Article Image

The Flap Queen

Op-Med is a collection of original articles contributed by Doximity members.

I began 2020 in tears — crying because I no longer wanted to do DIEP flaps. Crying because I doubted my abilities as a surgeon. Crying because I was afraid. I tried to blame the full moon. I tried to blame the new year. And I blamed myself.

A DIEP (deep inferior epigastric perforator) flap is a form of free flap breast reconstruction in which the lower abdominal tissue is transplanted to the chest to make a breast. It involves microvascular surgery, reconnecting an artery and a vein that are 2 mm in size so that tissue can survive. As a surgeon, the critical period for the success of this flap is the first 24 hours after surgery. During that time, the flap is connected to a tissue oxygenation monitor — I tell my patients it is a "pulse-ox for the breast."  

And here I was, getting ready to scrub in so that I could take my patient back to the OR and try to salvage her DIEP flap because her tissue oxygenation measurements were falling. And I was crying. 

Complications happen. I remember being told as a resident, “If you don’t have any complications, you aren’t operating enough.” Complications help us become better surgeons. We analyze what we can do differently so they don’t happen again. I’ve been in practice for over 15 years, so I understand this truth. But complications also affect us personally — I take every complication home with me, taking it apart piece by piece, reliving it at the dinner table, then reading and planning for the future so it will not happen again. I prided myself on my low complication rates. In our community, many referred to me as “the flap queen” because I did so many DIEP flaps. My husband is a cross-country coach and teacher. Living with a coach, I have learned that some runners are talented, others have a strong work ethic, and some have both. I believe this is also true of surgery. When I’ve worked with residents, I've observed that some have “good hands” and some appear awkward. As a runner, I’m primarily a hard worker — but as a surgeon, I believed that I had both, talent and hard work. Sewing on tiny blood vessels was my talent. Doing surgery was my talent. And I was still crying. 

For more years than I can remember, my days have started before dawn … alarm buzzes at 4:30 a.m., snooze button is pushed … up by 5 a.m., coffee, let the dogs out, go for a run, shower, round, and then on to the rest of the day, either clinic or the OR. The days just melded into a constant “go” — no time to think. This day had been no different. But rather than ending by going to bed, I was standing in front of the scrub sink. I was tired. I scrubbed. I walked into the OR. And I did surgery.

Shortly after that evening, the coronavirus made the news. At first, it was nothing to worry about. Then it was. One case became two, became three, became an epidemic, became a global pandemic. We were told, “conserve PPE,” “limit non-emergent patient interactions,” and finally, “don’t perform elective surgery.” I was confused. How long would this last? Would I remember how to operate? If a runner doesn’t run, she loses fitness and speed. Would that happen to me? I didn’t cry. I cancelled my surgeries. I rescheduled my patients. And I applied for federal assistance. 

During the moratorium on elective surgeries, I didn’t operate for seven weeks — the longest period of time during which I didn’t do surgery since 1996 when I graduated from medical school. For the first time in years, I did my daily runs without carrying a cell phone. I didn’t need to carry one because I had no patients in the hospital so no nurses needed to call me. I no longer pushed the snooze at 4:30 a.m. only to force myself out of bed at 5 a.m. Instead, I enjoyed the coffee my husband brought to me while lying in bed. I watched “Good Morning America” after my run before heading to the office. I began to enjoy living life at a slower pace. Sometimes, I drank coffee on the back porch and watched the sunrise.

I experienced a freedom that I hadn’t experienced since I became a surgeon. I had time.

Once the moratorium ended, I returned to work, performing reconstructive and cosmetic surgeries. My first day performing a microvascular bilateral breast reconstruction left me exhausted. The exhaustion continued for the entire week — my runs were slower, my body was stiff, and my empathy was lacking. I realized that I had missed surgery during the moratorium, but that I had not missed microvascular surgery. Now, I missed my time.

I learned that surgery is not the same as running. Seven weeks off didn’t affect my surgical ability or manual dexterity. I walked back into the OR as if I had never left. But I had changed mentally during those seven weeks. During my time off, I had time to think; I had time to paint; and I had time to write. For a few years, I had been contemplating reducing my schedule to four clinical days a week rather than five. Now, I did it. The pandemic gave me the courage to say my time was important. As I turned my focus inward, I learned that my identity is more than being a microvascular surgeon.

I have reached acceptance of change, of my old self, of welcoming the new. If we are constantly on the go, it becomes difficult to accept the gift of time. We live in a world in which we seek to impress — impressing other surgeons with how busy you are, how complex and difficult your cases are, how impressive your results are. Social media heightens this urge. 

I was the flap queen, and now I’m not. I’m me.

Illustration by Jennifer Bogartz

More from Op-Med