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An interview with Christine Rohde, MD, MPH, Chief of the Division of Plastic Surgery.
Reconstruction, Trust, and the Expanding Conversation
Plastic surgery has always involved shared decision-making, but patients now seem to have more reconstructive options than ever. How has that changed the conversation?
Shared decision-making has always been a big part of plastic surgery. I think even before many other surgical specialties, because we deal so much with quality of life and the patient’s perspective.
It’s just that now there are so many options, and to make sure that we cover them all, there’s even more to discuss. Sometimes the consultations can run long. Sometimes it takes multiple conversations to decide on reconstructive pathways.
But there are also choices I may make in the operating room based on what’s going to be safest, what’s going to look the best, and heal the best. So it does require a certain level of trust between a patient and a doctor. At the end of the day, in the operating room, there are decisions that have to be made based on expertise and experience. We’re trying to make decisions that patients hopefully would agree with if they could be awake during the operation.
The nice thing is that we have a big group of reconstructive surgeons, all with different expertise. Even if there is something that I may not offer, there is likely another surgeon within our division who can speak to those techniques.
Does that mean the process leading up to surgery can be longer now?
It can be both longer appointments and more conversations, depending on the patient. We try to see patients as soon as they have a breast cancer diagnosis, as soon as they think they may want to undergo breast cancer surgery.
Working so closely with our breast surgeons helps. As soon as patients see them, if they are willing to see a plastic surgeon, we try to see them as quickly as possible. That way, there is time between seeing us and scheduling surgery for them to think about things, have a second conversation, talk with their families, and work through what feels right.
How do you guide patients through breast reconstruction when there are now so many possible paths?
I have pictures that I show patients, and I go through what I think of as a mini talk with them at their visits, to give them a sense of what the options look like. But then I also say there are some decisions that I’ll make in the operating room, and I want to make sure patients are okay with that.
For example, whether we place the implant above the muscle or below the muscle. Most of the time, I go above the muscle. Sometimes there are situations where I may need to go below the muscle, if I think that is going to be safer and heal better. So part of the conversation is making sure patients understand that.
The other thing is giving people time to think. It can be overwhelming when you get a cancer diagnosis and then have this long conversation about reconstructive options. Patients don’t have to make that decision right there with me, right away. They can go home, think about it, talk with family, and then we can talk again.
The nice thing about video visits now is that patients don’t have to come back to see me in person just to talk through the counseling of the surgery and the decisions we might make. That is something that has definitely changed in the last five years, since COVID. We use video visits to have further discussions without burdening patients with another physical visit.
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Are there moments when what seems like the best option on paper does not translate into real life?
It is more a constant acknowledgment that the patient’s vision for what they want from reconstruction may differ from mine. When it is safe and reasonable, I try to defer to the patient’s wishes.
For example, with tissue expanders, I may have a patient who does not want to be very big, but they have a lot of extra skin, or a bigger implant might look better on their body. But if a patient really says, “No, I really don’t want to be big, and I really feel comfortable at this smaller size,” then I need to have a long conversation to understand what they envision for themselves and then try to achieve that.
It may not be what I would choose aesthetically, but it is really about listening to patients and trying to understand their perspective as much as possible. Everyone has their own thoughts about their body, and obviously I can’t know 100 percent what someone is thinking. But the goal is to understand as much as we can.
How do you talk with patients when their expectations may be beyond what surgery can realistically achieve?
There are times when I have to say, “This is just not realistic, and this is what we can realistically achieve.”
With reconstruction, we are often dealing with some deformity caused by cancer or trauma or something else. There is scar tissue, and there may be the impact of radiation—things we cannot control. We are doing the best we can within those constraints.
Sometimes it is a matter of saying, “This is the best that we can do with the tools that we have.” Some patients are better at understanding that than others, but it is an important part of the conversation.
Innovation with Evidence, Not Hype
Plastic surgery is often associated with innovation; the field of tissue engineering comes to mind. What feels promising right now?
There is not a whole lot new with tissue engineering, but there are some new things we are following. The nice thing about being in an academic place is that we are well-versed in what is new, what is innovative, and what is out there in the literature. Some of those things are worthwhile, and some things are not.
