Episode 7

Managing Complex Wound Care with Dr. Stephanie Heller

Episode Transcript

Dr. Randy Lehman: [00:00:07] Welcome to The Rural American Surgeon. I'm your host, Dr. Randy Lehman. On this show, you'll receive powerful insights and resources for rural surgeons. I'm a general surgeon in northwest Indiana, and this show is tailored around the nuts and bolts of rural general surgery practice. You'll find topics ranging from practical surgical tips to rural lifestyle, finance, training, practice models, and more.

We also have a segment called Classic Rural Surgery Stories, where you'll get a feel for how practice in the country differs from the city. Whether you're a surgeon, other specialist, primary care provider, or simply someone interested in healthcare for rural America, I'm glad you're here. Now, let's get into the show.

Hey folks, welcome back to another episode of The Rural American Surgeon. Today I've got the legend, Dr. Stephanie Heller, my program director at Mayo Clinic. Following her program directorship, she served as chair of the department. She recently finished her stint in those duties and is now excited about returning to her role as a busy general surgeon at the ivory tower, St. Mary’s Hospital, Mayo Clinic. Thank you so much for joining us, Dr. Heller. We really appreciate it.

Dr. Stephanie Heller: [00:01:14] Awesome. Thanks for having me, Randy. I'm really excited to be here.

Dr. Randy Lehman: [00:01:17] Yeah, you bet. So, just take a few minutes and tell us a little bit about how you became one of the peak surgeons in the United States.

Dr. Stephanie Heller: [00:01:27] Okay. I don't know about the "peak surgeon in the United States," but I went to medical school in Colorado. Initially, I thought I wanted to do emergency medicine, but then I got roped in with surgeons and wanted to be like them. So, I pursued surgical training and matched at the Mayo Clinic in Minnesota. At the time, I didn’t know much about the Mayo Clinic or even Minnesota, but I fell in love with this place and never left. I've been here 27 years this summer.

Dr. Randy Lehman: [00:01:53] Wow. That's fantastic. I know you've had a huge influence on my life. One thing before we get too far into this episode—I was going to ask this at the end, but let’s do it now. Your personality is something I truly admire. Everyone who knows you loves you, including me. I have never heard anyone say, “Oh yeah, Dr. Heller, she’s a menace.”

How are you like that? I think it’s just who you are, but some of us—myself included—had to go to the principal’s office and hear from you, “You’ve got to calm down.” We had to work on ourselves. What have you done to cultivate this really effective personality where people work for you and with you rather than feeling antagonized by you?

Dr. Stephanie Heller: [00:03:15] Yeah, well, thanks for that. I don’t know if I know the exact answer. I am a chill, even-keeled kind of person. I just don’t get revved up for almost anything, which may be its own problem. My philosophy on life and dealing with others is to "kill them with kindness." Even if someone is vexing me or fighting me on something I think is important, I approach it with kindness and try to understand their perspective.

I always try to stand in their shoes and understand what they are trying to accomplish. I also always, always, always assume the best of everyone. That’s just how I’ve always been. In that way, I don’t fit the stereotype of an intense surgeon. Yes, surgeons are intense because we do intense things. Our patients are often very sick, and we want the best for them. But I assume everyone around me is always trying to do their best. 

So even when it comes across as they're dorking it up or they're just—it seems like they're doing a bad thing—I try to come at it with that mindset.

Dr. Randy Lehman: [00:04:25] Yeah, that's a really good practical tip. I appreciate you saying that. If you come up with anything else, feel free to add it. So now, tell us—you went on to become the chair. Is that the right word?

Dr. Stephanie Heller: [00:04:37] Division chair.

Dr. Randy Lehman: [00:04:39] Division chair for general surgery at the Mayo Clinic. And that was a seven-year term, right?

Dr. Stephanie Heller: [00:04:45] Yep.

Dr. Randy Lehman: [00:04:46] Just completed?

Dr. Stephanie Heller: [00:04:47] I completed six years.

Dr. Randy Lehman: [00:04:48] Okay. And coming off of that, in what ways are you being let down? In what ways are you excited for the future?

Dr. Stephanie Heller: [00:04:58] Yeah, I've been a leader for a long time. I was program director for eight years, and then, with essentially no downtime, I became division chair for six. You know, it's hard to not be in charge, right? There comes an authority with being in charge—just naturally being able to tell people what to do.

Now, if somebody else is making changes, I have to go along with it or try to talk to them and maybe influence the changes. But I don’t have authority anymore. At the same time, I'm excited because I love being a surgeon. I love operating—that is what gives me strength. For these 14 years, even while operating, I was always thinking about what's going on with my residents or my other surgeons.

So, I'm looking forward to ratcheting that down and just being all in, in every moment, operating on my patients. I think it's going to be good. But I do worry about not having as much authority.

Dr. Randy Lehman: [00:06:00] And your group is essentially a tri-state acute care, general surgery, trauma, and ICU group. That was really helpful for me during training to see what the ivory tower looks like. When I’m out in a critical access setting and a patient presents in extremis with XYZ problem, I can see the resources available there that I clearly don’t have.

You serve as a catchment area for a lot of those patients with very, very severe surgical conditions. In your group, how many people are there now, and what does the practice itself look like? How many days per month are you on call? And when are you doing ICU versus acute care general surgery? Just give us a quick overview.

Dr. Stephanie Heller: [00:06:50] Yeah, so we’re... I sort of... You can glom it all together. We call it acute care surgery, but it’s surgical critical care. We run a surgical ICU with 12 beds for general surgery and trauma patients. We cover that 24-7.

Mayo is a level one trauma center, so all trauma from the area comes to us. We have four helicopters bringing in trauma patients 24-7. We also cover all emergency surgery at St. Mary’s Hospital, which includes appendectomies, gallbladders, twisted bowel, dead bowel, perforated bowel, abscesses, infections—those kinds of cases. We cover that 24-7 as well.

