The Longest Day Surgeons: At the Edge of Life

This programme contains some strong language

Every year, some three million major operations

are carried out in the UK.

Theatre doors are just here.

But few of us will know what really happens once we're put to sleep.

All right, all you've got to do now is think beautiful thoughts.

I don't think a patient can even comprehend

what you're doing in theatre to them, and that's what the plan is,

that they don't know what they've been through.

This series goes behind the theatre doors

at the Queen Elizabeth Hospital in Birmingham...

Let's get cracking, then.

-Right, okey dokey.

-..where, for the first time,

cameras have been allowed to join some of Britain's top surgeons

during their most high-stakes operations.

-Shall we go for it?

-Go for it.

Using new technology and pioneering skills,

they're treating conditions that used to kill.

We continue to push the boundaries,

continue to take the inoperable and make it operable.

This is surgery at its most experimental.

This is where I've got to get it right.

People didn't attempt this surgery a few years ago because it was just

perceived as being too big, too difficult and too scary.

But pushing the human body to its limits comes with great risk...

Keep it together, keep it together, keep it together.

..for the patients and the surgeons.

An operation will go wrong for a 30-second lapse of concentration.

Please work, because if it doesn't I'm going to cry.

Things worry you. You get very worried.

This is going completely in the wrong direction.

The trick is to not appear to be worried.

They need to be top of their game every time.

People often characterise surgeons as bombastic and arrogant.

Labcock, please. Long one to me. Slap it in, sweetheart.

You've got to be dedicated to it, you've got to love it.

Oh, my God! Jesus Christ!

You're only as good as your last result.

BLEEP.

This is what it takes to operate at the cutting edge of medicine.

You have to be jolly careful that you don't bugger it up.

It's do or die, really.

6am at the Queen Elizabeth Hospital in Birmingham...

PHONE RINGS

Hello, theatre reception.

..home to one of the biggest and busiest surgical units in Britain.

145 surgeons carry out over 35,000 operations a year,

from organ transplants to brain surgery...

-Anything else?

-No, that's it, thank you.

..supported by an army of technicians, orderlies and nurses.

Right, then, so, let's work out what I need where.

Today, the 42 operating theatres

will be used for 131 different procedures.

Every theatre has its own list of patients and most will host

several minor operations lasting a couple of hours each.

But 23 is booked out for the entire day for a single operation

so difficult and complex it could last over 12 hours.

It's going to be a long day today, isn't it?

It is.

The pressure's on.

The procedure needs not one but two senior surgeons,

Sat Parmar and Tim Martin.

A feature of these big operations, you know,

you talk about a 12-hour operation. Well, it's not just one operation.

It's lots of little operations bolted together.

-Fingers crossed we can finish by 7pm.

-Well, hopefully,

-we should finish on time unless, of course, there's any surprises.

-Yes.

The problem with these long operations,

it's both physically and mentally extremely tiring.

How do we cope with it?

I'm not really sure,

but I think it's because, firstly, we work extremely well as a team.

Fantastic. Thank you very much.

My relationship with Sat Parmar is like man and wife.

We just clicked straightaway.

Sat and Tim are maxillofacial surgeons,

specialising in head and neck cancers and facial reconstruction.

In theatre, they work side by side all day long.

You can only work simultaneously if you totally trust

your surgical colleague, and that's the case with Tim and I.

We've been working for 14 years and I have total faith in what Tim does

and, hopefully, he has the same with me.

Their operations are often the only hope for their patients.

Today, that patient is 53-year-old care worker Theresa Dallas.

Just four weeks ago, a scan revealed Theresa had a fast-growing tumour

in her upper jaw.

It started with a...

..pain in my face that I thought was an abscess on a tooth,

so it was like dentist, doctor...doctor, dentist.

And then the MRI scan came back

showing up this mass in my face, right-side face.

When they just say that word "cancer," it's like, oh, my God.

So it's... Yeah, nobody wants to hear that.

Theresa will die unless the tumour is removed.

She requires radical surgery

affecting the entire right-hand side of her face.

I will lose my right eye, my...

..jaw, I believe the top jaw...

..will need to be removed.

I'm prepared to give up my eye and my facial structure

or whatever it is that I will have to give up.

That's... No, I'll take that because there isn't another option.

Sit back and die...

..or just get on with it

and make the best of whatever comes out of it, really.

I best not think about that, I think.

Look at the tumour.

Theresa's surgery needs meticulous planning.

Surgical simulation expert Hitesh Koria

uses ground-breaking technology to turn CT scans

into an exact 3D replica

of Theresa's skull with the tumour shown in pink.

That shows up well, doesn't it?

Well, ideally, how far back would you want to make the cut?

What we're going to have to do is

take that half of the jaw out and she's just a bit unlucky

because the cancer's quite high up...

..so we've got to take the eye to try and ensure, as much as possible,

that we've got the cancer out, really.

So, if I take that away...

-Yeah.

-..you're left with that.

