The facial reconstruction and the first nasal replantations in modern medicine
Specialist in Oral and Maxillofacial Surgery, Prof. Dr.Med. Reinhard Bschorer - about one of the first nasal replantations in modern medicine, about the facial reconstruction and, finally, about the fact that the patient sometimes has to work as much as the doctor.
About the hardest operation
"We, micro-surgeons, should be bullfighters and hold on until everything is fine."
In 1998, you were one of the first doctors in the world to perform a complete nasal replantation. Please tell us what was the case.
Yes, I especially remember that it is extremely exhausting. Because it took a very long time. I then operated on for 3 days without a break. About the story: Mr. A., a 26-year-old young man recently engaged, was renovating his garden house. He stood up on a stool and began to cut a window in the wall with side cutters. Suddenly he lost his balance and toppled back. At the same time, he instinctively raised both hands and drove the side cutters over his face. He cut off his nose completely. Mr. A. did not even notice it. That the nose was cut off. He held his handkerchief as if he had a nosebleed. A friend immediately took him to the hospital - without a nose. His fiancée was still at home, after we called, she looked for his nose and found it in construction waste. She brought the nose to the hospital - and I said that we should do our best to reattach the nose. We first put Mr. A. under general anaesthesia and washed the wounds. I carefully examined the nose under a microscope and found only 2 very small arteries on the bridge of the nose, approximately 0.2 mm in diameter, the so-called arteries of the bridge of the nose. They seemed too small to be stitched. But what other choice did I have other than trying my best and it had to work out well. It took 14 hours to stitch these two small blood vessels with 1/100 mm suture material.
Yes. The operation was complex, required extreme concentration, so each suture took many times longer than usually on larger blood vessels. With each breath, the image in my eyepiece swayed and trembled. I had to sew everything at maximum magnification. But in the end it turned out well. The stitches were in place and the blood rushed into the nose, the nose immediately returned to its normal skin colour. I was pleased.
The patient was taken to the intensive care unit. Colleagues in the department, doing there utmost, worked to improve blood circulation and constantly monitored the colour of the skin of the nose. This let me rest a little. A couple of hours later, when I just lied down, the phone rang. The nose darkened and became more and more blue. Oh my God, I feared the worst. Now the blood flows into the nose, but does not flow back. Just imagine it as on the Autobahn, if there is an accident ahead, it gets crowded, a traffic jam forms. No car can move. A kilometre traffic jam. Likewise, blood cells accumulate in the blood vessels. And then, while the blood cells have stopped and are at rest, oxygen is formed in the blood pigment (haemoglobin ). Because of this, haemoglobin turns blue-violet. You can observe this when the lips turn blue from the cold in winter. In the cold, the body protects itself and provides blood flow to the heart and brain, but at the same time reduces blood flow to the lips and hands ... Okay, I brought Mr. A. back to the operating room. I opened the wound on the bridge of the nose and washed both blood vessels and the nose with a blood thinning solution. The traffic jams were cleared in time. I sewed both small blood vessels together again. The nose regained its normal colour and the patient went to the intensive care unit. But in the morning the same problem appeared again. I did not have a ready-made solution, I could not operate for so long again without fundamentally changing something. Perhaps leeches will help us eliminate the problem of removing used blood. The leeches were delivered by express delivery and placed on the nose. Given the good blood flow, I really hoped there would be enough leeches to release the used blue blood from the nose. But it did not get better.
I could not let a young man without a nose go!
By this time, I was so exhausted that I could no longer sleep. Imagine 1998. The internet was not as it is today. Then only 1% of the information flow went through it. At that time, in the hospital, I only had private access to the Internet and therefore to the medical database. I was constantly, sleepless, looking for an idea and came across an article by a Korean. In a similar situation, he installed a so-called graft shunt on his legs. A shunt is a kind of a bypass between an artery and a vein. Blood flow from an artery is redirected directly to a vein, and the artery and the vein are opened and surtured together. Thus, high pressure blood flows from the artery directly into the vein. It immediately became clear to me what to do. In the end, I could save 2 arteries on the bridge of the nose. I called the hospital and Mr. A. was immediately taken to the operating room. I had to do a bypass. "I immediately redirected one of the two small arteries on the bridge of the nose to a vein on his upper lip. So blood flowed into the nose through one artery and from a vein through another artery due to the drop in pressure. From that moment all worked out with his nose and Mr. A. could be woken up.
