Empathy and Innovation in Microsurgery with Dr. Arash Momeni

In this episode of Scrubcast, we sit down with Dr. Arash Momeni, an associate professor at Stanford University’s Department of Surgery, to discuss the latest advancements in reconstructive microsurgery.  From his recent clinical trial—an anticoagulant head-to-head—to the integration of augmented reality (AR) technology in surgical practice, he is always looking for new ways to enhance precision, safety, and patient comfort. Dr. Momeni also provides a comprehensive overview of the emotional and logistical complexities faced by patients diagnosed with breast cancer, emphasizing the importance of empathy and education in the surgical process.

Additionally, Dr. Momeni discusses his unique path to Stanford (completing residency TWICE) and his experiences with the American Society for Reconstructive Microsurgeons (ASRM) as the 2023 Godina Fellow and now Secretary.

Rachel Baker: [00:00:00] Welcome to Scrubcast, where we take a closer look at the research happening at Stanford University's Department of Surgery. I'm your host, Rachel Baker. Today we're speaking with Dr. Arash Momeni. Welcome to the show.

Arash Momeni: Thank you, Rachel. Glad to be here. True privilege.

Rachel Baker: I am so excited that you are here. It's taken me two years to get you on the show.

You are an associate professor in our division of plastic and reconstructive surgery with a focus on microsurgery. What initially drew you to plastics and then to tiny, itty bitty microscopic things. 

Arash Momeni: Thanks. Well, first of all, thank you for the invitation. I hope it wasn't too painful to get this, uh, on the books from your end.

We were waiting for a few things to, to happen and to click before coming on the show here.

Rachel Baker: I enjoyed the chase.

Arash Momeni: To answer your question, I knew early on that I wanted to become a surgeon. In fact, it was during my second semester of medical school we had anatomy and, [00:01:00] uh, it was during cadaver dissection that I have this very clear realization that surgery was for me.

It was hands-on, it was meticulous, and that kind of work really resonated deeply with me. And then over the next few years, I really explored that interest through numerous electives and a range of surgical fields. I did general surgery electives, vascular surgery, cardiac pediatric surgery, really trying to understand where I would fit in.

And what's really stood out to me about plastic surgery was its combination of really technical complexity. And creativity, and unlike many other surgical fields, it really isn't confined to a specific anatomical region. Instead, it is really guided by principles, if you will, tissue handling wound healing principles, aesthetic considerations that can be truly applied from head to toe.

And that kind of versatility, I suppose, was very, very appealing to me. And within plastic surgery, microsurgery offered this additional layer of precision and problem [00:02:00] solving that I found. Incredibly fulfilling. And it's a specialty that demands really both discipline and imagination. And that balance really drew me in.

Rachel Baker: Well, it seems like you like a challenge because you initially did your medical training in Germany and then you came to Stanford and did your residency twice. So, uh, it must have been something really exciting that made you want to do it all over again.

Arash Momeni: Well, I mean, I think, uh. What's not to be excited about when you hear Stanford, but yes, I did complete both medical school and my first residency in plastic and hand surgery in Germany at the University of Freiburg. But even early in medical school, I was at the University of Mainz, which is just west of Frankfurt, Germany. I had this persistent desire to receive part of my training in the United States, and I was drawn to what I imagined American surgical training to really be.

I imagined it to be very structured, rigorous, and incredibly dynamic, and I was fortunate then early two [00:03:00] thousands, I was fortunate to secure an elective at Baylor College of Medicine of all places in Houston, Texas, where I worked with Dr. Joe Cassilly and Scott LeMaire. I guess you can consider them both giants and aortic surgery and their approach to technical excellence and the environment.

During that rotation left the lasting impression. I followed that up with another elective with Dr. Chuck Brunicardi, who was at the time chair of the Michael E. DeBakey Department of Surgery at Baylor. And through those experiences, I was then encouraged to try to do a rotation at Stanford. And this is, again, early two thousands, and that was truly easier said than done.

It required finding a faculty sponsor, which wasn't easy as an international student, but uh, everyone who knows me knows that can be persistent at times. And so I, I still remember, and I tell the story over and over again. I still remember that I paged Dr. Sherry Wren in the office at Stanford, and she was the clerkship director at the time, and to my great fortune, she [00:04:00] responded, uh, truly with incredible generosity and agreed to sponsor me.

And that opportunity changed everything. I joined the pediatric surgery service at Packard and scrubbed on my first case with. Dr. Tom Krummel, who was chair of the Department of Surgery at the time, and that rotation was truly life changing. I ended up extending my time and rotating to the adult general surgery service as well.