Perfect. That shows that we're actually clear of the cancer.

After removing the tumour, jawbone and her eye,

they will try to reconstruct Theresa's face.

The face is really unique because it's the thing

we probably all value the most.

It's our appearance.

So, it's really critical for Theresa's quality of life

that we can make the reconstruction work.

To replace what they remove, the surgeons hope to use

a six-by-four-centimetre flap of bone and muscle

cut from Theresa's own hip.

I've just brought that hip in and tried to position it

as best as possible. Would you be OK with the contour of this?

I am, yeah. I like that, that looks good.

They plan to precise measurements.

Even so, until they do the actual operation,

they won't know if they've got it right.

I know my dad, my brother and my mum are worried sick.

Since the diagnosis, her family have been hugely supportive,

but Theresa is choosing to face surgery on her own.

Sometimes it's good to have people with you, but, for me,

not really what I want, not at this moment in time, really.

I've got a lot to think about.

So I'd rather do it in my own little world, on my own.

There is a significant chance Theresa could die

on the operating table.

Before going ahead, Sat must make sure she's willing

to go through with it, despite the risks.

-Good morning, Doctor.

-Hi, Theresa.

-How are you?

-Er, yeah, OK. I'm here!

SHE LAUGHS WRYLY

It is big surgery because it will take us till probably

about six or seven this evening.

You know, because of complications due to bleeding or chest infections,

there is a risk you don't even make it through the surgery.

Anything you want to ask me?

-I don't think so.

-OK.

A lot to take through.

Having someone's fate in your hands is terrifying.

The thing that helps me cope with it is knowing that

if we don't offer these patients surgery,

we know that the cancer's going to kill them.

So, in a way, we are their only chance.

It's all a bit scary.

I just want it over with now, I just want to be knocked out,

then I just won't know anything, will I? So...

And then, hopefully, the bonus will be if I wake up at the other side.

-So, the patient's name?

-Theresa Dallas.

Sat, Tim and the team are ready to begin the operation.

Expected duration of the surgery?

Be nice to finish by...

..6:30, 7pm.

6:30-7pm?

OK, I'll wager you that, nine o'clock.

LAUGHTER

I'll need a stool to stand on.

-Stepladder?

-Yeah.

LAUGHTER

-Behind you, Sat.

-Thank you.

Lovely.

With any big, long, complex operation,

I always get butterflies before I start,

but the moment I get knife to skin, I'm a lot more relaxed.

OK, knife, please.

Both Sat and Tim know that in procedures like Theresa's,

every decision counts.

An operation like this will truly go wrong for...

..a 30-second lapse of concentration.

And I know that sounds dramatic, but it's true and I've seen it.

Only a handful of surgeons at the Queen Elizabeth regularly take on

these marathon operations.

Consultant plastic surgeon Ruth Waters

also specialises in procedures that take the best part of the day.

They take so long because, like Sat and Tim,

her job is to remove and rebuild using the patient's own body.

I wanted to be a plastic surgeon

right from when I first started training as a doctor.

Ruth is an expert in a particularly complex type

of breast reconstruction.

Everything about our bodies is important to our sense of self.

And of course your breasts are so much more than that

because they say something about your femininity.

You know, not just in a sexual way, but in...

..just your image of yourself as a woman and feeling like a woman.

Ruth's patient today is 50-year-old Donna Wilson Mills,

who's come to hospital with her husband Rob.

Are you all right?

Coping.

-Oh, good.

-After multiple treatments for DCIS,

the earliest form of breast cancer,

Donna has made a monumental decision to have both of her breasts removed,

a double mastectomy.

It was a no-brainer because I'd had radiotherapy and you can't have

radiotherapy again in the same breast,

so there was no other choice, really. If it come back again...

..I'd got to have a mastectomy in any case,

so I opted for the double mastectomy.

I'm worried today about the operation because it's so long.

It's a ten-hour operation, and being under anaesthetic that long,

I'm a bit nervous about that but...

..apart from that, everyone assures me I'm going to be OK and asleep!

The operation will take so long because Donna will also have

her breasts reconstructed,

so Ruth will be joined by another plastic surgeon,

-Kate Nelson.

-They're impossible, they're like a challenge,

-trying to get these gowns on. There you go.

-Ta, OK.

Few hospitals offer this procedure because,

unlike conventional operations that use implants,

Donna's involves using tissue from her own body.

As Donna's breast tissue is removed,

two flaps of skin and fat are cut from Donna's abdomen.

These are shaped and inserted into the cavities created

by the mastectomies, giving Donna new breasts.

-It's difficult to imagine it, isn't it?

-Yeah, it is.

That literally just gets pulled down,

so this line meets that line.

-OK.

-And this is all going up there.

The operation lasts twice as long as one where implants are used.

It carries a bigger risk, but Ruth believes it's worth it.

If you have your own skin and fat,

it's wonderful because it mimics breast tissue so well.

It has the same consistency.

It's warm.

