Free Island Practice by Pam Belluck

are skeptical.
    “Hey, Dr. Lepore, do you want to cut these off?” Mary Monagle called out to him one day in 2010. Monagle, then the charge nurse on the hospital’s evening shift, was referring to loose flaps of skin under her arms that jiggled like Jell-O. The flaps were the result of gastric bypass surgery Monagle had undergone on the mainland to offload more than a hundred of her three-hundred-plus pounds.

    When Monagle approached Lepore about removing the flaps, he was intrigued. Poking what he called her “bat wings,” he sounded instantly confident. “I can do that.”
    “Really?” Monagle asked. The operation, a brachioplasty, is usually done by a plastic surgeon. Lepore had zero experience with it, and Monagle’s friends were astounded: “Are you crazy? Are you really going to let him do it?”
    “I trust him,” Monagle replied simply. Lepore ordered a $400 copy of Body Contouring After Massive Weight Loss and set about studying. Monagle figured this could be interpreted in two very different ways: “Oh my God, you’re going to let someone who needs a book do your surgery?” or “Wow. He bought a book.”
    “I want to do it right for you,” Lepore told her.
    The surgery took five hours, longer than usual because of Lepore’s unfamiliarity with the procedure and trouble finding a vein in which to insert Monagle’s IV. In first the left, then the right, Lepore made an incision that ran from Monagle’s arm pit to her elbow. He pinned down the excess fatty skin with clamps, then cut it off. He removed a pound and a half of skin on each side, and Monagle imposed only one condition: that the excised skin not be “jerkied and given to Ajax,” Lepore’s red-tailed hawk.
    Afterwards, Lepore was so proud of his handiwork that he had staff from all over the hospital come look. Monagle was overjoyed. “It’s hard to find a surgeon that you trust. I love that man.”
    Still, about six months later, when Monagle decided to move to Florida and asked if Lepore would perform an abdominoplasty or tummy tuck to reduce her excess belly fat, he said no, at least not until Monagle lost some more weight. “Otherwise it won’t look right,” he told her. So Monagle left but planned to return for the procedure, rather than have another surgeon perform it. “I’ll take a break from wherever I am and come back to have Dr. L do my abdominoplasty.”
    Lepore does not try everything. He usually declines, for example, to perform laparoscopic surgery, the less invasive form of operating in
which a surgeon, guided by images projected from a scope onto a video screen, works through small incisions, using tools to manipulate the tissue. Laparoscopic surgery is becoming popular because it leaves less scarring and usually involves less recovery time. But it requires surgeons to use long-handled instruments instead of their hands and be good at judging how much pressure they are applying.
    Lepore knows how to perform surgery laparoscopically—he took his first course in it in 1977—and he has the equipment. The problem is that he can’t do it as regularly as he would like.
    “Laparoscopic is fraught with problems. You have to be doing it again and again and again, and I don’t have that number of cases. It’s different enough that I don’t think I could do it safely. Laparoscopic is sort of like putting your arm behind your back as you do it. The view on the scope can be very misleading. It’s like working with chopsticks.”
    Lepore knows that not being able to offer laparoscopic puts him “at a disadvantage.” But to feel confident, he would first want to assist on scores of laparoscopic surgeries performed by experts. And for that, he’d have to go off-island. He would feel guilty leaving Nantucket so frequently.
    So when a fifteen-year-old girl came in with a perforated gastric ulcer, Lepore sent her for laparoscopic surgery at Children’s Hospital Boston. “I could have done it here, but it would have been a