The experience was transformative and really solidified my wish and desire to return to Stanford. And fast forward a few years, I was then a senior plastic surgery resident in Freiberg. When Dr. Jim Chang, then the American Society for Surgery of the Hand, Bunnell Fellow visited. That interaction opened the door for me to come back to Stanford this time as a preliminary intern in general surgery and eventually matched into plastics residency.

And the rest, as they say, is history.

Rachel Baker: Amazing. Wow. That's quite the journey. Well, so one of the things I see you doing most of the time in [00:05:00] the OR is breast reconstruction. And I've actually told several friends and colleagues that if I ever need a breast reconstruction, you are going to be the surgeon who does it, because I see the way you treat your patients and it's.

Amazing. So let's talk about how you approach your patients. And when they come to you and they say that they're having a mastectomy, they want a breast reconstruction, or maybe they don't want a breast reconstruction, what's your approach? How do you do this?

Arash Momeni: Well, first of all, there's many wishes for you. One of them is that you never need me in any capacity, professionally speaking.

But I think that the approach, my approach really begins with acknowledging that. A breast cancer diagnosis is incredibly traumatic, right? So, so because overnight women are thrust into this complex and overwhelming landscape where they meet all of a sudden specialties that they probably weren't even familiar with, medical oncologists, radiation oncologists, breast [00:06:00] surgeons.

So it's a lot to process both logistically but also importantly emotionally. And so it's important for us as reconstructive surgeons to acknowledge that and be mindful of that and remind ourselves. Because there is a certain level of desensitization that can happen in our day-to-day jobs, but it's important for us to acknowledge that that day might be for us another day at work.

But for that individual patient, it's perhaps the most impactful thing that they've experienced up until that point in their life. And on top of that, there is, I believe, still a lingering kind of societal image rooted in the history of how we've been treating breast cancer with radical surgery. And that societal image is that of women who were left disfigured after treatment.

And that perception, although admittedly outdated, understandably, creates a fear and anxiety. And as reconstructive surgeons, I believe we have a responsibility to alleviate those fears as best as possible and to educate patients about how far the field has truly come. What is important to also acknowledge is that these reconstructive [00:07:00] advances have really parallel the evolution of cancer surgery itself.

As ablative approaches have really shifted away from radical mastectomies to more conservative approaches, such as now nipple sparing mastectomies, we've seen a corresponding improvement really in reconstructive outcomes. And the goal is no longer just to rebuild, but to truly restore form in a way that's both natural and empowering for women.

And for me personally, it is essential to present. All available reconstructive options to each patient, ranging from implant-based reconstruction, autologous or flat based techniques, and hence, the subspecialty microsurgery, hybrid approaches and emerging innovations like flap neutralizations to restore sensation.

But just as importantly, I do emphasize that reconstruction is a personal choice. It doesn't impact recurrence or survival. But rather it is about quality of life, body image, and overall wellbeing. And so as a result, there is no one size fits all solution. And truly every [00:08:00] patient's journey is unique. And I see my role as helping them navigate that path as best as possible with clarity, with empathy, with respect for their individual goals and preferences.

Rachel Baker: See, that's why I want you to be my surgeon. So, so speaking of those deep flap reconstructions, the autologous flap reconstructions, um, I watched this very cool video. You were on PRS Journal and you were discussing AR—augmented reality—in DIEP flap reconstruction. I'll put a link in the description for our listeners so they can watch it as well.

What sort of innovations are right on the horizon for breast reconstruction? And microsurgery in general?

Arash Momeni: Totally. No, thank you for that. Uh, it is, it is, uh, as you pointed out, a really exciting area and we're seeing a rapid and meaningful integration of digital technology into the operating room.

The overarching goal, I think is quite clear. It is to enhance precision. I. Safety and if you will, efficiency of surgical care. And one prime example in reconstructive microsurgery is vascular or [00:09:00] perforator imaging. Perforators are these very small vessels that emanate from the main vascular trunk. And at Stanford, I've been fortunate to collaborate with Dr.

Bruce Daniels from radiology and his team to explore how AR or augmented reality can be used to project the vascular anatomy, specifically the vascular anatomy of the lower abdominal region directly onto the patient during flap harvest. For those that are not surgeons or not familiar with how things happen at the operating room, think of it as having a GPS map to a city you've never visited before, or.

To put it in another way, it's like turning a closed book exam into an open book one. And so that level of guidance obviously dramatically simplifies decision making in the operating room. It makes the surgery more efficient, and it reduces variability. And so, what's especially exciting is how this can enhance surgical education as well.