It attracted a lot of press attention at the time. We even had to hold press conferences, and my patient and I were presented in the studio of Günther Jauch in the Menschen-98 program as a medical achievement of the year.
So, at that time there were no instructions on how to carry out such replantation? Did you really have to improvise? It's amazing when new techniques are not invented in the laboratory, but in the operating room.
Yes, right. As time goes on, I blame myself for why I did not come up with a solution sooner. Okay, yes, it could have been faster, but at least it worked great. And first I was to implement it technically, in addition, this pressure in the race against local anaemia, it was not easy. And in such rare cases, there are no standards or guidelines. You need a good doctor with experience and, of course, the desired degree of luck, so that in the end everything really works out.
Was this your longest operation?
For sure. From time to time, of course, I took a break to eat and drink. But it seemed to me that I had operated for 3 days without a break. Without any breaks at all, I would not have been able to cope with small surtures.
Two years ago I was in Spain as a guest for micro-surgical transplantation. It was also a difficult case, and the operation lasted a very long time. But at the most critical moment, when a responsible colleague was almost in despair, he told me with a sudden smile on his face: "This is how we, micro-surgeons: we should be bullfighters and hold on until everything is fine."
About the philosophy of plastic surgery
"The patient knows what he wants, he told me that, and I can do it"
In maxillofacial surgery, there is often no “right” treatment option - the result depends on the doctor and his vision. Do you see this as an advantage, or rather a problem?
This is a problem in our area. There are many doctors who have their own opinion and act according to it. And often the opinions and views of the doctor and his patient do not coincide. Then, first of all, the patient has a problem. He does not get what he imagined. As a consequence, there is now a well-established jurisprudence that requires a so-called informed consent. This order is necessary for the opinion and idea of the treatment concept of the doctor and his patient to coincide. This informed consent must be discussed and agreed with the patient. As a doctor, I should be able to get to know the patient in this way and discuss the result with him, as well as simulate and show this result to the patient so that he can ultimately choose the best treatment for himself.
In reconstructive surgery today we have excellent opportunities for using 3D technologies: for example, I can superimpose a 3D face photo on a computer on a CT scan of a patient's bones. Then, on this CT scan, I can virtually change the facial bones, or simply lengthen or reduce the nose, or, for example, push the chin forward. I can explain to the patient and also illustrate what I can and cannot do. The patient can reflect and ask himself if this is in line with his ideas. If so, we prepare an Informed Consent. Then it means that the patient knows what he wants, he told me that, and I can do it. He gets what he wants, and as a result we have a satisfied patient. And, of course, which is very important, a satisfied doctor.
Do your patients often have unrealistic expectations?
When a patient comes for a consultation about aesthetic correction, it is very important to find out if his ideas are realistic or if the patient has ideas or wishes that are simply unrealizable. The problem that some patients face is the so-called body dysmorphic disorder, that is, the patient does not like his own body, he cannot identify with his body, and this is so strong that he can no longer perceive his normal social and professional activities. Each intervention in such a patient can make him even more unhappy. My task as a doctor is to recognize such a patient and direct him for targeted treatment, first of all, to a psychologist or psychiatrist. And they are already diagnosing and treating him, and only when the patient is officially ready for surgery, I can start treatment. Otherwise, you will end up in a vicious circle and create a very, very unsatisfied and unhappy patient. I should avoid this because a doctor swears to help a patient, not to harm or distress him.
Can a patient know in advance what the end result will be?
With the help of 3D photographs and 3D CT scans, we can give a patient a rough idea of the result. And everything related to external changes (nose, jaw angle, scar correction) can be modelled today, yes. But 3D modeling also shows the patient possible limits of modeling. Then it becomes clear to him that deviations are possible and that this can only be an approximate modeling of the direction.
