Thou shalt not utter the words “surgical illustration” around thy BMC peers without proper trigger warnings. However, just like any other challenging assignments you have completed, surgical illustration (“surgery” in short), will not kill you but make you stronger.

(** This post contains graphic surgery pictures. Viewer discretion is advised.**)

Love it or not, surgery will definitely be one of the most memorable projects you complete on your BMC journey. Michael takes great care in splitting the class into pairs, matching ones’ work style, lair location, and sometimes height* to another. The result is hopefully, a partnership that carries both of you through the most perplexing surgical literature, the most intimidating meeting with your surgeon, or the most brutal roast from Michael.

*: Prof. Michael Corrin admits that sometimes he would match a tall student with a short student, ensuring maximum visibility of the surgical field for both parties.

My partner M and I worked with Dr. Amr Elmaraghy, an orthopedic specialist from St. Joseph’s Health Centre. We received our appointment in early December, contacted St. Joseph’s OR staff mid-January (make sure to update your flu shots during the holidays young Jedi!), and scheduled our observership just before February. To prep us for surgery, Dr. Elm sent us three studies on the topics of pec major repair the week before OR day, which he co-authored.

We met Dr. Elm three hours before the scheduled surgery, and discussed the main goals of the illustration as well as the scope of the project. One knowledge gap Dr. Elm wanted us to address was the architecture of the pec and how pec tendon inserts on the humerus. Previous literature and anatomy atlas usually depict the layers of pec tendon “twist” onto the humerus, which Dr. Elm’s team found to be inaccurate. Instead of twisting, imagine each segment of pec major stacks on top of each other, pushing into a fan shape anchoring around the humerus like a deck of cards:

As useful as OR sketching is, having a camera (with the surgical team’s permission) and know what pictures to take won’t hurt. This is when having a partner becomes handy –– M was much more efficient at sketching, and I was more at ease using the Sony a6000. An hour later, M had captured most of the essential visual information, whereas I took 8 GB worth of photos. Between all the OR circling and lens switching, both of us also jotted down as much Dr. Elm’s live commentary as we could: “You see that white thing? That’s the Sternal head.” “I need a Hohmann retractor now!” Though not a focus of the procedure, I found taking pictures of the instrument table helped us a lot. I also deliberately took a lot of photographs of the surgeons’ hand motions. One may find a ton of reference pictures on the tools from manufacturers such as Athrex easily, but the chance for you to develop a visual record of how the surgeons interact with those tools doesn’t come by every day.

Based on our notes, M and I compiled a sequential report. For things that we missed, we consulted Dr. Elm’s old X-rays, surgery videos that he recorded himself, as well as demo videos recorded by the manufacturer. Since the surgery itself was relatively short, we broke down the procedure into mere seven major steps:

  1. Patient orientation and pathology.
  2. Locating the tear and making the first incision.
  3. Mobilizing the torn tendon.
  4. Suturing the tendon.
  5. Preparation for button insertion.
  6. Burron insertion.
  7. Advancing the torn to the humerus.

The next two months we fell into a routine: making the sketches at the beginning of the week –> bringing our sketches for Michael to critique end of the week (where Michael pointed out amateur mistakes such as “not enough tension” one figure, the tools are “not straight enough” in another) –> redrawing everything. Draw, meet, redraw, repeat. The pattern repeats itself until Michael or your partner had no major complaints about your sketches, resulted from your actual improvement, as well as their collective exhaustion. You can see the process for figure 1 here:

During this iterative process I changed my workflow in two major ways: 1) the complete abandonment of sketching traditionally. and 2) Maquette. Maquette. Maquette. For example, this is how my sketches looked at in the beginning:

And this how my sketches looked like a month later when I sketched everything with photoshop:

The reason for the switch was mainly due to considerations of surgical storytelling. Efficient depictions of surgical steps often require layering. The perspective is kept constant; by removing layers of anomy sequentially, the chronology of the events can be compressed comprehensively in 2D space. Traditionally, the sketches are done on translucent paper with graphite pencil, where each new panel is reassembled on a fresh sheet and registered by aligning pre-marked crosshairs. Sketching in photoshop not only eliminated an extra digitization step (which means extra traveling and queuing to use the studio flatbed scanner), it also makes sure that the depiction the constant elements in the panel stay consistent.

Using and building maquettes are essential skills for a medical illustrator. We learned how to model surgical tools in class using C4D, though depending on your need for the illustration, there is no need for making an elaborate maquette if all you wanted was to get the angle of your pec button inserter right:

It’s easy to get caught up in C4D, and this is why you need a good partner like M to keep you grounded.

I struggled to understand where and how the Krackow stitches were made on the torn tendon. Dr. Elm explained to us that the surgeon would start the suture going from medial to lateral. This creates interlocking loops on the lateral edge of the tendon, where the free ends of the sutures exit laterally to be pulled onto the bone.

I hope the above description is as confusing for you as it was for me. Though I took a decent shot of the tendon’s sutures, the tongue-like red blob did not help much. With the C4D window still open, my first instinct was to YouTube a tutorial “how to model thread”.

I was saved from going down another tutorial wormhole by M’s craftiness and good sense ––  homegirl made a maquette with yarn and socks for us:

The next stage of the illustration was to have your comp sketches reviewed by your surgeon. After receiving Dr. Elm’s approval, one last step remains –– inking.

Determined to keep an all-digital workflow, I “inked” all of my comp sketches in Illustrator:

Surgical illustration is probably the biggest project you take on as a BMC firstie. Looking back, I’m surprised by how simple the final product looks, though the process sure was not simple. It’s a great project to brush up your technical skills, both in traditional pen and ink and 3D modeling. If you come prepared for your weekly meetings and actually take time refining the details he pointed out, you will receive a ton of support from your instructor and will be amazed in the end that, you came out of the experience safe and sound after all. It really wasn’t that bad.

See my partner M’s illustrations here.