0:00:02 > 0:00:07This programme contains some strong language
0:00:07 > 0:00:09Every year, some three million major operations
0:00:09 > 0:00:10are carried out in the UK.
0:00:10 > 0:00:12Theatre doors are just here.
0:00:13 > 0:00:17But few of us will know what really happens once we're put to sleep.
0:00:17 > 0:00:20All right, all you've got to do now is think beautiful thoughts.
0:00:20 > 0:00:22I don't think a patient can even comprehend
0:00:22 > 0:00:26what you're doing in theatre to them, and that's what the plan is,
0:00:26 > 0:00:28that they don't know what they've been through.
0:00:28 > 0:00:30This series goes behind the theatre doors
0:00:30 > 0:00:33at the Queen Elizabeth Hospital in Birmingham...
0:00:33 > 0:00:35Let's get cracking, then.
0:00:35 > 0:00:38- Right, okey dokey. - ..where, for the first time,
0:00:38 > 0:00:41cameras have been allowed to join some of Britain's top surgeons
0:00:41 > 0:00:44during their most high-stakes operations.
0:00:44 > 0:00:46- Shall we go for it?- Go for it.
0:00:46 > 0:00:49Using new technology and pioneering skills,
0:00:49 > 0:00:52they're treating conditions that used to kill.
0:00:52 > 0:00:54We continue to push the boundaries,
0:00:54 > 0:00:57continue to take the inoperable and make it operable.
0:00:57 > 0:01:00This is surgery at its most experimental.
0:01:00 > 0:01:02This is where I've got to get it right.
0:01:02 > 0:01:05People didn't attempt this surgery a few years ago because it was just
0:01:05 > 0:01:08perceived as being too big, too difficult and too scary.
0:01:08 > 0:01:12But pushing the human body to its limits comes with great risk...
0:01:12 > 0:01:14Keep it together, keep it together, keep it together.
0:01:14 > 0:01:17..for the patients and the surgeons.
0:01:17 > 0:01:22An operation will go wrong for a 30-second lapse of concentration.
0:01:22 > 0:01:24Please work, because if it doesn't I'm going to cry.
0:01:24 > 0:01:26Things worry you. You get very worried.
0:01:26 > 0:01:29This is going completely in the wrong direction.
0:01:29 > 0:01:31The trick is to not appear to be worried.
0:01:31 > 0:01:34They need to be top of their game every time.
0:01:34 > 0:01:37People often characterise surgeons as bombastic and arrogant.
0:01:37 > 0:01:41Labcock, please. Long one to me. Slap it in, sweetheart.
0:01:41 > 0:01:43You've got to be dedicated to it, you've got to love it.
0:01:43 > 0:01:46Oh, my God! Jesus Christ!
0:01:46 > 0:01:48You're only as good as your last result.
0:01:48 > 0:01:50BLEEP.
0:01:50 > 0:01:53This is what it takes to operate at the cutting edge of medicine.
0:01:53 > 0:01:57You have to be jolly careful that you don't bugger it up.
0:01:58 > 0:01:59It's do or die, really.
0:02:09 > 0:02:136am at the Queen Elizabeth Hospital in Birmingham...
0:02:13 > 0:02:15PHONE RINGS
0:02:15 > 0:02:17Hello, theatre reception.
0:02:17 > 0:02:20..home to one of the biggest and busiest surgical units in Britain.
0:02:22 > 0:02:28145 surgeons carry out over 35,000 operations a year,
0:02:28 > 0:02:31from organ transplants to brain surgery...
0:02:31 > 0:02:34- Anything else?- No, that's it, thank you.
0:02:34 > 0:02:38..supported by an army of technicians, orderlies and nurses.
0:02:40 > 0:02:44Right, then, so, let's work out what I need where.
0:02:46 > 0:02:49Today, the 42 operating theatres
0:02:49 > 0:02:53will be used for 131 different procedures.
0:02:53 > 0:02:57Every theatre has its own list of patients and most will host
0:02:57 > 0:03:01several minor operations lasting a couple of hours each.
0:03:02 > 0:03:07But 23 is booked out for the entire day for a single operation
0:03:07 > 0:03:12so difficult and complex it could last over 12 hours.
0:03:13 > 0:03:17It's going to be a long day today, isn't it?
0:03:17 > 0:03:18It is.
0:03:18 > 0:03:20The pressure's on.
0:03:20 > 0:03:24The procedure needs not one but two senior surgeons,
0:03:24 > 0:03:26Sat Parmar and Tim Martin.
0:03:27 > 0:03:30A feature of these big operations, you know,
0:03:30 > 0:03:33you talk about a 12-hour operation. Well, it's not just one operation.
0:03:33 > 0:03:36It's lots of little operations bolted together.
0:03:36 > 0:03:39- Fingers crossed we can finish by 7pm.- Well, hopefully,
0:03:39 > 0:03:42- we should finish on time unless, of course, there's any surprises.- Yes.
0:03:42 > 0:03:45The problem with these long operations,
0:03:45 > 0:03:49it's both physically and mentally extremely tiring.
0:03:49 > 0:03:51How do we cope with it?
0:03:51 > 0:03:52I'm not really sure,
0:03:52 > 0:03:56but I think it's because, firstly, we work extremely well as a team.
0:03:57 > 0:03:59Fantastic. Thank you very much.
0:03:59 > 0:04:03My relationship with Sat Parmar is like man and wife.
0:04:03 > 0:04:05We just clicked straightaway.
0:04:05 > 0:04:08Sat and Tim are maxillofacial surgeons,
0:04:08 > 0:04:12specialising in head and neck cancers and facial reconstruction.
0:04:13 > 0:04:17In theatre, they work side by side all day long.
0:04:17 > 0:04:20You can only work simultaneously if you totally trust
0:04:20 > 0:04:24your surgical colleague, and that's the case with Tim and I.
0:04:24 > 0:04:30We've been working for 14 years and I have total faith in what Tim does
0:04:30 > 0:04:32and, hopefully, he has the same with me.
0:04:33 > 0:04:36Their operations are often the only hope for their patients.
0:04:38 > 0:04:44Today, that patient is 53-year-old care worker Theresa Dallas.
0:04:44 > 0:04:48Just four weeks ago, a scan revealed Theresa had a fast-growing tumour
0:04:48 > 0:04:50in her upper jaw.
0:04:52 > 0:04:53It started with a...
0:04:54 > 0:04:58..pain in my face that I thought was an abscess on a tooth,
0:04:58 > 0:05:03so it was like dentist, doctor...doctor, dentist.
0:05:03 > 0:05:06And then the MRI scan came back
0:05:06 > 0:05:11showing up this mass in my face, right-side face.
0:05:14 > 0:05:18When they just say that word "cancer," it's like, oh, my God.
0:05:19 > 0:05:22So it's... Yeah, nobody wants to hear that.
0:05:26 > 0:05:30Theresa will die unless the tumour is removed.
0:05:30 > 0:05:32She requires radical surgery
0:05:32 > 0:05:36affecting the entire right-hand side of her face.
0:05:36 > 0:05:39I will lose my right eye, my...
0:05:41 > 0:05:44..jaw, I believe the top jaw...
0:05:44 > 0:05:46..will need to be removed.
0:05:49 > 0:05:52I'm prepared to give up my eye and my facial structure
0:05:52 > 0:05:56or whatever it is that I will have to give up.
0:05:57 > 0:06:01That's... No, I'll take that because there isn't another option.
0:06:02 > 0:06:04Sit back and die...
0:06:05 > 0:06:07..or just get on with it
0:06:07 > 0:06:11and make the best of whatever comes out of it, really.
0:06:19 > 0:06:21I best not think about that, I think.
0:06:25 > 0:06:26Look at the tumour.
0:06:27 > 0:06:30Theresa's surgery needs meticulous planning.
0:06:32 > 0:06:35Surgical simulation expert Hitesh Koria
0:06:35 > 0:06:38uses ground-breaking technology to turn CT scans
0:06:38 > 0:06:40into an exact 3D replica
0:06:40 > 0:06:44of Theresa's skull with the tumour shown in pink.
0:06:44 > 0:06:45That shows up well, doesn't it?
0:06:47 > 0:06:50Well, ideally, how far back would you want to make the cut?
0:06:50 > 0:06:53What we're going to have to do is
0:06:53 > 0:06:57take that half of the jaw out and she's just a bit unlucky
0:06:57 > 0:06:59because the cancer's quite high up...
0:07:01 > 0:07:05..so we've got to take the eye to try and ensure, as much as possible,
0:07:05 > 0:07:08that we've got the cancer out, really.
0:07:08 > 0:07:09So, if I take that away...
0:07:09 > 0:07:11- Yeah.- ..you're left with that.
0:07:11 > 0:07:15Perfect. That shows that we're actually clear of the cancer.
