Nineteenth Century Medical Guide

Chapter 141 138. New Materials, New Methods

The essential difference between oral and maxillofacial surgery and other surgeries is the destruction of appearance.

For patients, severed hands and feet can still be replaced with artificial limbs, but facial defects are difficult to repair.It’s okay if it’s just pathological damage, but oral and maxillofacial surgery is destroyed because of the treatment of hidden deep lesions, which is difficult for many people to understand.

The maxilla is the largest bone in the face. Surgery is already very troublesome, and life and death are uncertain.Even if you do survive the surgery, your face may still be deformed by scar tissue.

If it were not for the guarantee of Watman's position and the recovery of the mandibular resection patient, the patient would rather endure the pain of rotten teeth than agree to cut off half of the maxilla.

The established diagnosis was still osteomyelitis after deep infection caused by severe dental caries. The patient's face had been slightly deformed, and the left cheek was slightly raised, which should be edema caused by inflammation.The surgical method is tentatively designated as "maxillary resection", but whether it is partial resection, subtotal resection, total resection or extended resection has not yet been decided.

Surgery quickly entered the topic.

The patient was sitting all the time. After anesthesia, the limp body was supported by the armpits and crotch cushions, and his head was leaned back on the cushion above the chair: "Because it is a maxillofacial surgery, we need to do a tracheotomy first to prevent blood flow." Backflow into the nasal cavity and cause suffocation."

Watman's tracheotomy was not much more proficient than Ignatz's. It was still a simple and rough incision, and then a hollow tube was inserted into the trachea, and the straps on both sides were fixed on the patient's neck.

Because there is no separation and hemostasis, the practice itself will cause blood backflow.But this is a small matter for Wattman, as long as the patient is still alive.

"The tracheotomy is complete and the air is moving in and out of the patient's lungs, avoiding the nose and mouth."

The two assistants began to "straighten" the patient's head, put the left face on top, opened the patient's mouth with a pressure plate and retractor, and began to confirm the extent of the lesion:

"Considering the patient's insistence on his appearance, I need to determine the scope of surgical resection. If it is only a small-scale maxillary infection, you can try to make an incision in the mouth, so that there will be no damage to the appearance. Give me a scalpel."

One assistant opened the patient's mandible, and another used two retractors to open the upper lip to create the surgical field for Watman.

The scalpel quickly cut into the buccal sulcus [1], stopped the bleeding, and found the infected area immediately: "The lesion is not small, and the intraoral incision field is too small. The partial resection promised to the patient before is impossible."

Watman and the two assistants cooperated very well. As soon as the words fell, the scalpel and several retractors all exited the mouth: "We switched to an extraoral incision. The main purpose is to expand the scope of surgery to obtain enough vision. We choose A longitudinal incision is made from the center of the upper lip, and then a transverse incision is made to the root of the nasal columella and then around the alar of the nose.”【2】

Following the rhythm of his speech, the scalpel drew a vertical line on the patient's upper lip, and then extended along the side of the nose to the bottom of the inner canthus (inner corner of the eye).The other side also needs to follow the upward arc of the smile at the corner of the mouth, and cut obliquely to the front of the ear. 【3】

Watman's maxillofacial surgery techniques are really exquisite, he does not hesitate to make every cut, and the depth of each cut is within his grasp.

"We have already made the incision." After the two assistants used gauze to stop the bleeding, they began to help him slowly cut the upper lip. "Let's cut the upper lip first. The blade needs to reach the bone surface. The technique must be decisive and not be afraid." Bleeding. If bleeding is always taken into account, the operation would take three hours to complete."

Although the words are good, the "quick hand and fast sequelae" before the emergence of anesthesia still affect Waterman.

Compared with Ignatz's rough technique, he is not slower than Ignaz. He can make pancakes from separating facial muscles. I'm afraid there are not many people in Europe.

Of course, the dean’s disregard of the bleeding does not mean that the bleeding does not stop completely. The necessary hemostasis is still needed: "Quickly ligate the large blood vessels, and let the rest of the small blood vessels go. It is enough for the patient to self-coagulate. Then we cut the side of the nasal cavity. The mucous membrane of the nasal wall is connected downward to connect the nasal cavity with the skin incision on the side of the nose. Then the skin muscle flap is opened."【4】

Carvey has no experience in maxillofacial surgery, holding a telescope, he couldn't help but squeeze forward.