It just behaves like you because it is you.

OK, so, we have to tell you about the risks.

There's a bit of a long list of risks, OK, so...

There's a high risk of blood clots.

There's a risk of chest infections and things like that.

You're not selling this, really!

-It's a bad time to go through all this, isn't it?

-It is, really!

-OK.

-No, it's fine.

-OK.

A lot of surgeons tend to be big characters and be very confident.

I don't think you necessarily have to be as flamboyant as, you know,

as some of the surgeons in the dickie bows kind of used to be.

There's lots more down-to-earth people.

You don't have to be from a posh background.

It's very important to be kind and compassionate and empathic.

I can't imagine even what it's going to look like after.

Just...

I'm just... Just, you know, taking it as it comes, whatever.

-Yeah.

-I look like I look like.

-You'll look smashing, I'm sure you will.

-OK.

-Do you know your way back?

-Yeah.

It's not an easy choice.

It's really hard.

People say, "You're making the right choice." Well...

..I haven't really got a choice.

So, today we've just got one patient to do.

She has chosen to have immediate breast reconstruction.

From the surgical point of view, she's got a good scan

and nice vessels, so we're happy with all that.

OK? Thank you.

And then ready, steady, slide.

Donna's operation in theatre eight

is so involved it requires 13 medical personnel.

For Ruth, every procedure like this is personal.

I was diagnosed with breast cancer in 2001.

I had to go through that journey of the surgery and the chemotherapy,

the radiotherapy, so I do understand what that diagnosis feels like,

to be on the receiving end of it and having to make those decisions.

And, inevitably, that's part of my being a surgeon

and how I treat my patients.

HE ISSUES INAUDIBLE ORDER

Whenever we discuss reconstruction with a woman,

we have to say it's never 100%.

So, there will be times when this doesn't work

and you may actually not end up with the reconstruction you were after.

There's not that many women out there who are actually

having to sit down and make that choice.

The prospect of having both your breasts removed

must be just enormous.

PHONE RINGS

Hello. Hiya.

I'm calling up for theatre three.

Just wondering if you can get the next patient ready, please?

By late morning, the next wave of patients head to surgery.

Theatre doors are just here,

so we'll let you say goodbye just before we go through.

In the QE's 42 theatres,

everything from appendectomies to amputations are under way

as most surgeons start their second operation of the day.

But, in theatre 23,

they're still in the first stage of Theresa's facial operation.

OK, I'll have some skin hooks.

In terms of Theresa's procedure,

the likelihood of things going wrong is fairly high

because of the complexity of the surgery.

To limit the time Theresa spends under anaesthetic,

Sat and Tim operate on two different sites simultaneously...

..Sat on Theresa's hip, Tim on her face and neck.

Don't pull too hard. Just stay nice and still.

They are both searching for the same thing -

blood vessels that are essential to a successful reconstruction.

Clean swab, please.

Once the tumour is taken out,

the flap of bone and muscle

with blood vessels attached will be removed from Theresa's hip.

The flap fits into the cavity created by the surgery.

To keep the flap alive,

its artery and vein are attached to another artery and vein

in Theresa's neck.

Everyone's anatomy is slightly different,

so it's an intricate job to find and isolate the right blood vessels.

Any sign of the vessel yet, Sat?

I think that's the main DCIA going down.

But I just can't tell for sure.

Sat is looking for the DCIA,

an artery that runs alongside the hip.

But it's buried deep within this mass of tissue, fat and muscle.

That's the main DCI. I think.

I suspect.

But it's quite deep.

But, hopefully, that will be it.

Clean swab, please.

I think that's the facial nerve branch, just there,

going up into the flap, isn't it?

Having two major surgical sites

is tougher on Theresa's body and tougher for Sat and Tim,

who have to work literally shoulder to shoulder.

It's going to be cosy.

-Am I in your way?

-No, no, it's all right.

There'll be lots of other surgeons who just would not get on

because of maybe arrogance, maybe egos.

-Sat, can I just have access for a sec?

-Sorry.

-Cheers.

I tend to be the grumpy one.

But, you know, he puts up with it.

Sorry, I was being a prima donna then.

-Just then?

-Yeah, just momentarily,

I flipped into prima donna mode.

Prior to that I was a straightforward, jobbing surgeon.

These are really quite high-stress cases and things can go wrong,

and, when they do go wrong, they go wrong very quickly.

I'm just struggling a little bit.

You can see that's the DCIA.

Yeah, there.

And then it's just doing something funny here and I'm not sure...

Sat finds the artery, but it doesn't look good.

It's not the best DCIA I've seen.

Just very low in the hip.

Really low in the hip. That's what's worrying me.

-Blade, please.

-At the other end, Tim's news is even worse.

Facial artery's tiny.

Is it?

Connecting the crucial blood vessels

is going to be even harder than they thought.

The main challenges of operating on the hip for this procedure is that,

although it gives you great-quality bone and great-quality muscle,

the blood vessel supplying that bone and muscle are extremely short.

