Monday, November 2, 2015

Artificial nose

How does one go about creating a new nose for someone who is lacking one?  This young man was attacked by a hyena while he was sleeping. The hyena bit off his nose and chewed on his face. The horror of such an event really cannot be imagined. He survived, but spent the next five years healing the wounds. The MSF team found him and asked me if I would be willing to try something. Normally I get exited about a challenge but I found myself dreading this case. There is a lot to lose. It is possible that the flap will die and then you have burned bridges and mutilated the patient even further. I would have preferred to send the boy to see a real Plastic Surgeon. Unfortunately there aren't any around here, and there were no funds to send him elsewhere. In these cases, you just bite the bullet and do the best you can. 


When in doubt, read. After investigating the options, I decided to go with the "Converse scalping flap". I actually saw one of these on the Mercy Ship, some years ago. It looks nice and neat on paper.  The reality is really quite different. 


Nasal reconstruction was one of the pioneering procedures in plastic surgery. This is partly due to the fact that amputation of the nose was a common punishment in India and other countries. This case was going to be tough because the whole nose was missing. I had to recreate both layers, the inside and outside. As the septum was gone, I would have to make do with a single common nasal chamber. 


This was the first step; to fashion a forehead flap which could be turned down and constitute the inside of the nose. 



The nose itself was created from a forehead flap.  This involves basically scalping the patient so the flap  will have sufficient blood supply. This leaves a big defect behind.  The area of the nasal flap is covered with a full thickness skin graft from the groin. 


The completed first phase is not pretty, by any means, but there is at least tissue over the hole. You're supposed to wait three weeks before cutting the bridge. You need blood supply to grow in from the wound edges. This kid had a some breakdown of the wound edges and an infection, so I waited an extra week. 


This is after the second phase of the operation. The bridge of the flap has been divided, the scalp has been put back in a place and another skin graft from the groin has been used to over the defect that remains.  Again, it's not pretty, but the gaping hole has been covered by something that vaguely resembles a nose.  It lacks any real support and it will need some work in the future. 

Throughout the whole ordeal this child has remained remarkably stoic. No emotion at all!  Is he happy about the procedure?  I have absolutely no idea!

The nose is a beautiful thing. You don't realize this until you see a person who lacks one. The expression "cutting off one's nose to spite one's face" is an illustration. This expression originated from an event which took place in 867 AD. Vikings attacked a convent in Scotland. The Mother Superior chose to disfigure herself by cutting off her nose and upper lip in order to preserve her chastity from the marauders. She urged other nuns to do the same. The attackers were so disgusted that they burned the building to the ground, with the nuns inside. Not sure if this strategy would be considered a success or a failure. 

These cases are hard on me. I work so hard, and in the end, the final result is something like, "well, he doesn't look quite as horrible as before!"  My prayer is that he will return home, glorying God for what has been done. We have shown him compassion and have done our very best for him. 

Things are going well here. I've been ill for the past two weeks or so. This has made me irritable and hard to get along with. I feel like I'm pulling through and hope to soon be back to my good-natured self. 

My apologies for a fairly technical post. It may not be everyone's cup of tea, but this is what I do. 

Warren