Reconstructive surgeons give people another chance for a normal lifeIn February 2007, 23-year-old Katie Salomonsen woke up with the right side of her face red and swollen. She went to Fairview Southdale Hospital, where doctors found an abscessed wisdom tooth. Three days later, an oral surgeon extracted the tooth. During the surgery, he discovered that the entire roof of Salomonsen’s mouth was black and scattered with ulcers. He had never seen anything like it and he biopsied the tissue.
Unbeknownst to anyone, an airborne fungus called Rhizopus had been attracted to Salomonsen’s abscessed tooth. Once in her mouth, it fostered the rare and deadly infection rhinocerebral mucormycosis (RCM) that burrowed under her hard palate and was swiftly moving through the sinus cavity behind her right eye and toward her brain.
When the pathologists identified the infection, Salomonsen’s doctor recommended that she transfer immediately to University of Minnesota Medical Center, Fairview. There, he said, she’d have the best chance for survival.
What happened to Salomonsen in the weeks and months that followed shows the power of collective expertise and combined experience, accompanied by a heavy dose of calculated risktaking. No one at the University had ever seen active RCM, but physicians from seven different disciplines came together to throw everything at it that they had, including drastic surgeries to halt its spread.
It would take a full and harrowing year to stop the infection. Salomonsen, who had recently finished chemotherapy and radiation for a brain tumor, battled every inch of the way. The fight for her life left her without an upper jaw, soft and hard palates, the cheekbone and sinuses on her right side, and a piece of her brain’s frontal lobe.
Eating and swallowing were extremely difficult. People had a hard time understanding her speech. She had trouble breathing through her scarred sinuses, and her face was sunken drastically on the right side.
“I was scared of everything at this point,” says Salomonsen. “I didn’t know what life was going to bring me.”
The surgeries also left two openings to her brain, one on the roof of her mouth, the other on the right side of her head. In both spots, the leatherlike covering of the brain called the dura remained the only protection from serious bacterial infections like meningitis.
For a year and a half, Salomonsen slowly regained her strength, and in spring 2008, it was time to begin rebuilding her face.
Second chanceDavid Hamlar Jr., M.D., D.D.S., is helping Salomonsen bring her life back toward normal. He joined the Department of Otolaryngology in 1994, adding a range of skills to a department that was already one of the best in the country. He is often called to do facial reconstructions to repair major injuries caused by traumas like car accidents, suicide attempts, and physical assaults. As a flight surgeon in the Air Force Reserves, he has deployed to Iraq and Afghanistan several times to care for military personnel with multiple injuries, many caused by improvised explosive devices. In addition, he sees veterans at the Minneapolis Veterans Affairs Medical Center.
“My goal is to reconstruct the foundation destroyed by my patients’ wounds,” he says of his surgery. “Missing bone should be replaced, as should soft tissue. I replace the larger building blocks; they can be fine-tuned later.”
Although Salomonsen had already been through so much, she was eager to meet Hamlar and start the reconstruction process.
“I was so happy,” she says. “Every time we had an appointment with him, he would say, ‘This is what I want to do and this is what’s going to happen.’ And then he’d ask, ‘Is this OK with you?’ He always made sure that I was all right with everything that was planned. I started being more hopeful about my life.”
The essential first surgeries for Salomonsen were to close the passageways to her brain.
To make it easier for her to speak and eat, Hamlar used what’s called the “free flap” technique, which involves using a piece of tissue or bone from one part of the body and putting it in another. It’s called “free” because the piece is completely separated from the donor site along with its pedicle of bundled blood vessels. The surgeon then stitches it in place and connects its pedicle to the reconstructed site’s own blood vessels.
Using a piece of Salomonsen’s belly muscle, including the skin, Hamlar refashioned her palates—the muscle and fat formed the hard palate; the skin mimicked the soft palate.
To fill the opening on the side of her head, Hamlar chose a product called PEEK—polyether ether ketone—a tough-as-bone material that can be sculpted. Working closely with a prosthesis maker, he made sure that the piece would exactly fit the space in her skull.
To put it in place, Hamlar made an incision along Salomonsen’s hairline and pulled down the skin of her face. After cleaning out the bone and tissue the infection had destroyed, he fitted the prosthesis and pulled the skin up over it, stitching it neatly in place.
“Not only did the prosthesis protect her, but it gave normal contour back to her face,” says Hamlar.
Salomonsen has many more surgeries ahead, with long healing times in between. Those surgeries include reconstructing an upper jaw and then implanting dentures, and refashioning her nose to make breathing easier. Joining Hamlar in this work will be his facial plastic and reconstructive colleagues, as well as an oral maxillofacial surgeon and maxillofacial prosthodontist.
“David Hamlar has always treated Katie with great compassion, insight, and skill,” says Salomonsen’s mother, Colleen Forar. “What he has done for her is life-changing, not just by medical standards, but in the way that Katie sees herself and her future.”
Toward an ordinary life
Surgeons in the Department of Otolaryngology work every day to give people back essential parts of themselves. Those may be actual physical parts, like missing jawbones or noses destroyed by cancer. Or they may be the ability to swallow or chew. Together, these various parts create something less tangible but often more crucial: our sense of self.
“We help patients heal and get back to their normal lives, their work, and their families,” says Amy Anne Lassig, M.D., a head and neck oncologist and microvascular surgeon. “Whatever we can do to optimize an outcome for patients is priceless to them. That’s why we do our best.”
