Projects - Nose Reconstruction
Article - Like Something from Nothing
Article - New Reconstruction Techniques
Article - Autogenous Nasal Tip Reconstruction of Complex Defects
excerpted from Johns Hopkins Magazine - Winter 2008 (link)
See the Magazine PDF
By Ramsey Flynn
When the Humvee started to roll over during a high-speed turn near iraq's border with Kuwait on the early afternoon of August 12, 2005 a piece of Michael Flecher's top-mounted turret gun caught him in the face, impaling him beneath the heavy machine moments later.
He remembers intense heat. He remembers standing up and taking a few steps and throwing his helmet off before passing out. Then he remembers waking up in Walter Reed Army Medical Hospital.
The center of his face was crushed, his nose completely erased into a formless scramble of flesh. By comparison, Fletcher’s other injuries—a blinded left eye, a left arm amputated at the shoulder—seemed almost incidental. That the 21-year-old was alive at all was a testament to modern combat medicine: Fast-thinking military doctors had restarted his heart three times during the medevac operation.
By the time Senior Airman Fletcher came into the care of Patrick Byrne at Hopkins in January of 2006, the four metal plates installed beneath the flesh of his mid-face had settled. Surgeons in Kuwait had placed them there just hours after his injury six months earlier, as an artificial foundation layer to protect the soft tissues beneath. But Fletcher still lacked any human approximation of a nose.
Byrne, an expert in facial plastic reconstruction, knew that building a new nose atop the crude foundation at the center of Michael Fletcher’s face would require a long series of difficult procedures. With the original nose missing entirely, he would have to craft one from scratch, harvesting raw parts from multiple locations throughout Fletcher’s body. He counseled Fletcher about the torturous changes ahead, and told him there might be an easier way. They could fashion a real-looking artificial nose.
Though Airman Fletcher welcomed anything that would reduce the awkward staring of strangers, he told Byrne he’d suffer any pain required to have a real nose again.
First, Byrne needed to form his own small army. With so little natural structure to work with, Byrne sought adventurous partners. One came in the form of Hopkins colleague Juan Garcia, an anaplastologist who’d already helped Byrne rebuild the faces of patients who’d suffered disfiguring nasal cancers. Garcia developed prototype prostheses that allowed surgeons like Byrne to plan difficult procedures preoperatively. Once surgery started, Byrne could also use these prostheses to help guide his scalpels.
But the Fletcher case was something else altogether. Much of the relevant skin, along with the patient’s underlying nasal structure, was completely absent. Byrne and Garcia would have to devise a novel approach to recreate Fletcher’s nose from scratch—while also matching the contours of his original nose.
In a process that graduated from silicone to stone and then to wax, Garcia fashioned a replica of the original nose.
Then he turned to technicians at Direct Dimensions, a suburban Maryland computer engineering lab, to transfer it to a 3-D image that would aid in the production of a clear plastic guide. The guide would be manufactured by precision plastics experts at Aberdeen Proving Ground. Once completed, it would serve as the governing mold that Byrne would fill with carefully sculpted flesh on the operating table—from parts of Airman Fletcher’s own body. Once the flesh version was sculpted, the guide could be discarded and the bandages applied.
The strategy required Fletcher to undergo six medical procedures over the course of nine months, starting in July of 2006.
By the afternoon of April 24, 2007, Fletcher was ready for his last procedure, some of it a redo, some of it just a minor refining of contours. During his pre-op visit with the patient, Byrne asked Fletcher which piece of music he’d most like to hear while going under.
“Got any jazz?” asked the native of New Orleans. Fletcher hadn’t been back to his hometown since he’d left for the service in 2004. Jazz sounded like a great idea. “I’ve got Allen Toussaint,” smiled Byrne.
Just a week later, Michael Fletcher returned to Hopkins for the long-awaited removal of his bandage. He was greeted by three television crews.
“Can you breathe?” one reporter asked as he entered the suite, closely followed by his wife.
“Yeah,” smiled Fletcher from behind the bandage. “Perfectly.”
Another asked what he most looked forward to after the bandage came off.
“Anonymity,” he answered quickly. “When you lose it, you know what it was. I want to be able to walk down the street with Yolanda and my boy and have no one notice me.”
With little ceremony, Fletcher took his place on a stool. Patrick Byrne stepped close, gently peeling the bandage away. Even through the remaining traces of surgical scarring, the new nose looked remarkably normal.
Fletcher looked around, trying to read the faces of the 10 people gathered around him for some sign of approval.
Finally, one of them handed him a mirror. “Wonderful,” said Fletcher.
Further questions ensued. One reporter asked if he could touch Fletcher’s new nose, and if Fletcher could feel the sensations normally.
Fletcher assured the reporter that he could. “The only difference between this and my old nose is that I can’t wiggle it.”
Now out of the Air Force and preparing for a new life somewhere in the immigration and customs service, Michael Fletcher has little need to wiggle his new nose. Two-year-old Mi-Trell, however, is doing a lot of that for him. “He’s having a field day with it.”