There is a new injectable fat that the FDA approved to use, but we are still reserving judgment. The advantage, at least in theory, is that you do not need to do liposuction to get fat from someone. Or if someone is extremely thin and does not have any fat, where normally we would not be able to offer fat grafting, this is kind of an off-the-shelf fat that we could inject.
What is it made of?
My understanding is that it is cadaveric fat. It is injectable fat cells with extracellular matrix and proteins, purified and sterilized. But the reason I am still reserving judgment is that scientifically, it does not quite make sense to me how it works, or how it survives. It is interesting, but we will see.
Is that the kind of thing that might be used first in one setting and then studied for another?
Yes. It is often the case that things initially get approved for one use and then, as people get data, the indication can expand. We can also use something that is FDA-approved off-label for something else. So that pathway is not unusual.
But with this, it is mostly for cosmetic use right now. It is not approved for reconstruction yet. It is interesting to me, but I am still cautious.
Will you touch on wound care and how approaches may make a difference in healing for patients?
There continue to be new wound care adjuncts that help heal wounds without needing flaps or more extensive surgery. There are always new ones around. Some work better than others, and we have an armamentarium of different ones that work in different situations.
That has been very helpful for many defects, especially when someone has a skin cancer. Having adjuncts that can help a wound heal without additional scars or additional procedures is something we are seeing more and more of. We use them a lot on the nose, on the face, and in other areas where it may be difficult to reconstruct. We have seen nice results with various materials.
It is helpful because they are off the shelf. There is no donor site and no scarring from using them. In the right situation, they can be very useful.
Microsurgery, Sensation, and Function
Microsurgery has opened up possibilities across reconstructive care. Where is it changing your work today?
There are several areas. In pediatric limb salvage, for example, we have talked before about transferring someone’s growth plate intact with its blood supply and using that. Thankfully, we do not have to do it that often, but it is an example of where we work closely with orthopedic surgery and neurosurgery.
When we talk about nerve injuries and limb salvage, the goal is to salvage limbs and function using microsurgery and working closely with our ortho and neurosurgery colleagues.
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There has been growing attention to nerve regeneration and sensory recovery in microsurgery. Are we at a point where patients can expect meaningful sensation to return with these techniques?
It is still emerging. There are techniques that we can do, but I think the data is still equivocal as to how well it works. It depends on who you talk to. There are people who swear by it and say it absolutely works.
I tend to be more skeptical about things, and I need to really see the science. Everything we do has a cost, whether it is extra time in surgery, donor site morbidity, or something else. So one of the things I have been studying is sensory recovery after mastectomy over time without any interventions, just to see what the body does at baseline.
We are mapping out sensory recovery in mastectomy patients and seeing how it varies from person to person. That helps establish a baseline, so when someone does an intervention, we can better understand how much of the recovery is the body’s own recovery versus the intervention making recovery go faster.
What are you seeing so far?
We are still in the middle of the study, so I cannot give results yet. But generally, people do recover sensation. It varies, and we want to understand what the contributing factors are.
For sure, nerves grow back. They grow back into end organs and provide sensation, but it depends on what has happened. It is certainly a continuing area of interest. We would love to restore sensation, but we want to make sure we are doing it in a way that actually works and makes sense.
How does microsurgery factor into breast reconstruction?
When we talk about breast reconstruction, it is not just using the belly for fat. There are different areas of the body that we can use. These are very complex surgeries, but we are able to provide them not only at the Columbia main campus, but also in Westchester.
That is important. Patients may see a microsurgeon in Westchester but then be told they need to go into the city for surgery. We can do microsurgical breast reconstruction in Westchester. We have it set up, and we have a great track record doing it there.
Global Surgery as a Longitudinal Partnership
You have spoken before about moving away from the traditional idea of surgical mission trips. How has SHARE (Surgeons in Humanitarian Alliance for Reconstruction, Research and Education) continued to evolve?
We continue to expand. We have various levels of grant funding and partnerships with different organizations, including Operation Smile and Smile Train. We also received an international grant to fund what we do in Kenya.