0:07:17 > 0:07:20After removing the tumour, jawbone and her eye,
0:07:20 > 0:07:24they will try to reconstruct Theresa's face.
0:07:24 > 0:07:27The face is really unique because it's the thing
0:07:27 > 0:07:30we probably all value the most.
0:07:30 > 0:07:31It's our appearance.
0:07:32 > 0:07:37So, it's really critical for Theresa's quality of life
0:07:37 > 0:07:41that we can make the reconstruction work.
0:07:42 > 0:07:45To replace what they remove, the surgeons hope to use
0:07:45 > 0:07:49a six-by-four-centimetre flap of bone and muscle
0:07:49 > 0:07:51cut from Theresa's own hip.
0:07:51 > 0:07:54I've just brought that hip in and tried to position it
0:07:54 > 0:07:59as best as possible. Would you be OK with the contour of this?
0:07:59 > 0:08:02I am, yeah. I like that, that looks good.
0:08:02 > 0:08:04They plan to precise measurements.
0:08:04 > 0:08:08Even so, until they do the actual operation,
0:08:08 > 0:08:10they won't know if they've got it right.
0:08:16 > 0:08:20I know my dad, my brother and my mum are worried sick.
0:08:20 > 0:08:24Since the diagnosis, her family have been hugely supportive,
0:08:24 > 0:08:28but Theresa is choosing to face surgery on her own.
0:08:28 > 0:08:31Sometimes it's good to have people with you, but, for me,
0:08:31 > 0:08:35not really what I want, not at this moment in time, really.
0:08:35 > 0:08:36I've got a lot to think about.
0:08:39 > 0:08:42So I'd rather do it in my own little world, on my own.
0:08:45 > 0:08:48There is a significant chance Theresa could die
0:08:48 > 0:08:50on the operating table.
0:08:50 > 0:08:53Before going ahead, Sat must make sure she's willing
0:08:53 > 0:08:56to go through with it, despite the risks.
0:08:57 > 0:08:59- Good morning, Doctor.- Hi, Theresa.
0:08:59 > 0:09:03- How are you?- Er, yeah, OK. I'm here!
0:09:03 > 0:09:04SHE LAUGHS WRYLY
0:09:07 > 0:09:10It is big surgery because it will take us till probably
0:09:10 > 0:09:11about six or seven this evening.
0:09:13 > 0:09:16You know, because of complications due to bleeding or chest infections,
0:09:16 > 0:09:19there is a risk you don't even make it through the surgery.
0:09:21 > 0:09:23Anything you want to ask me?
0:09:23 > 0:09:25- I don't think so.- OK.
0:09:25 > 0:09:27A lot to take through.
0:09:30 > 0:09:33Having someone's fate in your hands is terrifying.
0:09:34 > 0:09:40The thing that helps me cope with it is knowing that
0:09:40 > 0:09:43if we don't offer these patients surgery,
0:09:43 > 0:09:46we know that the cancer's going to kill them.
0:09:46 > 0:09:50So, in a way, we are their only chance.
0:09:55 > 0:09:57It's all a bit scary.
0:09:59 > 0:10:02I just want it over with now, I just want to be knocked out,
0:10:02 > 0:10:05then I just won't know anything, will I? So...
0:10:08 > 0:10:12And then, hopefully, the bonus will be if I wake up at the other side.
0:10:21 > 0:10:25- So, the patient's name? - Theresa Dallas.
0:10:25 > 0:10:29Sat, Tim and the team are ready to begin the operation.
0:10:30 > 0:10:32Expected duration of the surgery?
0:10:32 > 0:10:35Be nice to finish by...
0:10:35 > 0:10:36..6:30, 7pm.
0:10:36 > 0:10:386:30-7pm?
0:10:38 > 0:10:40OK, I'll wager you that, nine o'clock.
0:10:40 > 0:10:41LAUGHTER
0:10:47 > 0:10:49I'll need a stool to stand on.
0:10:50 > 0:10:51- Stepladder?- Yeah.
0:10:51 > 0:10:53LAUGHTER
0:10:56 > 0:10:58- Behind you, Sat.- Thank you.
0:11:00 > 0:11:02Lovely.
0:11:02 > 0:11:05With any big, long, complex operation,
0:11:05 > 0:11:08I always get butterflies before I start,
0:11:08 > 0:11:12but the moment I get knife to skin, I'm a lot more relaxed.
0:11:14 > 0:11:15OK, knife, please.
0:11:20 > 0:11:24Both Sat and Tim know that in procedures like Theresa's,
0:11:24 > 0:11:25every decision counts.
0:11:27 > 0:11:32An operation like this will truly go wrong for...
0:11:33 > 0:11:35..a 30-second lapse of concentration.
0:11:35 > 0:11:39And I know that sounds dramatic, but it's true and I've seen it.
0:11:48 > 0:11:51Only a handful of surgeons at the Queen Elizabeth regularly take on
0:11:51 > 0:11:53these marathon operations.
0:11:55 > 0:11:57Consultant plastic surgeon Ruth Waters
0:11:57 > 0:12:01also specialises in procedures that take the best part of the day.
0:12:02 > 0:12:05They take so long because, like Sat and Tim,
0:12:05 > 0:12:09her job is to remove and rebuild using the patient's own body.
0:12:11 > 0:12:13I wanted to be a plastic surgeon
0:12:13 > 0:12:18right from when I first started training as a doctor.
0:12:18 > 0:12:21Ruth is an expert in a particularly complex type
0:12:21 > 0:12:23of breast reconstruction.
0:12:23 > 0:12:27Everything about our bodies is important to our sense of self.
0:12:28 > 0:12:32And of course your breasts are so much more than that
0:12:32 > 0:12:36because they say something about your femininity.
0:12:36 > 0:12:39You know, not just in a sexual way, but in...
0:12:40 > 0:12:44..just your image of yourself as a woman and feeling like a woman.
0:12:44 > 0:12:48Ruth's patient today is 50-year-old Donna Wilson Mills,
0:12:48 > 0:12:51who's come to hospital with her husband Rob.
0:12:51 > 0:12:53Are you all right?
0:12:53 > 0:12:54Coping.
0:12:54 > 0:12:58- Oh, good.- After multiple treatments for DCIS,
0:12:58 > 0:13:01the earliest form of breast cancer,
0:13:01 > 0:13:06Donna has made a monumental decision to have both of her breasts removed,
0:13:06 > 0:13:08a double mastectomy.
0:13:08 > 0:13:13It was a no-brainer because I'd had radiotherapy and you can't have
0:13:13 > 0:13:16radiotherapy again in the same breast,
0:13:16 > 0:13:21so there was no other choice, really. If it come back again...
0:13:22 > 0:13:24..I'd got to have a mastectomy in any case,
0:13:24 > 0:13:26so I opted for the double mastectomy.
0:13:29 > 0:13:33I'm worried today about the operation because it's so long.
0:13:33 > 0:13:37It's a ten-hour operation, and being under anaesthetic that long,
0:13:37 > 0:13:39I'm a bit nervous about that but...
0:13:41 > 0:13:46..apart from that, everyone assures me I'm going to be OK and asleep!
0:13:48 > 0:13:52The operation will take so long because Donna will also have
0:13:52 > 0:13:54her breasts reconstructed,
0:13:54 > 0:13:57so Ruth will be joined by another plastic surgeon,
0:13:57 > 0:14:01- Kate Nelson.- They're impossible, they're like a challenge,
0:14:01 > 0:14:03- trying to get these gowns on. There you go.- Ta, OK.
0:14:03 > 0:14:06Few hospitals offer this procedure because,
0:14:06 > 0:14:09unlike conventional operations that use implants,
0:14:09 > 0:14:13Donna's involves using tissue from her own body.
0:14:15 > 0:14:18As Donna's breast tissue is removed,
0:14:18 > 0:14:21two flaps of skin and fat are cut from Donna's abdomen.
0:14:22 > 0:14:26These are shaped and inserted into the cavities created
0:14:26 > 0:14:29by the mastectomies, giving Donna new breasts.
0:14:30 > 0:14:32- It's difficult to imagine it, isn't it?- Yeah, it is.
0:14:32 > 0:14:34That literally just gets pulled down,
0:14:34 > 0:14:36so this line meets that line.
0:14:36 > 0:14:38- OK.- And this is all going up there.
0:14:38 > 0:14:42The operation lasts twice as long as one where implants are used.
0:14:42 > 0:14:46It carries a bigger risk, but Ruth believes it's worth it.
0:14:46 > 0:14:48If you have your own skin and fat,
0:14:48 > 0:14:52it's wonderful because it mimics breast tissue so well.
0:14:52 > 0:14:54It has the same consistency.
0:14:54 > 0:14:55It's warm.
0:14:55 > 0:14:59It just behaves like you because it is you.
0:15:00 > 0:15:02OK, so, we have to tell you about the risks.
0:15:02 > 0:15:05There's a bit of a long list of risks, OK, so...
