I like to base my blogs on comments or questions that patients or peers bring up in our day-to-day practice. Recently, my partner and I have been asked by others in the medical field which of us is the “plastic surgeon,” and which is the “microsurgeon?” Along similar lines, I’ve also been asked by patients to clarify what microsurgery actually means.
Microsurgery describes any surgery that involves structures that are so small that a microscope is required to perform the operation. If the operation involves connecting very small blood vessels, then it is more specifically referred to as microvascular surgery.
When we reconstruct a breast using tissue from the lower abdomen using techniques such as the DIEP flap, we performing both microsurgery and microvascular surgery:
- The skin and fat that is removed from the lower abdomen must include blood vessels that course through the six-pack muscle. In order to keep the muscle intact, the surgeon uses loupes, or magnifying glasses, to free the tiny blood vessels from the surrounding muscle tissue.
- Once the tissue from the abdomen has been freed, it is transferred up to the chest where the small blood vessels of the flap are then connected to small blood vessels on the chest. We use an operative microscope (see figure) to magnify the field and allow us to place the stiches that hold the vessels together. Once this microvascular part of the operation is done, the tissue is ready to be turned into a breast.
How small are the vessels that we are connecting? Generally speaking, for a DIEP flap breast reconstruction, the vessels are about 2 mm in diameter. For comparison, this is about the same width as the end of a ball-point pen.
If you think that’s small, the stitches that we use to sew the vessels together are even smaller! The stitches, or sutures, that we typically use for sewing these small arteries together measures between 30-40 microns in diameter. This is even thinner than human hair, which measures between 60-80 microns in thickness.
Getting back to the question above, who is the microsurgeon and who is the plastic surgeon? Well, Dr. Tiwari and I are both plastic surgeons and microvascular surgeons. We practice plastic surgery, focusing on operations of the breast and body, both reconstructive and aesthetic. We are also both certified by the American Board of Plastic Surgery. As I’ve written about in a previous blog, this certification is recognized by the American Board of Medical Specialties (ABMS). According to the ABMS:
“The primary function of each ABMS Member Board is to certify physicians in their primary specialty and subspecialty areas and to support the professional development of those Board Certified physicians throughout their career. This is accomplished through a comprehensive process involving educational requirements, professional peer evaluation, examination, and professional development.”
We both are also microvascular surgeons because we have completed fellowship training dedicated to microsurgery. While there are many highly qualified programs which offer this type of fellowship training, we both completed ours at the MD Anderson Cancer Center in Houston, Texas where microvascular surgery is performed almost daily by some of the world’s leaders in this field. In addition to this training, we are active members in the American Society of Reconstructive Microsurgery (ASRM), which serves “to promote, encourage, foster, and advance the art and science of microsurgery and complex reconstruction.” Click here to learn more about the ASRM and to see if your physician is a member.
As always, we are happy to take questions and comments at [email protected].