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BRITCOM 4
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00:00This program examines medical conditions and the procedures involved with treating them.
00:04Due to their graphic nature, viewer discretion is advised.
00:15I've been called a human dog toy, a Frankenstein.
00:21When I look in the mirror, I'm like, this isn't me.
00:23Every single interaction is a reminder that I'm different.
00:32What we're looking at here is really complicated.
00:35I agree.
00:37We're a group of doctors in Los Angeles, and we take on some of the most difficult cases in the world.
00:42Her nose and her jaw was torn out.
00:45Gosh.
00:46I was hit by a underage drunk driver.
00:48When she decided to drive off, a jaw shot in the car.
00:52There's a solid chance he doesn't have an entire jawbone.
00:55Okay, incision.
00:56Incision.
00:57Incision.
00:58From the moment you make the incision, looks like this is a bleeder, everything is difficult.
01:07My name is Dr. Andre Panossian, and I'm a board-certified plastic surgeon.
01:10This is obviously a critical step.
01:12This is, this has to work.
01:14My name is Dr. Jason Rustayan.
01:16I'm a board-certified plastic surgeon.
01:18It kind of looks like a bomb went off in here.
01:20My name is Dr. Millicent Rovello.
01:22I am a board-certified plastic and reconstructive surgeon.
01:26We treat people that are missing major portions of the face, missing jaws, missing ears.
01:31The list goes on.
01:33We can help people to open and close their eyes.
01:36We can give them a nose, or maybe they never had one before.
01:39Let's see if the results here...
01:42Yes!
01:43You know?
01:44You had to go through a lot, but we definitely have some options.
01:48I love what I do because our work can change a person's life.
01:53Yes!
01:54The idea is basically to give you that smile back.
02:00I like you so much.
02:02Yeah, we can give somebody their smile back.
02:05You can't underestimate how important that really is.
02:08My name is Dr. Jason Rustayan.
02:23I'm a plastic surgeon.
02:24I specialize in aesthetic surgery and also reconstructive surgery.
02:28In my career, I've performed thousands of surgeries.
02:31Everything from really complex rhinoplasty to rebuilding entire faces.
02:34I went into plastic surgery because the work we do is life-saving and life-altering.
02:41I like the high pressure, the challenge.
02:45It's what puts me at my best.
02:47Hey!
02:47Hey, how are you doing?
02:48I'm good, how are you?
02:49Excellent.
02:50My name is Dr. Millicent Rovello.
02:52I am a plastic and reconstructive surgeon.
02:54We all know what the stereotype of plastic surgery is, right?
02:57It's big boobs, it's big butts, it's facelifts, it's Beverly Hills.
03:01But there's another side of plastic surgery that many people have no idea exists.
03:07Surgeries to address traumas, rebuilding a nose, making a jaw that wasn't there before.
03:13I have the guy that got ran over by a drunk driver and was stuck under a muffler and had
03:19fourth-degree burns to the whole side of his face.
03:22I mean, that was a major reconstruction, no doubt about it.
03:25My name is Dr. Andre Panosian, and I'm a plastic surgeon.
03:30I specialize in peripheral nerve reconstruction.
03:32And for people with facial paralysis, I specialize in facial reanimation.
03:37We will hit problems during surgery where there's no manual to it.
03:42There's no phone-a-friend.
03:44It's all on you, using every trick in the book to make things work.
03:48We are a team of surgeons in Los Angeles, California.
03:52We take the most complex and challenging cases nationwide.
03:57The idea of being able to change that person's life forever, it's awe-inspiring.
04:02Okay, so I have a patient coming in.
04:04His name is Ron Sigler, very nice gentleman from Iowa.
04:08And he's got a big tumor on his face.
04:11I mean, this is massive.
04:12He has one that occurs on sort of half his face.
04:18And you see the pictures, and I'll show them to you.
04:20But you're going to be struck with the size of the tumor.
04:24And I'll sort of bring that up.
04:25And there is Ron Sigler.
04:28So as you can see, the tumor is massive.
04:33That's impressive.
04:35It's been going on for over four years now.
04:38When it first showed up, it was simply a bump on the nose.
04:41He was concerned about it, went to the doctor's office,
04:44which did reveal this diagnosis of a cancerous tumor.
04:48So is he having any pain associated with this?
04:51It looks like it would be painful.
04:52Yeah.
04:53It's sort of a generalized pain or an ache that these things can cause.
04:57You know, it's not our everyday to see something this large.
05:00You know, obviously it doesn't look good.
05:01But, you know, from a life-saving standpoint,
05:04clearly you can benefit from an excision.
05:07For sure.