Careful, careful.

If the flap blood vessels are too short,

it means it won't reach the blood vessels in the neck,

and you do have that panic, thinking,

"I really hope we can make everything work."

In Donna's double mastectomy and breast reconstruction,

plastic surgeon Ruth is on the hunt for Donna's blood vessels.

-There, I think.

-Yeah.

-Yeah.

She's looking for the artery and vein connected

to the parts of Donna's abdomen

they hope to use for the breast reconstruction.

Open a bit more, I think.

You lift up the skin and fat

until you get to this perforating blood vessel.

-Whoa! Look at that.

-Lovely.

-Stonking.

-Ruth has better luck than Sat and Tim.

The blood vessels are a good size.

OK, guys. Kate.

-Yeah?

-Look at that.

-Look at this.

Is that the best perforated you've ever seen?

-Oh, my word, that's lovely, isn't it?

-Isn't that beautiful?

-Yeah.

OK, I'd better not mess it up now.

THEY LAUGH

Once the mastectomies are performed,

these blood vessels will be crucial to giving Donna natural breasts.

The surgeons will try and connect the stomach flaps

to blood vessels in Donna's armpits.

Only then can the flaps be tucked under the skin into the cavities

to rebuild Donna's breasts.

First, Kate must meticulously remove

all the breast tissue to help prevent Donna getting breast cancer

-in the future.

-Yeah, that's got to go, as well, hasn't it?

It's an operation where you're doing, like,

a million strokes of the blade,

but with every single one you've got to bear that patient in mind,

that you're taking absolute care to remove every single little bit

of breast tissue that you possibly can do,

particularly if you're doing something like a risk reducing,

where their whole sanity and confidence relies on

the operation that you're doing right there and then

for the rest of their lives.

Donna's left breast is entirely removed.

Yeah, so there should be a form for the left.

Just needs weighing first.

It's weighed to determine how much fat will be needed

from Donna's tummy to replace it.

-What was it?

-909.

-909?

A woman making the choice to have a double mastectomy could say,

"Well, you know, just take it away, that's fine, that's job done."

But I think it's a so much easier decision to make if somebody can say

to you, "Yeah, we can do that,

"but we can also make you look and feel like a woman looks and feels."

For the reconstruction to meet that high standard,

Kate must take great care

of the skin around the site of the mastectomies.

One of the reasons why we'd like to do the reconstruction

at the same time as doing the mastectomy

is that, at that point, you're able to keep

the patient's own, natural skin.

You can keep the natural skin envelope with all the boundaries

of that and the natural droop of the breast,

which forms an envelope so that we simply don't need

to put a filling inside that to give a natural-shaped breast.

The filling will be the flaps of fat being cut from Donna's tummy.

-How's it going?

-Good.

-Fine, it's all pretty much done.

Right, so, hopefully, we can just...

..come through now.

There's the flap with the little blood vessel.

At the other end of the table, the first flap is taken to be weighed

to ensure there's enough to replace the breast tissue.

1231.

The flap is now ready to be plumbed in by trying to attach

the blood vessels to those of the mastectomy site.

Can we have the flap, please?

Now it's a race against time.

Getting the vessels reconnected quickly is important.

When we clip the vessels and take it off -

so that's called flap off time -

we have to be efficient in that time because all the time

that the flap's off, it's not got a blood supply.

It's like it's holding its breath, really.

So we need to get it connected as quickly as we can.

The QE is renowned for its reconstructive surgery.

Some of the most pioneering work is happening in the Burns Centre.

Professor Steven Jeffery is one of their leading surgeons.

Burn's obviously been round ever since mankind developed fire.

We've been burning ourselves and we've been burning each other!

OK, if you can lift this leg up for me.

Burns have got devastating consequences.

You can be left with horrible, disfiguring scarring.

Sometimes, the scarring is so bad that they're ashamed to go out.

-Sorry.

-Steven and his colleagues are always looking for

new ways to reduce scarring.

The ancients used to use lots of different dressings,

things that were naturally available.

So, they would use honey, they would use animal fat.

Now they're trialling a 21st-century way of treating burns.

But it comes from an unlikely source.

So this is the fish skin, as it comes.

From sterile in here.

You can use any fish, I think.

It just so happens that they fish a lot of cod in Iceland

and they used to throw away

a lot of fish skin, and somebody has discovered that it actually

makes a very nice dressing

to prevent pain and also reduce the scarring.

The patients are surprised, initially.

You have to forewarn them that it is going to smell fishy.

But I tell them that the fish smell is a good thing.

It means that the goodies that's in here

haven't been completely processed away.

If there's a smell, then there's also going to be the other stuff,

like omega-3 fatty acids.

They're known to be anti-inflammatory.

Inflammation means pain and inflammation means scarring.

The burns team are currently trialling the fish skin

in skin graft operations.

This is the fish skin.

It might be the right size.

Oh, perfect. Look at that.

Almost as if you designed that!