Our group consists of 16 surgeons. How often you’re on call is a bit complicated. The 16 of us divvy up the night calls. On any given night, there’s one of us in the building operating all night and a second one on call from home as backup. If things get too overwhelming, we can call in a partner. So, basically, it’s one-in-eight night call.

On weekends, it takes four of us to handle the workload, so it’s approximately one-in-four weekends. During the day, we split responsibilities. Usually, we cover the ICU for about a week at a time, trauma for about a week at a time, and acute care surgery with three or four of us covering a week at a time.

Dr. Stephanie Heller: [00:08:30] And then, in any off time that’s available, we all have small elective surgical practices. There are different specialties among us—some do more ventral hernias, some do robotics. I do enterocutaneous fistulas, which are complications of surgical cases, as well as bowel obstructions. There are a number of things we handle electively on the side.

Dr. Randy Lehman: [00:08:45] Yeah, okay. So, that’s just very different, right? Obviously, I know it inside and out, but from what I’m doing now, it’s so different. For example, as I’ve mentioned in previous episodes of this podcast, the call burden in rural settings can be much higher. It could be every other or every third day. It’s a very different setup.

For me, I’ve never taken in-house call. Now, I’m working in four different hospitals, all of which are critical access. The main hospital is where I took my first W-2 job, and I’m still basically a full-time surgeon there. I cover Q3 call a week at a time—Monday at 7:00 a.m. until the next Monday at 7:00 a.m.—and I’m on call at all times for all surgical emergencies for the hospital.

On average, I would say it’s three to four calls per week, of which one, maybe two, are operative in a typical week. If I do three or four operative cases in a week, that’s unusual. Part of the reason is that while I can handle the appendectomies and cholecystectomies, if a cholecystectomy presents with hemodynamic instability and a white count of 30, I can’t handle that.

We don’t have an ICU; we essentially have a PCU. We don’t have the ability to run a drip or vent for more than an hour or two. If we did, we have one CRNA in town at a time. They’re on for two weeks and off for two weeks. I would essentially be staying at the bedside, totally overwhelming our resources. Plus, our nurses aren’t used to managing those situations.

In a critical access setting, you also have to certify that the patient won’t reasonably stay for longer than a couple of nights. We have to keep our length of stay down. Those patients simply can’t stay. You find yourself in situations like this: I had a 90-year-old lady with a strangulated hernia containing bowel. Her CT showed the bowel was threatened. She also had a bad heart.

What do you do? You send her to a referral center, but how long will it take to get her to an OR? Definitely longer than six hours. Time is bowel. In that case, I took her to surgery. She had dead bowel, but it wasn’t perforated. I did a bowel resection and dropped it back in. She woke up with chest pain, so I did a troponin and EKG. She had an NSTEMI and needed to be transferred.

Is that a failure? I don’t think so. She got the operation much faster than she would have otherwise, and I managed her until she could be transferred. To me, that’s the right thing to do. But I remember being a resident at Mayo, talking to an anesthesiologist. He asked about my training and, when I mentioned the rural surgery track, he said it made no sense to do surgery in rural settings.

He argued that, with a referral center just 30 or 40 miles down the road, no surgery should be done in rural hospitals. Well, okay, but I now live in the town I grew up in. Just this summer, my grandpa was admitted on one side of the hospital, and my wife’s grandpa was admitted on the other side of the hall, right across the hall from each other, walking across and talking. And I get to visit them almost every day. If they were admitted to Lafayette or Crown Point, which are only 35–40 miles away, I probably wouldn’t have seen them at all. No, it’s too much of a burden.

And it’s, you know, I... I don’t want to call out the CEO or whatever. When, you know, the Albert Lea and Austin, right... I’ll drive 26 miles for groceries. You know, that’s just not the situation. We don’t want to leave, and we need our hospital to stay open. So, doing surgery in our hospital is also a way for it to continue to be viable.

It’s this trade-off. If I have one or two patients per year that need to transfer post-op, is that too many? You know, and that’s the thing every rural surgeon kind of has to wrestle with continuously. When we talk to anesthesia, we talk to nurse managers, and we think about it ourselves—where do we draw the line? Sorry for rambling on that.

Dr. Stephanie Heller: [00:13:52] I think, you know, a couple of thoughts about that. First of all, these communities not only want to be in their community, but it’s better for them. Family engagement helps them recover better. It’s a huge burden to travel 40 miles away. If someone’s working a full-time job and has a family to care for, traveling to a hospital to sit for five minutes with their loved one is difficult.

Being in the community means they can be part of the recovery process and help guide it. I think that’s invaluable. So, I’m completely with you. I think we were going to head in this direction, but that’s part of why we added the program that ultimately trained you. You were our first trainee in our rural surgery program.

I’ll give you the history—most big programs, and certainly the history of Mayo Clinic, aim to train surgeons to become what they see. So, if you see a big hospital, a quaternary referral center, and big cases, that’s what you’ll go out and do. That was our history.

I’ll give credit for changing that mindset to Claude Deschamps, our department chair. Around 2012 or 2013, he came to me—I’m not sure where he got the idea—but I think he recognized the need for rural surgeons to have new partners. Recruiting surgeons into rural areas was very hard. He saw the benefit of deliberately training someone for these practices, and it completely changed our mindset.

If you want to train someone to go into these practices, you first have to recruit the right person—someone from that setting. Then, you still have to train them well while giving them a vision for that type of practice. The average resident we train doesn’t have the broad skill set needed in rural settings. Your skill set is much broader than most of us who go into urban or suburban practice.

These communities absolutely need that. You gave the exact example—a lady with dead bowel. If you immediately transfer her, it will take more than six hours to get to an operating room. That’s worse for her. From an outcome standpoint, even if we perform a world-class operation, losing more bowel during that delay is detrimental.