05:07And this is not going to be a small one.
05:10Absolutely, yeah.
05:11In looking at Ron's case,
05:13I'm struck by the size and extent of his tumor.
05:17This is definitely super dangerous.
05:19It can lead to imminent death.
05:21We have to always sort of be honest with our patients in that regard
05:24and figure out, okay, does he get it?
05:26Does he know what the risks are, what the stakes are here?
05:29And they're high.
05:30When I go out in public, people stare all the time.
05:42I mean, you're seeing something that's kind of shocking.
05:46It has been a stress, and I am embarrassed.
05:50One woman, she looked at me and she was scared.
05:52I was like, wow, I guess I do look like a monster.
05:56Every day when you wake up with this on your face,
06:05I feel my left side.
06:07I'm like, it's still there.
06:09Oh.
06:10When I look in the mirror, I'm like, this isn't me.
06:13This growth is not me.
06:14I don't want it.
06:15I'm terrified because, you know, is this going to keep on growing?
06:22Is it going to kill me?
06:26It's about the size, I would say, an orange.
06:29When I grab it, it's just a little bit hard,
06:33like you would squeeze a piece of fruit.
06:37It's got some firmness.
06:39The weight is a problem.
06:41It's hard to smile, hard to eat,
06:43and it makes it hard to speak,
06:45hard to give another person a kiss even.
06:50You know, you've got to kind of move your head,
06:52like, the right way.
06:54The cheek kind of looks like it's, you know,
06:56inflated like a balloon,
06:57and I think it's ready to be popped.
07:02Hey, how's it going?
07:04Good.
07:04Good.
07:05Good.
07:07When it first started,
07:09I went to start seeing doctors,
07:10and they just wanted to do a massive surgery
07:15and leave a big hole in my face.
07:17I was terrified because it wasn't a very good outcome.
07:21I didn't go through with what they proposed.
07:26It was hard news for me to take,
07:29and so conditions weren't really that great at home.
07:33It was crushing.
07:36I felt like I wasn't a man.
07:37I wasn't a father.
07:38I wasn't myself.
07:41Everything's coming together right now.
07:43I want to be free of it.
07:46I've been worried about you for a long time,
07:48about it,
07:49because it's like anything that was ever moving forward is on it.
07:52You know, doctors would fall through,
07:55and I know my mom and my brother,
07:58they're worried about it,
08:00and it's just going to be a huge relief
08:02for the whole family when it's gone.
08:03It has to come off, period.
08:07There's no two ways about it.
08:09I hate watching it,
08:11and it's kind of hard to be next to you.
08:14You know?
08:17I'd be very glad to see it coming.
08:19Levi, my son,
08:20he wants the best for his dad,
08:22which is really has taken me back, you know?
08:28You know, the plan is to leave for Los Angeles,
08:34and I'd like you to come, of course.
08:36Yeah.
08:37And if there's any...
08:39I'm going to fly to Los Angeles to meet Dr. Pinozian.
08:43This has got to work, you know?
08:45I don't see another option out there,
08:47and so my life does depend on having everything work out.
08:50This is definitely not a common tumor.
09:04It's incredibly rare to have this particular tumor
09:07and diagnosis at the size it is.
09:09The diagnosis given to him was by way of a biopsy,
09:12so they took a little piece of the one on the nose,
09:15and they sent it to a pathologist.
09:16They look at it under a microscope,
09:17and they give you a diagnosis.
09:19His diagnosis is Dermatofibrosarcoma protuberans.
09:24It's a big, long mouthful of a word,
09:26but it basically is a type of cancer.
09:29What this type of cancer does
09:31is that it sort of occupies a space somewhere on the body,
09:34and it sort of expands from that space
09:36into neighboring tissues.
09:38So when that happens,
09:39it can erode into things like muscles or bones
09:42or cartilage or teeth sometimes.
09:45So this is a serious tumor.
09:46This needs to be removed.
09:51Hello.
09:52Hey.
09:53How are you?
09:54Great.
09:54How are you?
09:55Great.
09:55Dr. Panosian, good to meet you.
09:57Good to meet you.
09:58Levi.
09:58Levi, good to meet you.
10:00All right.
10:01Meeting Ron,
10:02I want to really kind of drill down
10:03into why he hasn't had this removed before.
10:07All right.
10:08So, Ron, tell me about the tumor.
10:12Tell me about it.
10:13When was the first time you noticed something was not quite right?
10:17That was in 2014.
10:192014.
10:20And tell me, what was it?
10:21It was obviously not this big lump.
10:23It was something different.
10:24No, it was just the nose.
10:26And so I went to the doctor,
10:27and he looked it over,
10:29and we just took a chunk off
10:30and took it in for a test.