0:15:05 > 0:15:07There's a high risk of blood clots.
0:15:07 > 0:15:10There's a risk of chest infections and things like that.
0:15:10 > 0:15:12You're not selling this, really!
0:15:12 > 0:15:15- It's a bad time to go through all this, isn't it?- It is, really!
0:15:15 > 0:15:18- OK.- No, it's fine.- OK.
0:15:19 > 0:15:24A lot of surgeons tend to be big characters and be very confident.
0:15:24 > 0:15:28I don't think you necessarily have to be as flamboyant as, you know,
0:15:28 > 0:15:31as some of the surgeons in the dickie bows kind of used to be.
0:15:31 > 0:15:33There's lots more down-to-earth people.
0:15:33 > 0:15:35You don't have to be from a posh background.
0:15:35 > 0:15:39It's very important to be kind and compassionate and empathic.
0:15:39 > 0:15:42I can't imagine even what it's going to look like after.
0:15:42 > 0:15:43Just...
0:15:43 > 0:15:47I'm just... Just, you know, taking it as it comes, whatever.
0:15:47 > 0:15:49- Yeah.- I look like I look like.
0:15:49 > 0:15:52- You'll look smashing, I'm sure you will.- OK.
0:15:59 > 0:16:00- Do you know your way back?- Yeah.
0:16:01 > 0:16:03It's not an easy choice.
0:16:03 > 0:16:05It's really hard.
0:16:06 > 0:16:09People say, "You're making the right choice." Well...
0:16:09 > 0:16:10..I haven't really got a choice.
0:16:14 > 0:16:18So, today we've just got one patient to do.
0:16:18 > 0:16:21She has chosen to have immediate breast reconstruction.
0:16:21 > 0:16:26From the surgical point of view, she's got a good scan
0:16:26 > 0:16:30and nice vessels, so we're happy with all that.
0:16:30 > 0:16:31OK? Thank you.
0:16:34 > 0:16:36And then ready, steady, slide.
0:16:37 > 0:16:40Donna's operation in theatre eight
0:16:40 > 0:16:44is so involved it requires 13 medical personnel.
0:16:44 > 0:16:48For Ruth, every procedure like this is personal.
0:16:48 > 0:16:51I was diagnosed with breast cancer in 2001.
0:16:53 > 0:16:57I had to go through that journey of the surgery and the chemotherapy,
0:16:57 > 0:17:02the radiotherapy, so I do understand what that diagnosis feels like,
0:17:02 > 0:17:06to be on the receiving end of it and having to make those decisions.
0:17:06 > 0:17:10And, inevitably, that's part of my being a surgeon
0:17:10 > 0:17:12and how I treat my patients.
0:17:14 > 0:17:16HE ISSUES INAUDIBLE ORDER
0:17:18 > 0:17:21Whenever we discuss reconstruction with a woman,
0:17:21 > 0:17:24we have to say it's never 100%.
0:17:24 > 0:17:27So, there will be times when this doesn't work
0:17:27 > 0:17:31and you may actually not end up with the reconstruction you were after.
0:17:34 > 0:17:37There's not that many women out there who are actually
0:17:37 > 0:17:39having to sit down and make that choice.
0:17:39 > 0:17:42The prospect of having both your breasts removed
0:17:42 > 0:17:45must be just enormous.
0:17:48 > 0:17:50PHONE RINGS
0:17:50 > 0:17:52Hello. Hiya.
0:17:52 > 0:17:54I'm calling up for theatre three.
0:17:54 > 0:17:57Just wondering if you can get the next patient ready, please?
0:17:57 > 0:18:01By late morning, the next wave of patients head to surgery.
0:18:01 > 0:18:02Theatre doors are just here,
0:18:02 > 0:18:06so we'll let you say goodbye just before we go through.
0:18:09 > 0:18:12In the QE's 42 theatres,
0:18:12 > 0:18:16everything from appendectomies to amputations are under way
0:18:16 > 0:18:19as most surgeons start their second operation of the day.
0:18:20 > 0:18:22But, in theatre 23,
0:18:22 > 0:18:26they're still in the first stage of Theresa's facial operation.
0:18:28 > 0:18:30OK, I'll have some skin hooks.
0:18:32 > 0:18:34In terms of Theresa's procedure,
0:18:34 > 0:18:38the likelihood of things going wrong is fairly high
0:18:38 > 0:18:41because of the complexity of the surgery.
0:18:42 > 0:18:45To limit the time Theresa spends under anaesthetic,
0:18:45 > 0:18:49Sat and Tim operate on two different sites simultaneously...
0:18:51 > 0:18:55..Sat on Theresa's hip, Tim on her face and neck.
0:18:55 > 0:18:57Don't pull too hard. Just stay nice and still.
0:18:57 > 0:19:00They are both searching for the same thing -
0:19:00 > 0:19:04blood vessels that are essential to a successful reconstruction.
0:19:04 > 0:19:05Clean swab, please.
0:19:10 > 0:19:12Once the tumour is taken out,
0:19:12 > 0:19:13the flap of bone and muscle
0:19:13 > 0:19:17with blood vessels attached will be removed from Theresa's hip.
0:19:19 > 0:19:22The flap fits into the cavity created by the surgery.
0:19:23 > 0:19:25To keep the flap alive,
0:19:25 > 0:19:28its artery and vein are attached to another artery and vein
0:19:28 > 0:19:29in Theresa's neck.
0:19:31 > 0:19:33Everyone's anatomy is slightly different,
0:19:33 > 0:19:37so it's an intricate job to find and isolate the right blood vessels.
0:19:39 > 0:19:40Any sign of the vessel yet, Sat?
0:19:40 > 0:19:44I think that's the main DCIA going down.
0:19:44 > 0:19:47But I just can't tell for sure.
0:19:47 > 0:19:50Sat is looking for the DCIA,
0:19:50 > 0:19:52an artery that runs alongside the hip.
0:19:54 > 0:19:57But it's buried deep within this mass of tissue, fat and muscle.
0:20:00 > 0:20:02That's the main DCI. I think.
0:20:05 > 0:20:07I suspect.
0:20:07 > 0:20:08But it's quite deep.
0:20:08 > 0:20:10But, hopefully, that will be it.
0:20:11 > 0:20:12Clean swab, please.
0:20:14 > 0:20:18I think that's the facial nerve branch, just there,
0:20:18 > 0:20:20going up into the flap, isn't it?
0:20:20 > 0:20:23Having two major surgical sites
0:20:23 > 0:20:26is tougher on Theresa's body and tougher for Sat and Tim,
0:20:26 > 0:20:29who have to work literally shoulder to shoulder.
0:20:29 > 0:20:31It's going to be cosy.
0:20:31 > 0:20:33- Am I in your way? - No, no, it's all right.
0:20:33 > 0:20:36There'll be lots of other surgeons who just would not get on
0:20:36 > 0:20:39because of maybe arrogance, maybe egos.
0:20:39 > 0:20:43- Sat, can I just have access for a sec?- Sorry.- Cheers.
0:20:44 > 0:20:46I tend to be the grumpy one.
0:20:46 > 0:20:48But, you know, he puts up with it.
0:20:48 > 0:20:49Sorry, I was being a prima donna then.
0:20:49 > 0:20:52- Just then?- Yeah, just momentarily,
0:20:52 > 0:20:54I flipped into prima donna mode.
0:20:54 > 0:20:58Prior to that I was a straightforward, jobbing surgeon.
0:20:58 > 0:21:04These are really quite high-stress cases and things can go wrong,
0:21:04 > 0:21:06and, when they do go wrong, they go wrong very quickly.
0:21:08 > 0:21:09I'm just struggling a little bit.
0:21:09 > 0:21:12You can see that's the DCIA.
0:21:12 > 0:21:14Yeah, there.
0:21:14 > 0:21:18And then it's just doing something funny here and I'm not sure...
0:21:18 > 0:21:21Sat finds the artery, but it doesn't look good.
0:21:21 > 0:21:24It's not the best DCIA I've seen.
0:21:24 > 0:21:27Just very low in the hip.
0:21:27 > 0:21:29Really low in the hip. That's what's worrying me.
0:21:30 > 0:21:35- Blade, please.- At the other end, Tim's news is even worse.
0:21:35 > 0:21:37Facial artery's tiny.
0:21:37 > 0:21:38Is it?
0:21:39 > 0:21:42Connecting the crucial blood vessels
0:21:42 > 0:21:44is going to be even harder than they thought.
0:21:44 > 0:21:49The main challenges of operating on the hip for this procedure is that,
0:21:49 > 0:21:53although it gives you great-quality bone and great-quality muscle,
0:21:53 > 0:21:58the blood vessel supplying that bone and muscle are extremely short.
0:21:58 > 0:21:59Careful, careful.