From where he is now, he can already see some not-so-good things, but the surface of the bone should be smooth, but there is a large hard lump that swells outward: "It feels like a tumor."

Watman heard Carvey's voice, and heard the surprised voices of other audience members: "Dr. Carvey's judgment is good. I have already discovered it when I was doing bone surface separation. The infection only exists in the gums and gums, and the scope is not counted. Big. Our real enemy is the maxilla, oh no, it may have involved the cheekbone, it is a bone tumor."

"The scope of surgery has to be further expanded." Carvey said.

"Yes, the entire maxillary and zygomatic bones have to be resected. As for whether to do an extended resection, it depends on the situation after the resection."

The scope of extended resection will be larger, upward is the eyeball, and inward is the pterygium, ethmoid sinus, and sphenoid sinus. At that time, the scope of the operation will be large, and whether it can recover after the operation remains to be seen.But Watman didn't seem to be too worried, and he was still moving forward.

"Let's solve the upper jaw first, and choose a small circular saw to saw the middle gap of the jaw."【5】

A nurse handed Watman the saw while she stood by with forceps and gauze.

The bones have a rich blood supply. When the hard and soft palate is cut open, the bleeding will be more violent. It is necessary to repeatedly stuff gauze into the patient's mouth to stop the bleeding.But because there are no large blood vessels, the bleeding can often be stopped by itself after a period of time.

"The area invaded by the tumor is very large, and local extended resection is required."

Watman used his fingers to judge the growth area of ​​the osteoma, and the instruments were frequently used. After using the circular saw, he switched to the chisel and hammer: "We use the chisel to cut off the junction of the frontal process with the nasal bone and lacrimal bone. We still need to be careful here. , the strength of the hammer must be well controlled, not too excited, otherwise it will damage other tissues.”【6】

duang, duang, duang
That's what he said, but judging from the movements of his hands, it wasn't that careful at all: "Get down, come down, come down, this part is broken! Let's switch sides and find the tumor boundary at the lower end of the orbital rim, It should be here” [7]

The two assistants continued to separate the skin and flesh, Watman made a simple positioning, and put the bone chisel on the said position.

duang, duang, duang
There was another heart-pounding crisp sound of thumping, only to hear him say "Okay!", all the bony joints on the front have been cut, and the rest is to chisel out the side between the maxillary tubercle and the sphenoid pterygoid. connection between. 【8】

After the muscle was cut, there were several bone chisel knocks, and the patient's left maxilla was completely cut off.

"Give me the pliers." Watman clamped the patient's teeth with a large pair of pliers, and slowly took out the bone fragment. "You can stop bleeding from the wound. I need to discuss bone reconstruction with Dr. Charles."

"Do you want stitches?" asked the assistants.

Watman looked at the wound and bone section: "It is obviously too late to do it directly. You can polish the section and suture it directly. If you really want to do it, you have to wait for him to recover after the operation, and then do the second-stage operation."

"understood."

Although it was thought that the scope of resection would be expanded before the operation, the total resection still slightly exceeded Watman's expectations.Originally, it was more likely that a subtotal resection would be done. Charles could make an artificial tray that fit the patient’s mouth only by making an inverted membrane during the operation.

Now that the bone is completely cut and the supporting point disappears, it seems that it is not enough to only make a dental tray.

"Among my patients, there are also patients with unilateral maxillary resection." Charles used a knife to remove the skin and flesh outside the bone, while talking about his experience in broken French, "At that time, I only chose to make a palate similar to the soft palate. The shield, put into his mouth, uses the prepared material.

This will not only keep the mouth clean, but also easy to clean.It's just that after taking it off, it will attract a lot of attention, so you need to avoid the crowd as much as possible. "

"Palate guard?"

"A very thin layer of solid material that fits over one half of the patient's soft palate."

"What material?"

