Reconstructing Lives

Plastic surgeons are seeing more patients who face serious challenges after surviving injuries in fires, accidents - and war

November 01, 2007|By Dennis O'Brien | Dennis O'Brien,Sun reporter

Juan Cruz, a former Defense Department accountant, was burned over 50 percent of his body when terrorists crashed an airliner into the Pentagon on Sept 11, 2001.

"All I remember is that I was burning. My clothes were burning, and there was smoke all around," said Cruz, 57.

Since then, he has been through 40 surgical procedures, two cornea transplants and major facial reconstruction. He has had to give up driving because his vision is so clouded.

But Cruz, whose face was reconstructed at the Johns Hopkins Bayview Medical Center, represents a patient that plastic surgeons are seeing more often these days: the kind who wouldn't have survived years ago.

As military surgeons, hospital emergency departments and urban trauma centers improve survival rates for victims critically injured in fires and accidents and on battlefields, their patients are increasingly winding up in the care of specialists whose domain has long been associated with the tummy tuck and the nose job.

"There's no question more people are surviving, and it's creating a whole new set of challenges," said Dr. Paul Cederna, a plastic surgeon from the University of Michigan Health Systems, who joined 6,000 colleagues in Baltimore this week for the American Society of Plastic Surgeons' annual convention.

At the meeting, Cederna said physicians still need better ways to connect nerve endings with prosthetic devices for better control. But advances in microsurgery are enabling them to reattach blood vessels - about the size of human hairs - and move tissues from one body part to another, such as from one leg bone to another, with more precision than ever.

"It's work done in pretty small areas, and it's very tricky," Cederna said.

Among the challenges remaining are finding better ways to treat patients like Cruz, who face long and complex recoveries. "The doctors have said I was alive because of all the different techniques they have now. I also like to think it's because I was in good shape," said Cruz, who does push-ups and runs up to two miles a few times a week.

At the American Society of Plastic Surgical Nurses' convention, held concurrently here, Cruz's doctor described his technique for restoring facial features on such critically burned patients.

"For someone to get facial burns, it's usually a case where the injuries are really extensive. In a major fire, your first instinct is to cover your face," said Dr. Robert J. Spence, director of burn reconstruction at the Johns Hopkins Burn Center.

To restore Cruz's face, Spence first created new skin by implanting a balloonlike sac in his shoulder and injecting it with saline once a week for about three months. The injections allowed Cruz to produce more skin - the way a pregnant woman produces more skin as her pregnancy progresses.

Such balloonlike "tissue expanders" have been used for decades to treat mastectomy patients, Spence said. Once the skin expands, Spence cuts into it and creates a flap that he uses to cover damaged areas of the patient's face.

Traditional skin grafts generally work well, but the flap technique means transferring tissue with blood flowing through it, so that there is less chance of changes in skin color and texture, as sometimes occur with grafts, according to Spence and other experts.

"It's generally been received very well," said Dr. Joel J. Feldman, a professor at Harvard Medical School who uses the same technique with facial wounds in Cambridge, Mass.

To calculate someone's chances of surviving burn injuries, experts used to add the patient's age to the percentage of his body covered by burns. Together, they represented the patient's risk of mortality, Cederna said. So a 50-year-old patient burned over 40 percent of his body was generally estimated to have a 90 percent chance of dying.

But that's no longer true. "What's a survivable burn now is different than it was 10 or 20 years ago," Cederna said.

The same applies to other trauma victims. "We have more of all kinds of survivors," said Dr. Eduardo Rodriguez, chief of plastic reconstructive and maxillofacial surgery at the Maryland Shock Trauma Center.

A key at the trauma center is performing reconstructive surgery soon after the injuries occur, before broken bones knit improperly, Rodriguez said.

"We're treating patients earlier, and the sooner we can treat them, the better things go for them," he said.

In the Persian Gulf, 95 percent of the soldiers and Marines wounded who make it to a combat support hospital survive - many with injuries that years ago might have killed them, said Lt. Col. Barry M. Martin, a plastic surgeon at the Walter Reed Army Medical Center.

"It's something that's raising new questions about how to do reconstructive surgery on many of the survivors," Martin said.

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