0:22:01 > 0:22:05If the flap blood vessels are too short,
0:22:05 > 0:22:08it means it won't reach the blood vessels in the neck,
0:22:08 > 0:22:11and you do have that panic, thinking,
0:22:11 > 0:22:15"I really hope we can make everything work."
0:22:22 > 0:22:25In Donna's double mastectomy and breast reconstruction,
0:22:25 > 0:22:30plastic surgeon Ruth is on the hunt for Donna's blood vessels.
0:22:30 > 0:22:32- There, I think.- Yeah.- Yeah.
0:22:32 > 0:22:35She's looking for the artery and vein connected
0:22:35 > 0:22:36to the parts of Donna's abdomen
0:22:36 > 0:22:39they hope to use for the breast reconstruction.
0:22:39 > 0:22:41Open a bit more, I think.
0:22:41 > 0:22:43You lift up the skin and fat
0:22:43 > 0:22:47until you get to this perforating blood vessel.
0:22:47 > 0:22:49- Whoa! Look at that.- Lovely.
0:22:49 > 0:22:53- Stonking.- Ruth has better luck than Sat and Tim.
0:22:53 > 0:22:57The blood vessels are a good size.
0:22:57 > 0:22:59OK, guys. Kate.
0:22:59 > 0:23:03- Yeah?- Look at that.- Look at this.
0:23:03 > 0:23:05Is that the best perforated you've ever seen?
0:23:05 > 0:23:08- Oh, my word, that's lovely, isn't it?- Isn't that beautiful?- Yeah.
0:23:08 > 0:23:10OK, I'd better not mess it up now.
0:23:10 > 0:23:13THEY LAUGH
0:23:13 > 0:23:16Once the mastectomies are performed,
0:23:16 > 0:23:21these blood vessels will be crucial to giving Donna natural breasts.
0:23:21 > 0:23:24The surgeons will try and connect the stomach flaps
0:23:24 > 0:23:26to blood vessels in Donna's armpits.
0:23:27 > 0:23:31Only then can the flaps be tucked under the skin into the cavities
0:23:31 > 0:23:33to rebuild Donna's breasts.
0:23:34 > 0:23:37First, Kate must meticulously remove
0:23:37 > 0:23:41all the breast tissue to help prevent Donna getting breast cancer
0:23:41 > 0:23:44- in the future.- Yeah, that's got to go, as well, hasn't it?
0:23:45 > 0:23:47It's an operation where you're doing, like,
0:23:47 > 0:23:50a million strokes of the blade,
0:23:50 > 0:23:53but with every single one you've got to bear that patient in mind,
0:23:53 > 0:23:57that you're taking absolute care to remove every single little bit
0:23:57 > 0:23:59of breast tissue that you possibly can do,
0:23:59 > 0:24:02particularly if you're doing something like a risk reducing,
0:24:02 > 0:24:04where their whole sanity and confidence relies on
0:24:04 > 0:24:06the operation that you're doing right there and then
0:24:06 > 0:24:07for the rest of their lives.
0:24:12 > 0:24:15Donna's left breast is entirely removed.
0:24:15 > 0:24:18Yeah, so there should be a form for the left.
0:24:19 > 0:24:20Just needs weighing first.
0:24:22 > 0:24:25It's weighed to determine how much fat will be needed
0:24:25 > 0:24:28from Donna's tummy to replace it.
0:24:30 > 0:24:33- What was it?- 909.- 909?
0:24:35 > 0:24:40A woman making the choice to have a double mastectomy could say,
0:24:40 > 0:24:43"Well, you know, just take it away, that's fine, that's job done."
0:24:43 > 0:24:48But I think it's a so much easier decision to make if somebody can say
0:24:48 > 0:24:51to you, "Yeah, we can do that,
0:24:51 > 0:24:56"but we can also make you look and feel like a woman looks and feels."
0:24:56 > 0:25:00For the reconstruction to meet that high standard,
0:25:00 > 0:25:01Kate must take great care
0:25:01 > 0:25:04of the skin around the site of the mastectomies.
0:25:04 > 0:25:07One of the reasons why we'd like to do the reconstruction
0:25:07 > 0:25:09at the same time as doing the mastectomy
0:25:09 > 0:25:11is that, at that point, you're able to keep
0:25:11 > 0:25:13the patient's own, natural skin.
0:25:13 > 0:25:16You can keep the natural skin envelope with all the boundaries
0:25:16 > 0:25:18of that and the natural droop of the breast,
0:25:18 > 0:25:21which forms an envelope so that we simply don't need
0:25:21 > 0:25:24to put a filling inside that to give a natural-shaped breast.
0:25:24 > 0:25:28The filling will be the flaps of fat being cut from Donna's tummy.
0:25:28 > 0:25:32- How's it going?- Good. - Fine, it's all pretty much done.
0:25:34 > 0:25:36Right, so, hopefully, we can just...
0:25:38 > 0:25:39..come through now.
0:25:40 > 0:25:42There's the flap with the little blood vessel.
0:25:42 > 0:25:46At the other end of the table, the first flap is taken to be weighed
0:25:46 > 0:25:49to ensure there's enough to replace the breast tissue.
0:25:52 > 0:25:541231.
0:25:54 > 0:25:57The flap is now ready to be plumbed in by trying to attach
0:25:57 > 0:26:00the blood vessels to those of the mastectomy site.
0:26:00 > 0:26:02Can we have the flap, please?
0:26:02 > 0:26:05Now it's a race against time.
0:26:05 > 0:26:09Getting the vessels reconnected quickly is important.
0:26:09 > 0:26:12When we clip the vessels and take it off -
0:26:12 > 0:26:14so that's called flap off time -
0:26:14 > 0:26:17we have to be efficient in that time because all the time
0:26:17 > 0:26:20that the flap's off, it's not got a blood supply.
0:26:20 > 0:26:22It's like it's holding its breath, really.
0:26:22 > 0:26:25So we need to get it connected as quickly as we can.
0:26:31 > 0:26:35The QE is renowned for its reconstructive surgery.
0:26:35 > 0:26:39Some of the most pioneering work is happening in the Burns Centre.
0:26:39 > 0:26:44Professor Steven Jeffery is one of their leading surgeons.
0:26:44 > 0:26:49Burn's obviously been round ever since mankind developed fire.
0:26:49 > 0:26:53We've been burning ourselves and we've been burning each other!
0:26:53 > 0:26:55OK, if you can lift this leg up for me.
0:26:55 > 0:26:58Burns have got devastating consequences.
0:26:58 > 0:27:01You can be left with horrible, disfiguring scarring.
0:27:01 > 0:27:05Sometimes, the scarring is so bad that they're ashamed to go out.
0:27:05 > 0:27:08- Sorry.- Steven and his colleagues are always looking for
0:27:08 > 0:27:11new ways to reduce scarring.
0:27:11 > 0:27:13The ancients used to use lots of different dressings,
0:27:13 > 0:27:16things that were naturally available.
0:27:16 > 0:27:19So, they would use honey, they would use animal fat.
0:27:20 > 0:27:25Now they're trialling a 21st-century way of treating burns.
0:27:25 > 0:27:28But it comes from an unlikely source.
0:27:29 > 0:27:31So this is the fish skin, as it comes.
0:27:31 > 0:27:33From sterile in here.
0:27:33 > 0:27:34You can use any fish, I think.
0:27:34 > 0:27:38It just so happens that they fish a lot of cod in Iceland
0:27:38 > 0:27:39and they used to throw away
0:27:39 > 0:27:42a lot of fish skin, and somebody has discovered that it actually
0:27:42 > 0:27:44makes a very nice dressing
0:27:44 > 0:27:47to prevent pain and also reduce the scarring.
0:27:48 > 0:27:51The patients are surprised, initially.
0:27:51 > 0:27:54You have to forewarn them that it is going to smell fishy.
0:27:54 > 0:27:56But I tell them that the fish smell is a good thing.
0:27:56 > 0:27:59It means that the goodies that's in here
0:27:59 > 0:28:02haven't been completely processed away.
0:28:02 > 0:28:05If there's a smell, then there's also going to be the other stuff,
0:28:05 > 0:28:07like omega-3 fatty acids.
0:28:07 > 0:28:11They're known to be anti-inflammatory.
0:28:11 > 0:28:15Inflammation means pain and inflammation means scarring.
0:28:15 > 0:28:18The burns team are currently trialling the fish skin
0:28:18 > 0:28:20in skin graft operations.
0:28:21 > 0:28:23This is the fish skin.
0:28:23 > 0:28:25It might be the right size.
0:28:25 > 0:28:28Oh, perfect. Look at that.
0:28:28 > 0:28:30Almost as if you designed that!
0:28:30 > 0:28:32HE LAUGHS
0:28:32 > 0:28:35They hope to prove it reduces scarring significantly.
0:28:35 > 0:28:39If you don't push the boundaries, you'll get the same results.
