The essential difference between oral and maxillofacial surgery and other surgeries is the destruction of appearance.
For patients, broken hands and feet can still be replaced with prostheses, but facial defects are difficult to repair. It would be fine if it was just pathological damage, but oral and maxillofacial surgeries are damaged because of the treatment of deep-seated lesions, which is difficult for many people to understand.
The maxilla is the largest bone in the face, and surgery is already very troublesome, with life and death uncertain. Even if you do survive the surgery, your face may still be deformed due to scar tissue.
If it weren't for Waterman's position and the guarantee of the patient's recovery after a previous mandibulectomy, the patient would rather endure the pain of rotten teeth than agree to remove half of the maxillary bone.
The final diagnosis was still osteomyelitis caused by deep infection caused by severe dental caries. The patient's face had been slightly deformed, and the left side of his face was slightly bulging. This should be edema caused by inflammation. The surgical procedure is tentatively designated as "maxillary resection", but whether it will be partial resection, subtotal resection, total resection or extended resection has not yet been decided.
The surgery quickly came to the forefront.
The patient sat throughout the entire process. After anesthesia, his limp body was supported by soft cushions under the armpits and crotch, and his head was tilted back on the cushion above the chair: "Because it is a maxillofacial surgery, we need to make a tracheotomy first to prevent bleeding. Backflow into the nasal cavity can cause suffocation.”
Waterman's tracheotomy was not much more skillful than Ignatz's. He simply cut in directly and inserted a hollow tube into the trachea, with straps on both sides fixed around the patient's neck.
Because there is no separation and hemostasis, the procedure itself will cause blood backflow. But this is a trivial matter to Waterman, as long as the patient is still alive.
"The tracheotomy is complete and air is flowing smoothly in and out of the patient's lungs, avoiding the mouth and nose."
The two assistants began to "correct" the patient's head, placing the left face at the top, opened the patient's mouth with a pressure plate and a retractor, and began to confirm the scope of the lesion:
"Considering the patient's insistence on his appearance, I need to determine the scope of surgical resection. If there is only a small area of maxillary infection, you can try to make an intraoral incision so that there is no damage to the appearance...Give me the scalpel .”
One assistant opened the patient's mandible, and another used two retractors to open the upper lip to create a surgical field for Waterman.
The scalpel was quickly cut through the labio-gingival and buccal grooves [1], and the bleeding was simply stopped. The infected area was immediately discovered: "The scope of the lesion is not small, and the intraoral incision field is too small. The partial resection promised to the patient before was impossible."
Waterman and the two assistants cooperated very well. As soon as he finished speaking, the scalpel and several retractors were all withdrawn from the mouth: "We switched to extraoral incision. The main purpose is to expand the scope of the operation to gain enough fields of view. We chose Make a longitudinal incision from the center of the upper lip to the root of the columella and then make a transverse incision...and then around the nose..." [2]
Following the rhythm of his words, the scalpel drew a vertical line on the patient's upper lip, and then extended it along the side of the nose all the way up to below the medial canthus (inner corner of the eye). The other side also needs to be cut diagonally along the upward arc of the smile to the front of the ear. 【3】
Waterman's maxillofacial surgery techniques are indeed superb. He does not hesitate with every cut and the depth of each cut is under his control.
"We have made the incision." After using gauze to stop the bleeding, the two assistants began to help him slowly incise the upper lip. "We will incise the upper lip first. The blade needs to reach the bone surface. The technique must be decisive and don't be afraid. Bleeding. If you keep taking care of the bleeding, the operation will take more than three hours to complete."
Although the words are good, the "quick hand speed sequelae" before the onset of anesthesia still affects Waterman.
His rough technique is only faster than Ignatz's, and he can make the separated facial skin and muscles look like shoveling pancakes. I'm afraid there are only a few people in Europe.
Of course, what the director said about not caring about bleeding does not mean that bleeding is completely stopped. Necessary hemostasis is still needed: "Quickly ligate the large blood vessels, let all the other small blood vessels go, and just rely on the patient's self-coagulation...and then We incise the mucosa on the side wall of the nasal cavity, connect the nasal cavity with the skin incision on the nasal side downward...and then open the skin-muscular flap." [4]
Kawei had no experience in maxillofacial surgery, so he couldn't help but squeeze forward while holding a telescope.