If a patient requires an operation related to a change in appearance, we first simulate the operation virtually. To do this, we use MRI or CT scans and thus obtain a three-dimensional image of the patient's skull and face. For example, we can excise a cancerous tumour on a computer, and a cavity appears, which we call a defect. Then we, together with the software engineer, reconstruct the patient's face. We can use a computer to move a part of the virtual hip joint to the jaw and check if it fits or, for example, the fibula is better. Then we cut this bone out virtually on the computer. When this happens, so-called cutting patterns are created. These are the templates that we print on a 3D printer. During a real operation, they are superimposed on the patient's bone, and the cut is carried out in the same way as on a computer. Then the planned cut is performed, and then everything is combined, like a key and a keyhole. Even after major surgery to remove the tumour, the patient looks the same today as before.
About the dilemma between health and beauty
“In cancer surgery, there is a basic rule that treatment should allow the patient to survive his underlying disease. And there can be no compromise. And only then do we start thinking about shape and beauty."
Is rhinoplasty the most frequent reason in the field of aesthetic surgery for which patients come to you?
Nose correction from an aesthetic point of view is one of the most common corrections in our hospital. That's right. Sometimes it is combined with functional impairment - then patients additionally have an important medical reason for rhinoplasty. For example, if a nose is long and even drooping in the form of a drop, the nose is elongated, and this makes it difficult for the air to flow.
And if we are talking about functionality? What are the most common cases?
Our hospital has a large emergency department and we treat many of the wounded. Nowadays there are many injuries associated with falling from a bicycle due to the season. Lately there have been a lot of falls from electric scooters. As a result, numerous injuries to the face, and many patients with a broken nose. Among the injuries of the face, a nose fracture is in the lead. Then, by incidence rate fractures of the zygomatic bone follow, that is, the bone directly under the eye. And only then fractures of the lower jaw.
You mentioned that you have patients with cancer - what is the treatment of such patients in your department?
Traditionally, in my area, oral cancer is caused by alcohol, smoking, or a combination of both. After consulting a patient, a thorough examination is always carried out. Then, samples are taken and further technical examinations - CT/MRI/PET-CT. After we have accurately determined the extent of disease, an interdisciplinary cancer conference discusses the possible optimal treatment. The cancer conference is attended by radiotherapists who can provide radiation therapy, as well as oncologists who are responsible for chemotherapy or immunotherapy. For oral carcinoma, surgery usually has a better chance of success. In the case of a broader disease area, combination therapy, that is, surgery + radiation therapy + chemotherapy, can provide an average of almost 75% 5-year survival.
The patient is then presented with a proposal for the best possible individualized treatment.
If he agrees with this proposal, preparations for the operation begin. We prepare him - we try to get him to quit smoking and drinking, move more or even exercise, we recommend a healthy diet. On the day of surgery, a tumour is excised within healthy tissues with a safety zone of 1 cm. Exactly to the extent that we can say - with a high probability that the cancer will not return. Large operations in our area can take up to 12 hours. If the patient is missing important tissues in the mouth or face after surgery, they should be replaced for everything to function as before. Today we do it as part of two-team operations right during the first operation: while one team removes a cancerous tumour, the second team prepares the tissue for transplantation. Skin is replaced by skin, muscle by muscle, bone by bone, or mucous tissue by mucous tissue. In increasing frequency, we immediately place dental implants in a new jaw. This means that the patient wakes up the next day in the intensive care unit, his cancer is removed, he has a new jaw and, ideally, already artificial teeth.
How do you choose between aesthetics and functionality in such cases?
The basic rule of cancer treatment says: first of all, it is necessary to take all measures in order for the patient to survive with his underlying disease. He must survive. Then, immediately after the removal of the cancer, the shape and function are restored - and the last thing we do, a little later, we work on the aesthetics. If one step in this sequence is skipped, there may be unnecessary risk in survival.
