By Elisabeth Geier
A type of plastic surgery performed to correct abnormalities caused by disease, trauma, birth defects, and other causes, reconstructive surgery can offer life-changing functionality, improved confidence, and a return to self after a difficult medical event.
For surgeons, the work is primarily focused on quality of life—a process of problem-solving, patient support, and surgical innovation. Repairing bone and tissue and reconstructing body parts to help achieve a “new normal.”
To shine a light on the sometimes complicated process of reconstructive surgery, two leading plastic surgeons at Columbia, Christine Rohde, MD, Chief of the Division of Plastic Surgery, and Thomas Imahiyerobo, MD, Director of Cleft and Craniofacial Surgery at NYP/Columbia, take us through their approach, step by step. From planning, patient counseling, modeling, and pre-surgical treatments through surgery, recovery, and long-term support.
Problem-solving through Assessment
“The term plastic surgery really comes from the Greek word plastikos, which means to change,” explains Dr. Thomas Imahiyerobo. “That’s what we’re trying to do as plastic surgeons: we’re trying to change someone’s circumstance.”
Change begins by identifying reconstructive goals defined by two factors: what a person needs and desires; and what the surgeon deems possible. A surgeon’s responsibility is to meet both goals as best they can.
As a pediatric craniofacial surgeon, Dr. Imahiyerobo works closely with families of infants and small children who were born with anomalous anatomy or dysmorphology, such as cleft lip and palate or craniosynostosis. In these cases, parents and surgeons alike have a general idea of what a body part should look like—the standard structure of a lip, ear, or skull—and planning for surgery means determining the best path toward that standard. “We’re trying to get them back to a position of normal,” says Dr. Imahiyerobo.
But for adult patients, planning reconstructive surgery can be more collaborative. Dr. Christine Rohde works with breast cancer patients to determine how they want their bodies to look after surgery. “There's a big role for patient decision-making in breast reconstruction, very different than some of the other surgeries,” she says. “Part of why I love plastic surgery is because patient goals and preferences are a huge part of our discussion.”
Starting with patient counseling to discuss the risks, benefits, and results of different options greatly helps patients decide what makes the most sense for them. To get a visual idea, Dr. Rohde brings an iPad presentation with before and after photos of a range of body types and breast sizes to show examples and set expectations for surgical outcomes.
Integrative care starts on day one
Reconstruction is often a multi-step or multi-surgery collaborative process reaching across departments that may start with “deconstructive work” like the removal of growths or cancerous tissue.
“A lot of times, patients just need to meet me and the other surgeons involved and learn about the procedures. We can begin educating them about how we can re-establish their function and their anatomy at the same time,” says Dr. Imiahiyerobo. “A real asset at Columbia is that we have so many people across so many different specialties who are top-notch at what they do.”
For breast cancer patients, plastic surgery and cancer treatment often begin at the same time too. “As much as possible, we do everything in the same operation,” Dr. Rohde explains. “Immediate reconstruction is better for the patient and better for the cosmetic results.”
The focus on integrative care means patients can meet with an oncologist, a radiologist, and a plastic surgeon on the same day. “We’re all in the same building,” says Dr. Rohde, “So if a patient wants to see a plastic surgeon immediately, we can make arrangements. We always fit people in.”
Manage change and honor expectations
Both Dr. Imahiyerobo and Dr. Rohde emphasize the importance of emotional care alongside medical treatment. Before surgery occurs, it’s important for patients to understand the scope and goals of the procedure, and what to expect afterward.
When it comes to pediatric operations, there are several people to consider: “You have to attend to the needs of the child who’s your primary patient,” says Dr. Imahiyerobo, “but you equally need to attend to the needs of the family and make sure everyone is on the same page and understands what the goals of surgery are.”
For adult patients adjusting to a body changed by illness or trauma, reconstructive surgery can be an emotional ordeal. “You’re taking someone who is used to seeing themselves in one way, and trying to get them back as close as we can, and those are hard transitions for adults to go through,” says Dr. Imiahiyerobo. Much of the point of pre-surgical counseling is to empower patients to make choices about the way they want to look.
“We always emphasize that getting the cancer taken care of is the priority, but at the same time, there are opportunities to change things,” says Dr. Rohde. Some breast reconstruction patients opt to increase breast size or appreciate the results of a tummy-tuck that repurposes belly fat as breast tissue. Those with larger breasts may choose to have a reduction and lift alongside lumpectomy. And some patients opt against reconstruction altogether, but the conversations are largely similar—It’s about deciding what their body will look and feel like after treatment.
Digital planning and 3D models
“I think of surgery a lot like aviation or space exploration,” says Dr. Imahiyerobo. “For 60 seconds of lift off, you've done 60 hours of planning.” For him, that means breaking down procedures into smaller steps and having contingency plans and techniques in place to handle “unexpected turbulence.”
In recent years, virtual surgery planning software has made it possible to visualize surgical outcomes. “This is particularly helpful when we're trying to do something with the bony skeleton,” says Dr. Imahiyerobo. “If someone comes to me with an anomaly of their skull or their facial skeleton, I can get a CT scan, and within the virtual surgery programming software, I can do some mirror imaging techniques, or I can compare to normatives.”
From there, computer-aided modeling, or 3D printing, lets Dr. Imahiyerobo take digital designs and turn them into high-fidelity physical models that are actually brought into the operating room. “It really helps us bring our results to another level,” he says.
In breast reconstruction, surgical planning includes determining what type of reconstruction to pursue, depending on patient preferences and body composition, as well as projections for best outcomes.
- Implant-based reconstruction starts with a tissue expander, a temporary implant that is gradually inflated to stretch skin and muscle to create space for permanent silicone implants. With a tissue expander, patients can decide along the way what size looks and feels best to them.
- Tissue-based reconstruction takes tissue from another part of the body–typically the belly–and uses it to reshape the breast.
Dr. Rohde estimates that at least 60 percent of breast reconstruction patients have tissue-based reconstruction using microsurgery, a more technically difficult technique available at Columbia. “As an academic center, we have all of the most innovative, latest and greatest ways of doing these surgeries,” she says. “Outside of major urban centers, it's not something that's available to everyone. And, the advantage of [tissue-based microsurgery] is that it looks and feels more natural because it's your own tissue.”
Looking to the future
The reconstructive surgical process doesn’t end on the day of the operation. “If we're doing a really good job as surgeons, we’re checking in with our patients and their families again,” says Dr. Imahiyerobo. “On their emotional health and wellbeing, and adding more resources as we go along.”
Post-surgical support at NYP/Columbia includes counseling, follow-up visits, and even community events like the annual Cleft Lip and Palate Team Day, a patient-facing celebration to build community among families with similar diagnoses.
For many patients, reconstruction takes place in stages, sometimes for several years. As people age and their bodies change, they may seek additional changes. “Patients always know that there’s going to be times when they're going to come back and have revisions done or implants replaced,” says Dr. Rohde. “And getting to be part of this really important process, to help patients in a really difficult part of their life, is so rewarding.”
Dr. Imahiyerobo sees patients from birth through childhood, and sometimes well into their teens. “It's a huge privilege to be able to grow up with some of these patients,” he says, “I think we underestimate how affected our patients are, whether it’s a congenital problem or a cancer surgery, who they are has been changed, or a little piece of them has been taken away. And reconstruction is a healing process.” It’s about finding self again, gaining closure for the challenges that led to surgery, and honoring what makes one’s life one’s own.