Trainees can now visualize anatomy in real time, overlaid on the patient. Which accelerates understanding in a way, textbooks simply cannot match or [00:10:00] provide. And we currently are expanding this work. We are further refining the technology, we're studying outcomes, we're integrating it more into our clinical workflows, and I think this is a very, very exciting field.

Beyond this, there are many other innovations being actively investigated at Stanford. One example is flap prioritization, something that I just mentioned. The goal here is not just to restore form but also function specifically sensation to the reconstructed breast. And that's a truly profound shift in how we think about reconstruction.

We're removing away from replacing tissue to truly rebuilding what was lost, and all that is really just the beginning, right? Believe the broader horizon includes things like intraoperative navigation, mixed reality for remote collaboration and teaching, and even AI driven surgical planning. And I genuinely believe the future of surgery is.

Is definitely digital and we're only at this point scratching the surface, but it's good to be at the cutting edge here at Stanford.

Rachel Baker: It's super exciting. I cannot wait to see what all of you come up with in the next couple of years. [00:11:00] So the reason that you kept pushing me off, I think is because of your clinical trial looking at prophylaxis for venous thromboembolisms, uh, or VTE, which is, I believe, essentially a blood clot, correct?

Arash Momeni: That's correct.

Rachel Baker: Okay. So, uh, we just talked about vascular being able to see veins and arteries and things, so I'm guessing that you see this complication a lot in breast surgery, because you're reattaching all of these blood vessels.

Arash Momeni: Yeah. So first of all, I hope that I, that you didn't feel that you were pushed off.

I, I, I would certainly never do that, but, um, venous thromboembolism or VTE is. Fortunately, I should say, not a very common complication in breast reconstruction, but when it does occur, it can be devastating. So, the impact is quite significant. It has a significant public health burden because it is a very common complication after surgery in general, but fortunately, not [00:12:00] very common in breast reconstruction, but.

I perform a large number of microsurgical breast reconstructions, and in our earlier work we found that among all surgical treatments for breast cancer, the combination of mastectomy with autologous reconstruction really carries the highest risk for VTE. Hmm. And that finding really became the impetus for a long line of research in our group.

And so we began by identifying specific risk factors for VTE in patients undergoing microsurgical breast reconstruction, things like body mass index, operative time, previous clotting history, the matter in which we would close the abdomen after flap hearts. And all of that groundwork eventually led to our recent randomized control trial that you are referring to.

Rachel Baker: Exciting. So, you looked at the current standard enoxaparin, which is a low molecular weight heparin and apixaban, which actually I think my dad [00:13:00] took for V-fib. It's a direct oral anticoagulant. So why the head-to-head and what did you find out?

Arash Momeni: That's a great question and it's uh, exactly what we did in our recent RCT or randomized controlled trial.

We indeed compared apixaban. Which is taken as a pill. Enoxaparin, which is the current standard of care, which is given by injection. And the reason for this head-to-head design was to isolate the effects of the medication itself by keeping all other factors equal between the two study cohorts, same patient population.

Or same patient population characteristics, same surgical approach, same perioperative care and protocol. The only variable was the VTA prophylaxis regimen that was different between these two cohorts, and that gave us the clearest possible read on safety and effectiveness. And what we found was very encouraging.

Apixaban was just as safe as Enoxaparin. There was no increase in bleeding risk, which is always a key concern [00:14:00] whenever you use blood thinners or anticoagulants. And from the patient perspective, the benefit was quite significant because taking a pill is obviously much more comfortable and convenient than having injections.

Rachel Baker: Absolutely.

Arash Momeni: And so as a result, I've now updated my practice. My patients receive apixaban postoperatively after free flat breast reconstruction. And I think this reflects the kind of incremental, but. I believe meaningful change that comes from doing focused and rigorous clinical research is not just about preventing complications, it's also about improving the overall patient experience.

Rachel Baker: Well, so we're almost out of time, but I do absolutely want to ask you about the American Society for Reconstructive Microsurgeons. You were their Godina fellow in 2023, which is a huge honor. Can you just talk about some highlights?

Arash Momeni: Yeah. So thank you very much. Yes. It was, uh, an extraordinary honor for me.

The Godina Fellowship is named after Marco Godina. He was a true pioneer in microsurgery, and his life was unfortunately, [00:15:00] tragically cut short at the age of 43, which is the age I was when I received it. He left an indelible mark really on our field, and this fellowship was created in his honor and legacy, and so being selected as a Gudina fellow is truly the highest recognition that you can get as a neurosurgeon.

The fellowship year itself was just one continuous highlight. As you can imagine, I had the privilege of being invited to some of the most prestigious institutions in the US and and abroad, just to name a few in the US. I visited Memorial Stone, Kettering Cancer Center, MD Anderson, University of Pennsylvania, Yale, NYU.