10:32And what did they say it was?
10:34They just said it was a benign tumor,
10:37and that was basically it.
10:38So what was the next time that you went to the doctor?
10:41The next time was in 2016.
10:43Uh-huh.
10:44I really wanted to get it removed.
10:46He said, well, our team feels it's rare cancer,
10:50and, you know, that word cancer.
10:52You got cancer.
10:53Right.
10:54Oh, it was very difficult taking that news,
10:56and they gave me all this info
10:57about five years to live, you know?
10:59It just hit me, like, even I was scared.
11:03The next step was, how do I remove it?
11:05What are we going to do?
11:06And so he said, well,
11:08you have to see other specialists now.
11:11It was transferred to another doctor
11:14who was a dermatologist,
11:15and she tried to do a biopsy.
11:20Wow.
11:21And then when was the first time
11:22that you noticed this tumor just start to expand?
11:27On the cheek, it was 2018.
11:282018, when it started growing.
11:30Okay.
11:31And at that point,
11:32did you visit anybody to say,
11:34hey, this is brand new.
11:35This wasn't there before.
11:37Well, they said that after all their tests
11:40and so forth looking into the case,
11:42it would be a radical surgery.
11:44We have never done this before.
11:45You could lose an eye.
11:47You could lose some teeth,
11:50and we may not be able to reconstruct your nose.
11:54It looked like Frankenstein to me,
11:56the process,
11:58and I don't know if I would have a better life
12:00after the surgery.
12:02So I just left it.
12:04I don't blame you.
12:05I think that's a scary proposition.
12:07It is intense to see such a tumor
12:11of this magnitude on a person's face.
12:14This tumor needs to come out right now
12:17because these types of tumors
12:18can be a death sentence.
12:22I have a patient,
12:23her lower lip is very enlarged.
12:26It's a pretty severe case.
12:28I don't know if I can remove a whole lot.
12:30If you start cutting away muscle,
12:32it could paralyze her mouth.
12:35Incision.
12:36It's not great that the nerves
12:38and the muscles are sort of entangled
12:40with this tumor with the flick of a blade.
12:42You can paralyze his face,
12:44and that's it.
12:45It's the end of it.
12:46It's an unusual diagnosis.
13:01You have a large mass on the cheek
13:04that once you remove it,
13:06you've got to be able to reconstruct it.
13:07But I totally get where you're coming from with this.
13:10So let's take a look a little bit more closely.
13:13I just want to kind of come in a little bit closer
13:15and just take a good look at everything here.
13:17And let's just get a sense for the weight of it.
13:19And it's pretty heavy.
13:20I mean, this is not a light object whatsoever.
13:24It's almost like I can pick it up
13:26off your face completely.
13:27Yeah.
13:27In fact, let's just see if you give me a smile,
13:31and you can see it kind of rise up.
13:33So it's, to some degree,
13:34it is sort of sitting on the muscles of facial expression,
13:37which is, in this case, is the smiling muscle.
13:39Here, let me have you do a pucker.
13:41Good.
13:42And relax.
13:43Can you try to sneer?
13:45Can you blow up your cheeks and relax?
13:49Is that really heavy and a lot of force?
13:51It is heavy, yeah.
13:52Yeah.
13:52And in fact, let me have you open your mouth.
13:55And it's really amazing because it's completely clear.
13:58It doesn't even intrude into the mucus lining.
14:00It's probably all the way through the cheek,
14:02to some degree.
14:03This is a pretty impressive mess, to be honest.
14:07I mean, this is something that most people
14:09would rush to getting removed.
14:11So we have your MRI here.
14:13I want to pull it up.
14:14And here we go.
14:15This is sort of looking at you from the feet up.
14:19And as you can see, here's this big mass here.
14:22But you can see that there's a pretty good rind to it, almost.
14:26There's a little bit of a space,
14:27a little tiny shadow between the skin and the tumor itself.
14:32It's got a pretty dense structure to it overall.
14:35It's almost like a softball, basically.
14:37It's got this density to it.
14:39Let's talk about what we want to do.
14:42In a nutshell, we want to just remove the mass, OK?
14:45So what we're going to do is basically make an incision on top.
14:48Remove the big bulk that we see there.
14:50And then continue over towards the nose
14:52and remove that piece as well.
14:54We're going to tuck all the scars in very nicely,
14:56do a nice job of it.
14:57And that's basically it, OK?
15:00Let's get it removed.
15:01Let's get it removed.
15:02Levi, you're on board?
15:03Yeah.
15:04Good stuff.
15:06The stakes are kind of high for this type of tumor removal.
