An interview with Christine Rohde, MD, MPH, Chief of the Division of Plastic Surgery.
Jump to:
- International Surgical Partnership Expands Care in Africa
- Benefits of Cosmetic Surgery at an Academic Center
A Personalized Approach to Reconstructive Surgery
Starting in the realm of reconstructive surgery, what’s new in breast reconstruction?
There’s always interest in ways to improve how we do breast reconstruction. We’re doing much more pre-pectoral reconstruction now compared with 10 years ago, meaning putting implants above the muscle as opposed to below, but there's certainly no one-size-fits-all operation for patients.
For example, if someone's skin is very, very thin and you need an added layer of protection from the outside, going under the muscle would be a safer option. We spend a lot of time during office visits discussing all the various options and helping the patients decide what is best for them.
Are there any new alternatives to implants?
We're still doing the autologous DIEP (deep inferior epigastric perforators) flap, using their own tissue from the lower abdomen [that includes skin, fat, and blood vessels]. We can use other parts of the body too. The fat grafting alone, very few people do, and I don't think it works very well. So, when patients ask about that, we just advise them that we do fat grafting quite a bit with reconstruction, but only to improve outcomes, not to reconstruct the entire breast.
Do you use hybrid approaches to breast reconstruction?
Yes, absolutely. We do it in a few different ways. If we do tissue from the back, a latissimus lap, we usually do it with an implant because there's not enough tissue from the back. Or if we do the flap from the belly and the patient still wants to be bigger, then we can consider doing an implant. Those are the main ways that we might combine an implant and your own tissue.
In the future, could non-native tissues be used or transplanted for breast reconstruction?
One area of research is whether you can tissue-engineer fat to make a breast. There are other ways we can think about using some kind of matrix and fat grafting into it. I don't think it quite makes sense to, for example, transplant someone else's breast because the effects of the immunosuppression risks far outweigh any benefit.
Has implant technology changed in recent years?
It has. There are many implant options. Most are silicone or saline, and silicone has different levels of cohesivity that impact how soft or structured it is. So, we can discuss the optimal type of implant a patient wants in a very individualized way.
Are there other aspects of research that excite you?
I think that tissue engineering continues to be the next horizon in plastic surgery, but we're still not quite there. A lot of the research we do is on patient-reported outcomes and looking at ways we can maximize patient satisfaction and optimize safety. I'm proud to say that our division continues to be one of the major contributors of research to regional and national plastic surgery meetings with a variety of clinical outcomes and basic science research.
We recently wrote an article on orthoplastic surgery; how has the new clinical partnership of orthopedic and plastic surgery progressed?
Yes, we have set up an Orthoplastics Surgery Program here, and we continue to work in a multidisciplinary way for limb salvage. In real-time, we solve the complex reconstruction problems that come with diseases like sarcoma or bone cancer. We meet with the patients before surgery, discuss surgical plans, and work together in the OR to get the best aesthetic result for each individual patient. This has definitely led to greater patient satisfaction.
Does this orthoplastic partnership include pediatrics too?
Absolutely, both. We have a whole team of pediatric orthopedic surgeons and pediatric plastic surgeons who work together for limb salvage whether the patient is a child or an adult. We have the expertise to take care of them.
Is there anything new in microsurgery techniques?
More attention is being paid to nerve regeneration and ways to improve sensation after surgeries. Microsurgery is one way to hook up nerves or use nerve grafts. I don't have any hard solutions to tell you about, but now we can see the appearance and shape of things and figure out how best to restore nerves after reconstruction.
What are some of the most common reasons someone would need microsurgery?
Generally, for reconstruction, if you have some area of your body that needs to be removed, we can reconstruct it in a way with most similar tissues from another part of your body. So it can be for many reasons.
For example, a breast reconstruction where we can do a tummy tuck and take that skin and fat and make a breast out of it. If someone has a sarcoma and normally would need an amputation, we can take muscle from another part of your body that you won't miss and be able to cover the wound as well as potentially create functionality.
Is that part of the collaborative orthoplastic approach as well?
For sure. We have done a few sarcoma cases in pediatric patients who needed their growth plate removed in the shoulder, and we've been able to take the fibula with the growth plate from the leg and use microsurgery to hook it back up. Without that, the removal would impact growth and the child would end up with one arm much shorter than the other. By transplanting the fibula, they can continue to grow normally.
Any other developments in reconstructive surgery to know about?
There are two exciting things! One is that we can offer a full spectrum of care that includes vascular anomalies and lymphatic disorders. Dr. June Wu, who is a plastic surgeon and basic science researcher, is the world expert in this field, and we are the only designated lymphatics center of excellence in New York.
The other is that we’re building a Craniofacial Center where pediatric patients would be able to come for craniofacial care at Columbia and see all of their doctors and get counseling in one place. We have a new craniofacial attending joining Dr. Thomas Imahiyerobo this fall and even the building designs are done. We’re just clearing space to start construction.
Surgical Partnership Expands Across the Globe
Plastic surgeons at Columbia are very involved in surgical training overseas. Can you tell us a little bit about the international work you do?
I'm the Research Co-Director for an organization through the Plastic Surgery Foundation called SHARE [Surgeons in Humanitarian Alliance for Reconstruction, Research and Education]. Essentially, it's an organization dedicated to increasing global plastic surgical capacity.
