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t m c » p u l s e | n o v e m b e r 2 0 1 7 28 "People start popping up to protest, which is what happens. It's their job to make sure that surgical innovation is not a euphemism for human experimentation." Selber, who already established a reputation in innovative transplantation from performing the world's first skull- scalp-kidney-pancreas transplant, leveraged the success of his leadership during that groundbreaking surgery to gain permission from the various regulatory groups, quality officers, perioperative service leaders and key stakeholders within the institution for the Fields sisters. "The first person through the wall always gets bloody," Selber said. "If you're going to be the first person to do something, you have to be prepared to take criticism and defend your ideas with medical and scientific rationale and vision. But once you demonstrate the ability to build and lead a multidisciplinary, multi-institutional team for a very heavy lift like this, the medical community writ large has more confidence in your ability to conduct team medicine and surgical innovation." After Selber presented his meticulous plans for the surgery, arguing that although elaborate and unusual, it was the most log- ical and appropriate solution to an almost impossible problem and would give Marian a quality of life she hadn't enjoyed for nearly six years, MD Anderson finally gave him the green light. "MD Anderson sees the benefits of achieving great things in cancer care for our patients," Selber said. "This is an institution that prides itself on being able to do things that nobody else can do. That's what makes it the best cancer center in the world. If we can't do this kind of thing here, where can it be done?" 14 Hours On June 26, Marian went in for the first leg of the surgery. Knowing the recurrent nature of the disease, Torres needed to cut wide and deep into Marian's back to make absolutely sure that the surrounding tissue was tumor-free. She carved out a large sec- tion of Marian's skin, fat and muscle all the way down to her ribcage and worked with a spinal tumor surgical oncologist to shave off part of Marian's spine from her neck down to her pelvis. It was paramount that no tumor cells remained. What was left of Marian's back was a gaping 20 by 30 centimeter hole—nearly 8 inches by 1 foot—that spanned from shoul- der blade to shoulder blade and extended from her neck down to her pelvis, leaving her ribs and spine completely exposed. It was a jarring sight, even for Torres. "It sounds very morbid [because] it was a really big resection," Torres said. "During the procedure, somehow it doesn't feel right when you're doing something like that because it's so massive." The pathology team, led by Victor Prieto, M.D., Ph.D., then carefully analyzed the specimen to confirm that all margins were clear of any remaining tumor cells before moving onto the reconstruction. Everything was clear. Four days later, on June 30, the twins moved into their respective operating rooms. Selber and a team of five additional plastic reconstructive surgeons worked on Mary Jane first. Selber drew incisions on her abdomen in the shape of a large oval, spanning from hip to hip and belly button to bikini line. He removed a slab of Mary Jane's flesh and the tiny blood vessels that supplied it, measuring almost 10 inches wide by 22 inches long, pulled taut the walls of her abdomen and sutured the skin together— taking her from a size 14 down to a size 10. "It was certainly the largest free tissue transfer that I've ever seen or been involved with," Selber said. Selber and the team then transferred Mary Jane's abdominal graft to the other operating room down the hall, where Marian was lying on her stomach with her back muscles and fascia completely exposed. He placed the tissue from Mary Jane's stomach on Marian's hollowed back, and began to tease and coax the multitude of tiny arteries and veins until they were all precisely connected. The entire procedure took 14 hours. The Fields twins, who have lived together most of their lives, prepare dinner at their home in Independence, Missouri.