HE LAUGHS

They hope to prove it reduces scarring significantly.

If you don't push the boundaries, you'll get the same results.

If you want to get better than that and reduce scarring,

you have to innovate and you have to try new techniques.

Very good, thank you, all.

It's 2pm, and many theatres

are preparing for their third operation of the day.

That's not the case in theatre 23,

where Sat and Tim are preparing to remove the tumour

from Theresa's face and harvest bone and muscle from her hip

for the reconstruction.

OK, if I can use the drill before Tim and then I'll use the saw.

I'm going to use the saw in about the next 15 minutes,

ten minutes.

They've been operating for over three hours.

I've got backache.

Do you want a massage, Sat? Who's on massage duty?

So, OK, can I have that cutting guide, please?

And the screws.

So, now, this is the bit that really saves us time in terms of operating.

Empty screwdriver, please.

Screw, please.

Sat attaches the plastic cutting guide to the hip.

It's based on the exact dimensions of the cavity

that will be left in Theresa's face.

Both the screws are on the guide, yeah?

It allows him to cut not just the right size,

but importantly the right shape.

OK. Saw, please.

-Lovely chisels.

-Thank you.

SAW BUZZES

The cutting guides are so beneficial

because now we can really reconstruct

the defects in a totally predictable and accurate manner.

Just hold that. I don't know why it's stopped.

No.

Is it possible to put my saw on, please?

It's not working.

My saw's not working.

Oh! No, it is. My mistake. Sorry.

-Was it me?

-No, it's me.

The daunting task of removing the tumour on Theresa's right upper jaw

and her eye is Tim's responsibility.

SAW BUZZES

Whenever you're taking out a cancer, you try to do it en bloc.

If you start taking it out piecemeal, you leave

bits behind, it all gets very messy.

You'll feel the hard cancer and you cut round it,

aiming for a centimetre all the way around it.

Mallet, please.

They use a chisel and mallet to complete cuts in the bone.

At the end of the day, I would say that the surgeon is a technician

or a tradesman when it comes to the theatre.

I'm a carpenter because I cut bone.

I am a plumber.

A good suck at the back there.

I, you know, may be a bit of an artist

because I do the soft tissue.

Chisel, please.

But you're cutting up people's faces,

you're doing incisions on their face,

and so you've got to be kind of confident

about where you're going and what your outcome's going to be.

The hip flap is carved and ready for transplant.

Looks stunning, doesn't it?

Sat moves to help Tim as he makes the final cuts

around the eye so it can be removed, along with the tumour and upper jaw.

This is where I've got to get it right.

When you're just a short way away from the brain,

you've got to be a little bit more careful.

Taking the eye out is really quite a tense moment

because there's a direct communication

between the eye socket into the brain,

and this may result in a lot of bleeding at the time.

When you get a bleed from that,

this bleed just kind of relentlessly fills the wound...

Same in the bottom end here, thank you.

..but you've just got to get on.

You can't afford to dilly-dally.

You've got to make a decision and you've got to go for it

because if you don't, until it's out,

blood's welling up and you can't control the bleeding.

Stay as you are. No, don't pull. No, no, stay as you are.

And it always looks messy.

Superficially, it looks as though you're tearing it out

with your bare fingers,

which realistically you probably are, actually,

but in a measured way.

A good clean.

Specimen...

There.

Put that on one side, please.

Theresa's upper jaw and her right eye have been successfully removed,

a huge but necessary sacrifice for Theresa.

I don't think, clearance wise, we could improve on that.

OK.

It's 3pm and the operation has been running for four hours.

But now Sat and Tim have to do what's possibly the most complicated

part of the procedure.

We always have this period where the cancer's come out,

and you feel great that we've achieved one of our main objectives.

But then, suddenly, you remember that now

you've got to reconstruct this patient, put them back to normal.

We'll need a Kocher in a second.

You reach this point where you've removed it

and you've got a big hole and you've got to fill it.

And sometimes you do look at the hole and, you know,

you do think, "Flipping heck."

If you don't get this reconstructed,

the impact on the patient will be a fundamental disaster.

If Sat and Tim are able to successfully rebuild Theresa's face,

she will eventually be provided with a new eye.

The QE's maxillofacial prosthetics centre is the largest of its kind

in Britain.

Here, nine prosthetists specialise in replacing the body parts

that patients are missing.

We make a vast array of things, really.

Our most common prosthetic to make are prosthetic ears,

but we also make eye prostheses, nose prostheses,

fingers, thumbs.

We're really, really busy at the moment.

We're probably looking at between 40 and 50 prosthetics

packed in each week.

In the past, patients like Theresa would have been offered

just a pair of glasses with a painted-on eye.

But Kelly Morris creates individually tailored

silicon prosthetics.

You have the magnets themselves in the back of the prosthesis.

The magnets attach to metal pegs

implanted in the patient's eye socket during their surgery.

What's good about magnets is they're so easy,

they tend to just pull into the correct location each time.

