As the surgery proceeds, we encounter each layer one by one. There is the excitement of the unknown – each person is different, each surgery is different. The complexities of individuality are apparent during each operation. But the unkown is countered by the familiarity of routine. The vast majority of the time, the layers are encountered as you expect them, often pristine and unadulterated. This is when the beauty of nature is most apparent. When you deviate from the midline, as we discussed with the fascia, you encounter the muscle. These encounters may be inadvertent or they can be purposeful. Just as surgeons have various tools with subtle differences and specific names, so too are there different incisions suited to and specific for various operations. The subcostal incision, while often relatively small, is poorly tolerated as the muscles are unsympathetically transected. This incision is necessary for exposure…. but it is not the easiest in terms of recovery. On the other hand the intimating-appearing midline abdominal incision can be very well-tolerated. It’s not always size that matters, it’s geography too. Depending upon what incision you have chosen, your encounter with the muscle varies.

I can not say that I have a “favorite” muscle, in fact I like many of them for different reasons. The rectus abdomini, your midline vertical pair, play a big role in body physique and appearance as well as strength. The lastissimi, your broad back muscles function not only to assist the shoulder joint, but also offer structural stability to the body. There are the muscles of the lower extremity that are the workhorses of locomotion. Yet even these strong muscles, with shortened names made famous by body builders and work-out enthusiasts (“lats”, “quads” and “delts”) are surprisingly gentle and frail when their protective fascial covering is removed. The muscle fibers when exposed can tear and fray. They can be thinned out and shred during surgery. They are easily transected by scalpels and cautery. I find this delicacy endearing and somewhat satisfying – a lesson from life and nature that true strength comes in various forms and that functioning within a system, as a team, is far superior than the capability of each component on its own. The whole, as we all know, is greater than the sum of its parts.

Do not get me wrong – the muscle, particularly as a pedicle with nerves and vessels, has tremendous healing power. These muscular flaps are revered as surgical tools. Reconstructive plastic surgeons spend their entire careers manipulating muscular flaps to replace large tissue defects after injuries or other surgeries. This is how many women get breast reconstruction after mastectomies, or abdominal wall reconstruction after an injury or illness. As a surgical oncologist my job is to remove cancer even at the expense of neighboring tissue, if that is what is required to get the cancer successfully out. And thankfully, our friends in plastic surgery know how to put it all back together to preserve function. So these muscles are not the equivalent of a bully, strong-appearing but hiding an inner weakness. They are work horses of strength, integrity, and function. But on their own, broken down into the individual fascicles of which they are composed, they lose some of this cohesiveness and their underlying delicacy is exposed.

I think this is often the case within the macrocosm of illness, just as it is reflected in the microcosm of tissue. There is a joke in surgery that the tougher the exterior, the slower the recovery. This speaks to the various types of strength that exist within the world. There is obviously the physical brawn, but there is also the emotional resilience, the intellectual flexibility, and the psychological understanding. These are strengths often under-represented by our physical appearance. I pay homage to the fragility of life, people, tissues and revel at the contrast of expectation to reality each time I gingerly sew muscle to muscle. I counsel myself to “approximate not strangulate” as I gently pull the muscle fibers together just close enough to heal but not hard enough to tear. And I remember that we are all a mix of strong and delicate, functioning most perfectly as a whole not as an isolated unit. And I try and remind myself to build myself and others when I can, to respect the body when it is vulnerable, and to allow it the utmost harmony with itself and the world around it in order obtain optimal function. This is not possible all of the time, but the lessons learned from the bodies of others reminds me to keep trying in my own life, and to encourage each patient and family to keep trying as well.

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