by Anup Patel, MD, MBA with assistance from Dr. Akshay Deshpande (microsurgery fellow)
India proves home for me for many reasons despite being born in the United States. First, most of my family and many of my friends reside there. Second, Cents of Relief, the nonprofit that I co-founded with Rina, my wife, endeavors to empower victims of human trafficking in India through healthcare and education. Third, with some good fortune, I have had the chance to participate in cleft and burn missions across India in conjunction with Operation Smile. Thus, with my remaining elective time, I decided to head to India after Paris to continue my plastic surgerytraining.
Following a tumultuous departure from France including having all of my credit cards, driver license, and cash stolen off a train, I managed to arrive at Charles de Gaulle Airport and board the ten-hour flight from Paris to Mumbai. Yet, while I hate long journeys, ten hours seemed to be the average time each patient traveled to get to the next hospital I began my stint at. That hospital was none other than Tata Memorial Hospital (TMH) in Mumbai: India’s “Mecca” for oncological resection and reconstruction. Yatin mama (uncle on mother’s side) and Shrutimami (aunt on mother’s side), who work in the medical field, contacted their friend Dr. Shirpad Banavalli, the chair of medical oncology at TMH, to assist me in garnering a rotator position in TMH’s arm of plastic and reconstructive surgery.
Synonymous with the “best in cancer treatment, “TMH treats a wide-range of cancer pathology divided into disease-management groups (DMG). Dr. Banavalli, the chair of medical oncology, advocates this approach as it enables patients with a certain disease to see all the respective consultants in a single area maximizing efficiency. I opted for the head and neck oncologic DMG not only because of a strong interest in the field, but also because Dr. Stephan Ariyan, one of my attendings, recommended it highly.
As a side note, Dr. Ariyan visited TMH in the 1980s at the request of Dr. Jatin Shah, the current chief of head and neck surgery at Memorial Sloan-Kettering, for them to perform joint head and neck tumor extirpation and reconstruction. Dr. Ariyan remembers vividly going to the floor to identify patientswho would require head and neck reconstruction with the pectoralis major myocutaneous flap, which he described its use for head and neck defects in 1979.(1) The task proved immensely difficult as he looked down the hallway seeing numerous patients, with varying types of head and neck tumors, in different anatomical locations, at various disease stages. He told me at TMH one will witness every type of head and neck tumor including many fungating and exophytic lesions due to the abject poverty that delays treatment.
Walking into TMH, everything Dr. Ariyan said proved true. The patients come from all over India, often using every bit of their money just get to TMH, only then to find themselves without any funds left for food or lodging. Thus, one can routinely find patients waiting for surgery sleeping on the footpaths outside the hospital. The ones covering their mouths with masks or handkerchiefsare attempting to hide some sort of fungating lesion in order to avoid the associated social stigmata. The clinics are teeming with patients, many of whom, must wait weeks before being brought to the operative room.
To keep up with this demand, the plastic and reconstructive surgery service at TMH routinely perform three to four free flaps per day operating from head to toe. Specifically, at TMH, of the 500 free flaps performed last year, 400 were for head and neck defects, 50 for breasts, and 50 for lower extremity and chest wall defects.
The unit consists of Dr. Prabha Yadav, its chief, Drs. Vinay Kant Shankhdhar and Dushyant Jaiswal, its two-full time attendings, and a slew of residents and fellows. Drs. Akshay Deshpande and Saumya Mathews proved to be the fellow and resident, respectively, whomI got linked up with and, ultimately, became close friends with. Every member of TMH welcomed me into the operating rooms and took me through the thought-process of the case. Our exchange facilitated provocative discussions continuing to advance the field of reconstructive surgery.
In one operating room, Dr. Jaiswal designed a free fibula flap with a double skin paddle to resurface the mandibular defect (Fig 2).(2) The double skin paddle enabled one free flap to provide both internal mucosal lining and external cutaneous coverage. Rapidly, the flap was elevated identifying the perforators to the skin, dissecting the anterior and lateral compartments off the bone, and garnering adequate pedicle length. The flap was inset and the microanastomosis were performed with the microscope. With the fibula fixed in place with a plate, the soft-tissue was redraped restoring facial harmony.
While at our institution the veins are generally anastamosed using couplers, at TMH, largely due to the costs constraints, the veins are hand-sewn. The high-volume combined with the surgical skillset at TMH enables the veins to be done as if couplers were being used. In fact, one case I remember standing out was when Dr. Vinay Kant Shankhdhar performed an end-to-side internal jugular vein to the vena comitantes of a free ALT flap for resurfacing the oral commissure and submental area. Using horizontal mattresses stitches to compensate for the size discrepancy, he performed the otherwise challenging suturing effortlessly. After the arterial anastomosis was completed, the flap turned pink without any leaks from the anastomoses.
In fact, these attendings love teaching holding a monthly microsurgical workshop that includes a cadaver dissection course for learning the essentials of flap harvest. The course selects four candidates (on a first-come, first-serve basis) who are required to pay the course fee of $600. The course focuses on head and neck reconstruction providing instruction on how to perform free flaps such as fibula, anterolateral thigh, and radial artery forearm as well as pedicled flaps such as the pectoralis major myocutaneous flap. Comprehensive, didactic lectures are delivered on flap harvest techniques and later in the day the attendees are taken to the operating room to observe the relevant surgeries from Monday to Thursday. The last day consists of an organized cadaver dissection course where the attendees harvest the flaps on the cadaver under the guidance of the faculty.
The TMH plastic surgery section proved to be one of my best experiences witnessing how in a resource-constrained setting, its staff delivers optimal care to treat some of the most complex oncological cases in the world. The gregarious and welcoming attitude stems from how Dr. Yadav as she treats each and every person with respect and kindness. The surgical education utilizes articles from Plastic and Reconstructive Surgery to stimulate thought and discussion for the weekly didactics and M and M lecture. Furthermore, Drs. Akshay and Dr. Saumaya told me the white journal’s videos and online content enable them to quickly review technical steps for cases the next day.
Those of you wanting to see diverse oncologic pathology, particularly in the head and neck region, should visit TMH to see how the plastic surgery unit here continues to work advance the reconstructive frontier.
Figure 1: Tata Memorial Hospital’s clinic with Saumya and Akshay
Figure 2: Dr. Jaiswal and a fellow are harvesting a free fibula flap for a head and neck oncologic defect at Tata Memorial Hospital.
1. Ariyan S. The pectoralis major myocutaneous flap. A versatile flap for reconstruction in the head and neck. Plast Reconstr Surg. 1979 Jan;63(1):73-81. PubMed PMID: 372988.
2. Yadav PS, Shankhdhar VK, Dushyant J, Seetharaman SS, Rajendra G. Two in one: Double free flap from a single free fibula osteocutaneous unit. Indian J Plast Surg. 2012 Sep;45(3):459-65. PubMed PMID: 23450653. Pubmed Central PMCID: 3580343.