Dr. Randy Lehman: [00:16:34] Right, right. And then you have uncontrolled sepsis or intra-abdominal contamination. That’s my thought as well. I really appreciate the program—it obviously changed my life. For a resident listening to this, my advice would be to trust the match. That’s my main takeaway because, honestly, Mayo was my number two choice.

Dr. Randy Lehman: [00:19:45] But it doesn’t matter because whoever you match with, you know they wanted you too. So, it’s actually even better if it’s not your number one because you think, “Oh, I could have matched anywhere, but I fit this program because they selected me, and I selected them highly.”

What helped me mentally was being labeled—like stamped—with this rural track. I owned it from day one. Of course, I imagined myself in my hometown hospital, a critical access setting where I was born and wanted to return. So, when I was a first-year resident on call, and she’s doing a AAA, I was standing next to her thinking, “When I’m in a critical access setting and this patient comes in the door, what am I going to do?”

She walked me through it. Now that I’m starting my fifth year out, I might do things a little differently because I focus more on the critical care needs of the patient and expeditious transfer. I now know my limitations at my hospital. Even if I tried to operate, I honestly don’t think it’s the right setting for such a procedure. But it’s really hard to know that until you’re there. At least as a first-year, I was trying to plan.

The other thing is, our track has dedicated senior-level rotations in ortho, urology, ENT, plastics, and OB-GYN. For example, I know I’m not going to do big head-and-neck cancer resections, so it’s pointless to do a St. Mary’s ENT rotation. You have to go out to La Crosse and rotate with the surgeons doing tonsils, tubes, thyroids, and head-and-neck cysts—the bread-and-butter procedures that will show up in your practice. The same logic applies to every specialty.

Even as a resident, I didn’t fully realize that scopes and C-sections are 80% of the value you bring to a rural practice. That’s where the demand is. What I do daily can vary based on experience and the resources at my hospital, like whether we have good urology or ortho coverage.

For instance, I regularly do carpal tunnels, vasectomies, hysterectomies, ovarian torsions, tubal ligations, and lots of skin cancer cases. I occasionally do rotational flaps, a skill I picked up from plastics. Today, we’re going to discuss split-thickness skin grafts. These are the types of things I handle, but I didn’t realize early on how important scopes and C-sections would be.

I’m trying to create a bit of a community where we can have these discussions. Anyway, thanks a lot for the training. I’m glad we got a chance to share a bit about my life and my training, even though this is your interview. Do you have anything else to add, or should we roll into the “How I Do It” segment?

Dr. Stephanie Heller: [00:20:20] Let’s do “How I Do It.”

Dr. Randy Lehman: [00:20:21] All right. I like tricks and slick techniques. One of my favorite things is making something hard look easy. That’s what I enjoy—whether flying helicopters or doing surgery. You have a great technique for split-thickness skin grafts, so I asked you to share the details. Before we dive into your process, let’s talk about the main indications for split-thickness skin grafts in your practice. What are they?

Dr. Stephanie Heller: [00:21:01] Yeah, the two main indications for me are non-healing wounds. I see a variety of cases—usually traumatic wounds that are too large to heal on their own.

Dr. Stephanie Heller: [00:21:01] But my other big indication, where I have to nuance how to do a skin graft, is to cover enterocutaneous fistulas. This makes them easier to manage until we can perform a larger operation to address them.

Dr. Randy Lehman: [00:21:26] So, mostly traumatic wounds. Not so. I have this patient right now—I’d like to pick your brain about it. It’s a radiated leg from a sarcoma resection in the past. The wound is on the anterior shin, which is the worst location. I hate the anterior shin.

I get basic cases like skin cancers there. I’ve tried full-thickness skin grafts, flaps, and split-thickness skin grafts, which sometimes take. But then you get patients with chronic venous stasis and similar problems. I’ve moved my practice toward excising the cancer, packing the wound, and letting it heal. But sometimes split-thickness grafts are the thing. Now, with this chronic non-healing wound, where do I go next?

Dr. Stephanie Heller: [00:22:14] Yeah, I like that philosophy. I wait as long as possible before grafting wounds. An open, clean wound is safe. You teach the patient how to take care of it. Over time, wounds contract, epithelialize, and heal. Start there.

I love that approach because many wounds will heal naturally, leaving you to deal only with what remains. But I agree—you’re talking about the hardest of the hard wounds: a radiated shin. There’s not much tissue there. That’s where a plastic surgeon’s rotational flap might be indicated.

I’m always honest with patients. A skin graft may or may not take in that location, but we can give it a try if they don’t want to pursue a big flap procedure. Sometimes, grafts take if you’ve been working on a clean wound. Another key factor for lower extremity wounds is edema control.

Encourage patients to elevate the leg whenever they’re in bed, watching TV, or sitting. When they’re out and about, they should use a firm ACE wrap. The more you can control edema, the better a skin graft will take.

Dr. Randy Lehman: [00:23:31] Yeah, perfect. Your ideal patient is obviously a young, healthy person with a big shark bite. The wound is clean, and anything will take in that location. But those aren’t usually the patients that find your clinic, right?

Dr. Stephanie Heller: [00:23:46] Exactly. My patients usually aren’t young or healthy.

Dr. Randy Lehman: [00:23:50] For a radiated field, do you have any other tricks? You mentioned pedicle flaps or vascular techniques. How about using nitro paste or something like that?

Dr. Stephanie Heller: [00:24:04] My experience with grafting in radiated fields is pretty limited. The only other option, and this usually involves a referral, would be hyperbaric therapy. This can help create a robust granulation bed, improving the chances of a graft taking. Hyperbaric therapy is probably the most proven intervention for radiated fields.

Dr. Randy Lehman: [00:24:28] Yeah. Thanks for rabbit-trailing with me. Let’s make it simple. Let’s say you have a large wound. Actually, I have one more question. What do you quote your patients when they ask how quickly their wound will heal if they just use dressings?