15:08This is going to be a lot of work,
15:09trying to remove this without creating extra damage.
15:12We have our work cut out for us.
15:14OK.
15:14All right.
15:14Well, thank you.
15:15Let's do it.
15:16Good to meet you guys.
15:17OK.
15:19Take care, guys.
15:27I have a patient coming in.
15:28Her name is Danielle, and she was born with a port wine stain.
15:33A port wine stain is a vascular birthmark.
15:37It's mainly composed of blood vessels.
15:39Danielle's looks very severe.
15:41Her birthmark is taking over almost half of one side of her face.
15:46In addition, her lower lip is very enlarged.
15:51It's a pretty severe case.
15:52When these birthmarks affect the lip, the lip can actually keep growing over time.
15:59Because abnormal blood vessels continue to grow.
16:02Hopefully, I can help her.
16:06When I was younger, I'd have to deal with people looking at me, asking questions.
16:10And it was like, I feel like I have to hide this just to, like, live my life.
16:18People just ask, did you get punched?
16:22Were you in a fight?
16:24Did someone hit you?
16:26Are you allergic to something?
16:28Those are the kind of questions that I get.
16:33They don't really care.
16:34They're trying to be rude.
16:37I like this.
16:38This is more you.
16:40Put a little plant in there.
16:41I have a port wine stain birthmark.
16:53It's congenital.
16:54Everyone has blood vessels and capillaries in their skin.
16:56I just have way more than normal, and they're close to the surface of my skin, so that's
17:00what gives it that look.
17:02And it goes from this side of my face all the way over, down my ear, behind my ear, down
17:08my neck, and down my throat.
17:09I don't feel anything.
17:11It feels like normal skin, but it has affected my lip.
17:14There's just so much blood flow that my lower lip has just slowly grown over time.
17:17Because my lip is so big, I often end up biting my lip, like, while I'm eating, or sometimes
17:23I have a hard time, like, I'll stumble over my words.
17:26My biggest worry if I didn't have surgery on my lower lip is that my lip would just keep
17:30growing and growing over the years, and it wouldn't stop.
17:33Some days I feel like I want to just go out and not have to worry about people looking at
17:38me, or asking questions, or whatever.
17:41That makes sense.
17:42Yeah.
17:43In college, my first year, social media was, like, just getting going, and very popular
17:47to post pictures of yourself online, and I posted a picture of myself.
17:51I'd only had one lip surgery at that point, so my lower lip was still very big, and some
17:56random person commented, DSLs, just as a comment, and I was like, I have no idea what that means.
18:03So I had to look it up, and it stands for lips.
18:07That made me feel, like, terrible, because someone really said that to me on the internet, and
18:15I just, like, deleted that comment, and I wasn't on social media for a while.
18:20I'm excited to go to L.A.
18:30I bet you are.
18:31Yeah.
18:32Like.
18:33I'm so happy for you.
18:34I know.
18:34It's really, I don't know.
18:35I've never, I've never been.
18:37My plan is to fly to L.A. to meet with Dr. Rubello.
18:40I would like to have a laser surgery on my birthmark and on my lip.
18:44This is my last attempt to have one lip surgery that will be, like, the last, the last one.
18:52Are you nervous at all?
18:54I am nervous that she'll look and just kind of be like, hmm, can't really do that much,
19:00which would really be a bummer.
19:02If Dr. Rubello couldn't do surgery on my lower lip, I don't know what I would do.
19:14This program examines medical conditions and the procedures involved with treating them.
19:22Due to their graphic nature, viewer discretion is advised.
19:24Okay, today's Ron's surgery day.
19:47We are taking off his big facial tumor.
19:50So that's going to be incredibly satisfying for everyone in the room, I'm sure.
19:54But especially for Ron.
19:56Excited? Are you excited?
19:57Yeah.
19:58Yeah.
19:58Yeah, I'm a little nervous, but I know it's all going to work out.
20:03Yeah.
20:05This has been a long journey for me.
20:07I have been through a lot having cancer, having no really good solution for having it removed and out of my life.
20:17The excitement is overwhelming to take this step to get the tumor off my face.
20:24Good morning.
20:24How are you doing?
20:26Great.
20:26Today's the day, huh?
20:27Yeah.
20:27Okay.
20:28So how do you feel?
20:29I feel great.
20:30Excited.
20:31Yeah, absolutely.
20:32Now, one of the things I'd like to do is mark out sort of the extent of what we see while you're awake.
20:37Okay.
20:37So you want my glasses on?
20:39If you don't mind, that'll be great.
20:42Excellent.
20:44As we sort of shift things over.
