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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.

By March 2000Comments

On Labor Day, 1998, Dr. A. Jay Burns, a plastic surgeon affiliated with the Children’s Medical Center of Dallas, got a call from a colleague at St. Francis Hospital in Tulsa, Oklahoma. “We’ve got a severe facial-trauma case to send you,” Burns recalls his friend saying, “a dog mauling like you’ve never seen before. We’ve done what we can to stabilize the patient, a two-year-old boy who was bitten by the family dog.”

Burns remembers telling his friend that it couldn’t be that big a deal. At 42, he had seen a lot of horrific facial injuries in his time and performed many difficult facial reconstructions. And he knew that what might seem like an extraordinary case of trauma to a smaller hospital like St. Francis was likely a routine case at Children’s, which has the busiest pediatric emergency room in the nation. “It was a dog bite,” he remembers thinking. “How bad could it be?”

But when he first saw little Mycha Herbert in Children’s Pediatric Intensive Care Unit three days after the incident, Burns says, “I was completely overwhelmed. I’d never seen anything like it before, and I knew I’d never see anything like it again.”

From just below his eyes to just under his chin, the toddler’s face had been filleted from the bone by the dog’s powerful jaws. The tissues of his cheeks, nose, lips, mouth, and chin were simply gone, leaving only the glistening white bone of his skull and two very stunned eyes where once there had been an impish face. Though Mycha’s tongue and teeth were intact, the damage was so total that the doctors at St. Francis had had to insert a tube through his throat so that he could breathe and a feeding tube directly into his stomach so that he could receive nourishment. Mycha’s parents — Bobby, 24, and Veronika, 19 — weren’t certain what had happened, but it appeared that their son had startled the family dog, a six-month-old Staffordshire terrier named Blue, and the dog had snapped at Mycha, locking his jaws on the lower two thirds of the boy’s face with a single bite. Mycha must have then stumbled, causing the facial tissue to shear off the cranium more or less in a single piece.

“For the first time in my career, I truly didn’t know what to do,” says Burns, a rangy, baby-faced man with a receding hairline and a self-effacing manner. But he knew instinctively that whatever solution he devised for Mycha (pronounced Mi-cah), he was probably going to make history with it. Reconstructive facial surgery had come a long way in just the decade and a half that he’d been practicing it. Vascular microsurgery had made the transfer of so-called free flaps — patches of tissue that include skin, muscle, fat, blood vessels, and nerves — from one place on the body to another a fairly routine matter, without the need for awkward connecting tubes of tissue (called pedicles) to supply blood to the grafted site, and improved anti-rejection drugs were allowing even grafts from donors to “take.” The occasional miracle was now possible. Still, as far as Burns knew, creating essentially a whole new face for a patient out of his own tissue had never been tried before.

So he began networking with colleagues for suggestions. Two serious options emerged. One, proposed by Dr. Steve Byrd, was a wholesale face transplant from a donor. This had never been done either, but the doctors learned from experts in the field that new techniques and medications made it at least feasible. However, they realized that a transplant would involve a lot of red tape — advertising for and finding a donor, for starters. “We just ran out of time,” recalls the 53-year-old Byrd. “We had a kid on a respirator we needed to save.”

The second option was even more daunting than a transplant. Though the most flap transfers any reconstructive surgeon had ever attempted in repairing a damaged face was three, Burns and Byrd could see how grafting as many as five flaps to intact tissue on different parts of the boy’s exposed skull could give surgeons the flexibility necessary to fashion somewhat more-normal facial features, restore more muscle movement and strength, and better re-establish nerve conduction. But their timing had to be exquisite: Once harvested, a free flap of tissue must be completely hooked up to its new site within four to six hours or it will die. In fact, Burns was expecting at least two of the flaps to do just that. And even if attached in time, the grafts could fail for all sorts of reasons: clotting or spasms in the newly grafted blood vessels, for example, or failure of grafted nerve tissue to grow new nerves properly. Meanwhile, severe trauma would also be inflicted on the parts of Mycha’s body where hunks of tissue would be harvested for grafting.

There were other questions as well. The Herberts were of limited means and uninsured, so the hospital would have to pick up the tab for Mycha’s medical expenses, which would surely amount to several hundred thousand dollars. Moreover, the initial round of surgical procedures alone could tie up an operating room for days — something unheard of at a busy trauma hospital like Children’s. Finally, Burns knew that he couldn’t mince words with the boy’s young parents, who were, to complicate matters further, expecting their second child soon. Mycha would have only a fifty-fifty chance of surviving the operation, he told them. And if he did survive it, there was no guarantee that his newly reconstructed face would work, or that it would ever look normal.

Bobby Herbert, who was an unemployed construction worker at the time, didn’t flinch. “We’d been thinking Mycha wouldn’t make it at all, so any chance to save him was fine by me,” he recalls. The hospital, for its part, was just as resolute. “I was expecting all sorts of problems,” says Burns, “but they said they’d find the money somewhere and that we could have the OR for as long as we needed. Everybody donated their time. This case really brought out the best in everyone.”

So on the evening of September 15, a team of seven surgeons, six anesthesiologists, and dozens of support personnel embarked on the biggest challenge of their medical careers. Working in teams of two, the surgeons would rotate in ten- to twelve-hour shifts until the job was done. Mycha’s surgery was planned in meticulous detail. “We literally wrote out a script that we all agreed to,” recalls Byrd. “We knew that if we varied from the script, it might affect the success of the overall operation.”

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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