0:28:39 > 0:28:42If you want to get better than that and reduce scarring,
0:28:42 > 0:28:46you have to innovate and you have to try new techniques.
0:28:46 > 0:28:48Very good, thank you, all.
0:28:58 > 0:29:00It's 2pm, and many theatres
0:29:00 > 0:29:04are preparing for their third operation of the day.
0:29:04 > 0:29:07That's not the case in theatre 23,
0:29:07 > 0:29:10where Sat and Tim are preparing to remove the tumour
0:29:10 > 0:29:13from Theresa's face and harvest bone and muscle from her hip
0:29:13 > 0:29:15for the reconstruction.
0:29:15 > 0:29:21OK, if I can use the drill before Tim and then I'll use the saw.
0:29:21 > 0:29:24I'm going to use the saw in about the next 15 minutes,
0:29:24 > 0:29:26ten minutes.
0:29:26 > 0:29:29They've been operating for over three hours.
0:29:30 > 0:29:32I've got backache.
0:29:32 > 0:29:35Do you want a massage, Sat? Who's on massage duty?
0:29:37 > 0:29:41So, OK, can I have that cutting guide, please?
0:29:41 > 0:29:43And the screws.
0:29:45 > 0:29:50So, now, this is the bit that really saves us time in terms of operating.
0:29:50 > 0:29:52Empty screwdriver, please.
0:29:52 > 0:29:54Screw, please.
0:29:56 > 0:29:59Sat attaches the plastic cutting guide to the hip.
0:29:59 > 0:30:03It's based on the exact dimensions of the cavity
0:30:03 > 0:30:05that will be left in Theresa's face.
0:30:05 > 0:30:08Both the screws are on the guide, yeah?
0:30:08 > 0:30:11It allows him to cut not just the right size,
0:30:11 > 0:30:14but importantly the right shape.
0:30:14 > 0:30:16OK. Saw, please.
0:30:21 > 0:30:23- Lovely chisels.- Thank you.
0:30:27 > 0:30:31SAW BUZZES
0:30:31 > 0:30:33The cutting guides are so beneficial
0:30:33 > 0:30:36because now we can really reconstruct
0:30:36 > 0:30:41the defects in a totally predictable and accurate manner.
0:30:45 > 0:30:47Just hold that. I don't know why it's stopped.
0:30:47 > 0:30:48No.
0:30:56 > 0:30:59Is it possible to put my saw on, please?
0:31:00 > 0:31:02It's not working.
0:31:05 > 0:31:07My saw's not working.
0:31:07 > 0:31:10Oh! No, it is. My mistake. Sorry.
0:31:10 > 0:31:11- Was it me?- No, it's me.
0:31:13 > 0:31:17The daunting task of removing the tumour on Theresa's right upper jaw
0:31:17 > 0:31:20and her eye is Tim's responsibility.
0:31:20 > 0:31:23SAW BUZZES
0:31:25 > 0:31:28Whenever you're taking out a cancer, you try to do it en bloc.
0:31:28 > 0:31:30If you start taking it out piecemeal, you leave
0:31:30 > 0:31:31bits behind, it all gets very messy.
0:31:34 > 0:31:36You'll feel the hard cancer and you cut round it,
0:31:36 > 0:31:38aiming for a centimetre all the way around it.
0:31:39 > 0:31:41Mallet, please.
0:31:41 > 0:31:45They use a chisel and mallet to complete cuts in the bone.
0:31:49 > 0:31:53At the end of the day, I would say that the surgeon is a technician
0:31:53 > 0:31:56or a tradesman when it comes to the theatre.
0:31:58 > 0:32:01I'm a carpenter because I cut bone.
0:32:02 > 0:32:04I am a plumber.
0:32:04 > 0:32:06A good suck at the back there.
0:32:06 > 0:32:09I, you know, may be a bit of an artist
0:32:09 > 0:32:11because I do the soft tissue.
0:32:11 > 0:32:12Chisel, please.
0:32:17 > 0:32:19But you're cutting up people's faces,
0:32:19 > 0:32:20you're doing incisions on their face,
0:32:20 > 0:32:23and so you've got to be kind of confident
0:32:23 > 0:32:27about where you're going and what your outcome's going to be.
0:32:30 > 0:32:34The hip flap is carved and ready for transplant.
0:32:34 > 0:32:37Looks stunning, doesn't it?
0:32:37 > 0:32:40Sat moves to help Tim as he makes the final cuts
0:32:40 > 0:32:46around the eye so it can be removed, along with the tumour and upper jaw.
0:32:46 > 0:32:48This is where I've got to get it right.
0:32:48 > 0:32:51When you're just a short way away from the brain,
0:32:51 > 0:32:53you've got to be a little bit more careful.
0:32:53 > 0:32:57Taking the eye out is really quite a tense moment
0:32:57 > 0:33:00because there's a direct communication
0:33:00 > 0:33:03between the eye socket into the brain,
0:33:03 > 0:33:06and this may result in a lot of bleeding at the time.
0:33:08 > 0:33:10When you get a bleed from that,
0:33:10 > 0:33:13this bleed just kind of relentlessly fills the wound...
0:33:13 > 0:33:15Same in the bottom end here, thank you.
0:33:15 > 0:33:17..but you've just got to get on.
0:33:17 > 0:33:20You can't afford to dilly-dally.
0:33:20 > 0:33:23You've got to make a decision and you've got to go for it
0:33:23 > 0:33:25because if you don't, until it's out,
0:33:25 > 0:33:28blood's welling up and you can't control the bleeding.
0:33:28 > 0:33:32Stay as you are. No, don't pull. No, no, stay as you are.
0:33:32 > 0:33:33And it always looks messy.
0:33:33 > 0:33:36Superficially, it looks as though you're tearing it out
0:33:36 > 0:33:38with your bare fingers,
0:33:38 > 0:33:40which realistically you probably are, actually,
0:33:40 > 0:33:43but in a measured way.
0:33:43 > 0:33:45A good clean.
0:33:47 > 0:33:50Specimen...
0:33:50 > 0:33:52There.
0:33:53 > 0:33:54Put that on one side, please.
0:33:56 > 0:34:02Theresa's upper jaw and her right eye have been successfully removed,
0:34:02 > 0:34:05a huge but necessary sacrifice for Theresa.
0:34:07 > 0:34:11I don't think, clearance wise, we could improve on that.
0:34:11 > 0:34:12OK.
0:34:14 > 0:34:19It's 3pm and the operation has been running for four hours.
0:34:19 > 0:34:23But now Sat and Tim have to do what's possibly the most complicated
0:34:23 > 0:34:25part of the procedure.
0:34:25 > 0:34:27We always have this period where the cancer's come out,
0:34:27 > 0:34:31and you feel great that we've achieved one of our main objectives.
0:34:33 > 0:34:37But then, suddenly, you remember that now
0:34:37 > 0:34:41you've got to reconstruct this patient, put them back to normal.
0:34:41 > 0:34:43We'll need a Kocher in a second.
0:34:43 > 0:34:45You reach this point where you've removed it
0:34:45 > 0:34:47and you've got a big hole and you've got to fill it.
0:34:47 > 0:34:52And sometimes you do look at the hole and, you know,
0:34:52 > 0:34:55you do think, "Flipping heck."
0:34:55 > 0:34:58If you don't get this reconstructed,
0:34:58 > 0:35:02the impact on the patient will be a fundamental disaster.
0:35:10 > 0:35:14If Sat and Tim are able to successfully rebuild Theresa's face,
0:35:14 > 0:35:17she will eventually be provided with a new eye.
0:35:21 > 0:35:25The QE's maxillofacial prosthetics centre is the largest of its kind
0:35:25 > 0:35:28in Britain.
0:35:28 > 0:35:32Here, nine prosthetists specialise in replacing the body parts
0:35:32 > 0:35:34that patients are missing.
0:35:38 > 0:35:41We make a vast array of things, really.
0:35:41 > 0:35:45Our most common prosthetic to make are prosthetic ears,
0:35:45 > 0:35:51but we also make eye prostheses, nose prostheses,
0:35:51 > 0:35:53fingers, thumbs.
0:35:53 > 0:35:55We're really, really busy at the moment.
0:35:55 > 0:35:59We're probably looking at between 40 and 50 prosthetics
0:35:59 > 0:36:02packed in each week.
0:36:02 > 0:36:05In the past, patients like Theresa would have been offered
0:36:05 > 0:36:09just a pair of glasses with a painted-on eye.
0:36:09 > 0:36:12But Kelly Morris creates individually tailored
0:36:12 > 0:36:14silicon prosthetics.
0:36:14 > 0:36:17You have the magnets themselves in the back of the prosthesis.
0:36:17 > 0:36:19The magnets attach to metal pegs
0:36:19 > 0:36:23implanted in the patient's eye socket during their surgery.
0:36:23 > 0:36:26What's good about magnets is they're so easy,
0:36:26 > 0:36:29they tend to just pull into the correct location each time.