20:47When we mark patients out preoperatively, I'm always trying to figure out how is gravity impacting what I'm seeing?
20:53So this is where the mass sort of almost like hangs from this spot.
20:59I want to know where the borders are exactly before any incision is made.
21:03I want to know planning out where I'm going to put my incision.
21:06They serve as a reference point that we're not going to lose our anatomic bearings.
21:11I think that's looking good from my standpoint as far as incisions go.
21:15Anything else?
21:16Levi, you good?
21:17Yeah.
21:17What are you going to do today?
21:19Wait for the news?
21:22All right, guys.
21:23I'm going to go get ready, okay?
21:25Okay.
21:26And I'll see you inside.
21:27Sounds good.
21:27All right.
21:28I'll take it easy.
21:33Woo, it's cold.
21:39Okay.
21:45So it's sort of confirming what we're seeing on the MRI right now.
22:06This big mass right here has this shell around it.
22:10Sort of it's this capsule that's containing it.
22:14So it's almost like you can stick a finger in there.
22:16In fact, let's just see if we can push through all the way.
22:20And we can.
22:22Hopefully it just pops out.
22:24So as I'm cutting into it, I want to get that skin lifted up over the tumor
22:28so that we can get to the nitty-gritty of the muscles that it may be attached to.
22:37Let's get real left.
22:38We're at the point where we got this tumor exposed, and, you know, it's different from
22:51what we thought.
22:52The hope was that this tumor was sitting on top of the muscles.
22:56As we got in there, it's very much insinuated into the muscle layer.
23:00So a lot of the muscle fibers are going into it.
23:02Now we've got to figure out how we're going to separate those muscle fibers, keep them intact,
23:06keep them functioning while we get this deeper tumor removed.
23:10This is actually going to make the surgery way more complicated.
23:30I just flew out from New York to meet with Dr. Ravello in L.A.,
23:34and I'm just worried that my lower lip could just continue to grow and grow and grow.
23:39So I'm really hoping that this works out with Dr. Ravello.
23:42Hello.
23:43Hi.
23:43Hi.
23:44Danielle.
23:45Nice to meet you in person.
23:46Me too.
23:47How's everything going?
23:48Good.
23:48Hi, Joe Capelli, Danielle's dad.
23:50Joe, nice to meet you.
23:51Where are you guys coming from?
23:53New York.
23:53New York.
23:54Well, welcome.
23:54I'm so glad you guys made it.
23:56Yeah.
23:56If you could just sort of go over your history and where you are now.
23:59So from the beginning, born with a port wine stain, so we started having laser surgery
24:05starting at like two years old to lighten it.
24:10So I've had like 15 to 20 laser surgeries on my port wine stain.
24:15There is one mainstay of treatment for port wine stains, and that's laser therapy.
24:21Laser therapy actually zaps the blood vessels and sort of causes them to die or close off.
24:26And that in turn allows the appearance of the birthmark to decrease.
24:31So when you have the laser treatment, do you notice a difference afterwards?
24:37Yes.
24:37Like each time you do get better?
24:39I've always seen improvement, especially the more intense the laser is.
24:43Yeah, of course.
24:44Of course.
24:44Of course.
24:45And then let's talk a little bit about the lip surgeries that you've had.
24:48My lip started growing over time, so I've had two surgeries to debulk my lower lip and
24:54make it a little smaller.
24:55And each time you saw a difference, right?
24:57Yeah, my lip was definitely smaller.
24:59I have noticed that since my last surgery, which was in 2016, that there's some volume
25:05slowly coming back.
25:07The challenge of doing lip surgery is that you are working with an extremely functional
25:12area.
25:13It's not just pieces of skin that we can remove and close together.
25:17There's very important muscles of the lip.
25:19They allow us to close our mouth completely.
25:22They allow us to form facial expressions.
25:25They allow us to smile.
25:27And if you cut away muscle, now you've actually lost the function of the lip.
25:32All right.
25:32Let's do a quick exam here.
25:34Okay.
25:35Let's see.
25:36I can definitely see where the laser helped, because I can see the areas that are still
25:41affected, and then areas that are almost non-pigmented.
25:45My neck seems to respond really well.
25:46Yeah, that is a really good response.
25:49Let's see the lip here.
25:50Go ahead and open it a little bit.
25:51So you have an incision here on the inside that I can see.
25:57And actually, where that incision is, there's definitely a decent amount of scar tissue.
26:02This side of the lip is pretty soft, but over here, it gets a little bit harder.
26:06And I see some of that down here as well from your previous surgery.
26:10We have laser treatment options for her port wine stain.
26:13But the lip is going to be tricky, because she's already had a couple of surgeries.