Dr. Stephanie Heller: [00:24:54] I tell them about a millimeter a day from each edge. But you also have to account for contraction in a well-granulated bed, which will shrink the total wound size.

Dr. Stephanie Heller: [00:25:01] Just to set expectations, I tell everybody a couple of months. A lot of wounds will get darn close, and within a couple of months, the wound will be dramatically different and easier to care for. So, I say, “Give it a couple of months to deal with this problem, and then let’s see where we are.” Just to level-set.

Dr. Randy Lehman: [00:25:27] Yeah. So, this guy—tiger bite to the abdomen—has a wound that’s 6 by 12 inches. It just happened. Do they need the split-thickness skin graft that day, or do you pack the wound until it granulates and then graft on that?

Dr. Stephanie Heller: [00:25:49] Any fresh wound? Just pack it. Keep it clean. I let patients shower—soapy water is fine. Everybody’s obsessed with sterile wounds, but once a wound’s open, it’s just like our skin. So, you can shower with soapy water, change dressings a couple of times a day, and wait for it to granulate. You’re looking for bright pink tissue in the middle.

The biggest benefit of a skin graft is grafting onto something completely flat. So, I recommend dressings as long as possible until you have a perfectly flat, granulated wound. That’s when I graft it.

Dr. Randy Lehman: [00:26:27] And that’s Kerlix, lightly moistened, fluffed, placed in the wound twice a day?

Dr. Stephanie Heller: [00:26:32] Yes. Simple dressings, with soapy water showers in between.

Dr. Randy Lehman: [00:26:36] How about a VAC? When do you use that?

Dr. Stephanie Heller: [00:26:38] VACs are fine. I’m a fan, but they’re more complex. You usually need a nurse to change it three times a week. If it works logistically, VACs are great. Sometimes they’re easier for patients, but if they’re too complicated, I stick with moist-to-dry dressings.

Dr. Randy Lehman: [00:26:57] Okay, let’s say this patient followed the regimen for 14 days. Now the wound is 90% granulated. Do you graft it now or wait another week?

Dr. Stephanie Heller: [00:27:08] I’d wait another week.

Dr. Randy Lehman: [00:27:09] Okay, so we wait another week. By three weeks, it’s 100% granulated. Does that sound like the right time frame?

Dr. Stephanie Heller: [00:27:15] That’s the soonest I’d consider it. If the wound is granulating and contracting nicely—getting smaller, they’re living their life—I might even wait longer.

Dr. Randy Lehman: [00:27:28] What if this guy is a T-shirt model, and it’s soaking through his Calvin Klein shirts? He doesn’t care about aesthetics; he just needs it to stop seeping.

Dr. Stephanie Heller: [00:27:40] Let’s do it. We’re going to graft.

Dr. Randy Lehman: [00:27:43] So, he comes to your operating room. Anesthesia, prep, position—please talk to me like I’m a resident.

Dr. Stephanie Heller: [00:27:51] First, decide where to harvest the skin. The easiest option is the anterior thigh. When they’re in bed for the next few days, they’re not rolling on it. A donor site can be painful, but this location is easy to care for. It’s a common choice.

However, not everyone’s thigh provides enough skin—some patients are too thin. If your patient is also a shorts model, they may not want a scar on their leg. In that case, you can take skin from the back or any area with extra skin.

One unique option my mentor and partner, Henry Schiller, taught me—he was a burn surgeon—is taking skin from the top of the head. Initially, it horrified everyone when he introduced it at Mayo Clinic. It seemed strange, but after seeing it done a few times, I became a believer.

Dr. Stephanie Heller: [00:29:01] The advantages of taking a skin graft from the top of the head include no visible scar if the patient is concerned about appearance. Secondly, the skin on the head is robust and thick, which yields a beautiful skin graft. Hair grows back, and there’s very little pain in that area.

The top of the head doesn’t move much, so it causes less discomfort compared to other donor sites. Movement under a donor site usually causes pain, but this doesn’t happen with the scalp. I once saw my mentor take a graft from the top of the head of one of our nurses. The patient didn’t take a single pain medication and went home the same day.

Shaving the head, taking the graft, and allowing the hair to grow back produces excellent results. It’s an option to consider based on the patient’s preferences and the case specifics.

Dr. Randy Lehman: [00:29:44] If the patient is a man with a family history of male pattern baldness, does that affect your decision?

Dr. Stephanie Heller: [00:29:50] It does. They need to understand that they might have a visible scar or a darker patch on their scalp if they lose hair later in life. Most patients in that scenario don’t seem to care, though.

Dr. Randy Lehman: [00:30:06] Would you ever take the graft from the side of the head to avoid that?

Dr. Stephanie Heller: [00:30:09] You can, but it’s more complicated. Getting the dermatome positioned correctly near the ears adds logistical challenges.

Dr. Randy Lehman: [00:30:18] How much of the hair around the area do you shave?

Dr. Stephanie Heller: [00:30:23] When I’ve done it, I just shave the whole head. Otherwise, it’s difficult to position the dermatome properly. Shaving the whole head allows for a fresh start and simplifies the process.

Dr. Randy Lehman: [00:30:34] Does hair grow back at the donor site?

Dr. Stephanie Heller: [00:30:38] Yes, all the hair grows back.

Dr. Randy Lehman: [00:30:41] What about at the graft site? Does much hair grow there?

Dr. Stephanie Heller: [00:30:44] No, the follicles are much deeper. The graft site ends up hairless.

Dr. Randy Lehman: [00:30:48] That’s great to know. Let’s say the patient prefers taking the graft from the anterior thigh. Would you use general anesthesia because of the pain?

Dr. Stephanie Heller: [00:30:57] Yes, general anesthesia is standard for thigh grafts because the donor site can be quite painful.