Lassig is one of only a handful of surgeons in Minnesota, and among three in the department, who excise head and neck cancers and then reconstruct the lost tissue or bone, sometimes in a single surgery that can last 15 to 20 hours or more. She does the microvascular part of her work bent over a microscope, sewing together tiny blood vessels.
At the University, the survival rate for patients with head and neck cancers is above the national average. And the success rate for reconstructive surgery is extremely high, even though the department tends to get the most complicated cases in the state and patients whose treatments have failed elsewhere, according to Lassig.
“These procedures are very finicky,” she says. “If they’re not done correctly, the reconstructed tissue or bones will not survive.”
In a recent surgery, Lassig and her colleagues removed half the tongue of a young mother who has oral cancer. Using the free flap technique, Lassig replaced the lost tissue with a section of the woman’s forearm.
Without the reconstructive surgery, the woman would not have been able to manipulate food in her mouth or speak clearly.
Following the successful surgery, “her articulation is excellent,” says Lassig. “She’s a wife and mother with two children to care for and she’s completely functional in the world and understandable to those she meets.”
With surgery on the face and neck, preserving every millimeter of healthy tissue is crucial. Tissue left intact results in a more normal appearance, less reconstruction needed, and a site that can potentially support a facial prosthetic.
If a nose, for example, is completely removed because of cancer or an ear is sheared off and lost in a car accident, they may need to be replaced with an implant. Unlike Salomonsen’s prosthesis, which is covered with her skin, these prostheses do not become an integral part of a person’s body. They are held on by catching under folds in the skin or sinuses, with adhesives, by attaching to metal implants imbedded in the skull, or by fixing them to eyeglasses. Prostheses are designed to be removed. Made from silicone, these small works of art are completely unremarkable. And that’s a good thing.
As a working medical illustrator and facial and plastic reconstructive surgeon, the University’s Bill Walsh, M.D., is unique in the country and the ideal person to create the artifice that allows his patients to move comfortably through life. To him, art and reconstructive surgery call on the same principles of light, shadow, and proportionality.
Among Walsh’s special skills is preparing the surgical site to receive a prosthesis after he has removed a cancer or stabilized a wound. He has an intimate knowledge of how tissue acts and how scars form. He stitches together angles and planes of skin, for example, which will stretch and tighten in just the right way as they heal to allow attachment of a prosthetic nose or ear.
Then he works with the prosthetist to design the nose or ear for that specific person and surgical site, making sure it is tinted correctly and the edges are so thin and perfectly colored that one can’t tell where the real skin begins or ends.
Walsh sees one more important similarity between art and facial reconstruction. “You know that indescribable feeling that a great piece of art can give you?” he asks. “It is the same feeling I get as a surgeon when I see my patient realize that their reconstructed face reflects their true inner beauty.”
To make a reconstructed face move like a normal face is the Holy Grail for surgeons. Our facial movements can convey a myriad of emotions in an instant, and we are wired to react to those movements, however subtle they may be. We can detect a smile from 300 yards and can judge its sincerity quickly as the person approaches. If we are unable to move our face and express our emotions, we have lost an essential human communication tool.
Peter Hilger, M.D., president-elect of the American Board of Otolaryngology, is one of the world’s leading plastic surgeons and helps people with facial nerve paralysis regain at least some of the movement in their faces. Signals from the brain connect with our 44 facial muscles through a labyrinthine network of nerves, but we have not yet mapped every nerve branch and where it meets the muscles. This keeps surgeons from reconstructing a face with perfectly lifelike movements.
That easily discernable smile is actually produced by many muscles that simultaneously pull horizontally and vertically, down and obliquely. Yet, depending on where the facial nerve is damaged, Hilger can perform a variety of surgeries that will at least partially restore a patient’s ability to show joy.
In one procedure for a person with severe Bell’s palsy, for example, he will splice a nerve harvested from elsewhere in the body into the healthy facial nerve on the unaffected side of the person’s face. He will then connect it to a muscle on the damaged side of the face, allowing the person to produce a near symmetrical smile. In another, he will attach one of the nerves from the temporalis muscle that we use to chew to the corner of a patient’s mouth. A physical therapist will then work with the patient until he or she learns to produce a smile by biting down in a specific way.
“We are social creatures and we need to be in the world,” says Hilger. “That means having personal interactions with folks without distracting them by your appearance, or without turning yourself into a recluse. Even if a patient can eat and talk, if you’ve not given him or her the opportunity to rejoin society, you’ve missed part of the reconstructive objective.”
Reconstructive surgery has come far since the University’s Department of Otolaryngology was established 100 years ago, but Hilger is eager to offer even more to his patients. And he believes that reconstructive surgery is now poised for “quantum leaps of improvement.”
Those improvements are partly inspired by international advances in face transplants, which are moving facial reconstruction closer to the ideal marriage of form and function. That marriage can allow people with faces once damaged by disease, trauma, or birth defects to live a normal life.
“The work that our reconstructive surgeons do is truly transformative,” says Bevan Yueh, M.D., M.P.H., chair of the Department of Otolaryngology. “Their work helps patients regain the confidence to re-engage in society: to walk down a sidewalk, to go to church, and to eat a meal at a restaurant.
“Imagine how devastating it would be to have those activities taken away from you, and imagine how wonderful it would be to have these simple activities restored.”
By Martha Coventry