what they were doing. And then in the end, the day of was like clockwork, everything went exactly as it was supposed to do, with just a couple little glitches. There were a couple really cool things, one was just the teamwork that it involved, two was that you can prepare and then you can perform. And then three was that at one point, the person who donated their organs, there were probably four different organ teams harvesting, and so they’re taking his heart, his kidneys, the lungs, the liver, I think his eyes, I mean literally everything. And what a gift. I mean it’s a horrible thing that happened to him and his family, but probably 10 lives he potentially saved and changed.
RF: The interest in the face transplant I think is also linked to the fascination that the public has with transformations. It is an operation that is almost out of a movie, still, and I think that it shows what we as plastic surgeons are able to do, and I think that has been very positive…I’ve got to say that the way Dr. Rodriguez has prepared, I don’t think one could do it better. We had done simulated surgeries over and over again, as surgeons on cadavers, with the entire operative team several times. He asked the team members for their feedback, from the nurses to the x-ray techs to the surgeons, and adjusted his plans with information he felt was contributory. I think the results speak for themselves, and I think everyone who was involved with the surgery, either medical or non-medical, found it to be a significant part of their professional service.
What is the most special thing about plastic surgery?
VT: One of the things that’s different is that we have longer term relationships with patients, definitely within surgery, we know our patients more, we see them for longer…I think because a lot of what we do is patient driven. A lot of stuff we do isn’t necessary, it’s driven by patients who have a desire to restore something, and so by definition we’re always engaging with patients and having a dialogue about what their goals are and our ability to deliver on those goals, so it’s always a constant discussion and because of that you have a much more developed relationship than you do with somebody who has a defined problem that absolutely has to be fixed, and once you’re done with that they’re done. All these things create a situation where you know your patients and I think that’s one thing that’s really fun and more rewarding, because you’ve gone through this thing together with them and you’ve hopefully gotten them to where they want to be and that’s cool because I think that’s what’s missing in modern medicine. I mean, what does everyone complain about? The loss of the relationship, right? Like primary care doctors who don’t have enough time. We obviously have constraints too, but we’re still able to maintain more and I think that’s what always made the field rewarding, regardless of what you do, and I think that we’re still able to maintain that more than most….I think that to me it’s the collaborative nature between patients and surgeons and that’s what’s fundamentally different. We’re making choices based on what the patients want and what we think we can deliver, and when you do that and it goes well patients are ultimately really happy because they felt like you heard them and committed your time and skill to help get them to where they want to go and it feels like a collaborative event as opposed to a one-way, that’s unique I think.
AH: I think it’s using your very particular skill set which includes your technical expertise and your artistic eye to literally change someone’s life. And it’s not a temporary change, it’s a permanent change, and it’s solving a problem for them that might not be solved otherwise.