Another example of aesthetics and functionality: In northern Germany, many people have a weak/undeveloped chin. If on this point a patient turns to a plastic surgeon, who does not understand anything about the teeth or jaw, he will simply apply a little silicone on the chin. If the patient comes to us, through orthodontic treatment, the jaw will be set in the correct position with the help of clamps and surgery. And after the treatment, the patient's teeth will align with each other and automatically with the chin. I mean, these patients should be treated by a specialist in the field of maxillofacial surgery, and not by someone who only deals with aesthetics. At the very least, our arguments need to be heard.
Can a patient make his own decision in such cases? If, for example, he wants a purely aesthetic result.
Of course, he can. But only after an intensive counselling interview. We explain to him what he can overlook for himself and that, perhaps, later it will already be irreparable. The patient should give written consent, which means that he is responsible for his decision and for the consequences.
"About what many professions lack - when someone says "thank you""
That means, the result in your area of specialisation depends not only on your work, but sometimes on the patient himself?
That's true! I had a young patient with the so-called Mobius syndrome. Her nerve, which is responsible for facial movements, was paralyzed on both sides. From birth, she had underdeveloped nuclei of the so-called facial nerve on both sides. Imagine, the girl did not have any facial expressions, only the lower jaw moved on her face. I gave the girl a muscle transplant. A fine muscle, called Musculus gracilis, was transplanted from both thighs to the face on both sides. I connected the nerves of these muscles of the lower extremities with the nerves of the chewing muscles of the cheeks.
When you do such transplantation, you wait like in the hot seat: because the nerve regenerates at a rate of 1 millimetre a day, and you wait - I hope it will happen, I hope it will work out well. And this girl learned in six months to reprogram her chewing nerves to the muscles of the thigh on her face. And she got normal facial expressions. It was great.
That means, the girl "ordered" the brain to move the chewing muscles? The nerve that was originally responsible for this muscle was functioning in a new place?
Yes, correct. At the very beginning, she spent an hour every day in front of a mirror and gave orders to the brain to move the chewing muscles, and the muscles of the face moved. So the girl learned to consciously control the muscles of her face - to smile, raise the corners of her mouth and squint.
Do you keep in touch with your patients after treatment?
I have patients whom I treated for the first time immediately after birth and before they grew up, they came for a control examination every year. Some people continue to communicate with me regularly by phone or WhatsApp. I have no problem with this. I love my profession, and if someone keeps communicating with me for a long time, it means that the patient is happy, otherwise he would turn to someone else.
Recently, communication in the form of video consultation has been possible. This means that if someone from Moscow wants to contact me directly, they can get a login and talk to me face to face on the video consulting platform. Such a video-conference can be held by three people, with the participation of an interpreter.
Do you have a lot of patients from other countries?
Before the COVID pandemic, I saw patients from other countries almost every week. These are always interesting patients with no less interesting diseases. They have been looking for a treatment option for a long time, and they are really worried about it. This is not always the case here in Germany - because it is a free insurance service. But foreign patients are different, they are very interested.
At the end of last year, we treated a patient from Moscow. Little boy. He had a tumour directly on the optic nerve of the eye. On the optic nerve, Nervus opticus. The boy's parents consulted in various hospitals not only in Germany, but also in Switzerland and Italy, and everywhere they received different advice. I thought the tumour needed to be removed. Others were of the opinion that it was probably not a tumour at all, and suggested that treatment with injections be performed. The parents made a decision about the operation. A decision to remove the tumour under a microscope using neuronavigation. The tumour was removed from the optic nerve. For a long time it was unclear if the boy would be able to see again. I regularly communicate with the boy's parents on WhatsApp. On the videos I received on WhatsApp, I saw the boy's pupils contract and dilate in the light. Suddenly, three months later, information came in that the boy saw in black and white. And a week ago I found out - he now sees in colour again. This is a lengthy process. And you just rejoice every time you hear the news about him. In the end, you performed an extremely difficult, tiring operation and helped the little man as a result.