26:17And being able to differentiate what's muscle, what's related to the port wine stain, and
26:22what's just scar tissue is going to be a challenge.
26:25If you go in there and you start cutting away muscle, it could paralyze her mouth.
26:35That side's definitely a little bit firmer on that side.
26:38I'm sure you can feel that.
26:40Danielle's lower lip is much larger than her upper lip.
26:44This could potentially keep growing and could become more of a problem to address that.
26:50I'll remove what's obviously scar tissue and as much diseased tissue as I can, while preserving
26:55normal anatomy.
26:57I do think that we have some options.
27:00I think we should start with the laser you've already had that you've responded really well
27:04to.
27:05I'd like to go back in and get those areas that still need to be addressed on the face
27:08and neck.
27:10And then I would like to reduce the size of the lower lip.
27:12So go in through your same incision on the bottom and take out some of that scar tissue
27:16to make it smaller.
27:18And what we don't want to do is be too aggressive and take out normal functioning muscle that
27:23you need in the lip.
27:24But I do think we can make it at least a little bit smaller.
27:27Great.
27:28So part of the reason the lower lip looks like it's so much larger is because the upper lip
27:31is smaller.
27:32Yes.
27:32Yeah.
27:33So I'd like to do a little bit of filler and Botox in the upper lip to make it a little
27:37bit larger to give it a little bit more symmetry.
27:40I never really thought about making the upper lip bigger to match a little bit like proportionally.
27:46Right.
27:46I was always trying to make the lower lip smaller, smaller, smaller.
27:49So that's a really cool idea.
27:51Okay.
27:51So you want to do this?
27:52I'm so excited.
27:53Okay.
27:53She's in.
27:53We really only have laser treatment options for her port wine stain.
27:58My concern is that she may have plateaued in her treatment response, but I think it's
28:03worth a shot.
28:04For the lip, I don't know if I can go in and remove a whole lot more.
28:09So that is the big unknown.
28:10She is a very complex case.
28:12This is not going to be an easy surgery.
28:24So now we're on the intense part of this surgery.
28:26We're on the bottom half of the tumor.
28:28Yeah, this little guy's a monster.
28:31It's not great that the nerves and the muscles are sort of entangled with this tumor.
28:35And I got to do my best to separate the tumor away from these structures without damaging
28:40them.
28:46Yeah, pretty much every cut counts.
28:47I mean, you can hit a nerve, a blood vessel.
28:50At this level, anything goes.
28:52These nerves don't always look big.
28:55They're tiny and inconsequential in their appearance sometimes.
28:58You could go right through it with the flick of a blade.
29:00You could paralyze his face and that's it.
29:03It's the end of it.
29:04So I'm being super cautious, super meticulous as I'm approaching these deeper structures.
29:26Now we're almost ready to take the big giant piece off his cheek.
29:29We're on the bottom most surface.
29:31There's only a little tiny connection left.
29:34It's such a relief to have this thing finally off his face.
29:55There she is.
29:56That's what we pulled out.
29:58That's what he was living with for four years.
30:00Pretty impressive.
30:01It basically feels kind of like a mushy softball.
30:05So it's almost like you could squeeze it, but then not all the way.
30:08But it's pretty fleshy, that's for sure.
30:12I mean, this thing was like an atom bomb that went off in his cheeks.
30:15I'll set this back here for now.
30:19It just rolls around.
30:20The next step is going to be to address the lip and the nose.
30:24We're taking this out in a piecemeal fashion.
30:27It doesn't want to come out in one piece.
30:29It just breaks off.
30:30So all these little bits came out from the upper lip, believe it or not.
30:33The nose is a little bit different.
30:35Took the entirety of that mass from inside the nostril.
30:41Okay, that's that.
30:44So I'm feeling pretty good.
30:45We got what we wanted out, which was that big mass on the cheek.
30:49I'm sending this off to pathology.
30:52I won't know definitively what this thing is until they give me a final result.
30:56Can it be something worse from the diagnosis that he's already been given?
31:00It can be.
31:01Is this one of these cancers that can spread, for example, go to the lungs, go to the brain?
31:06We don't know that yet.
31:07So are you ready for this?
31:23Yeah.
31:23Yeah?
31:24Yeah.
31:24I'm a little nervous.
31:25It'll be good.
31:26It'll be fine.
31:26Yeah.
31:27Hello.
31:28Hi, doctor.
31:29How are you?
31:30I'm okay.
31:30How are you guys?
31:31I'm good.
31:31I'm really good.
31:32Yeah?
31:32Yeah.
31:33You ready?
31:33I am.
31:34Good.
