In April of 2024 the compiler of these short notes (Ravin Thatte) had an occasion to listen and see the presentation of Dr. Amit Mulay who recounted his experiences of offering microsurgical services to several hospitals in the metropolitan area of Pune and a large city of Pimpri Chinchwad to the north of that city. That paper by Dr. Mulay was presented in the meeting of the Maharashtra association of plastic surgeons. Maharashtra is a state in India and Pune together with Pimpri Chinchwad is a highly industrialized area. Pune is the second largest city in that state next only to Mumbai.
The Metropolitan area of the city of Pune and its adjacent city of Pimpri Chinchwad covers a total area of approximately 665 square kilometers. Dr. Amit Mulay provides microsurgical services to 25 small and big hospitals while staying in Pimpri-Chinchwad. Till date in a practice that started in 2016 Dr. Mulay has performed a little less than 800 microvascular cases and is still going strong.
Micro surgical skills were once the basic requirement for plastic surgeons but over the years as India has developed, that skill has now become a specialty on its own particularly for reconstructions in the area of head and neck following removal of malignant and other tumors as well as trauma particularly in the hands and legs. The stories of these specialist surgeons are interesting because they have adjusted to these reconstructive needs and evolved over the years to perfect their craft. This blog already has a chapter on rural microsurgical outreach (Chapter 84) and the compiler of this blog thought that such experiences in an urban setting would help the readers of this blog who attempt to give similar services. Dr. Amit Mulay was therefore requested to write his experiences in the first person singular and the text was then edited to suit the blog’s format by the compiler.
I was born in Pimpri Chinchwad area forty years ago and have seen the exponential growth of that town into a thriving city during my adult years but had never imagined that I would continue to stay in the area and offer microsurgical service not only in Pimpri-Chinchwad but all over the city of Pune. After securing my MBBS degree I opted to do post-graduation in general surgery and did my diplomat of the national board in that subject under Dr. Bapaye at the KEM hospital in Pune. What followed was a junior consultant position in onco-surgery in the Ruby Hall clinic also in Pune. Here my job profile was to assist five different onco-surgeons mainly for head and neck cancers and later also assist Dr. Jigjinni who would perform micro surgical reconstructions for the defects left behind by the onco-surgeons. Such was the work load that in a mere one and half years in that position I had helped in almost one hundred and fifty microvascular free flaps. However my heart was set on specializing in onco-surgery. I cleared the examination for the super specialty courses but as luck would have it the options of the institutions that my rank allowed were not to my liking for more than one reason and therefore, I settled for the next best option of specialization in plastic surgery with which I was already somewhat familiar. I then trained in plastic surgery at the Maulana Azad medical college and the Lok Nayak hospital in New Delhi under the mentorship of Dr. Rajeev Ahuja and Dr. P.S. Bhandari. During this period of training I must have assisted for almost 50 micro vascular free flaps out of which I had done seven flaps on my own and it soon became clear in my mind that I wanted to specialize in micro surgery. With that thought in mind I always looked out for cases that needed an AV fistula prior to dialysis and never lost an opportunity in washing up and doing lacerations across the wrist and the lower forearm. I finished my training in New Delhi in 2016.
As I awaited my results I returned to Pune and started assisting Dr. Jigjinni with whom I had worked earlier in the Ruby Hall Clinic. He was not only an excellent surgeon but was truly a kind mentor who allowed me do cases on my own albeit under his supervision first and later allowed me to handle cases on my own. Once the results of my Mch examination were declared and I had passed the examination I sought and obtained a visiting observer’s post at the CGM Hospital in Taipei Taiwan a leading center for plastic and reconstructive surgery in the world. I focused on learning more of microsurgery here and it is here that I learnt the nuances of perforator flaps for example antero-lateral thigh flap (ALT) the deep inferior epigastric perforator flap (DIEP) and the medial sural artery perforator flap (MSAP). After my return I started my practice in Pune and because I knew many an onco-surgeon from my earlier stint at the Ruby Hall Clinic it was not difficult to settle down in practice. I still remember my first case done in a small nursing home thanks to Dr. Sujai Hegde which was a success and in a matter of two more days I had done another similar case in the same nursing home which too was successful.
The small hospital where the first microsurgical procedure was performed by Dr. Amit Mulay
I then started to get calls for cases when Dr. Jigjinni was not available and soon became busy as onco-surgeons and orthopedic surgeons whom I did not know started calling me for their reconstructive work and in the first six months of my practice I had done as many as 30 free microvascular flaps and 200 in the first two years. And the number has been maintained and even increased over the years.
In the initial few months of my practice my routine used to be arduous leaving home at six in the morning occasionally starting my case at eight in the morning after finishing my rounds of my patients in other hospitals. What followed was my outpatient clinic followed by a case or cases of reconstruction for traumatic injuries. The upshot was I would reach home by 11 at night and was exhausted. The distance between Pimpri Chinchwad and Pune city is approximately 30 kilometers.
Since then, I have reorganized my life in the following manner.
- Re distribution and selection of work – Though I do reconstruction for onco-surgeons both in Pimpri Chinchwad as well as in Pune I have restricted my trauma work only to the Pimpri Chinchwad area.