You don't see the junction between the prosthesis

and the patient's natural tissues.

Kelly colours the glass eyeball by hand using oil paints,

painstakingly copying each patient's photo

to get a perfect match.

Most people don't realise that so many colours make up the eye itself.

They usually can't understand why it takes so long and you think,

"Well, because you've got to paint up all these tiny little

"striations in the eye."

But then they're usually pretty bowled over when they see it

and they see what a close match it actually is.

The finished eye will be fitted to a silicon mould,

taken from the patient's own face,

and matched precisely with their skin tone.

It will be attached several months after the operation,

when the facial reconstruction has had time to heal.

Once it's fitted, I think that people

are generally quite overwhelmed.

Usually they're in tears and they can't believe that, you know...

That's the really rewarding part of what we do,

seeing that transformation in people.

Giving them their lives back, basically.

It just allows them to go out and be who they are, as before.

Getting the patient's body back to its original state is the aim of all

of the reconstruction surgery at the QE.

Like in theatre eight, where Donna is having her breasts reconstructed.

Right, yeah, let's go for it like that.

Both flaps of skin and fat have now been extracted from her abdomen.

Now, this is the artery, which we're preparing.

So Ruth and surgeon Rob Warner face the difficult task of connecting

the blood vessels in the flaps to the ones in Donna's armpits.

So, from the armpit, this is the flap side.

So blood's going to be flowing in the artery up here.

The success of the reconstruction depends on them sewing together

blood vessels that are only three millimetres wide.

The vessels are fairly small and the suture is tiny,

as thick as a hair or something.

I'll put the stitches in.

So, on this side, we've now got the artery

and the veins joined together.

OK, so left flap is on.

I'm just putting the last stitch in the vein.

OK, so the blood flow to both flaps is working well.

With the vessels connected,

Ruth inserts the tissue under the skin

and begins shaping it into new breasts.

Right, OK.

So we know that the mastectomy specimen was 900g

and we know the weight of the flap's about 1,200.

So we need just to get the same weight. We need to take 300 off.

So what we're going to do is cut some off it now.

Getting the size and contours right is crucial.

Definitely at least a bit more to come.

What plastic surgery is about is form and function.

This is what we do - we restore form and function.

So we've got the left flap tucked in, roughly in position.

So now, with this one, which is all good to go,

we've taken a little bit off, but we're going to just try

and tuck it in and sit it roughly where it wants to sit.

Function is not just being able to pick up your cup of tea,

it's being able to walk out the door and face the world.

It's being able to go out and meet a partner

without feeling embarrassed or, you know, wanting to hide yourself away.

So the function is engaging with life again

and being able to do those things with confidence.

Although the calculations say that that's not much smaller,

I don't think we should make them smaller than that at the moment.

I think that looks nice for her.

When my girls were young and they used to say to my husband,

"Oh, what is it that Mummy does?" he says, "Oh, she cuts people up."

And I said, "No, that isn't true.

"I don't. I put people back together again!"

So, all of this bit now is really about just shaping,

trying to make things look nice,

trying to make them look symmetrical and a good shape.

Donna's nipples will eventually be reconstructed using her own tissue,

but only several months after surgery,

when her new breasts have settled into place.

Ruth and Kate can still do the groundwork.

We're going to end up with a circle of skin of the flap

in the middle of the breast where, ultimately,

we hope we'll be able to create a nipple for her.

I'm just going to draw that circle on here

and then get rid of the rest of the skin that is underneath.

Right, this all looks good.

-We just need to take that edge off there.

-Yeah.

-Yeah.

I'm from quite an artistic family.

My dad does a lot of painting, my brother's a sculptor,

and I think the plastic surgery's

kind of an extension of that, really.

There's so much variability in the techniques

that you can use to improve not just the aesthetic

but the function and form of the human body.

And from the background that I was in,

I enjoy putting my artistic mind into a medical specialty like that.

That's really nice, isn't it?

Yeah, I think that looks all right, doesn't it?

-I think that's a good size for her.

-Yeah.

When you get them through it,

that is such a great thrill.

That never goes away.

Every time it's a great feeling for me,

and getting that job well done is really why I can carry on doing it.

OK, so we're done.

Fabulous.

It's 4:30 in the afternoon.

The last trays from the sterile instrument store

are being dispatched to theatres for the final procedures of the day.

There you go, oesophagus tray.

No, that's not what I need. An abdo tray.

Oh, my God! Abdominal trays, that's down there.

-That looks like the last one on the shelf.

-Oh, right, OK.

I just figured we need an amputation set

because there is bone. They might cut through the...

Yeah, for the neck they only use...

To just lift up... So they can get in and lift up

and they pull it through there.

By now, over 110 different operations,

from spinal surgery to lung transplants, have taken place...

..while in theatre 23, after close to six hours,

Sat and Tim are starting the final stage of Theresa's operation.

Sat, what have you got to do on your bit, there?

Literally, we're just...

