The 20-year-old patient presented to the UAMS Emergency Department via ambulance from Malvern, about 50 miles away. The patient’s nose, upper lip and most of his right cheek were amputated by the edge of a hollow metal pole that came through the patient’s windshield during the single-vehicle rollover accident. He also had multiple facial fractures with extensive damage to the palate and teeth.At the accident site, the property owner directed emergency responders to the severed portion of the patient’s face some distance from the vehicle. The avulsed tissue was properly stored and brought to the ED along with the patient.Only One ChoiceMauricio Moreno, MD, director of the UAMS Head and Neck Cancer Division and a fellowship-trained microvacsular surgeon, saw the patient in the ED and determined that the only choice was to attempt one of the largest known composite facial replantation surgeries in medical literature.The ischemia time was critical to the outcome since most successful replantations of facial tissues are performed in less than 8 hours. Due to inclement weather, an effort to fly the patient to UAMS had been aborted, and nearly six hours had passed when the patient was taken to surgery.Without a successful replantation, the patient’s prognosis was poor for both function and appearance. No amount of plastic and reconstructive surgery would provide a cosmetically satisfactory result, and the patient’s ability to eat, drink, or speak would be severely affected.Prior to surgery, Moreno consulted with UAMS’ Marcus Moody, MD, a facial plastic and reconstructive surgery specialist, who agreed that the facial bone fractures could be repaired at a later date.The ChallengeSuccess depended on reintroducing blood supply via a microvascular anastomosis of the facial artery to the angular artery and microvascular anastomosis of the retromandibular vein to the facial vein. Given the nature of the injury, the vessels were severely damaged at the point where they were transected. In order to overcome this problem the vessels were dissected from the transection site until they appeared less damaged, and the anastomosis was made at that point. This was one of the most technically challenging aspects of the case. Very short vessels forced the release of some tissues in the face and neck in order to achieve a tension-free anastomosis.Moreno worked as quickly as possible, completing the replantation in about two hours, maintaining the total ischemia time just under eight hours.Six days after surgery, while the patient remained sedated in the ICU, the retromandibular vein thrombosed and the patient was taken back into surgery to repair the clotted vessel. Two days later the same vessel thrombosed again requiring a third – and final – microsurgical procedure.The episodes of thrombosis likely were related to the vessel trauma that resulted from the accident.Leeches HelpBecause the tissue was unable to accommodate the increased blood flow, medical leeches were flown to UAMS and applied to the replanted tissue for 72 hours. The leeches corrected the venous insufficiency, which can have the same deleterious effect as when replanted tissue gets too little blood supply.The replantation was a success. It appears to be the largest composite nasal replantation in the medical literature of about 15 cases described worldwide.Ninety percent of the tissue survived; only a small portion of the patient’s nose and right cheek did not survive, but that tissue can be replaced.The patient lost vision in his right eye, and the right side of his face is paralyzed as a result of the trauma. Multiple procedures will be needed to repair the numerous facial fractures, restore facial symmetry and achieve the best possible cosmetic and functional outcome.
Monday, April 11, 2011
UAMS mails out a publication called UAMS Consult a few times each year. I found a pdf file of their March 2007 issue online (no longer active, 2013) but couldn’t find the current one with this case report. So I’m taking the liberty (they may ask me to take it down) to publish it here.
Kudos to UAMS.