An interview with plastic surgeon Neal Topham
By Abbey J. Porter
The term “plastic surgery” might bring to mind cosmetic procedures like nose jobs and tummy tucks, but the work of NEAL S. TOPHAM, chief of plastic and reconstructive surgery, couldn’t be more vital to his patients. A specialist in microsurgery—using tissue from one part of the body to rebuild another—Topham helps erase the marks of cancer, both physical and psychological, and restore patients to wholeness.
What is the role of plastic surgery in the cancer world?
The plastic surgeon’s job is to fix the defect that’s sometimes created when a tumor is removed. With microsurgery, you go to an unaffected part of the body for tissue to use for the repair. If you had to remove part of a patient’s jawbone, for instance, you might use tissue from his leg to rebuild it.
When you perform a surgery, what are your goals?
Well, it’s not just about restoring form; it’s about function as well. If someone has an intact jawbone, they can talk and eat. If someone loses their tongue, is it possible to make it so they can swallow again? These are normal activities that, if you lose them, leave huge holes in your life. And there is an aesthetic concern as well; once you restore the patient’s form and function, you can come back and make refinements so their appearance is as palatable as possible to the rest of the world.
What role does the aesthetic part play in the patient’s recovery?
It plays a huge role. Take breast reconstruction, which is about 50 percent of the cases I do. That doesn’t have a functional role, but it has a psychological one. If a patient has a mastectomy and walks around the rest of her life with a scar across her chest, it can be a reminder of what she went through. If I can restore her so she has a breast that is aesthetically pleasing, she can heal and eventually say, ‘Oh, that’s in my past. It’s a big part of what I’ve gone through, but I don’t dwell on it.’ There are studies that show that patients do better, psychologically, when they are restored.
How did you become interested in this line of practice?
After medical school, I started in general surgery and when I rotated with plastic surgeons, as soon as I saw some of the things they did… You know how sometimes something speaks to you? I realized that’s where I wanted to go. In my mind’s eye, that’s what I always envisioned surgery being. I liked the creativity of it; no two procedures are the same.
When it comes to your work, what are you most proud of?
The satisfaction comes from, basically, not seeing the patient anymore—when they are healthy enough and restored to a point that they’re just another person out there. I think that’s the best achievement. It would be nice to say that they remembered you and everything, but hopefully they are just out there functioning. Ideally, they’ve overcome it and been fixed to a point where they just move on.
I see patients take a lot of different approaches. Some people are just huge pioneers, amazing people that can take on this problem and push right through it. Some people, it can be overwhelming for them, so it’s important to basically walk them through it.
What’s the hardest part?
The hardest part is the failure—when what we try to do doesn’t work out. I had a patient recently who was undergoing breast reconstruction, but her tumor came back and totally overcame her, and she is going to succumb to it. It was hard to see, when she knew it had come back and we had to stop the reconstruction, which was very important to her. It was like the cancer had become real to her, because she was not going to progress and have a family and do the things that normal people do, and the realization that this was basically it for her came during one particular conversation we had…You want people’s hopes and dreams to stay alive, and that day, she was seeing that she was going to lose this battle.
Does it get easier over time?
It has gotten easier. I think the more experience you gain, the more you accept that sometimes in this battle against cancer, you can’t win—and sometimes victory can be really sweet. I think I prepare myself a lot better than when I started out and if something didn’t work I was really distraught and frustrated. You learn to roll with it more, and I think that comes with being more seasoned. It used to be more up and down for me. Now it’s more level, in terms of understanding what my role is and where I can actually do what I need to do and where I can’t. Learning that—where you can and can’t—is probably the toughest lesson.
It sounds like this work can be pretty difficult to handle.
Yeah, there are times you go home and feel like crying. You can’t sleep, and you’re worried about what’s happening. There are times when you question how long you can do it. Historically, there is a huge attrition rate in microsurgery. People start off in it and gradually move to other areas; a lot move into aesthetics. The cases are long, and they can be grueling—a surgery can go 16 hours. I think some surgeons can’t fight that battle forever, and they turn it over to the next generation.
What keeps you coming back?
The day of his Forward interview, Topham had recently returned from lending a hand with a complex case. The surgery, which took 16 hours, might have taken longer but for the benefits of new technology: virtual, or computerized, surgical planning. Read more »
Part of it is that you just have to. That’s one thing; you just kind of have to. And part of it is that it’s a worthy goal. The people who come in—if you don’t do it, who is going to help them? If you give up, it helps nobody. Eventually, the times when you are frustrated or disappointed will wear off and something good will happen.
Do you have to coordinate a lot with your patients’ other caregivers?
That’s right. Mainly, I’ll coordinate with a surgeon in another specialty. I work with head and neck surgeons, breast surgeons, gynecological surgeons, surgical oncologists— all of them. That makes our specialty unique. All the other specialties rely on us to come in and be like “the closer” in a baseball game. Of course, I work with medical oncologists and radiation oncologists, too, to plan chemotherapy and radiation therapy. It’s nice to be part of a group of physicians who are working together and aren’t just in our own practices, not communicating. That’s one of the advantages of being here at Fox Chase.
How aware are patients, at the outset, of the reconstructive aspect of their treatment?
People don’t necessarily consider the plastic surgeon who’s going to fix them, but I think it’s important for them to think about. In the end, that’s one of the things that can be most important. You want the cancer gone, of course, but you also want everything done that can be done to restore you and help you move forward.