Put vessels, a teeny little bit of cleaning,

detach it, we're going to take it to top end.

They're ready to try and rebuild her face with the flap from her hip.

At the moment, she's got this big hole.

So the sole purpose of that flap is

it will create a new jawbone and roof of the mouth,

so she won't have a hole here.

The problem with these facial reconstructions is that

quite often it can be right at the end that things start to go wrong.

And we know that if we get it wrong,

this will have lifelong ramifications.

The last thing you ever want is a patient who is cured of cancer

but wishing they'd never gone through the treatment

because they can't live with their final result.

-You can start thinking about disconnecting.

-Yeah?

Sat detaches the flap from its blood supply at the hip.

OK, I'm going to lift this muscle up.

When you've detached the flap, it's just a lump of meat.

It doesn't have a blood supply until you plummet in at the top end.

-OK.

-Could someone do the lights for us?

Like in Donna's op, once the flap is moved,

it needs to be connected to blood vessels.

If that doesn't work, the reconstruction will fail.

Sucker on, please.

So that's going to go palatal.

OK. I don't think I dare do any more.

-No, I agree.

-Before they work on the blood vessels,

the flap needs to be fixed in place with a metal plate and screws.

OK, have we got a drill bit?

That looks good there.

Yeah. Yeah, perfect.

That looks bang on, really.

Yeah.

We're going to need the table right down.

The vessels they need to connect are even smaller and shorter

than in Donna's operation.

Right at the end of this operation,

you are then doing the more delicate microsurgery

and everything's dependent on that,

because if that doesn't flow,

well, you're in a no-return situation.

So here you can see...

So that's the facial artery and we're going to join it up.

And even though we've got all that, you can see,

we haven't got a lot of room to play with.

It's not much, is it? Even...

Rotate it the other way, that's lovely.

Thanks, Sat. These blood vessels are quite small.

They've often had a bit of a battering.

By the time you're starting to plummet in,

they've been pushed and pulled and stretched.

There's a bit of a funny something going on there.

Oh, there's a hole.

Oh, fuck.

They've discovered a hole in the side of the artery

-in Theresa's neck.

-Is that a hole, too?

-Yeah.

-Oh, bugger.

-If the damaged vessel is connected,

it will leak catastrophically.

Do you want to throw a clamp on that in case it shoots up?

I'll grab hold of it here.

To salvage the artery,

Tim needs to carefully cut off the section where the hole is.

May I have, please, the straight micro scissors, please?

OK, you don't have a lot to play with, Tim.

I know. This is the thing about microvascular surgery -

we do these 12-hour operations and these vessels are delicate,

and literally at any point,

one simple mistake can jeopardise the whole operation.

I'm just going to go for it, Sat.

OK, clamp, please.

The defect is removed.

Only now, the short blood vessel is even shorter.

When you're a bit short,

it sort of adds to the tension if it doesn't reach.

It's going to be fucking tight.

The two vessels Tim has to stitch together are very fragile

and only one to two millimetres in diameter -

as small as a pinhead.

If you just hold those together, Sat, I will cut.

-Can you hold them together?

-Yeah.

This is a bugger of a line, isn't it?

Can we get some different curved micros?

I'm quite renowned in theatre for getting tetchy

when things just aren't going quite to plan.

Just to let you know, this is quite a tricky little bastard one

because it's short.

Lovely. If you could stay like that.

-Pull a bit more on that one. No, don't move.

-Sorry.

Don't move, everyone. Don't move.

Stay still.

Please work, because if it doesn't I'm going to cry.

I have not enjoyed that at all.

Fantastic.

Tim successfully connects the flap artery to the artery

in Theresa's neck.

Well done, Tim.

Well, yeah, that's very kind of you...

No, that was difficult. That was hard.

If it's working, that's all I'm bloody bothered about.

OK, so the vein's looking nice. It's not engorged.

This is looking nice.

The anastomosis looks a lot better than it should do.

-OK.

-So, Doppler...

Doppler over here, I think.

They use a Doppler ultrasound scanner

to check blood is flowing in the vessels.

-Have we got the Doppler machine here?

-Yeah.

-OK.

-This scanner picks up the sound of the blood flow.

So we know that's OK.

Surprising, given the way I did that anastomosis.

-The whole thing was difficult.

-I was sweating bricks.

-I know.

With the blood flow confirmed, Sat and Tim concentrate on closing

the huge incision in Theresa's face.

-We're closing.

-Could I have some scissors, please?

-I'm knackered.

-It's just the stress.

I don't think a patient can even comprehend

what you're doing in theatre to them,

or what life would be like without reconstruction.

And I suppose they come out of an operation

not really knowing what they've been through.

She's actually, when you feel, she's got a great prominence.

Not overdone at all.

If that stays like that, that's really nice.

Before making the final sutures,

the duo want to use the Doppler again

to double-check the blood flow.

Could you just indulge us with the Doppler for a minute, as well?

Cheers.