Under his guidance, everyone became interested in this material.Standing in the operation preparation area, Charles took out a can of strange stuff from the box beside him:
"I chose gutta-percha from India, a natural rubber from the Asian tropical rainforest named gutta-percha. But this is just the most basic material, and I have added a lot of other ingredients to make it A material with moderate hardness and softness. I named it after my surname and called it 'Stent'."【9】

"Is it really guaranteed to be solid?"

"Guys, please believe in this perfect combination of Asian plants and European chemistry. This rubber can do anything."

Watman knew that half of his purpose in coming here was to advertise, and inviting him here was also tacitly acquiescing to this request.It's just that the operation has changed now, and the omnipotent rubber will also encounter things that cannot be done: "Dear Dr. Charles, it seems that using this rubber is not enough."

Charles was not discouraged: "You can try the palate guard I mentioned first, it is very useful."

"What about the teeth?"

Charles dug out his own dental pliers from the box again: "Pull them out one by one, throw away the bad ones, and insert the good ones when making the palate guard. After they solidify, they will be perfectly fixed. "

Watman has to admit that this new material is very reliable. After all, he was called here to make a good dental tray: "The palate guard is really good, but now the upper jaw has been cut off, and this rubber plate is missing. point."

Charles looked at the bone in his hand, lost in thought.

"Unless you can get it to attach to the wing."

"This won't work, it's rubber, even if it is fixed, it will tear off due to occlusion." Charles cleared his throat, still not forgetting to advertise his material, "This thing is not cheap, if you don't write a letter Invite me to come to Vienna with this material, I am afraid he will have to eat with his right tooth."

"Now it seems that only relying on the palate guard can only eat with the right teeth." Watman shook his head lightly, as if he had made up his mind, "I don't only need to make a dental tray now, I'm afraid I have to make another piece of the upper jaw. to support the tray."

"Make another upper jaw???" Charles didn't understand what he meant, "Do you want to put this bone back?"

"How is this possible? It's a bone tumor. It's justified to put it back after it's been cut out." Watman said, "You can use new materials from Asia, and of course I can also use Asian materials."

"what material?"

"ivory."

Charles watched Watman find a large piece of ivory from the equipment box with very surprised eyes:

"Since I listened to Dr. Kawi's advice last time, I asked a friend to buy a wonderful piece of ivory imported from India. Just use a saw and file to make a maxillary model according to this bone, and insert your tray underneath, You can put it completely in the patient's mouth and reproduce his maxilla."

"Just to make the upper jaw for a sailor? It's ivory, and I came to Vienna, and I used the best dental tray material in Europe." Charles sighed at Watman's family fortune, "You are too willing to spend money. .”

"As far as I know, no one has done this before?" Watman smiled, not taking money seriously at all. "As long as I make it and publish it, it will be the world's 'first'!"

"Worthy of being the dean of the Vienna Academy of Surgery." Charles also agreed with this approach, but the problem remained the original one. "After the bone is made and the material of the dental tray is fitted, what should I do with the connection parts on both sides?"

"Connection part."

"If it's rubber, you can still do thermal bonding on both sides, maybe not strong, but at least the surface looks good."

"Now it's bones."

"Are you asking me to put rubber between bones?"

Watman smiled wryly: "From your expression, it doesn't seem realistic."

"It's not impossible to try, but once it falls off, it's better to make a palate guard."

It's an easy multiple-choice question, if making an ivory maxillary is the same risk as using just plain rubber, why not go for a relatively cheap rubber palate guard.

"It would be nice if the muscle and soft tissue could grow back and attach to the bone."

The innovation of surgery needs to face one problem after another. Once the thinking storm of the brain stops, it will make it difficult for doctors to get out of the whirlpool.In fact, it's not that they are not strong enough, but that they need guidance from some people or things.

Just when Charles and Watman were a little helpless, and the audience was actively discussing the reconstruction materials selected for the second-stage operation, a voice suddenly sounded on the stage, attracting everyone's attention: "Since the muscles cannot be attached, we will Attach them."

"Kavi?" Watman didn't know whether to be excited or to sigh. In short, this guy must have a new idea, so he asked quickly, "What do you mean by that?"

"The ivory itself is strong enough that it is entirely optional to use metal plates and small rivets for the external fixation."

(End of this chapter)