Cancer patients often leap two gigantic hurdles in the race against disease. First comes treatment to stay alive. Next is life after treatment.
And for patients such as Sandra Smith, who lost most of her jaw and the floor of her mouth to oral cancer, living now includes smiling, speaking clearly and chewing tender meat with replacement parts that move and function almost as well as the originals.
Smith and about 6 million other people across the United States are beneficiaries of advances in reconstructive surgery that some doctors say they could not have imagined 10 years ago.
The ability to create Smith's new, living jawbone; to rebuild breasts without destroying abdominal muscles; and to restore function to limbs or fingers damaged by accident hinges on the relatively newfound ability of doctors to stitch together veins and arteries whose diameters are about the size of the tip of a ballpoint pen.
"Reconstructive surgery has never been more exciting," said Dr. Allen Van Beek, a Minnesota plastic and reconstructive surgeon and president of the Plastic Surgery Educational Foundation, an arm of the American Society of Plastic Surgeons. "It goes well beyond what would have been possible without the advent of microsurgery."
Most people have heard the term microsurgery when a person loses a finger in an accident and the severed digit is placed in an ice-filled baggie and rushed to the hospital along with the patient. A surgeon in Boston started experimenting with replacing and restoring function to severed fingers in the 1950s.
But it wasn't until the 1980s that researchers began to perfect the optics and the tools that allow doctors to see and stitch together thread-thin vessels. Doctors also increased their understanding of how tissue lives and receives blood. Material developed to suture the vessels is now one-half the diameter of a strand of human hair, said Dr. Rajiv Chandawarkar, a plastic surgeon at the University of Connecticut Health Center in Farmington.
Someday, Van Beek said, the technology could allow doctors to transplant hands or arms the same way they might transplant a donated kidney today. A researcher in Canada is experimenting with replacing the entire faces of people disfigured by burns, other mishaps or birth defects, Van Beek said.
Sandra Smith was first diagnosed with jaw cancer 20 years ago, at the age of 27. Then, surgeons replaced her diseased jaw with a titanium plate and dead bone grafted from her hip. The cosmetic replacement looked good, but Smith could not use the rebuilt part of her mouth. And she lost feeling in her tongue.
All of that, she says, was a small price to pay for a healthy, happy life that she filled easily tending bar, raising three children, giving birth to a fourth, who is now 8 years old, and becoming a nurse's aide at a rehabilitation center near her home in Brooklyn, Conn.
Like using a miter saw
Last December, she discovered that the cancer had recurred at the edges of the titanium plate. This time, Smith was ready for a fight. She was not prepared to come away from the ordeal with a jaw that felt and worked almost as well as the healthy one she was born with.
When she went to see her surgeon, Dr. Jeffrey Spiro, at the University of Connecticut Health Center, she was offered a consultation with Chandawarkar, who moved to Connecticut a few months earlier from the M.D. Anderson Cancer Center at the University of Texas in Houston.
Chandawarkar trained in India, where head and neck cancer is common because of the widespread use of chewing tobacco and various chewing roots there. He said he believes every patient facing cancer surgery deserves to see a plastic surgeon before any tumor is removed.
"The surgical oncology guy is going to take a portion of [their tissue] away, the radiologist is going to burn them, the medical oncologist is going to poison them. Shouldn't they see a guy who's going to put them back together?" Chandawarkar asked.
Before they could rebuild Sandra Smith, Spiro and Chandawarkar removed her old jaw from her chin to her cheek. They also took out the floor of her mouth and the lymph nodes in her neck.
The doctors then moved down to her leg, where they isolated the fibula, the slender bone between the knee and the ankle. They did not disturb the more important of the shinbones, the tibia. They made sure to take the arteries and veins that supplied the fibula and surrounding skin.
Before severing the blood vessels from the leg, the doctors cut the bone into small pieces. The pieces were cut at angles and attached to a titanium mold of Smith's jaw. Chandawarkar likened the process to using a miter saw to form perfect corners when installing crown molding in a home.
Next, they cut the vein and artery from the leg and moved the replacement jaw to where it belonged, carefully reattaching the vessels to those that supply blood to Smith's face.
"All you need is an artery and vein that will feed the tissue," Chandawarkar said.