Dr. Randy Lehman: [00:31:17] What if the patient is like one of mine—an 85-year-old lion tamer with a history of coronary artery disease and a prior stroke? Have you ever performed this without general anesthesia?

Dr. Stephanie Heller: [00:31:21] I haven’t done it without general anesthesia.

Dr. Randy Lehman: [00:31:22] I have.

Dr. Stephanie Heller: [00:31:22] Really?

Dr. Randy Lehman: [00:31:26] Yes, I’ve done it using a tumescent technique with local anesthesia. I’ve performed several procedures with limited anesthesia, sometimes under MAC. For one patient, I used a 2-inch guard on the dermatome for a smaller wound.

It’s incredible how much older patients can tolerate, especially with good guidance. Their nerve endings seem less sensitive. I started with EMLA cream, applied local anesthetic, and carefully harvested the graft. The patient didn’t feel a thing and tolerated it well under light MAC.

Dr. Stephanie Heller: [00:32:10] Wow. I’ve never done that, but I might add it to my repertoire. It makes sense.

Dr. Randy Lehman: [00:32:22] This patient, however, is young and healthy, so we’ll go with general anesthesia. He’s supine, and we’ll prep the wound site widely.

Dr. Randy Lehman: [00:32:30] So, what do you do to debride the wound right before the graft?

Dr. Stephanie Heller: [00:32:34] A lot of my skin grafts are on granulation over bowel, which is a special case. But assuming this is more of a subcutaneous tissue wound with fascia beneath, the goal is to clean up the very surface. That’s where bacterial contamination will be.

I use a Goulian knife, which is a long blade, almost like a barber’s straight razor. I gently run it over the top surface of the granulation tissue to remove the very top layer. This exposes fresh granulation underneath, making the area cleaner for grafting. If there’s bowel underneath, I obviously don’t use this method. In those cases, I irrigate thoroughly and roughen the surface with a lap pad to reduce the bacterial load.

Dr. Randy Lehman: [00:33:28] Salt is Mayo Clinic speak for a lap pad, by the way.

Dr. Stephanie Heller: [00:33:31] Yep. Exactly.

Dr. Randy Lehman: [00:33:34] Okay, and do you prep the wound with Betadine, not Chlorhexidine?

Dr. Stephanie Heller: [00:33:40] We usually use Hibiclens.

Dr. Randy Lehman: [00:33:42] Got it. Do you use the same prep for the thigh donor site?

Dr. Stephanie Heller: [00:33:46] Yes, we use the same prep for both.

Dr. Randy Lehman: [00:33:48] Let’s talk about the dermatome. What are your settings?

Dr. Stephanie Heller: [00:33:54] I set the dermatome to 10/1,000th of an inch, which is about 0.3 millimeters in thickness. That’s my standard setting for most cases. If someone has thicker skin, I might set it slightly thicker, or thinner if needed. But 10/1,000th has served me well.

Dr. Randy Lehman: [00:34:14] Okay. Now, the pièce de résistance—tumescent. How do you prepare it?

Dr. Stephanie Heller: [00:34:19] The tumescent solution is a liter of lactated Ringer’s with 1 milligram of epinephrine and 500 milligrams of lidocaine. When I’m ready to harvest, I measure the wound and donor site, decide how much skin I need, and mark the area on the thigh.

The solution is in a sterile basin. I use three 60cc syringes with large 18-gauge needles. My scrub tech draws up the syringes quickly, and I inject the solution deep into the dermis and the top of the subcutaneous layer. I aim to inject nearly the entire liter to make the skin flat and firm—like a hard, flat board—so the dermatome glides smoothly over the surface.

Dr. Randy Lehman: [00:35:17] Let me teach you a trick.

Dr. Stephanie Heller: [00:35:20] Sure!

Dr. Randy Lehman: [00:35:23] Vascular surgeons have a pump for vein ablations. It’s fantastic for this and saves you from getting carpal tunnel.

Dr. Stephanie Heller: [00:35:34] That sounds great—I already have carpal tunnel from all the manual work.

Dr. Randy Lehman: [00:35:35] You can mix the solution in a saline bag, hook it to the pump, and control it with a foot pedal. It simplifies the process. The goal is the same: firm, raised skin like an orange, ready for a smooth harvest.

Dr. Stephanie Heller: [00:35:46] That’s brilliant. I’ll definitely try it.

Dr. Randy Lehman: [00:35:47] So, what size mesh do you use?

Dr. Stephanie Heller: [00:36:07] I use a 2:1 Braun mesh. It’s consistent and works well.

Dr. Randy Lehman: [00:36:13] If the wound is 6 centimeters, do you use a 3-centimeter guard?

Dr. Stephanie Heller: [00:36:18] Exactly. That’s the ratio I stick with.

Dr. Randy Lehman: [00:36:23] I know they measure the mesh in inches.

Dr. Stephanie Heller: [00:36:23] Right, but I always use 2:1 mesh because we don’t want fluid to accumulate underneath. I barely stretch it. Whatever my wound size is, I aim for almost the same size of a swath from the dermatome because I’m not trying to stretch it out.

Dr. Randy Lehman: [00:36:45] It’s more to let the fluid out?

Dr. Stephanie Heller: [00:36:47] Exactly.

Dr. Randy Lehman: [00:36:48] Got it.

Dr. Stephanie Heller: [00:36:49] The sizes are almost identical.

Dr. Randy Lehman: [00:36:51] So you’ve created this hard board, and now you’re ready to go with the dermatome. Do you use mineral oil?

Dr. Stephanie Heller: [00:36:58] I just apply more Hibiclens.

Dr. Randy Lehman: [00:37:01] Hibiclens, then come in with the dermatome at a 45-degree angle?

