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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.
00:07I can't separate myself from my scars.
00:09I do get stares.
00:11It makes people uncomfortable.
00:14I just so happened to go out one night, living my life, and boom.
00:20It happened.
00:21Monkeypox was definitely a shock.
00:24The nose is being pulled through the scar that goes all the way down to light my shoulder.
00:29I really want to help him with that.
00:31But he has so much scarring and it's so severe.
00:35He is going to be an extremely tough case.
00:38My concerns about treating him are going in and futzing around with a lesion that we're not that familiar with.
00:46The amount that I'm going to have to take out is fairly large.
00:48It's a deep wound.
00:50It's a critical step because this has to work.
00:52There's no going back.
00:54If you don't take the right amount, it's game over at that point.
00:59So I have a patient coming in, real severe burn.
01:06It happened at two years of age, I believe, and now he's in his 20s.
01:10So this is Sergio Reyna.
01:12I really want to help him.
01:13He's the most severe burn patient I've seen, at least.
01:16I mean, the burns can be so devastating.
01:18I mean, you guys both know they are some of the most difficult cases.
01:22And that scar tissue, it doesn't behave like normal skin.
01:25No.
01:26It's thick.
01:26It's not pliable.
01:28It doesn't stretch.
01:29I mean, as you go through his photos, he really has a tail of two faces almost.
01:33You can see one side, amazingly good-looking kid.
01:37And then on the burn side, the scar contractor just prevented him from ever developing the right side of his face.
01:45It's not just aesthetic.
01:50It's functional.
01:50It's functional.
01:51You know?
01:51When approaching plastic surgery of the face, you first have to consider the function.
01:55Are they going to be able to move their face better?
01:58Are they going to be able to breathe better?
02:00Well, Jason, my concern with you doing the nose is what are you going to do about the scar on the center part of his face?
02:07That scar band is going to want to pull it back to the side.
02:11Your reconstruction's not going to hold.
02:13Yeah, I mean, you're absolutely right.
02:15I've got to replace a ton of skin there with blood supply so that it can actually heal.
02:19And any graft or any flap may fail.
02:21These things are tough.
02:23They're hard.
02:23Because everything could go right.
02:25Yeah.
02:25You know, but it may still not give enough movement.
02:28Yeah.
02:29It's going to be a challenge.
02:30This stuff is not a chip shot by any means.
02:32Let's get him out here, take a look in person, and see how we can help him.
02:36Absolutely.
02:36I agree.
02:43When I'm out in public, I do get stares.
02:51I can't separate myself from my scars.
02:54They made me who I am.
02:55The scars on my face pull so tight that my face completely shifted to the right.
03:07It pulls the eye, the nose, and the mouth.
03:10And the way the eye looks, it makes people uncomfortable.
03:14When I look in the mirror, I see a fighter.
03:22I see someone that, even though he's covered in scars, he's still pushing forward.
03:28And I'm just going to continue to fight on.
03:31One of the things I always say is that I'm like a Picasso painting.
03:37I'm worth a million dollars, and I look like art.
03:41When I was two, I was in a house fire.
03:48It was a summer day.
03:50My dad said he was going to cut the grass.
03:53But me and my little brother, we decided we wanted to help him out and cut the grass with him.
03:59We climbed a chair to pull down the gallon of gasoline on our own, and that spilled.
04:04It reached a water heater, and that ignited the fire and sent me and my little brother ablaze.
04:11I took the bigger blunt of it.
04:17He barely experienced some burns below the knees, while for me, it was my entire body.
04:24Hey, Serge.
04:25What are you doing?
04:27Just finishing up packing.
04:28Okay.
04:29Have some warm clothes and some looser clothes for when we're at the beach.
04:32So the plan is that I'm going to fly out to Los Angeles to meet with Dr. Rubenstein.
04:36My sister, Livia, is tagging along to take care of me and also be there for support.
04:40Okay, so are you ready to get all the pictures for social media?
04:43Oh, yeah, definitely.
04:44Hopefully you're good with the camera.
04:46I'll try.
04:47When I was graduating from Texas A&M, I simply just took some photos of myself and also with
04:53my parents, and I put it on social media.
04:56When I first was posting, it was a little nervous, but that post went viral.
05:00Got a lot of likes, and a lot of people liked the authenticity that I showed.
05:06I also like to say that I'm hot, and instead of measuring in a scale of 1 to 10, you need
05:11to measure me in Fahrenheit.
05:13I'm technically hotter than most of you.
05:15You know how, like, I've seen you since you were little.