How does SHARE approach surgical missions differently than many organizations have in the past?
People think of traditional mission trips as a team that goes and does a bunch of operations and then you leave, but that's really not a modern-day surgical mission. What we're about is teaching, providing resources, and providing mentorship to surgeons around the world so that they can do the optimal surgeries for the communities where they live. Essentially, we’re visiting professors. We partner with the American College of Surgeons Health Outreach Program for Equity in Global Surgery (ACS H.O.P.E.) and right now are sending surgeons to Kigali, Rwanda, to collaborate with the two plastic surgeons there, teach plastic surgery residents, and help with their curriculum.
What types of surgical teaching are prioritized on these missions?
I go as part of a microsurgery teaching group, but we also have hand surgery, burn surgery, general reconstruction, cosmetic surgery, and craniofacial surgery. Microsurgery is about moving tissue from one part of the body to another and then hooking up the blood vessels under a microscope. When we think about the last frontier of plastic surgery in Sub-Saharan Africa, it is microsurgical reconstruction, because the surgeons there have the equipment and surgical expertise to do pretty much everything that we do here.
Why is microsurgery the “last frontier?”
It might just be under-resourcing, but microsurgery requires extra training. It requires special instruments and experience in dealing with transplanting tissues around the body. And, of course, it usually requires an operating room microscope. So, it’s kind of been something that has not been pursued in Africa until recently. That’s why we send the group in a way that they need the most, with a focus on microsurgery.
What brings you back each time and makes you so passionate about the work?
It's the relationship building that we get to do longitudinally. And it's also knowing that what we do has an exponential effect. Essentially, this residency was started in Rwanda by the two plastic surgeons in the country, one trained in France and one trained in South Africa. They got back to Kigali and realized that they were the only two plastic surgeons in a country of several million and that they couldn't possibly take care of all the plastic surgical needs, mostly related to burn trauma and cancer. They couldn't possibly do it with just the two of them. So, they decided to start a residency just six years ago.
They just graduated their first class of residents! While I was there, residents from Burundi, Zambia, and Congo came to train. It's already become a hub of plastic surgical training. And you can just see how quickly those trained in this program will go back to where they live and train more people. Because of it, there's already been really rapid growth in the number of plastic surgeons in Rwanda.
The Benefits of Cosmetic Surgery at an Academic Center
Private practices often dominate the field of cosmetic plastic surgery with advertising, outreach, and even TV shows. Why should someone consider a surgeon at an academic institution?
When you come to a place like Columbia, you know that your surgeons are up to date on the latest techniques and technologies. You know that your whole team is people who are committed to not only the surgical procedure but perhaps even being the ones who are writing papers about the best ways to do things. Columbia has vetted us in a way that doesn't happen for private practitioners. So you can be assured that people who are hired by Columbia are the top surgeons for their field in the country.
What can you offer patients who want to see before-and-after photos as part of their research before choosing a surgeon?
I’ve never loved asking a patient if we can share their photos publicly, but we always go through pre- and post-op pictures during consultation. We have plenty of photos, and it’s so beneficial to view them while in consultation. There's so much information on the web that people can access, but it's information without any context. You may find things online, but without the context of an individualized examination and personalized care, it's really hard to compare what happens to you individually as a patient to what you read online. That's why it's so important to come see us in person, have us examine you, and talk to you about what the best procedure is for you personally.
How often are you doing surgical revisions to cosmetic procedures done elsewhere?
We’ve always done revisions in general, so it’s common. If somebody seeing me had surgery done somewhere else, we'll evaluate them and see if there is something that we can revise. But I do try to encourage people to see their original surgeon first. Unfortunately, we do see a lot of complications of surgeries done in places by surgeons who aren't as well trained or properly credentialed. We try to do the best that we can for them.
Do you offer any non-surgical procedures?
We do fillers and botox. We don’t have lasers at the moment.
What are the benefits of seeing a surgeon for something like fillers?
The main benefit is that you're having it done by someone who has trained and really understands the anatomy. Someone who can take care of you completely through the whole process of rejuvenation. It's not just injections, let's say eventually you have other concerns that injections aren't going to help. We are the ones who start you off with the less invasive type of procedures, and we can take care of you through the whole process if you eventually want a facelift, fat grafting, or other things that are part of rejuvenation.
There's additional safety when you're having it done by a surgeon, too. If there are issues, we can address them, as opposed to if you get injected at a clinic and then they have a problem and must send you to us.
Give us an overview of how the cosmetic surgery program has developed at Columbia.
It’s exciting. We now have our own cosmetic surgery center in Westchester, which enables us to perform cosmetic procedures at competitive rates. Because of that, we've been able to expand our capacity to perform cosmetic procedures and the full spectrum of facial rejuvenation and breast and body contouring. And we can do all that at our center, which is across the street from NYP Westchester.
What makes you most optimistic about the future?
I'm optimistic that we can continue to do cutting-edge research that leads to cutting-edge surgeries that continue to increase the quality of life of our patients. Our goal is to help patients live their best lives through reconstructive and cosmetic surgery.
Related:
- The Modern International Surgical Mission Starts Local and Stays Local
- Orthoplastic Surgery: Function Follows Form
- Oncoplastic Surgery: An Interdisciplinary Trend Towards Breast Conservation in Breast Cancer Surgery