Dr. Stephanie Heller: [00:37:04] Yes, 45 degrees. You really need to push into the skin. If you just skim over the top, you’ll miss areas. You have to dive into the skin and push firmly. The dermatome regulates the skin depth, so trust it and apply enough pressure.

Dr. Randy Lehman: [00:37:19] Got it. Then you come off smoothly, take a perfect specimen, and place it on the plastic board that comes with your mesh measure?

Dr. Stephanie Heller: [00:37:29] The Zimmer Biomet mesh doesn’t come with a plastic board. We just lay the skin on it and run it through the measure.

Dr. Randy Lehman: [00:37:35] Okay. How could a resident mess that up?

Dr. Stephanie Heller: [00:37:39] The key is to lay the skin out properly. If it starts to bunch up, the mesh will over-punch, creating larger holes than intended. It needs to roll through as a single layer. If it bunches, you’ll have uneven results, which you don’t want.

Dr. Randy Lehman: [00:37:56] Agreed. For any residents listening to this podcast, remember, as you ratchet the graft through, don’t let it pull back into the ratchet. Keep pulling it down smoothly.

Dr. Stephanie Heller: [00:38:22] Exactly. Don’t let it feed itself back into the ratchet mechanism.

Dr. Randy Lehman: [00:38:25] And another mistake is putting the skin graft on upside down.

Dr. Stephanie Heller: [00:38:33] That’s a major issue. Up to this point, the process is straightforward, but putting the graft on upside down will ruin it. I always inspect the graft under surgical lights. I stick it on my hand to assess whether it’s shiny or matte. Then, I flip it over to confirm. The shiny side must go down.

I toss the graft onto the center of the wound, letting it lay naturally with the shiny side down. With wet saline gloves, I gently press and smooth it out. I check for lumps, bumps, or curled edges, slowly working it flat. I keep pushing and swiping until it’s perfectly aligned with the wound edges.

Dr. Randy Lehman: [00:39:31] How do you secure it?

Dr. Stephanie Heller: [00:39:33] I staple around the edges. Once it’s flat, I use about eight staples around the wound to hold it in place. Then, I cover the graft with Adaptic.

Dr. Stephanie Heller: [00:41:00] So, I take Adaptic, which is a non-stick gauze, and cut it into small strips. This is a technique I learned from my colleague, Dr. Schiller, a burn surgeon. Instead of applying a single layer of Adaptic—because peeling it off later could disturb the graft—you layer small, overlapping strips. This way, when you need to peel it up, you can do it carefully and minimize the risk of damaging the graft.

I completely cover the graft with Adaptic, then place a VAC sponge over the top. I prefer to bivalve the sponge to make it thinner and easier to apply. Once the graft is down, it must not move. If it moves, it can shear, bleed, or fail. So, I carefully secure the sponge and set the VAC to 125 mmHg suction.

After application, I give patients relative movement restrictions. They can go to the bathroom but should avoid extensive walking for the first few days. For a clean wound, I’ll wait several days before doing a VAC change. If the wound is infected or involves a fistula, requiring daily cleaning, I’ll take them back to the OR or a well-lit area, peel off the Adaptic, gently clean the wound, and reapply the dressing.

Pseudomonas or stool contamination can destroy a graft, so daily care is critical for dirty wounds. After seven days, the graft is usually secure enough to remove the VAC and switch to regular dressing changes.

Dr. Randy Lehman: [00:42:07] If the patient comes in as an outpatient and wants to go home, do you allow that?

Dr. Stephanie Heller: [00:42:16] My partner did it once with a nurse who had a scalp graft. If you arrange for a home VAC, it’s feasible. The VAC provides stable dressing and minimizes the chance of shearing the graft, which is the biggest risk. With proper planning, skin grafts can absolutely be managed as outpatient cases.

Dr. Randy Lehman: [00:42:34] I’ve used a bolster dressing with Xeroform gauze and Prolene stitches to secure it. That way, the dressing doesn’t move. I’ve left it for five days before changing it. But it sounds like you’re changing them more frequently in infected cases.

Dr. Stephanie Heller: [00:43:00] For clean wounds in healthy patients, five to six days is reasonable. My cases are usually more complex—often with fistulas or contamination—so I check and change dressings more often.

Dr. Randy Lehman: [00:43:17] For a clean wound, would you let the dressing stay untouched until the final removal after seven days?

Dr. Stephanie Heller: [00:43:26] With a good graft, even after five days, you often don’t need the bolster anymore.

Dr. Randy Lehman: [00:43:31] So, you just leave it there?

Dr. Stephanie Heller: [00:43:33] Exactly.

Dr. Randy Lehman: [00:43:44] If the graft is on their leg and they’re sleeping, I’m paranoid about them tossing and turning and losing it. Do you put anything on to secure it?

Dr. Stephanie Heller: [00:43:44] Once the graft is stuck, typically by day five to seven, I use Vaseline gauze, a wad of Kerlix for padding, and then a mesh netting over the top. That setup is usually pretty safe.

Dr. Randy Lehman: [00:44:05] Got it. One more question about the Adaptic strips. When you put the VAC sponge over them, do you add anything like bacitracin, or is it just dry Adaptic?

Dr. Stephanie Heller: [00:44:12] It’s just dry Adaptic.

Dr. Randy Lehman: [00:44:14] And about the VACs—at Mayo, they’re ubiquitous, almost like water. You can get them without any issue. In rural America, though, it’s not that easy. Who typically gets the VACs for you? Is there a way to simplify the process?

Dr. Stephanie Heller: [00:44:45] I have to admit I’m spoiled—VACs just appear for me. However, I have a friend, a private practice plastic surgeon in Georgia, who partners directly with 3M. She says they’re eager to work with providers and handle the paperwork for insurance submissions. That might be a good route for rural providers. Honestly, I think VACs are amazing and quite user-friendly. I even think patients could be taught to change their own VACs if needed.