05:20Like, what number of surgery would this be?
05:23I've probably gone to the hospital for some type of operation, like, 50 to 60 times.
05:28Each one of those times, they might do, like, three to four different surgeries.
05:31So I'm probably in the hundreds.
05:33What are you hoping for?
05:34Like, what is, like, your expected outcome?
05:36I just want to improve my mobility on my head and neck, because when it gets really tight,
05:41you know, it just stretches everything, the mouth, the nose, and the eye, all the way
05:46down to, like, my neck and shoulder area.
05:48You got that scar that, like, connects to your shoulder.
05:51Yeah.
05:51Basically, this scar connects to my shoulder and to my arm a little bit.
05:56So when I'm putting weight on my arms, I also feel it on my face.
05:59I want to be able to move more naturally and not feel the rope that is the scar constantly
06:09tugging on my face.
06:12I know you, like, been through a lot and, like, you kind of manage it, but I don't really
06:18care, like, about how you look.
06:19It's just, like, the quality of life.
06:21Yeah.
06:22Having Sergio as a brother is pretty cool, you know?
06:25Sometimes I wish I had some of his confidence.
06:27He has inspired me to be my best selves.
06:32He also, like, provides emotional support for, like, us, like, whatever we're going through.
06:37He knows how to help.
06:39This is also probably going to help just a little bit with dating.
06:42You know, everybody always wants to go out with someone that's cute.
06:46Because of the way I look, I know I definitely get shot down quite a bit more than other people.
06:51Getting a Sergio on my face might improve that a little bit.
06:54Mm-hmm.
06:55Yeah.
06:55Who knows?
06:56Maybe I end up finding some girl, and I'll bring her to mom, and she'll start saying,
07:02you get married.
07:03I'm like, not yet.
07:03Give me a few more years.
07:05I'm like, I know you want grandkids, but not yet.
07:06Yeah, I mean, mom's kind of harsh.
07:08I'm not going to lie.
07:10I'm already extremely excited, but I'm trying to keep the hopes down a little bit.
07:14I just hope he could help me.
07:16Hi, welcome.
07:27Hi.
07:27In the past, I've already felt that experience of a doctor telling me, no, I just can't help you.
07:33If the doctor says that he cannot help me, I'm definitely going to probably get depressed.
07:41And that's why I'm a little bit nervous right now, hoping that they can, and we'll just have to wait and see.
07:46Hi, Sergio, how are you doing?
07:54Doing pretty good.
07:55It's good to see you.
07:56It's fun to see you.
07:56Hi, how are you doing?
07:57Doing good.
07:57And this is your sister?
07:59Yes, this is my sister.
08:00Perfect.
08:00Nice to meet you.
08:01What's your name?
08:01Livia.
08:02Livia, very nice to meet you.
08:03So you made the trip.
08:04Yes.
08:05It's about time.
08:05You came from Texas?
08:07Yes, it was Dallas, Texas.
08:09Awesome.
08:09Okay, cool.
08:10So, you know, again, thanks for coming all the way out here to meet me and, you know, really want to try to help you.
08:17So tell me what you've gone through so far in terms of reconstructive efforts.
08:20Okay.
08:21So for facial reconstructive efforts, I've had some stuff worked on my lip, my nose, my mouth, and my ear.
08:29But most of that happened when I was still little.
08:31Okay.
08:31What can we do now to improve your quality of life in any way?
08:35Yeah, so right now, one of the main things I'm trying to focus on is releasing as many scars as I can, like, making my mobility improve.
08:44Okay.
08:45So, like, with the nose, it's being pulled through the scar that goes all the way down to, like, my shoulder.
08:51When I turn, it just pulls it really hard.
08:53And it pulls also the mouth and the eye and, I guess, the forehead to appear.
08:57Then I would also like to get some work done on the nose to, like, improve the structure and, like, make it a little bit more even.
09:04Is it okay if I do an exam and take a look inside your nose?
09:08Yeah, go ahead.
09:08Okay, perfect.
09:08Burn cases, you know, when they're severe like they are in Sergio's, it's just so devastating.
09:15All that scar tissue, when he moves, you can see how much it really pulls.
09:19That's going to be extremely challenging.
09:21The depth of the burn, we don't know.
09:24It's hard to tell as far as, you know, whether it went all the way through the nose.
09:29It's really hard to see in there because the opening is so small.
09:32You know, for sure, I know it's shifted all the way over here because of the scar tissue, but go ahead and breathe.
09:38That's your good side, right?