We have expanded our visiting professor program from Rwanda to Kenya and Tanzania. Dr. Munabi is going to Tanzania with SHARE for a craniofacial trip to teach there.
A lot of people go on what are called surgical missions, which can be great, but they can also be problematic because they are not sustainable and do not grow local infrastructure or local talent. I am hoping this can expand people’s ideas about how we build surgical access around the world.
What does a sustainable global surgery partnership look like in practice?
Some of the unique things are the collaborative spirit and the longitudinal relationships. We have pods. I talk to my pod of surgeons at least once a month. We talk about cases, challenges, practice management, and other issues.
Then we have clinical assemblies with a larger group, and we have visiting professorships. If we operate on someone, it is really about teaching residents and surgeons how to do the operation. Then we get follow-up on WhatsApp about how the patients are doing.
Technology has changed what is possible. We can do a lot virtually. We can send videos. We can have conversations in real time. In our clinical assemblies, people are tuning in from all over the world.
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You mentioned a recent case in Tanzania. Can you talk about that?
The most recent trip to Tanzania was the first microsurgery visiting professorship there. They operated on a young woman and saved her leg. Everyone had been talking about amputation, and they did a flap to save her leg.
Today, they sent a video of her walking with a huge smile on her face. That kind of continuing follow-up is so nice. It shows what these longitudinal relationships can mean.
Has this work changed how you practice or teach back home?
In some ways, yes. We do learn back and forth. Our surgical colleagues in less-resourced areas are able to do beautiful flaps, for example, without microsurgery. I have learned from them some of their techniques for doing more with less.
It also changes how I think about teaching residents. We are teaching residents all over the world, not just in the United States, and that impacts how I think about surgical education here.
There are ways that we take things for granted because of our resources. This work brings you back to the basics and to thinking about how we approach problems surgically without all of the resources we have. It helps residents think through those options, because we do not know where people will end up practicing. We should always be aware of the different settings where someone may practice surgery.
Cosmetic Surgery in an Academic Medical Center
Cosmetic surgery has become a highly marketed product. What is the case for having cosmetic surgery in an academic medical center?
There are definitely patients who understand what we can offer. There are patients who say, “I wouldn’t go anywhere except here.” They are seeking us out.
But I think those patients are still fewer than the ones who are more influenced by social media, advertising, and everything else that exists in the cosmetic space.
We offer the various cosmetic surgeries. We are also the ones training the future cosmetic surgeons. Many of our residents go on to become the most prominent cosmetic surgeons in New York City and across the country.
It is true that we also have other interests: reconstruction, research, academics. But that also means we are at the cutting edge. We are aware of what is new, but we have also thought critically about what is new and what works. It is not just about the shiny new thing. It is about what actually helps patients more. And we are rigorous about it.
How do you approach cosmetic consultations in a culture where patients may arrive with ideas shaped by social media or trends?
We are never going to compete with a scarcity model or the kind of marketing that exists in some parts of cosmetic surgery. That is just not who we are.
A lot of our cosmetic surgery patients are people we have done reconstruction on, or their family members. They know what we do. They know our approach. They know we are not trying to sell them on anything.
I have heard patients say that they like coming to me because they do not feel like I am picking apart how they look or trying to sell them on things. I am having an honest conversation about what their wishes are and what I can do surgically to help them with that.
Do you think patients are becoming more interested in ‘natural results’ or aging more naturally?
I think so. I think there already is a movement among celebrities to look natural and let themselves age naturally.
The nice thing about plastic surgery is that we will always have something to do, whether it is the most extreme makeover, just a little touch-up, or doing something to help make a skin cancer heal as well as possible. Even with shifting winds, as long as we are focused on what patients need and want, we can adapt.
There are so many branded forms of body contouring now. What should patients understand about liposuction itself?
There are a lot of them. We do not offer all of those branded devices. There are pluses and minuses to them, but we do liposuction really nicely. If you do liposuction well, you do not necessarily need all the fancy things around it.