Dr. Randy Lehman: [00:45:37] That’s a good point. I inherited a wound care service at my hometown hospital under unusual circumstances. The surgeon managing it had a stroke, and the hospital reached out to me because of my interest in wound care. I was still employed at another hospital, but I worked out a deal to help both facilities. It was serendipitous in a way—though, of course, not good that the other surgeon had a stroke. I was starting to develop a good friendship with him, and it was a significant loss for many of us.

Anyway, what I learned is that having a certified wound ostomy care nurse is incredibly helpful. They handle logistics like VAC management, submitting paperwork, and ensuring continuity of care. If you have a wound care service at your hospital, it’s a great resource for primary care doctors, ER docs, and hospitalists. It’s also a good revenue generator for the hospital and an excellent service for patients.

Dr. Stephanie Heller: [00:46:24] That makes a lot of sense.

Dr. Randy Lehman: [00:46:25] Exactly. A dedicated wound care nurse not only focuses on the wound but also considers underlying factors like diabetes, uncontrolled comorbidities, or venous stasis. I’ve had great success with chronic wounds by addressing vein issues. For example, I’ve seen longstanding wounds heal completely after venous ablation.

Dr. Randy Lehman: [00:47:58] Thinking about it that way, rather than just looking at the wound and saying, "Oh my gosh, there's a wound there," helps. Those are my thoughts on realistically getting a VAC.

Dr. Stephanie Heller: [00:47:58] And that brings it back to why it's so important to have local care. If you have to drive 40 miles three times a week for dressing changes, that’s untenable for the family and the patient.

Dr. Randy Lehman: [00:48:12] Yeah. You know, a 10,000-foot runway at the old Rochester International so the prince from Abu Dhabi can fly in on a private 747 for their umbilical hernia repair by a second-year resident, flying over thousands of capable surgeons on the way. Love that. Great follow-up, though. That’s the practice—it was great to train there.

One last thing—thank you so much for your time. Enterocutaneous fistula practice is niche, but since you brought it up with the VACs, what does the rural surgeon in the U.S. need to know about enterocutaneous fistulas? Prevention, recognition, treatment—what are your key thoughts?

Dr. Stephanie Heller: [00:49:10] Prevention is exactly where I’d start. When I get these referrals, the pattern is almost always the same. An operation was done, it was done well, and then a complication happens—which happens to all of us. But if you’re slow to recognize and act on complications, that’s when fistulas develop.

For example, not wanting to open an infected wound because it’s unpleasant—nobody likes infected wounds. But if you’re slow to open a wound, the fascia can fall apart, exposing the bowel. That’s how fistulas form. Similarly, being slow to recognize a leak and delaying re-exploration can lead to a hostile abdomen, creating conditions for a fistula.

Postoperative care is critical. Recognizing complications early, having the infrastructure to act, and staying engaged with patients is key. If a wound isn’t healing properly, aggressive management is needed to prevent it from eroding down to the bowel. That’s when fistulas happen.

Once you have a fistula, it’s a different level of complexity. Optimizing nutrition, managing care, and knowing when to operate are essential. For me, it’s easier to take a step back with a referred fistula case because I have objectivity—it’s not my complication.

But when it’s your own patient, especially in a close-knit community, it’s hard not to rush back to the operating room. The temptation to fix it quickly is strong, but timing is everything with fistula surgery. Sometimes it’s three months, sometimes it’s a year—it depends on the underlying situation.

Dr. Randy Lehman: [00:49:10] That’s really insightful.

Dr. Stephanie Heller: [00:52:17] That is harder to do when it's your patient, your complication, and the family is looking at you. But keeping that perspective of wanting to get the patient through it and back to a normal life is critical. That takes time. Sometimes it also takes another set of eyes or a different surgeon looking at it. Other times, it's about owning it and saying, "Here’s the reality, and this is how we get you to better."

Dr. Randy Lehman: [00:52:17] How do you know when you're ready for the operation?

Dr. Stephanie Heller: [00:52:20] Yeah. Our guiding principles are these: if the operation resulted in closed fascia, but there was a leak, and you put a drain in the leak but it’s still leaking, you typically can go back at around three months.

The caveat is getting scans to ensure the belly isn’t still inflamed. If the belly shows lots of inflammatory changes, you may need to wait longer. If it looks like a friendly belly but there’s a persistent fluid collection, three months is reasonable.

If it was a difficult belly before—such as one with complex adhesions—it’s at least six to eight months. If it was a really bad belly, where the fascia couldn’t be closed, or if micromesh was used, a rule of thumb is to wait a year. Avoid going back into that belly for at least a year.

Dr. Randy Lehman: [00:53:34] What’s the patient doing during this time?

Dr. Stephanie Heller: [00:53:36] Initially, a lot of the care happens in the hospital. It’s about optimizing nutrition, often with TPN. If the fistula is distal, the patient may be able to eat, get up, and move around, which helps them get stronger for the big operation ahead. It’s like training for a marathon—getting in shape and optimizing their medical care.

In the perfect world, most of this happens outside the hospital. After setting up the care plan, including TPN and wound care, many patients can live as outpatients, often managing TPN and wound care at home. It depends on the specific case, but the goal is to maximize out-of-hospital time.

Dr. Randy Lehman: [00:54:22] Yep. I think that’s enough about fistulas. Thank you for taking the extra time. It’s such a unique topic and very relevant. If you’re doing any acute care surgery, you’ll encounter this at some point in your career.

Why don’t we shift gears a little? One segment of my show is the financial corner. Do you have a particular money tip for residents or young attendings? Maybe something you wish someone had told you, or something you did that worked well?

Dr. Stephanie Heller: [00:54:59] Yeah, a few things come to mind. Going into medicine, we’re all masters of delayed gratification, right? It’s college, then medical school, then residency—it just keeps going. The whole time, you’re kind of poor, thinking, "I’ll make money eventually."