Have we got a signal?

What the fucky ducky, ducky, ducky?

The scanner is not detecting a blood flow.

We're going to have to have a look at this.

You're not happy with your pick-up?

No, the Doppler's not working.

Without a blood supply, the flap will die in Theresa's face.

In a very small number of patients, it won't work out.

And the patient will be significantly worse off

than when you laid your hands onto them and operated.

And you have to just keep on reminding yourself

that you're doing it with the best intentions.

Amazing. It's keeping her mouth open.

-Bloody hell.

-What did they do?

-Close the mouth?

-Fucking hell!

The unusual position of Theresa's jaw

had been temporarily pressing on the blood vessels.

It's 7:30pm.

After 8.5 hours, Theresa's operation is over.

After a big operation, you would have thought to yourself,

"I'm going to go home and I'm going to go to sleep."

You just don't. You just continue kind of buzzing, thinking about it.

I can't let go.

I will often take my work home.

I will sometimes wake up through the night thinking about...

You know, what could I have done differently?

What will I do? Et cetera. So it does affect me.

From a personal point of view, there are two really satisfying aspects,

so the technical challenge of doing a major operation

and it being a technical success.

You all right there, Theresa?

But then also you've got the satisfaction

of seeing the patient doing well

and hopefully Theresa kind of demonstrates that.

Hello there. You're just waking up from the operation, OK?

Just try and keep nice and still for me.

It's one week since Donna had a double mastectomy

and breast reconstruction.

Surgeon Ruth Waters comes to check on her recovery.

When women come and we tell them about

what the reconstructive surgery involves,

you're telling them that they're going to have this huge operation,

but the goal at the end of it is to make them feel

as if it hadn't happened.

-Hi, Donna. How are you?

-All right. You?

-Yeah.

-Good.

-So, how are you feeling?

-Yeah, I'm OK.

-I had a bit of pain today.

-Yeah.

But it seems to be going under control again.

OK. Excellent. Do you mind if I have a quick look now?

-No, you carry on.

-OK.

OK, so that's looking lovely.

Nice size and shape.

Donna's operation went really, really well. We're very pleased.

So now, what Donna should do is think,

"That was something I had to do, it's done

"and I'm going to get on and have a hell of a good life."

They look approximately breast-shaped at the moment, anyway.

Yeah, they do. I looked down and thought, "God, I've got cleavage."

-It's quite nice, you know?

-Yeah.

-It's nice. Yeah.

I just didn't imagine anything like that.

No, they don't feel at all how I thought they'd feel.

I thought they'd be numb, you wouldn't be able to feel them.

But, no, I can feel them, they do feel part of me.

Erm...

They just feel like my old ones, really.

Theresa also returns to the Queen Elizabeth Hospital

for a check-up with consultant surgeon Sat Parmar.

In the old days, they were able to remove the cancer,

but what they were lacking was the ability

to reconstruct the face or the mouth.

Patients often had open wounds in their face.

Many of these patients would never then venture out again.

I'd like to think now that with modern reconstruction techniques,

very few patients ever regret undergoing a lot of the surgery

we put them through.

-Hi, Theresa.

-Hello.

-Come through.

-How are you?

-Not bad. How are you?

-I'm good.

-Nice to see you.

-And you.

-You all right? Come through.

Let's have a look at you. Pop yourself on the chair.

When I look at the symmetry of your face, it's really very good.

Yeah. My dad and my brother said,

"You know, it does, it looks amazing."

My brother was like, "Wow, I didn't expect you to look like that.

"I thought you'd look awful!"

When you get a result like Theresa's,

you're pleased because you've put her through a huge ordeal.

You know, for me, you look entirely normal.

Your speech is normal, you're eating well.

-You've got one eye, which we plan to sort out.

-Yeah.

Before Theresa gets a new eye fitted,

she'll need several post-op consultations.

I don't know whether we showed you before.

-Yeah, it's amazing.

-It is amazing.

Really, creepily amazing, actually, isn't it?

It all blends in and the beauty of the implants is

it will only fit in one position only.

-So you can't go out with a, like, wonky eye.

-No.

At least you have an idea of what we're going to do.

Thank you.

I do feel positive for the future.

-Thank you for coming in, Theresa.

-Thank you, Sat.

-See you soon, good luck...

-Yeah, lovely to see you. Thank you.

Bye-bye. Bye.

It does make you think that you have to make the most.

I don't think I made the most of what I had before,

so I think I'm going to have to make double the most

of what I've got now.

Everything looks extremely positive.

She already looks remarkably good.

She's speaking and eating normally.

She's got her zest back.

That's what we're there for, really,

is getting the patients healed from the cancer,

but back to normal.

Next time... With patients in the last chance saloon...

-We found something.

-It's spot the organ, isn't it?

..surgeons try to save a man's life...

-Expected duration of surgery?

-As long as it takes.

..by stopping his heart.

I'm not going to get sort of religious about it,

but it is literally on the edge of life and death.