31:34We're going to do the laser procedure in here.
31:36Okay.
31:36Just trying to blend that pigmentation.
31:39Once you've finished with the laser, we're going to go back to the operating room and
31:41work on the lip.
31:42Sound good?
31:43Yes.
31:43You ready to get started?
31:44Yes.
31:44Like right now?
31:45Yes.
31:45Okay.
31:46Good.
31:46Me too.
31:47All right.
31:47Good luck, honey.
31:47I'll see you later.
31:48Love you.
31:48Love you.
31:50The first thing we're going to do is get you numbed up.
31:52Okay.
31:52Put a numbing cream on the skin.
31:54Whatever you do, don't lick your lips.
31:56No.
31:56Oh, my God.
31:57Your tongue will go numb for sure.
31:59The first part of Danielle's treatment is going to be the laser to reduce her port wine stain.
32:04The laser is designed to target specifically pigments on the red spectrum.
32:08The idea is that this laser zaps that red pigment and sort of blows it up.
32:12You can see where the skin that had been treated got this dark bruised color, and that's actually
32:27a really good thing.
32:28That's what you want to see, because it means that those areas picked up the laser and those
32:32blood vessels were blasted.
32:33We lasered the rest of her face and neck, and now we've moved on to doing her lip surgery.
32:39I don't know what I'm going to find when I go into the slip.
32:52She's already had a couple of debulking surgeries, but my plan is to go in and remove a whole lot
32:58more.
32:59My concern is that she's going to have a lot of scar tissue mixed in with normal tissue,
33:04and I'm not going to be able to tell what the difference is between the two.
33:08We have to be pretty precise about removing scar tissue without compromising functioning
33:13muscle.
33:14So my plan is just to go in here, excise this old scar, scoop out as much abnormal tissue
33:21and scar that I can, advance this in, and close it a little bit more to reduce some of
33:25that mucosal show.
33:27Okay.
33:29Incision.
33:39Normal lip, there's a distinct separation between each of the layers of the lip, and
33:44usually it's a very smooth dissection.
33:46You can go sort of layer by layer.
33:48And in her, all of the layers are sort of fused together.
33:51This is definitely not ideal.
33:53It's scary when you can't find normal anatomy, because you don't know what you can take,
33:59what you can't.
34:00Maybe there's some normal muscle in there.
34:02I can't see any.
34:03All I'm looking at is this really firm, unhealthy, unnatural-looking tissue.
34:07This was literally the worst outcome I could have hoped for.
34:19This is definitely not ideal.
34:22So we've been chiseling away at some of this hard scar tissue, and we haven't been able
34:27to find any muscle that actually jumps when we touch it.
34:30Muscles should jump and contract, and we just haven't seen that so far.
34:33It kind of looks like a bomb went off in here.
34:36Planes are fused together as a result of previous surgeries, as well as just your underlying
34:41disease.
34:43It's like when you have a layer cake, and somebody smashed it, and then you're told to
34:46go in and unsmash it and find out where the layers are.
34:49It's impossible.
34:50And then you find that one jelly layer, and you're like, ah, I know where I am.
34:57We have muscle.
34:58We found some muscle.
35:00We found some muscle.
35:01Ah, we've removed some of the scar tissue that was sitting on top of the muscle, and
35:05for the first time, we see the jumping muscle.
35:09See that?
35:11Ah, that's good.
35:12Yeah, that's what we were talking about, looking for.
35:14It's a big win.
35:15Finding the muscle was a huge relief, because now I have a roadmap to this lip.
35:19So identifying the muscle allows us to now know, okay, this is the normal tissue, and
35:24everything that we've come through above it is abnormal, and we can get rid of it.
35:28So we've debulked to the level that I'm happy with, that I feel safe debulking, and now we're
35:34going to start closing.
35:35We get this lip all closed up.
35:36You really can't tell at all that we've done anything, because it's so swollen.
35:40But I know we took out a lot of scar tissue, so I'm confident that it's going to make a
35:44difference.
35:45And now we're going to do a little bit of Botox, and then we're going to put a little
35:48bit of filler throughout the entire upper lip, just to give it a little bit more volume
35:51to match the lower lip.
35:53All right, we're done.
35:56We're all finished.
35:57The hard part is now on Danielle.
35:59The tissue of the lip is paper thin.
36:02It heals fast, but until it heals, it is very fragile.
36:06I'm pretty happy.
36:07I never attempt to faint.
36:09I never leave the room being like, yes, nailed it.
36:12No.
36:13It's usually the dudes that are high-fiving each other and patting themselves on the back
36:16and, oh, so good.
36:18Once we're healed, once everything's done, then I will allow myself to say, good job.
