Health
Saving Face
When Mycha Herbert was two, the family dog bit off his nose, cheeks, and lips. It took a team of Dallas surgeons almost forty hours to recreate them.
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The procedure was done from the inside out. "In most reconstructions, you're only providing 'coverage,' skin over a wound, or 'lining' — say, tissue for the inside of the nose where you've had to excise a tumor," says Burns. "This involved both, and in amounts that were unprecedented. It was like remodeling a house after a tornado has hit it. You start with the wiring — the nerves — then move on to the plumbing, the blood vessels. Then you start rebuilding interior walls and then the exterior."
Byrd, a leading expert in nerve grafting, hooked up the "wiring" of the new face using sural nerve taken from Mycha's calves. (The sural nerve is favored for grafting because it's accessible and its excision will diminish leg function only slightly, if at all, and won't leave a noticeable scar.) In several areas he was able to splice severed nerve tissue back together again. In other areas, where some of the nerve stumps (where the nerves attach to the muscle tissue) had been torn away, he had to improvise: He hooked two 2- to 3-inch tentacles of sural nerve to branches of the main trunks of the facial nerves, which rest below and behind each ear. Then he draped the sural nerves across each bare cheekbone and tagged them with a blue suture so that Burns could easily find the "loose wires" to connect to nerves in the muscle tissue that would be grafted to Mycha's skull in a later phase of the procedure.
The operation proceeded to the boy's mouth. Two narrow six-inch-long flaps of soft tissue from the inside of Mycha's forearms — the body's tissue that most closely approximates the tone and texture of the mouth's mucous membrane — were harvested to shape interior cheeks, the upper and lower sulcuses (spaces) between the lips and the gums and between the cheeks and the jawbones, and a new set of lips.
After hooking up the "plumbing" — attaching blood vessels in the harvested tissue to the external carotid artery and vein, the face's main blood supplier — Burns sewed the swaths of tissue to the boy's upper and lower gums all the way back to the joint of the jaw, creating the interior of the mouth and lips. Then he folded the edge of one swath of tissue upward and the edge of the other downward, to make lips. The actual orifice of the mouth was created by sewing the ends of the upper and lower lips together.
Next Burns added a layer of muscle to the new face. Though the grafted muscle could never restore a normal face's complexity and nuance of movement — there are some forty muscles around the mouth, cheeks, and chin alone — at least it would enable Mycha to open and close his mouth, to chew and breathe and talk. "In any reconstruction there's a tension between blood and beauty," Burns says. "Our first priority was to give Mycha back a functional face that would allow him to live without tubes for breathing and eating. The aesthetics came after that."
Two 3- to 4-inch pieces of the long, sausagelike gracilis muscle were removed from Mycha's thighs and their blood vessels hooked up to the blood supply at the grafting site. The muscle tissue was sewn around the boy's mouth and back to the jaw joint on both sides of his face, giving him the ability to open and close his new mouth.
Now the surgical team was ready to apply the finishing touch to Mycha's new face by covering the freshly grafted nerves, blood vessels, and muscles with a U-shaped piece of tissue (muscle, fat, and skin) from his abdomen, fitting it around his jawline and up over his cheekbones. Small magnets that would soon hold a prosthetic nose in place were implanted inside the nasal opening. (When he's in his late teens, after his cranium has stopped growing, Mycha will get a permanent new nose made from harvested rib bone, cartilage, and skin.)
Now, almost forty hours into the operation, Mycha's new face had finally taken shape. Puffy and lantern jawed and seemingly frozen in a slight smile, it was a different face from the one he had had just two weeks before. But amazingly, all five free-flap grafts had survived, and he appeared in good shape to begin his arduous recovery.
Despite his apparent success, Burns was ambivalent about his handiwork. "I knew he was better off, but how much?" he remembers thinking. "But when I asked the nurses back at the ICU what they thought, some of them started crying and saying it was a miracle. And you know, I think it was."
Seventeen months after his operation, the little boy has bounced back from his bizarre trauma, and its equally traumatic medical aftermath, remarkably well. He was in and out of various rehab programs — for his damaged leg and stomach muscles, for example — well ahead of schedule. He did struggle for some time with the massive amounts of scar tissue created by the surgery. His lower jaw was so inflexible, for instance, that he had to drag it open with a finger to speak, but an operation last fall cleaned out much of the excess tissue, reducing what his dad had come to call his Jay Leno chin considerably and giving his lips more definition.
But Mycha still doesn't look normal — and he probably never will, even though he will undergo numerous surgeries to refine his features. Because no other tissue of the body can truly emulate the lips, his look artificial, like those of a stuffed doll. He will never be able to make more than a couple of basic facial expressions. And his parents and doctors will have to watch out for developmental problems, particularly with his speech. But he can breathe and eat with his new face, and the one part of him that, magically, appears completely untouched by the trauma is his psyche. "The docs say he was so young when it happened, he doesn't remember any of it," says Bobby Herbert, observing his son's uninhibited romping on the playground at Children's one morning. "He was lucky in that way."
Whether Mycha's luck will hold out is difficult to say. These days he's something of a celebrity in his hometown of Tulsa. And in the corridors of the Children's Medical Center, where he personifies the hospital's avowed mission to treat the poorest, sickest kids, he is fawned over by everyone from janitors to administrators. But both Burns and Mycha's father know that at some point in the not-too-distant future he may find himself regarded as a freak — that his toughest challenges are yet to come.
Having given his share of media interviews about Mycha's operation and having written a paper for the professional journal Plastic and Reconstructive Surgery, Burns is ready to return to cosmetic nips and tucks and his work with a birthmark clinic. "That was it for me," he says. "I don't want another case like that. What we did for Mycha was special, and I'm proud of it. But in the end, only God can make a face."
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