Otolaryngology | Minnesota Medical Foundation

Rebuilding faces, rebuilding lives

2010-11-16T19:47:19Z

Reconstructive surgeons give people another chance for a normal life

In 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 chance

David 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.”

Art unseen

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.”

Moving parts

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

Web extras

Rehab specialists complete the picture

“Nobody gets to be a cowboy here,” says one facial reconstructive surgeon in the Department of Otolaryngology. Read this web-exclusive article.

Slideshow

Video

University of Minnesota plastic surgeon Dr. Peter Hilger explains the mechanics of smiling and facial reconstruction.

Video

Dr. Hilger explains how surgeons help patients regain facial movement.

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U hospitals rank among nation's best

2010-11-16T19:09:21Z

The University of Minnesota Medical Center, Fairview and University of Minnesota Amplatz Children’s Hospital are again among an elite group of hospitals named the nation’s best by U.S. News & World Report.

The annual rankings are based in part on reputation, death rate, and care-related factors such as nursing and patient services.

This year University of Minnesota Medical Center, Fairview ranked among the top 50 hospitals in the United States in six medical specialties: kidney disorders (18th), pulmonology (23rd), gastroenterology (29th), cancer (37th), otolaryngology (44th), and orthopaedics (46th).

University of Minnesota Amplatz Children’s Hospital this year was named among the nation’s top 30 children’s hospitals in two medical specialties—kidney disorders (9th) and cancer (24th).

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Physicians team up to preserve hearing in people who have acoustic neuromas

2010-11-16T18:03:49Z

Is brain surgery a team sport? Two University of Minnesota faculty members are making a good case that it is.

They’re joining forces to treat acoustic neuromas—small tumors that grow on nerves that connect the inner ear with the brain—using new technology to preserve the patient’s hearing.

Acoustic neuromas typically are noncancerous and slow-growing tumors, according to the National Institutes of Health. But as the tumors do grow, they can press on nerves that affect hearing and balance.

They’re often removed through surgery, a technique that has improved in effectiveness with the advent of brain imaging techniques. Even so, the cochlear nerve, which is responsible for hearing, can easily be damaged in the surgery, especially for those who have larger tumors, resulting in deafness.

But Stephen Haines, M.D., head of the University of Minnesota Medical School’s Department of Neurosurgery, and Samuel Levine, M.D., a professor in the Departments of Otolaryngology and Neurosurgery, are working together to produce better outcomes for patients by using advanced imaging and monitoring techniques to keep patients’ hearing intact.

Surgery for acoustic neuromas requires the displacement of a bony canal, sometimes less than a centimeter long, running from the inner ear to the brainstem. During this procedure, imaging equipment helps Haines and Levine see as they perform the delicate work.

And as they remove the tumors, another technological tool offers assistance: equipment that monitors auditory brainstem response, the electrical signals neurons in the brain fire when detecting sound.

If the response remains in the normal range, the physicians know that the surgery has not affected hearing, Levine says. If necessary, they can adjust their approach to keep the cochlear nerve undamaged.

In this team procedure at University of Minnesota Medical Center, Fairview, Levine takes charge of accessing the tumors through the ear, and Haines handles their removal.

Levine compares their collaboration to the teamwork required by marriage, and Haines agrees.

“Working together like this is a matter of personal interaction and compromise, and we’ve learned a lot from each other,” Haines says. “This technique really requires the expertise of both specialties. It won’t work if you’re stubborn about only using the approaches you learned during your training.”

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Medical School hires new head of otolaryngology

2007-10-01T21:59:31Z

The Medical School’s Department of Otolaryngology has selected Bevan Yueh, M.D., M.P.H., as its new head following a national search.

An accomplished researcher and author of more than 50 journal articles, Yueh also is an award-winning teacher lauded for his ability to mentor students and take an active role in training residents.

“Dr. Yueh is an outstanding clinical researcher who has studied treatment outcomes extensively,” says Medical School Dean Deborah Powell, M.D. ” He also is a skilled head and neck surgeon and an outstanding academic leader.”

A native Minnesotan, Yueh comes from the University of Washington in Seattle, where he was a professor in the Department of Otolaryngology, director of the Clinical Outcomes Unit, and an affiliate member of the Fred Hutchinson Cancer Research Center. He earned his M.D. at Stanford University School of Medicine and his M.P.H. at Yale University School of Epidemiology and Public Health.