36:24So I am pretty happy, which is actually pretty good for me.
36:43Danielle's coming in today for her follow-up, and I'm really, really excited to see how she's
36:47coming along.
36:48I'm really looking to see how much we were able to decrease the size of the lower lip,
36:53and I want to see how much we were able to take some of the pigment out of that birthmark.
36:58The concern is always that the lip is going to grow more.
37:00So maybe we did the surgery and shrunk it, but in the interim, it's continued to grow.
37:05So that is definitely a concern.
37:06Hello.
37:07Hello.
37:08Hi.
37:09Hey, how are you?
37:10I'm good.
37:11How are you?
37:12I'm doing okay.
37:13You look great.
37:15I'm doing okay.
37:16You look great.
37:18There used to be so much volume that it really seemed lopsided, and now it's just
37:23like really even.
37:25My neck was always kind of blotchy before, so the neck was like amazingly light, and then
37:30the rest of my face did lighten up quite a bit.
37:32It just feels good.
37:33Yeah.
37:34Oh, it looks good.
37:35Yeah.
37:36And I know that it's only going to get better as the swelling continues to come down and
37:39soften up.
37:40Yeah, I'm really excited too.
37:41I just know it's going to get even better and better and better, even though it looks
37:44fantastic right now.
37:45All right.
37:46You're going to have a good one.
37:47You too.
37:48I just thank her so much from the bottom of my heart because I think it's changed my
37:51life in a bunch of different ways.
37:53I feel like myself, I feel good on the inside, and now I feel good on the outside.
37:58I feel more confident, and I feel like the way that I look belongs now, and I feel like
38:05it just is the way it's supposed to be.
38:25Ron's coming in for his follow-up.
38:27What I hope to see today, we want to see the normal anatomy return.
38:31We want to see how things are moving in the face.
38:35The surgery was basically a big biopsy.
38:37We sent that specimen to the lab, and now we have the report.
38:40We're going to go over that with Ron.
38:44Hey.
38:45Hello.
38:46There's the man.
38:47How are you?
38:48I'm doing great.
38:49How are you?
38:50You look awesome.
38:51This is great.
38:53Are you glad you did it?
38:54I am very glad.
38:55Good, good, good.
38:56I'm very happy.
38:57I mean, this is a big win so far, as far as I can tell.
38:59But let me sort of come in a little bit closer and just see how these scars and everything
39:03are looking.
39:04Okay.
39:05And look at that.
39:06It's looking really good.
39:07The scars are healing nice.
39:08You got a good contour to the cheek.
39:10The symmetry is quite good as well, and this is great right now.
39:13So, one of the things that I wanted to talk to you about was the actual diagnosis.
39:20We got the pathology report back, and it is dermatofibrosarcoma protuberance.
39:28What that means is essentially that it is still considered a malignancy or a cancer, if
39:32you will.
39:33I do have concerns about recurrence.
39:37It is still something to kind of keep in the back of your mind.
39:41It is cancer.
39:42Well, it's not the best news, having cancer, but it's going to cause me to be more vigilant,
39:51to look after the small girls that I might get, and to take care of them right away.
39:56I think we have a little bit of a follow-up plan in place.
39:58We still got to be vigilant about this, but I think you got a bright future ahead.
40:02Well, you know, I want to thank you for the work that you do.
40:06It has changed my life.
40:08It is an absolute pleasure.
40:10Okay.
40:11Thank you very much.
40:12Of course.
40:13I'm really grateful for Dr. Frenossian.
40:16He's given me hope, my family hope, and he's got a great gift.
40:21All right.
40:31So, you guys remember our guy, Ron?
40:33Oh, yeah.
40:34Oh, yeah.
40:35Oh, he sent us a video.
40:36Let's just check it out.
40:37Yeah.
40:38Hi, doctors.
40:39It's Ron, and I'm in Iowa.
40:42As you can see, I don't have a tumor on my face anymore, and, you know, it's really changed
40:46my life.
40:47I sell insurance now, which I never would have been able to do before.
40:51Every once in a while, we'll do a spinning wheel for bonuses.
40:55I got on board a couple of times.
41:00I just really thank you guys.
41:01It's just really a pleasure to be able to do the things that I can now.
41:06Wow.
41:07That's incredible.
41:08Awesome.
41:09Pretty cool, huh?
41:10Yeah.
41:11That's awesome.
41:12One thing that I just didn't know at the time of the surgery is, can we preserve his ability
41:15to smile, which we did, as you can see there.
41:18What I'm most impressed with is just sort of the change in his demeanor.
41:22I mean, he just exudes this confidence and happiness.
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