- Instruments – I have now divided my instruments into those meant for microsurgery and the rest. The latter I do not carry as in the past but make sure such instruments are available in the hospitals that I work. Microsurgical instruments I carry myself and look after them with care. I have on purpose readjusted to the fact that most hospitals are not geared up adequately for microsurgical work and therefore anticipate problems take corrective measures and avoid delays and frustration. This is crucial in keeping me in balance for my work which might run for hours In this matter I have now started to buy and share disposable items needed during microsurgical work with the hospitals where I do cases and thus avoid unnecessary aggravation.
- Staff – I also now employ a properly trained “OT assistant on a full-time basis and pay him a good living wage. This assistant helps me during surgery, in looking after my fine instruments and looks after my appointments and messages. In addition, if required I call upon a nurse whenever required or a young graduate doctor. I have trained all of them to do dressings of patients in the post-operative period which saves me a lot of time After the first couple of years because I need to travel long distance, I now employ a full-time driver and save a lot of energy and can relax during the commute and also study. One great benefit of employing the driver has been complete freedom from the aggravation of finding a place to park my car. Occasionally to save time I use a metro when travelling within the city. When a proper microscope is not available in a particular facility, I am forced to use a loupe and over the years I have now started using ergonomic loupes to suit my posture and this has avoided neck strain from which I suffered in the early years. To suit the conditions in some hospitals where a microscope is not available, I do not stand on prestige and use these loupes to harvest flaps with larger vessels.
From left to right: Kiran Chavan (Driver), The author, Gopal Rathod (male nurse), Sachin Chavan (male nurse)
- Investment – Over the years I have realized that investment in good instruments such as micro clips or fine saws for work on the fibula go a long way in improving technique and results and saving time. Therefore, I spend liberally on instruments if necessary, on the imported variety because the return on such investments must not be based merely on money but also from the stand point of comfort and improving results. This decision is by far the best that I have taken in my career so far.
- Co-habitation – I was always aware that reconstruction following surgery for cancer or for orthopedic cases was a dependent specialty and often I will have to see the patient on the table sometimes even after draping. One has therefore to be quick with one’s hands and one’s brain. Quite often one may not even be sure of the nature and size of the defect till the primary surgeon finishes his excision. When surgery involves the head and neck area it might be possible to operate and harvest a flap from other areas of the body. In Such circumstances I dissect and isolate the concerned vessels of the flap by a suitable incision but do not island the flap till the defect is known and then decide on the size.
- When the defect requires reconstruction for both lining and cover, I do not hesitate to perform two flaps including an islanded local flap if necessary. I have realized that this decision is safer in the long run in terms of an uneventful result.
- Post-operative monitoring of a flap’s viability is a fine but manageable art. This is particularly so in private and semiprivate hospitals where the resident medical officers are not trained in modern medicine but are drawn from the Ayurveda and Homeopathic streams. But the situation is not unsurmountable. I make it a point to train these doctors and the nurses on how to observe and detect signs of a failing flaps with photographs and to err on the side of safety in informing me. Thanks to modern technology they can also send me photos of the flaps by way of an app or an e mail. These photographs have to be taken at regular intervals and are taken with or without a flash to come to an accurate conclusion. The staff who send photographs have alternate numbers to contact me if the primary number fails.
- As a routine I do not use anticoagulants or volume expanders during before or in the postoperative period and see that urine output is maintained approximately 1cc per kilogram per hour. A drop in the output is treated by fluid challenge and rarely by a transfusion of albumin .I do not use ionotropic infusion or diuretics and do not use coagulants such as pause and do not remember to have had to explore a flap for a hematoma by far the most dreaded complication which results in flap failure. This is achieved mainly by keeping the patient normotensive during the intraoperative as well as the post-operative period. My staff is trained to do post-operative dressings. If a suction drain has been employed, it is always clamped prior to removal lest it sucks on the area of anastomosis.
- While I am proficient in using a variety of free flaps the four flaps that are performed most frequently are Latisimus dorsi, the anterolateral thigh flap, the free fibula flap and the radial artery flap. The requirements of instruments for each of these flaps are somewhat different. A list of instruments for each flap has been made and the assistant finds it easy to arrange the required instruments on the trolley. I have already mentioned how I buy and share general instruments and other requirements with some hospitals where I work.
A trolley arranged for a head and neck case
- Fitness – Both during my undergraduate and post graduate years of training I did not pay any specific attention to my physical fitness and diet, and I had gone overweight bordering on morbid obesity. By the time I went into practice I suffered from a variety of aches and pains particularly in my upper back and neck and even developed plantar fascial inflammation. Then “Covid” happened, and I had the time to think of my life anew. I also read that even chess players with no apparent physical demands lay great store on physical fitness. And my job was no different. I therefore took up physical fitness seriously, bought a bicycle undertake long trips on it and slowly built an in-house gym. I also corrected my diet and have lost nearly 20 kilos since then. I now feel that I am a different person both in my mind and body and enjoy my work far more than before.
The author of the article on his bicycle
Short Notes in Plastic Surgery 