0:36:29 > 0:36:32You don't see the junction between the prosthesis
0:36:32 > 0:36:34and the patient's natural tissues.
0:36:36 > 0:36:41Kelly colours the glass eyeball by hand using oil paints,
0:36:41 > 0:36:45painstakingly copying each patient's photo
0:36:45 > 0:36:46to get a perfect match.
0:36:46 > 0:36:50Most people don't realise that so many colours make up the eye itself.
0:36:52 > 0:36:55They usually can't understand why it takes so long and you think,
0:36:55 > 0:36:57"Well, because you've got to paint up all these tiny little
0:36:57 > 0:37:00"striations in the eye."
0:37:00 > 0:37:02But then they're usually pretty bowled over when they see it
0:37:02 > 0:37:06and they see what a close match it actually is.
0:37:06 > 0:37:09The finished eye will be fitted to a silicon mould,
0:37:09 > 0:37:11taken from the patient's own face,
0:37:11 > 0:37:13and matched precisely with their skin tone.
0:37:15 > 0:37:18It will be attached several months after the operation,
0:37:18 > 0:37:21when the facial reconstruction has had time to heal.
0:37:22 > 0:37:25Once it's fitted, I think that people
0:37:25 > 0:37:27are generally quite overwhelmed.
0:37:28 > 0:37:31Usually they're in tears and they can't believe that, you know...
0:37:31 > 0:37:34That's the really rewarding part of what we do,
0:37:34 > 0:37:35seeing that transformation in people.
0:37:35 > 0:37:38Giving them their lives back, basically.
0:37:38 > 0:37:43It just allows them to go out and be who they are, as before.
0:37:48 > 0:37:52Getting the patient's body back to its original state is the aim of all
0:37:52 > 0:37:55of the reconstruction surgery at the QE.
0:37:55 > 0:37:59Like in theatre eight, where Donna is having her breasts reconstructed.
0:38:01 > 0:38:04Right, yeah, let's go for it like that.
0:38:04 > 0:38:08Both flaps of skin and fat have now been extracted from her abdomen.
0:38:09 > 0:38:14Now, this is the artery, which we're preparing.
0:38:14 > 0:38:18So Ruth and surgeon Rob Warner face the difficult task of connecting
0:38:18 > 0:38:23the blood vessels in the flaps to the ones in Donna's armpits.
0:38:23 > 0:38:26So, from the armpit, this is the flap side.
0:38:26 > 0:38:29So blood's going to be flowing in the artery up here.
0:38:29 > 0:38:33The success of the reconstruction depends on them sewing together
0:38:33 > 0:38:36blood vessels that are only three millimetres wide.
0:38:37 > 0:38:39The vessels are fairly small and the suture is tiny,
0:38:39 > 0:38:42as thick as a hair or something.
0:38:42 > 0:38:44I'll put the stitches in.
0:38:46 > 0:38:49So, on this side, we've now got the artery
0:38:49 > 0:38:51and the veins joined together.
0:38:51 > 0:38:53OK, so left flap is on.
0:38:54 > 0:38:58I'm just putting the last stitch in the vein.
0:38:58 > 0:39:03OK, so the blood flow to both flaps is working well.
0:39:03 > 0:39:05With the vessels connected,
0:39:05 > 0:39:08Ruth inserts the tissue under the skin
0:39:08 > 0:39:11and begins shaping it into new breasts.
0:39:12 > 0:39:13Right, OK.
0:39:13 > 0:39:16So we know that the mastectomy specimen was 900g
0:39:16 > 0:39:21and we know the weight of the flap's about 1,200.
0:39:21 > 0:39:26So we need just to get the same weight. We need to take 300 off.
0:39:26 > 0:39:29So what we're going to do is cut some off it now.
0:39:31 > 0:39:34Getting the size and contours right is crucial.
0:39:36 > 0:39:40Definitely at least a bit more to come.
0:39:40 > 0:39:44What plastic surgery is about is form and function.
0:39:44 > 0:39:47This is what we do - we restore form and function.
0:39:47 > 0:39:52So we've got the left flap tucked in, roughly in position.
0:39:52 > 0:39:55So now, with this one, which is all good to go,
0:39:55 > 0:39:57we've taken a little bit off, but we're going to just try
0:39:57 > 0:40:03and tuck it in and sit it roughly where it wants to sit.
0:40:03 > 0:40:07Function is not just being able to pick up your cup of tea,
0:40:07 > 0:40:10it's being able to walk out the door and face the world.
0:40:10 > 0:40:13It's being able to go out and meet a partner
0:40:13 > 0:40:18without feeling embarrassed or, you know, wanting to hide yourself away.
0:40:18 > 0:40:20So the function is engaging with life again
0:40:20 > 0:40:23and being able to do those things with confidence.
0:40:23 > 0:40:26Although the calculations say that that's not much smaller,
0:40:26 > 0:40:29I don't think we should make them smaller than that at the moment.
0:40:29 > 0:40:31I think that looks nice for her.
0:40:31 > 0:40:34When my girls were young and they used to say to my husband,
0:40:34 > 0:40:38"Oh, what is it that Mummy does?" he says, "Oh, she cuts people up."
0:40:38 > 0:40:40And I said, "No, that isn't true.
0:40:40 > 0:40:44"I don't. I put people back together again!"
0:40:44 > 0:40:48So, all of this bit now is really about just shaping,
0:40:48 > 0:40:50trying to make things look nice,
0:40:50 > 0:40:54trying to make them look symmetrical and a good shape.
0:40:54 > 0:40:58Donna's nipples will eventually be reconstructed using her own tissue,
0:40:58 > 0:41:01but only several months after surgery,
0:41:01 > 0:41:04when her new breasts have settled into place.
0:41:04 > 0:41:07Ruth and Kate can still do the groundwork.
0:41:07 > 0:41:10We're going to end up with a circle of skin of the flap
0:41:10 > 0:41:13in the middle of the breast where, ultimately,
0:41:13 > 0:41:17we hope we'll be able to create a nipple for her.
0:41:17 > 0:41:19I'm just going to draw that circle on here
0:41:19 > 0:41:23and then get rid of the rest of the skin that is underneath.
0:41:23 > 0:41:26Right, this all looks good.
0:41:26 > 0:41:31- We just need to take that edge off there.- Yeah.- Yeah.
0:41:31 > 0:41:34I'm from quite an artistic family.
0:41:34 > 0:41:36My dad does a lot of painting, my brother's a sculptor,
0:41:36 > 0:41:38and I think the plastic surgery's
0:41:38 > 0:41:40kind of an extension of that, really.
0:41:40 > 0:41:43There's so much variability in the techniques
0:41:43 > 0:41:46that you can use to improve not just the aesthetic
0:41:46 > 0:41:48but the function and form of the human body.
0:41:48 > 0:41:50And from the background that I was in,
0:41:50 > 0:41:55I enjoy putting my artistic mind into a medical specialty like that.
0:41:55 > 0:41:57That's really nice, isn't it?
0:41:57 > 0:41:59Yeah, I think that looks all right, doesn't it?
0:41:59 > 0:42:01- I think that's a good size for her. - Yeah.
0:42:03 > 0:42:06When you get them through it,
0:42:06 > 0:42:08that is such a great thrill.
0:42:08 > 0:42:10That never goes away.
0:42:10 > 0:42:13Every time it's a great feeling for me,
0:42:13 > 0:42:19and getting that job well done is really why I can carry on doing it.
0:42:19 > 0:42:21OK, so we're done.
0:42:23 > 0:42:24Fabulous.
0:42:29 > 0:42:32It's 4:30 in the afternoon.
0:42:32 > 0:42:34The last trays from the sterile instrument store
0:42:34 > 0:42:38are being dispatched to theatres for the final procedures of the day.
0:42:38 > 0:42:41There you go, oesophagus tray.
0:42:41 > 0:42:43No, that's not what I need. An abdo tray.
0:42:43 > 0:42:46Oh, my God! Abdominal trays, that's down there.
0:42:46 > 0:42:48- That looks like the last one on the shelf.- Oh, right, OK.
0:42:51 > 0:42:54I just figured we need an amputation set
0:42:54 > 0:42:56because there is bone. They might cut through the...
0:42:56 > 0:42:58Yeah, for the neck they only use...
0:42:58 > 0:43:01To just lift up... So they can get in and lift up
0:43:01 > 0:43:02and they pull it through there.
0:43:05 > 0:43:09By now, over 110 different operations,
0:43:09 > 0:43:13from spinal surgery to lung transplants, have taken place...
0:43:14 > 0:43:17..while in theatre 23, after close to six hours,
0:43:17 > 0:43:21Sat and Tim are starting the final stage of Theresa's operation.
0:43:22 > 0:43:25Sat, what have you got to do on your bit, there?
0:43:25 > 0:43:26Literally, we're just...
