Plastic Surgery Perspectives: Hand Surgery

"Plastic Surgery Perspectives" is a recurring series of posts on the PRS Resident Chronicles blog led by Stav Brown, MD, Plastic and Reconstructive Surgery Research Fellow in the Department of Surgery at Memorial Sloan Kettering Cancer Center, New York. In this installment of the series featuring leaders in hand surgery, Dr. Brown interviews L. Scott Levin, MD. – Rod J. Rohrich, MD, Editor Emeritus, Plastic and Reconstructive Surgery

Interview by Stav Brown, MD
Research Fellow, Memorial Sloan Kettering Cancer Center

Scott Levin, MD
Chair, Department of Orthopaedic Surgery, Co-Director, Penn Nerve Center, Paul B. Magnuson Professor of Bone and Joint Surgery, Professor of Plastic Surgery at UPenn

PSR: Why did you choose plastic surgery and hand surgery in particular?

Dr. Levin: My exposure to hand microsurgery started when I was an undergraduate at Duke, pushing patients around and mopping floors. That's where I saw some of the first cases of replantation. I first started my career training in general and thoracic surgery – and two years of general thoracic were required as a prerequisite in the early 1980s before you could even enter into orthopedic training. During that time, I became very enamored with vascular surgery. It was clear that if I was going to master surgery of the upper extremity, microsurgical skills would be essential. I figured that if I really wanted to know about soft tissue, I had to become a plastic surgeon. I had an opportunity to work with Harry Buncke, MD, and decided I would extend my training for three years, which included a hand fellowship in Louisville with Harold Kleinert, MD, and Joe Kutz, MD, along with other luminaries such as Rob Acland, MBBS. I came back to Duke to finish my plastic surgery training, heavily influenced by late William Barwick, MD, and Chris Peterson, MD. All these factors were instrumental in my evolution as a clinician and educator.

PSR: How has hand surgery changes since you started?

Dr. Levin: One of the main things – which is an area of concern – is that we are going backward in our enthusiasm and passion for hand surgery and microsurgery, which could be related to reimbursement. There are only a few people in the United States doing consummate, trauma hand surgery who truly have the concepts needed to keep up with other places in the world. I'm concerned that we aren't training people like a Neil Jones, MD, or Joe Upton, MD, at the rate necessary to service the needs of our population. We certainly have turned our back on a number of areas that our colleagues around the world do effectively and with great results.

Another thing is that the concept of super microsurgery needs to find its place, particularly in the extremities. Despite outstanding work by people such as Joseph Dayan, MD, and David Chang, MD, the adaptation of lymphovenous anastomosis is something that I think needs to continue to evolve – specifically for the upper extremity and the hand surgeon. That is an area only plastic surgeons who perform a lot of microsurgery will become interested in, and it should find its place in our educational programs.

PSR: Is there a particular clinical case that influenced you?

Dr. Levin: The first vascularized composite allotransplantation (VCA) we did absolutely convinced me that this is the future – and we've done subsequent work in vascularized joint and vascularized bone transfer in the lab. I'm absolutely convinced that once we crack the barriers – not only insurance and funding, but also those related to immunosuppression – this will become, as Joe Murray said, the "Nobel Prize winner." The new field of restorative surgery for hands, faces, penis and abdominal wall is exciting. We've even started a uterus transplant program here at Penn. Steve Kovach, MD, one of my partners here, is an exquisitely talented microsurgeon, and I've helped those who work on infertility here get a program up and running that has now seen three or four babies born to women who've had uterus transplantation. It comes down to VCA, a vascular anastomosis, immunosuppression and teamwork. Plastic surgeons have always been the innovators within medicine. We go beyond what's thought of as conventional.

PSR: What most excites you about the future of hand surgery?

Dr. Levin: The idea of robotic microsurgery is exciting. By way of disclosure, I consult for a company called MMI, which has key opinion leaders from around the world who agree that this area has tremendous promise for the future. Plastic surgeons are also leaders in this area, as we continue to reinvent ourselves and think outside the box. All of us should continue to have imagination and, rather than say, "It can't be done," we need to ask: "How do we do it?" I started my internship 41 years ago. What's plastic surgery or hand surgery going to look like 41 years from now? The problems that were thought to be intractable 41 years ago we solve routinely now with a variety of techniques – bone substitutes, microsurgery, tissue engineering, microneural surgery, brachial plexus, you name it. A lot of what we have now didn't exist 41 years ago, so just imagine 41 years from now. Hopefully somebody will read this interview someday and say, "What that guy was talking about is so archaic. Taking tissue from one part of the body and moving it?"

If we really look down the road, the idea of seeing xenotransplantation, robotic surgery, regenerative peripheral nerve interfaces, osseointegration – all of those new areas will continue to find their place in plastic surgeons' armamentarium. The world is our oyster and we're only limited by our imagination and our grit. As Angela Duckworth, a psychology professor at Penn, who wrote the book Grit, says: It takes grit to go from identifying a problem to solving it. If we have grit, imagination, determination, a strong work ethic and teamwork, we will continue to make great advances.

PSR: What do you look for in a hand surgery fellow?

Dr. Levin: I've trained general surgeons, orthopedic surgeons and plastic surgeons as hand Fellows for almost 33 years. A Fellow has to come with good, fundamental knowledge and passion for the field. I don't think you can perform the full range of hand surgery if you're not doing microsurgery. Hand surgery has no specialty boundary, so the ideal hand surgery Fellow is passionate and wants to contribute new knowledge through academic work. The ability to get along with others is important, since surgery is a team sport. The most important thing is the strong work ethic. William Osler, MD, who was the chair of medicine at Penn, wrote that the key to success is surgery comes down to two words: "Hard work."