From where he is now, he can already see some not-so-good things. The bone surface that should be smooth is actually a large hard lump that swells outward: "Why does it feel like a tumor?"
Waterman heard Kawei's voice and the surprise of other viewers: "Dr. Kawei made a good judgment. I already discovered it when I was doing bone surface separation. The infection only exists in the gums and gums, and the scope is not included." Big. Our real enemy is the maxilla, oh no, it may have affected the zygomatic bone, it is a bone tumor."
"The scope of surgery needs to be further expanded," Kawei said.
"Yes, the entire maxillary and zygomatic bone must be removed. As for whether to do an extended resection, it depends on the condition after the resection."
Expanding the scope of the resection will be wider, with the eyeball upward and the pterygoid process, ethmoid sinus, and sphenoid sinus inward. By then, the scope of the operation will be large, and it remains to be seen whether the patient can recover after the operation. But Waterman didn't seem too worried and continued to move forward boldly.
"We'd better deal with the upper jaw first and use a small circular saw to cut the middle slit in the jaw." [5]
A nurse handed the saw to Waterman, and she stood by with pliers and gauze.
Bones have a rich blood supply. When the soft and hard palates have just been incised, the bleeding will be fierce. Gauze needs to be repeatedly inserted into the patient's mouth to stop the bleeding. But because there are no large blood vessels, the bleeding can often stop on its own after a period of tamponade.
"The area invaded by the tumor is very large, and extensive local resection is required."
Waterman used his fingers to determine the growth area of the osteoma. He used instruments frequently. After using the circular saw, he switched to an osteotome and a hammer: "We use an osteotome to cut the connection between the frontal process, the nasal bone, and the lacrimal bone. We still need to be careful here. , the force of the hammer must be controlled well, and not too excited, otherwise it will damage other tissues.”[6]
duang, duang, duang...
That's what he said, but judging from the movements of his hands, it was not careful at all: "Come down, come down, come down... Okay, this part is disconnected! Let's change sides and find the extraorbital The tumor border at the lower edge should be right here..."[7]
The two assistants continued to separate the skin and flesh. Waterman made a simple positioning and placed the osteotome at the mentioned position.
duang, duang, duang...
There was another breathtaking clear thumping sound, and he was heard to say "Okay!". All the bone connections on the front had been cut open, and what was left was the gap between the maxillary tubercle and the pterygoid process of the sphenoid bone on the side. connections between. 【8】
After incising the muscle, there were several more knocks of the osteotome, and the patient's left maxilla was completely cut off.
"Give me the pliers." Waterman clamped the patient's teeth with a large pair of pliers and slowly took out the bone fragment. "You stop the bleeding of the wound. I need to discuss bone reconstruction with Dr. Charles."
"Do I need suturing?" the assistants asked.
Waterman looked at the wound and bone section: "It's obviously too late to do it directly. You can polish the section clean and suture it directly. If you really want to do it, you have to wait for him to recover after the operation, and then do the second stage surgery."
"knew."
...
Although he had expected that the scope of resection would be expanded before the operation, the total resection was a little beyond Waterman's expectation. Originally, it was thought that a complete resection would be more likely. Charles would only need to do the pouring during the operation to make an artificial dental tray that fit the patient's mouth.
Now that all the bones have been cut away and the supporting points have disappeared, it seems that just making a dental brace is not enough.
"Among my patients, there are also patients who have undergone total unilateral maxillary resection." Charles used a knife to remove the skin and flesh outside the bones while talking about his experience in broken French. "At that time, I only chose to make a palate similar to the soft palate. The guard is placed in his mouth using this prepared material.
This will not only keep your mouth clean, but also make it easy to clean. However, it will attract a lot of attention after taking it off, so you need to try to avoid the crowd. "
"Palate guard?"
"A very thin layer of solid material that fits over half of the patient's soft palate."
"What material is it?"