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U gains in 'Best Hospitals' rankings

2007-10-01T18:15:08Z

University of Minnesota Medical Center, made impressive gains in this year’s U.S. News & World Report’s “Best Hospitals” edition.

The medical center ranked among the top 50 hospitals in the country in nine medical specialties, with eight of the nine specialties ranking higher than last year. Specialties receiving top-50 rankings in 2007 were cancer; digestive disorders; ear, nose, and throat; endocrinology; gynecology; heart and heart surgery; kidney disease; neurology and neuroscience; and respiratory disorders.

According to the report, only 173 of 5,462 hospitals evaluated met the standard of treating a variety of demanding illnesses and procedures within a specialty.

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Collaboration gives one patient her sight and life back

2006-04-01T18:02:42Z

When Linda Williams walked into the clinic for her first appointment with Andrew Harrison, M.D., she had crossed, protruding eyes, and her eyelids couldn’t close completely. She was miserable and in desperate need of help.

A couple of years earlier, after the birth of her second child,Williams had been diagnosed with Graves’ disease, a hyperthyroid disorder associated with anxiety, high energy, sudden weight loss, and difficulty sleeping. It eventually affects the eyes in about half of the patients with the disease, but only 5 percent of those patients require treatment for their symptoms.Williams was one of them.

“Linda had the classic findings of thyroid eye disease when I first saw her,” says Harrison, an assistant professor of ophthalmology and otolaryngology and director of ophthalmic plastic and reconstructive surgery. “Besides protruding eyes, or proptosis, she had crossed eyes, or restrictive strabismus, because the swelling in her eye muscles prevented the normal movement of her eyes. She also had problems with eyelid retraction, and her eyelids were spread open wider than normal. This is a troublesome combination.”

Williams’s symptoms were being treated with oral steroids, which were not only ineffective but resulted in excessive weight gain. The first thing Harrison did was to gradually decrease her dosage of steroids; he then began injecting localized steroids near her eyes.

It soon became apparent that Williams would need surgery to correct her protruding eyes. Harrison and George Goding Jr., M.D., of the Department of Otolaryngology told Williams about orbital decompression surgery. The surgery is extremely delicate and requires the collaborative expertise of an ophthalmologist to remove bone from behind the eyes and an otolaryngologist to remove bone from between the eyes and the sinuses. These steps make more room for the eyes to settle back into their sockets.

In spite of her symptoms,Williams was initially reluctant to have eye surgery. “I think Dr. Harrison’s confidence is what persuaded me to go ahead with it,” she says. “He didn’t try to talk me into it, but he told me about each procedure I needed and explained how it would help. I knew I could trust him when he told me I wasn’t the worst case he had seen.”

The orbital decompression surgery was performed first. “Not until I woke up after surgery did I realize how much pain I had been in,” says Linda. “Before the surgery I had this sensation of twisting and grinding behind my eyes, and that was gone.”

Next, in order to correct her eye misalignment, Linda underwent strabismus surgery by Stephen Christiansen, M.D. A few months later, Harrison performed bilateral eyelid surgery, lowering Linda’s upper eyelids so that her eyes would close properly.

The 37-year-old mother from Coon Rapids, Minnesota, looks back on her days before surgery with some amazement.

“Before I had surgery I wasn’t out in public very often,” she says. “Because my eyes looked so unusual, people stared at me, especially children. I had double vision because of my crossed eyes. Before eyelid surgery I had to sleep with an eye mask because my eyes wouldn’t close. In my Graves’ disease support group, I heard from women who would tape cotton balls over their eyes before going to sleep. It’s a terrible thing not to be able to close your eyes completely.”

“It’s also a pleasure to work with Dr. Goding from otolaryngology, with Dr. Christiansen for the strabismus treatment, and with the endocrinologist who is managing Linda’s Graves’ disease,” says Harrison. “Cases like Linda’s make it imperative that we work as a team so that she gets all the treatment she needs.”

After her surgeries,Williams feels like her life is under control again. “I don’t know what would have happened to me if I hadn’t had those surgeries,” she says. “I didn’t feel right and I didn’t feel like I could care for anyone, and I’m the mother of two little boys with special needs.

“Having doctors who work together and who look at the whole picture has been so helpful to me,” says Williams. “My doctors at the University make me feel like family.”

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