0:43:26 > 0:43:29Put vessels, a teeny little bit of cleaning,
0:43:29 > 0:43:31detach it, we're going to take it to top end.
0:43:31 > 0:43:34They're ready to try and rebuild her face with the flap from her hip.
0:43:36 > 0:43:39At the moment, she's got this big hole.
0:43:39 > 0:43:41So the sole purpose of that flap is
0:43:41 > 0:43:44it will create a new jawbone and roof of the mouth,
0:43:44 > 0:43:46so she won't have a hole here.
0:43:46 > 0:43:49The problem with these facial reconstructions is that
0:43:49 > 0:43:53quite often it can be right at the end that things start to go wrong.
0:43:53 > 0:43:55And we know that if we get it wrong,
0:43:55 > 0:43:59this will have lifelong ramifications.
0:43:59 > 0:44:03The last thing you ever want is a patient who is cured of cancer
0:44:03 > 0:44:07but wishing they'd never gone through the treatment
0:44:07 > 0:44:10because they can't live with their final result.
0:44:14 > 0:44:18- You can start thinking about disconnecting.- Yeah?
0:44:19 > 0:44:24Sat detaches the flap from its blood supply at the hip.
0:44:24 > 0:44:26OK, I'm going to lift this muscle up.
0:44:26 > 0:44:30When you've detached the flap, it's just a lump of meat.
0:44:30 > 0:44:33It doesn't have a blood supply until you plummet in at the top end.
0:44:34 > 0:44:37- OK.- Could someone do the lights for us?
0:44:37 > 0:44:40Like in Donna's op, once the flap is moved,
0:44:40 > 0:44:42it needs to be connected to blood vessels.
0:44:42 > 0:44:46If that doesn't work, the reconstruction will fail.
0:44:46 > 0:44:49Sucker on, please.
0:44:49 > 0:44:50So that's going to go palatal.
0:44:52 > 0:44:54OK. I don't think I dare do any more.
0:44:54 > 0:44:57- No, I agree.- Before they work on the blood vessels,
0:44:57 > 0:45:01the flap needs to be fixed in place with a metal plate and screws.
0:45:01 > 0:45:02OK, have we got a drill bit?
0:45:04 > 0:45:06That looks good there.
0:45:06 > 0:45:09Yeah. Yeah, perfect.
0:45:12 > 0:45:15That looks bang on, really.
0:45:15 > 0:45:17Yeah.
0:45:17 > 0:45:20We're going to need the table right down.
0:45:20 > 0:45:24The vessels they need to connect are even smaller and shorter
0:45:24 > 0:45:27than in Donna's operation.
0:45:27 > 0:45:29Right at the end of this operation,
0:45:29 > 0:45:33you are then doing the more delicate microsurgery
0:45:33 > 0:45:35and everything's dependent on that,
0:45:35 > 0:45:37because if that doesn't flow,
0:45:37 > 0:45:40well, you're in a no-return situation.
0:45:40 > 0:45:43So here you can see...
0:45:43 > 0:45:46So that's the facial artery and we're going to join it up.
0:45:49 > 0:45:51And even though we've got all that, you can see,
0:45:51 > 0:45:54we haven't got a lot of room to play with.
0:45:54 > 0:45:57It's not much, is it? Even...
0:45:57 > 0:46:00Rotate it the other way, that's lovely.
0:46:00 > 0:46:03Thanks, Sat. These blood vessels are quite small.
0:46:03 > 0:46:05They've often had a bit of a battering.
0:46:05 > 0:46:07By the time you're starting to plummet in,
0:46:07 > 0:46:09they've been pushed and pulled and stretched.
0:46:10 > 0:46:13There's a bit of a funny something going on there.
0:46:14 > 0:46:16Oh, there's a hole.
0:46:16 > 0:46:18Oh, fuck.
0:46:18 > 0:46:22They've discovered a hole in the side of the artery
0:46:22 > 0:46:24- in Theresa's neck. - Is that a hole, too?- Yeah.
0:46:24 > 0:46:28- Oh, bugger.- If the damaged vessel is connected,
0:46:28 > 0:46:31it will leak catastrophically.
0:46:31 > 0:46:34Do you want to throw a clamp on that in case it shoots up?
0:46:34 > 0:46:36I'll grab hold of it here.
0:46:36 > 0:46:37To salvage the artery,
0:46:37 > 0:46:41Tim needs to carefully cut off the section where the hole is.
0:46:41 > 0:46:44May I have, please, the straight micro scissors, please?
0:46:45 > 0:46:49OK, you don't have a lot to play with, Tim.
0:46:49 > 0:46:52I know. This is the thing about microvascular surgery -
0:46:52 > 0:46:56we do these 12-hour operations and these vessels are delicate,
0:46:56 > 0:46:58and literally at any point,
0:46:58 > 0:47:03one simple mistake can jeopardise the whole operation.
0:47:05 > 0:47:07I'm just going to go for it, Sat.
0:47:18 > 0:47:20OK, clamp, please.
0:47:20 > 0:47:22The defect is removed.
0:47:22 > 0:47:26Only now, the short blood vessel is even shorter.
0:47:28 > 0:47:30When you're a bit short,
0:47:30 > 0:47:33it sort of adds to the tension if it doesn't reach.
0:47:33 > 0:47:35It's going to be fucking tight.
0:47:35 > 0:47:39The two vessels Tim has to stitch together are very fragile
0:47:39 > 0:47:42and only one to two millimetres in diameter -
0:47:42 > 0:47:44as small as a pinhead.
0:47:44 > 0:47:46If you just hold those together, Sat, I will cut.
0:47:46 > 0:47:49- Can you hold them together?- Yeah.
0:47:49 > 0:47:52This is a bugger of a line, isn't it?
0:47:52 > 0:47:55Can we get some different curved micros?
0:47:56 > 0:47:59I'm quite renowned in theatre for getting tetchy
0:47:59 > 0:48:03when things just aren't going quite to plan.
0:48:03 > 0:48:06Just to let you know, this is quite a tricky little bastard one
0:48:06 > 0:48:08because it's short.
0:48:09 > 0:48:11Lovely. If you could stay like that.
0:48:11 > 0:48:15- Pull a bit more on that one. No, don't move.- Sorry.
0:48:17 > 0:48:19Don't move, everyone. Don't move.
0:48:27 > 0:48:29Stay still.
0:48:30 > 0:48:33Please work, because if it doesn't I'm going to cry.
0:48:38 > 0:48:40I have not enjoyed that at all.
0:48:41 > 0:48:43Fantastic.
0:48:43 > 0:48:47Tim successfully connects the flap artery to the artery
0:48:47 > 0:48:48in Theresa's neck.
0:48:48 > 0:48:50Well done, Tim.
0:48:50 > 0:48:53Well, yeah, that's very kind of you...
0:48:53 > 0:48:56No, that was difficult. That was hard.
0:48:56 > 0:48:59If it's working, that's all I'm bloody bothered about.
0:48:59 > 0:49:01OK, so the vein's looking nice. It's not engorged.
0:49:01 > 0:49:03This is looking nice.
0:49:03 > 0:49:07The anastomosis looks a lot better than it should do.
0:49:07 > 0:49:09- OK.- So, Doppler...
0:49:09 > 0:49:11Doppler over here, I think.
0:49:11 > 0:49:14They use a Doppler ultrasound scanner
0:49:14 > 0:49:16to check blood is flowing in the vessels.
0:49:16 > 0:49:20- Have we got the Doppler machine here?- Yeah.
0:49:20 > 0:49:24- OK.- This scanner picks up the sound of the blood flow.
0:49:26 > 0:49:28So we know that's OK.
0:49:30 > 0:49:33Surprising, given the way I did that anastomosis.
0:49:33 > 0:49:36- The whole thing was difficult. - I was sweating bricks.- I know.
0:49:36 > 0:49:40With the blood flow confirmed, Sat and Tim concentrate on closing
0:49:40 > 0:49:45the huge incision in Theresa's face.
0:49:45 > 0:49:47- We're closing.- Could I have some scissors, please?
0:49:47 > 0:49:49- I'm knackered.- It's just the stress.
0:49:52 > 0:49:54I don't think a patient can even comprehend
0:49:54 > 0:49:56what you're doing in theatre to them,
0:49:56 > 0:49:58or what life would be like without reconstruction.
0:49:58 > 0:50:01And I suppose they come out of an operation
0:50:01 > 0:50:03not really knowing what they've been through.
0:50:03 > 0:50:07She's actually, when you feel, she's got a great prominence.
0:50:07 > 0:50:10Not overdone at all.
0:50:10 > 0:50:14If that stays like that, that's really nice.
0:50:14 > 0:50:16Before making the final sutures,
0:50:16 > 0:50:18the duo want to use the Doppler again
0:50:18 > 0:50:20to double-check the blood flow.