Under his guidance, everyone became interested in this material. Charles stood in the surgery preparation area and took out a jar of mixed strange stuff from the box next to him:
"I chose gutta-percha shipped from India, a natural rubber from the Asian rainforest called gutta-percha. But this is just the most basic material. I also added many other ingredients to make it I made a dental tray material with moderate hardness and softness. I named it after my own surname and called it 'Stent'."[9]
"Can it really be guaranteed to be strong?"
"Everyone, please believe in this perfect combination of Asian plants and European chemistry. This rubber can do anything."
Waterman knew that half of his purpose in coming here was to advertise, and by inviting him here he acquiesced to this request. But now the operation has changed, and the omnipotent rubber will also encounter things that cannot be done: "Dear Dr. Charles, now it seems that using this kind of rubber is not enough."
Charles was not discouraged: "You can try the palatal guard I mentioned first. It's very useful."
"What about the teeth?"
Charles took out his dental forceps from the box again: "Pull them out one by one, throw away the bad ones, and insert the good ones when making the palatal guard. After solidification, they will be perfectly fixed. "
Waterman had to admit that this new material was very reliable. After all, he was asked to come here to make a good dental brace: "The palatal guard is really good, but now that the maxillary bone has been completely cut off, the rubber plate lacks fixation. point."
Charles looked at the bone in his hand and fell into deep thought.
"Unless you can connect it to the pterygoid process."
"No, this is rubber. Even if it is fixed, it will be torn off due to bite." Charles cleared his throat, still not forgetting to advertise his material, "This thing is not cheap. If you hadn't written If you invite me to come to Vienna with this material, I'm afraid he will have to rely on his right tooth to eat."
"Now it seems that I can only eat with the right tooth if I only rely on the palatal guard." Waterman shook his head gently, seeming to have made up his mind, "Now I not only need to make a dental tray, I'm afraid I also need to make another upper jaw bone. To support the dental tray.”
"Make another maxillary bone???" Charles didn't understand what he meant. "Do you want to put this bone back again?"
"How is this possible? This is a bone tumor. It makes sense to put it back after finally cutting it off." Waterman said, "You can use new materials from Asia, and of course I can use Asian materials."
"what material?"
"ivory."
Charles looked at Waterman with very surprised eyes and found a large piece of ivory from the equipment box:
"Since I listened to Dr. Kavi's advice last time, I asked my friend to buy a perfect piece of ivory imported from India. Just use a saw and file to make a maxillary model according to this bone, and insert your dental tray underneath. You can put it completely into the patient's mouth and recreate his maxilla."
"Just to make a maxilla for a sailor? It's ivory, you asked me to come to Vienna, and you used the best dental tray material in Europe..." Charles sighed at Waterman's family fortune, "You He’s too willing to spend a lot of money.”
"As far as I know, no one has done this before?" Waterman smiled, not taking the money seriously at all. "As long as I make it and publish it, it will be the world's first!"
"As expected of the president of the Vienna College of Surgery..." Charles also agreed with this approach, but the problem was still the same, "After the bones are made, what should I do with the connection parts on both sides after the dental tray material is fitted? ?”
"The connection part..."
"If it's rubber, it can be thermally bonded on both sides. It may not be strong, but at least it looks good on the surface."
"Now the bones."
"Are you asking me to put rubber between bones?"
Waterman smiled bitterly: "Judging from your expression, this seems unrealistic."
"It's not that you can't try, but once it falls off, it's more practical to make a palatal guard."
It's a simple multiple choice question, if making an ivory maxilla involves the same risk as using just plain rubber, then why not use a relatively cheap rubber palatal guard.
"It would be nice if the muscle and soft tissue could grow back and attach to the bone."
Innovation in surgery needs to face one problem after another. Once the brainstorming stops, doctors will be trapped in a whirlpool and it will be difficult to get out. In fact, it's not that they are not strong enough, but that they need some guidance from some people or things.
Just when Charles and Waterman were a little helpless and the audience was actively discussing the reconstruction materials used in the second-stage surgery, a voice suddenly sounded on the stage, attracting everyone's attention: "Since the muscles cannot be attached, then we can Help them attach.”
"Kavi?" Waterman didn't know whether to be excited or sigh. In short, this guy must have a new idea, so he quickly asked, "What do you mean by this?"
"The ivory itself is hard enough, and you can choose to use metal plates and small rivets for external fixation."