But you don’t want to miss out on the benefits of compounding interest. Starting a retirement account early is critical. Even as a resident, when you’re getting paid, putting a little bit into a retirement account is so important to take advantage of compounding interest.

Dr. Stephanie Heller: [00:56:41] The other is, I don’t know. For me, it’s always a balance. Would I like a big flashy car? Sure, I would enjoy it. But it’s not worth it. To me, it’s all about balance. Just focus on what brings you joy. For me, flashy cars aren’t it. I drive a used Honda. During residency, I drove a used Suzuki Esteem. You probably don’t even know what that is—it was a little, tiny, nothing car. I’ve never driven a brand-new car because it just doesn’t have value to me.

I like travel, so we’ll splurge on travel a few times a year with my family. I also enjoy doing fun stuff with my kids, so we’ll splurge on that. But I don’t like new cars. We’ve lived in the same house for over 20 years, and we’re already looking to downsize, probably sell it and get something smaller at some point. So, save money for what truly gives you joy, but start your retirement savings as soon as possible, as soon as you’re making money.

Dr. Randy Lehman: [00:56:41] Yeah, I love that. Thank you. I like that there’s starting to be a theme here. You know, whether it’s a car, a house, or whatever, you can have anything you want as a surgeon, but you can’t have everything you want.

Dr. Stephanie Heller: [00:56:53] Exactly.

Dr. Randy Lehman: [00:56:54] That’s beautiful. Thank you for those tips. Now, for the last segment of the show: resources for the busy rural surgeon. I know you’re involved in the American College of Surgeons. Do you have any specific tips for rural surgeons who are professionally isolated? How can they stay connected and current? What should they do?

Dr. Stephanie Heller: [00:57:16] Yeah, it’s kind of the same idea: you can do many things, but you can’t do them all. The College is amazing. They have a rural surgery section you can join. They even have a dedicated website for rural surgery, so you can find others in that same tribe and connect.

I think the College is a great place to start. There’s also the Northern Plains Surgical Association, now renamed the North American Rural Surgery Society. That’s another group focused specifically on rural surgery. Are there other groups you know of?

Dr. Randy Lehman: [00:57:45] That’s the main one. They just changed the name last year to North American Rural Surgery Society. It originally started as the Northern Plains Vascular Surgical Society, created by rural surgeons still performing vascular procedures. But as practices evolved around 2015, the leaders decided to pivot. They still wanted to meet annually and found value in getting together.

It’s a Saturday-only conference held on Martin Luther King Jr. weekend. And if it sounds like I’m pitching it, it’s because every rural surgeon should carve out time every year to attend. There’s a dinner on Friday night, followed by resident presentations and debates on Saturday, with CME sessions. Saturday night is another dinner, and there’s talk of adding a social event on another day.

If your program has a rural surgery track, like Dr. Rivera’s program, you should consider sending representatives. Do you have an associate program director now?

Dr. Stephanie Heller: [00:58:55] I think she’s working on it.

Dr. Randy Lehman: [00:58:57] I think having one is crucial for a large institution like yours. You need someone local to represent your program. If you have a rural surgery program director and a key resident or two who attend, that’s a lifeline. I’ve developed some great friendships through these events, and we text each other about patients or discuss how to handle cases.

Dr. Randy Lehman: [01:00:23] What sort of resources do you have in your hospital? How do you manage this problem—hiatal hernias or other things? From what other practicing rural surgeons have told me on this show, having a network of people you can call is essential. You need a person. And the best way to have a person is to maintain contacts from residency.

I called so many people when I first came out. Then as time goes on, you meet people locally where you are. Additionally, ACS, the Northern Plains Rural Surgical Society, and ACS communities are great resources. You can chat online and make friends. I don’t know much about the International Hernia Society—I’m on it, but these are more specialized things I’m not regularly doing. If something seems crazy, ask four of your friends if they think it’s crazy too. Then, just keep doing what works.

Dr. Stephanie Heller: [01:00:23] Well, and I think the other key thing is it’s so hard to recruit a partner for you guys, right? One resource I’d suggest is the American College of Surgeons’ rural surgery website. They have an education page listing programs that officially train rural surgeons. Honestly, there are many programs across the country training rural surgeons, but the programs that self-designate and commit to training at least one rural surgery resident per year are key.

If you’re recruiting, I’d recommend reaching out to those programs to see who’s coming out and if they’re interested in your area.

Dr. Randy Lehman: [01:01:01] Yep. Well, what an honor. Thank you for taking all this time. I just can’t express how grateful I am. I hope to catch you at ACS or somewhere around. Please let me know if there’s anything I can do to help you. Is there anything you’d like to share—any closing comments, or a way the audience can connect with you?

Dr. Stephanie Heller: [01:01:26] No, thank you for inviting me. This is such an honor. You were our first trainee, and I’m so excited to hear about your practice and what you’re doing. It’s exactly what we hoped to accomplish, and I’m glad we helped you achieve your goals. I’m incredibly proud of you.

If anyone has an interest in building a rural program, I’m happy to take a call anytime. For you specifically, if you ever have a question, you know you can call me 24/7—you’ve got my number. Also, as you think about changes we need for our rural trainees, let me know what cases we didn’t cover. I know you’re doing things we never trained you for, and your feedback can help us train better surgeons in the future.

Dr. Randy Lehman: [01:02:16] Yep. Let me know how I can help—whether it’s talking via telecommunication or finding an excuse to fly up to Rochester.

Dr. Stephanie Heller: [01:02:26] Yeah.

Dr. Randy Lehman: [01:02:28] Thanks again. And thank you to everyone for watching. Please don’t forget to like and subscribe. If you know a rural surgeon who could benefit from this, please share. I’m excited to build this community. I’ll see you all on the next episode of the Rural American Surgeon Podcast.