0:50:21 > 0:50:27Could you just indulge us with the Doppler for a minute, as well?
0:50:29 > 0:50:31Cheers.
0:50:36 > 0:50:38Have we got a signal?
0:50:50 > 0:50:53What the fucky ducky, ducky, ducky?
0:50:53 > 0:50:57The scanner is not detecting a blood flow.
0:50:57 > 0:51:00We're going to have to have a look at this.
0:51:00 > 0:51:03You're not happy with your pick-up?
0:51:03 > 0:51:05No, the Doppler's not working.
0:51:05 > 0:51:09Without a blood supply, the flap will die in Theresa's face.
0:51:12 > 0:51:15In a very small number of patients, it won't work out.
0:51:16 > 0:51:19And the patient will be significantly worse off
0:51:19 > 0:51:22than when you laid your hands onto them and operated.
0:51:22 > 0:51:25And you have to just keep on reminding yourself
0:51:25 > 0:51:28that you're doing it with the best intentions.
0:51:44 > 0:51:47Amazing. It's keeping her mouth open.
0:51:47 > 0:51:49- Bloody hell.- What did they do?
0:51:49 > 0:51:52- Close the mouth?- Fucking hell!
0:51:52 > 0:51:55The unusual position of Theresa's jaw
0:51:55 > 0:51:58had been temporarily pressing on the blood vessels.
0:52:02 > 0:52:04It's 7:30pm.
0:52:04 > 0:52:09After 8.5 hours, Theresa's operation is over.
0:52:11 > 0:52:14After a big operation, you would have thought to yourself,
0:52:14 > 0:52:16"I'm going to go home and I'm going to go to sleep."
0:52:16 > 0:52:20You just don't. You just continue kind of buzzing, thinking about it.
0:52:20 > 0:52:21I can't let go.
0:52:21 > 0:52:25I will often take my work home.
0:52:25 > 0:52:27I will sometimes wake up through the night thinking about...
0:52:28 > 0:52:31You know, what could I have done differently?
0:52:31 > 0:52:35What will I do? Et cetera. So it does affect me.
0:52:35 > 0:52:39From a personal point of view, there are two really satisfying aspects,
0:52:39 > 0:52:41so the technical challenge of doing a major operation
0:52:41 > 0:52:43and it being a technical success.
0:52:45 > 0:52:47You all right there, Theresa?
0:52:47 > 0:52:49But then also you've got the satisfaction
0:52:49 > 0:52:51of seeing the patient doing well
0:52:51 > 0:52:55and hopefully Theresa kind of demonstrates that.
0:52:55 > 0:52:58Hello there. You're just waking up from the operation, OK?
0:52:58 > 0:53:00Just try and keep nice and still for me.
0:53:19 > 0:53:22It's one week since Donna had a double mastectomy
0:53:22 > 0:53:24and breast reconstruction.
0:53:24 > 0:53:27Surgeon Ruth Waters comes to check on her recovery.
0:53:27 > 0:53:30When women come and we tell them about
0:53:30 > 0:53:34what the reconstructive surgery involves,
0:53:34 > 0:53:38you're telling them that they're going to have this huge operation,
0:53:38 > 0:53:43but the goal at the end of it is to make them feel
0:53:43 > 0:53:46as if it hadn't happened.
0:53:49 > 0:53:54- Hi, Donna. How are you? - All right. You?- Yeah.- Good.
0:53:54 > 0:53:57- So, how are you feeling? - Yeah, I'm OK.
0:53:57 > 0:53:59- I had a bit of pain today.- Yeah.
0:53:59 > 0:54:02But it seems to be going under control again.
0:54:02 > 0:54:06OK. Excellent. Do you mind if I have a quick look now?
0:54:06 > 0:54:07- No, you carry on.- OK.
0:54:08 > 0:54:11OK, so that's looking lovely.
0:54:12 > 0:54:15Nice size and shape.
0:54:15 > 0:54:18Donna's operation went really, really well. We're very pleased.
0:54:18 > 0:54:20So now, what Donna should do is think,
0:54:20 > 0:54:23"That was something I had to do, it's done
0:54:23 > 0:54:25"and I'm going to get on and have a hell of a good life."
0:54:25 > 0:54:29They look approximately breast-shaped at the moment, anyway.
0:54:29 > 0:54:32Yeah, they do. I looked down and thought, "God, I've got cleavage."
0:54:32 > 0:54:35- It's quite nice, you know? - Yeah.- It's nice. Yeah.
0:54:35 > 0:54:39I just didn't imagine anything like that.
0:54:39 > 0:54:42No, they don't feel at all how I thought they'd feel.
0:54:42 > 0:54:45I thought they'd be numb, you wouldn't be able to feel them.
0:54:45 > 0:54:49But, no, I can feel them, they do feel part of me.
0:54:49 > 0:54:51Erm...
0:54:51 > 0:54:53They just feel like my old ones, really.
0:55:03 > 0:55:06Theresa also returns to the Queen Elizabeth Hospital
0:55:06 > 0:55:10for a check-up with consultant surgeon Sat Parmar.
0:55:10 > 0:55:13In the old days, they were able to remove the cancer,
0:55:13 > 0:55:15but what they were lacking was the ability
0:55:15 > 0:55:18to reconstruct the face or the mouth.
0:55:18 > 0:55:23Patients often had open wounds in their face.
0:55:23 > 0:55:28Many of these patients would never then venture out again.
0:55:28 > 0:55:32I'd like to think now that with modern reconstruction techniques,
0:55:32 > 0:55:37very few patients ever regret undergoing a lot of the surgery
0:55:37 > 0:55:41we put them through.
0:55:42 > 0:55:46- Hi, Theresa.- Hello.- Come through.
0:55:48 > 0:55:51- How are you?- Not bad. How are you?- I'm good.
0:55:51 > 0:55:56- Nice to see you.- And you. - You all right? Come through.
0:55:56 > 0:56:00Let's have a look at you. Pop yourself on the chair.
0:56:00 > 0:56:05When I look at the symmetry of your face, it's really very good.
0:56:05 > 0:56:07Yeah. My dad and my brother said,
0:56:07 > 0:56:09"You know, it does, it looks amazing."
0:56:09 > 0:56:12My brother was like, "Wow, I didn't expect you to look like that.
0:56:12 > 0:56:15"I thought you'd look awful!"
0:56:15 > 0:56:18When you get a result like Theresa's,
0:56:18 > 0:56:23you're pleased because you've put her through a huge ordeal.
0:56:23 > 0:56:27You know, for me, you look entirely normal.
0:56:27 > 0:56:29Your speech is normal, you're eating well.
0:56:29 > 0:56:32- You've got one eye, which we plan to sort out.- Yeah.
0:56:34 > 0:56:37Before Theresa gets a new eye fitted,
0:56:37 > 0:56:40she'll need several post-op consultations.
0:56:41 > 0:56:43I don't know whether we showed you before.
0:56:43 > 0:56:45- Yeah, it's amazing. - It is amazing.
0:56:45 > 0:56:48Really, creepily amazing, actually, isn't it?
0:56:48 > 0:56:50It all blends in and the beauty of the implants is
0:56:50 > 0:56:52it will only fit in one position only.
0:56:52 > 0:56:56- So you can't go out with a, like, wonky eye.- No.
0:56:56 > 0:56:58At least you have an idea of what we're going to do.
0:56:58 > 0:57:00Thank you.
0:57:00 > 0:57:02I do feel positive for the future.
0:57:02 > 0:57:04- Thank you for coming in, Theresa. - Thank you, Sat.
0:57:04 > 0:57:07- See you soon, good luck...- Yeah, lovely to see you. Thank you.
0:57:07 > 0:57:08Bye-bye. Bye.
0:57:08 > 0:57:11It does make you think that you have to make the most.
0:57:11 > 0:57:14I don't think I made the most of what I had before,
0:57:14 > 0:57:17so I think I'm going to have to make double the most
0:57:17 > 0:57:18of what I've got now.
0:57:21 > 0:57:23Everything looks extremely positive.
0:57:23 > 0:57:27She already looks remarkably good.
0:57:27 > 0:57:29She's speaking and eating normally.
0:57:29 > 0:57:32She's got her zest back.
0:57:33 > 0:57:36That's what we're there for, really,
0:57:36 > 0:57:39is getting the patients healed from the cancer,
0:57:39 > 0:57:43but back to normal.
0:57:43 > 0:57:46Next time... With patients in the last chance saloon...
0:57:46 > 0:57:49- We found something. - It's spot the organ, isn't it?
0:57:49 > 0:57:51..surgeons try to save a man's life...
0:57:51 > 0:57:54- Expected duration of surgery? - As long as it takes.
0:57:54 > 0:57:56..by stopping his heart.
0:57:56 > 0:57:59I'm not going to get sort of religious about it,
0:57:59 > 0:58:02but it is literally on the edge of life and death.