The basic process uses very tiny incisions. We inject fluid that helps minimize bruising and bleeding and helps prepare the tissues. Then we use a suction-assisted device. I usually use power-assisted liposuction. It is used to contour areas where there is stubborn fat that cannot be addressed otherwise.
What does “liposculpture” mean from a surgical perspective?
There are a lot of terms for things that we have always done.
To me, liposculpture can mean a couple of things. One is that we are sculpting the body using the liposuction cannula, with how we remove fat and where we remove fat from. But I also think of it in terms of using fat to inject, or fat grafting, and using that as material to sculpt areas such as divots, hip dips, breast reconstruction, and other areas where we are trying to improve contour.
The phrase “mommy makeover” is everywhere, even if many surgeons dislike the term. What procedures are usually being combined?
Usually a breast lift and a tummy tuck, or a breast lift, breast augmentation, and tummy tuck are probably the most common procedures included in that category.
Are you also seeing more men seeking body contouring or chest procedures?
Those are all things we do regularly. For men, that may include liposuction and surgery for gynecomastia, or what people sometimes call “man boobs.” The terminology changes, but the procedures themselves are things we do readily and regularly.
Lymphatic Care, Research, and Access
Where does lymphatic surgery stand now, and how broad is the program’s approach?
We are still plugging away at lymphedema. We have a broad approach. We have surgical procedures to try to help prevent lymphedema if someone is at high risk with breast surgery. We have flap surgeries and lymph node surgeries that we can do to treat lymphedema in the early stages.
Then we have researchers, and Dr. June Wu in particular, doing research in lymphatic malformations, lipedema, which is different from lymphedema, and other lymphatic abnormalities. The goal is to understand novel treatments and novel approaches to lymphatic diseases.
That is why we are the only place in New York City with this comprehensive care network for lymphatics through the Lymphatic Education & Research Network. Memorial Sloan Kettering also has certification, but ours is a comprehensive network because we are beyond just Columbia; we include a number of hospitals. We approach lymphedema and lymphatic abnormalities from many different sides, both clinically and through research.
How are you thinking about access to plastic surgery care across the region?
We are trying to expand our reach farther and farther north into New York, into places like Middletown and Goshen, starting with the Hudson Valley and moving north of there.
We are well aware that there are a lot of choices and opportunities for patients in New York City. But the farther away you get from New York City, the fewer choices and options patients have. We are trying to bring the same level of service, including state-of-the-art reconstruction, craniofacial care, and cosmetic options, to areas that are not as saturated with physicians.
Your research has long focused on understanding outcomes from the patient’s perspective. What are you trying to capture now that older measures may have missed?
Everything we do in research is trying to answer questions we do not really know yet. In everything we do, we are trying to understand the patient perspective, whether it is a new way of doing reconstruction, lymphatic surgery, or even how we understand obesity.
One thing we are studying is newer definitions of obesity. It is not just BMI anymore. There is something called the body roundness index (BRI), and there are other published measures of obesity. We deal with patients with obesity, so we want to better understand whether there is a better way to gauge obesity and how that correlates with complications or satisfaction after surgery.
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What Comes Next
Do you see robotics becoming a major part of plastic surgery?
I do not as much because plastic surgery is so much about remodeling the external body, the skin, and the tissue. Robotics is often about minimally invasive surgery and getting into deeper spaces.
It is definitely used, and people are definitely trying to expand its use. I just do not think the technology is there yet to be that useful in plastic surgery. That may change. With what we have currently available, I think robotics will find a niche and take hold in that niche, but I am not sure it is going to expand hugely into plastic surgery as a whole.
What makes you optimistic about the future of plastic surgery?
I am optimistic about the next generation of surgeons because we are involved in training them. They are curious about the world. They want to develop new techniques, and they want to innovate.
Plastic surgery is a very competitive specialty, and research is such a huge part of getting into plastic surgery residency. It is exciting to have such brilliant young minds interested in going into a surgical specialty and, hopefully, continuing to transform it.
Related:
- Orthoplastic Surgery: Function Follows Form
- Reconstructive Surgery is a Life-Changing Process of Innovation and Integrative Care
- State of the Union: Cleft and Craniofacial Surgery Today