In total, I traveled—let me think—to 18 programs across 11 countries. So that was a very busy but meaningful year, but a particularly meaningful and unexpected moment came during my visit to Luana and Slovenia, the birthplace of Marco Godina, where I had the opportunity to meet with the president of Slovenia, Natasha Pirc Musar.

And so for, for a surgeon that kind of—if you will—diplomatic [00:16:00] recognition is quite rare and it, it underscored just how far-reaching Dr. Godina's impact was. All in all, it was truly an unforgettable experience, not only professionally, but also personally. And it gave me the chance to learn, to teach and to build relationships with colleagues across the globe.

Relationships that have lasted to this day and certainly beyond. And I'll carry those lessons with me throughout the rest of my career.

Rachel Baker: Amazing. Well, so you are now secretary of the ASRM. Congratulations. That's a new title. What are you hoping to accomplish with this leadership position?

Arash Momeni: Yeah, thank you.

It is truly, uh, an honor to be the secretary of ASRM. Obviously been a member of the society for many years, and ASRM has played a central role in my professional development. One of the immediate goals for this year is to create a more interactive platform for our members and for member engagement, we wanna move beyond the traditional meeting format and kind of the sterile newsletter format and foster ongoing dialogue, whether that's through digital content, mentorship opportunities or [00:17:00] collaborative research initiatives.

In addition to that, I serve as the chair of the ASRM, Future Growth Fund, and as a team, we recently secured funding to launch a new Visiting Scholar program, which is truly designed to support early career surgeons and promote academic exchange across institutions. So it's a great example of how I believe we're working with donors and industry to invest into the next generation of leaders in reconstructive microsurgery.

And ultimately, I really see this role as a chance to give back to the society, to the members, to help amplify the voices of our members and to ensure that the society continues to evolve in, in meaningful and inclusive ways.

Rachel Baker: That sounds so exciting. I can't wait to see how you do this. That sound means that it's time for our lightning round.

On each episode of Scrubcast, we ask each of our guests the same three questions, and the first one is, who is a surgeon you admire and why? [00:18:00]

Arash Momeni: That's easy. Dr. Rod Hentz, master technician, but more than that kind and generous human being, exceptional mentor, he was able to give you the feeling as a trainee that you were much better than you were.

He was able to move the OR table miraculously under your knife, scissors, whatever you had, and he was just this master surgeon with a very quiet confidence, humility, and dedication to teaching. That really let left a lasting impression on me. Just an amazing individual.

Rachel Baker: Awesome. Love that. The second question is, what is the best advice you have received in 10 words or fewer?

Arash Momeni: Stay curious. Embrace discomfort. Keep growing. Lift others up.

Rachel Baker: Well, I think that you and Joe Forrester would get along really well.

Arash Momeni: We do actually get along well. That's perfect.

Rachel Baker: You have similar mantras. Was that given to you by someone?

Arash Momeni: that was given to me by my [00:19:00] former chair in Germany. I guess you got a little glimpse of that when, uh, I said embrace discomfort.

That, that, that, but, um, that helps you grow. You know, you, you go to the gym for example. You push yourself and then you know that you had a good workout. And the same happens in surgical training and in your day-to-day life. I think it's important to try to improve, constantly, keep moving and improving.

Rachel Baker: Absolutely. The final question is, what is your preferred OR music.

Arash Momeni: It depends on the day. The range is from classical music to EDM hits most commonly EDM hits.

Rachel Baker: It's quite the range.

Arash Momeni: I know. It sets the tone for being efficient in the OR, but at times I listen to classical music as well.

Sometimes Mozart, sometimes Ludovico analogy, uh, but mostly EDM hits these days. It's been interesting. Yeah. Alright.

Rachel Baker: Love it. Well, it has been an absolute pleasure chatting to you. [00:20:00] Before we go, one final question. That is, what is next for Dr. Momeni?

Arash Momeni: I gotta go to the OR in a bit, so that's next.

Rachel Baker: Awesome. Have a great time.

Arash Momeni: Thank you.

Rachel Baker: Thanks again for coming on the show.

Arash Momeni: Thank you so much, Rachel. Absolute pleasure.

Rachel Baker: And thank you to our listeners for tuning into this episode of Scrub Cast. Until next time, stay sharp.

And that brings us to the end of another episode. If you like Scrubcast, we hope you'll tell your friends and subscribe wherever you get your podcasts.

Scrubcast is a production of Stanford University's Department of Surgery. Today's episode was produced by Rachel Baker. The music is by Midnight Rounds, and our chair is Dr. Mary Hawn.