09:40Mm-hmm.
09:40Okay, and then this side, if we get that totally covered, pretty tight, right?
09:45It's a struggle.
09:46You know, this I could really see, it's really tight onto your upper lip.
09:51This is, and turn that way, let's see what happens.
09:53See, you can feel that just gets so much tighter every time you turn your head over there.
09:59The place I feel the tension the most is on the nose, like right here.
10:04Uh-huh.
10:05And then if I turn it a little bit more, I start feeling it here and down here.
10:10So that's the band, and it goes all the way into your shoulder, right?
10:12Yes.
10:14He has so much scarring, and it's so severe.
10:18He is going to be an extremely tough case.
10:22Part of my cheek fell off.
10:25I have not seen a monkeypox case before.
10:28Exactly how deep this extends is hard to say.
10:31Jeffrey's going to be awake for this procedure.
10:34Can you feel any of it?
10:37I'm fractured.
10:38I'm working with the rib wrap, and all of a sudden it breaks.
10:41This sucks.
10:42It's game over at that point.
10:58I have a patient, Sergio Reyna.
11:01He got burned at two years of age.
11:04Extensive burns to most of his body and the right side of the face, and I really wanted
11:10to help him with that.
11:11Let's go over what we're seeing here, okay?
11:13You had the burn so young that that right side of your face never got the chance to develop
11:20the left side of your face, and it's kind of frozen in time the way it would have been
11:25when you were younger.
11:26Yeah.
11:26Because I'm blind from this side, I also don't really know exactly how this side looks without
11:31doing like three different mirrors and doing all that, but when I look at a mirror, I can
11:36actually see like four-year-old or five-year-old me.
11:40Yeah.
11:40Yeah, it is stuck in time.
11:42It's stuck in time.
11:43The biggest challenges in Sergio is he has two sides to his face.
11:47On the left side, he has an adult face, and on the right side, it's more that of a child's
11:52face, and the nose kind of tells the story.
11:56He has a web of scar bands that are all attached to the nose, and I got to get all these scar
12:02bands released if I'm going to have any chance to get his nose in the middle.
12:05The good news is we have surgical options to make things better and straighter.
12:09I can't go back and make his right side of the face into his normal 20-year-old face.
12:14I can just try to get him better.
12:16Now I'm going to pull up the images that the 3D camera took.
12:18Okay.
12:19Okay, so...
12:20Oh, wow.
12:21You rarely get to see that right side of your face, I think you told me.
12:24Yes.
12:25Right?
12:25So I think this was going to be really helpful, so we kind of know our start point.
12:31And I wanted to show you the right side.
12:33Oh, yeah.
12:33Anyways, that this is really tethering that down, and you can see how small the hole really
12:39is there.
12:40But probably one of the most important things, notice, you know, you have a little bit of
12:44extra height here, but notice that there's no tip.
12:47Mm-hmm.
12:47The tip's soft cartilage, and it never got to kind of grow as well.
12:52That's why it's kind of pulled over to the right, because all this scar tissue, everything's
12:56pulled over to the right.
12:57All right.
12:58Let's go to the other side.
12:59You can see it really shows up, too.
13:02Yeah.
13:03Nothing's there.
13:04Here is the side-by-side of the direction I want us to go in.
13:09And, you know, that's a really handsome face.
13:12It really is.
13:13Yeah.
13:14Wow.
13:15I got excited.
13:17Being able to see an actual nose there is pretty cool.
13:21I'm not looking like Voldemort anymore.
13:23So let's go through the plan for you, okay?
13:27The nose is the most important for you.
13:29I know it's the start point for this inability for you to even turn your face over to the
13:33left.
13:33I want to get your nose straighter.
13:35I want it to breathe better.
13:38And I want it to look as good as possible and go in this direction, okay?
13:42Yeah, sounds good.
13:43The best source for the external skin of your nose is the forehead.
13:47Okay.
13:47Basically, we're going to probably take this left side for one really good reason.
13:52You have less hair right there that extends up.
13:55A forehead flap is this intricate, complex procedure that's been done since, you know,
14:00the beginning of plastic surgery.
14:02We'll draw basically an upside-down nose on the forehead, make those cuts, and then flip
14:07it down from the forehead onto the nose.
14:09There's a blood vessel that supplies this that comes from here.
14:12So we have to keep this part connected for about three weeks.
14:15This allows it to heal.
14:16Over time, your body grows new blood vessels into this, and then we could disconnect the
14:21two.
14:21Does that all make sense so far?
14:22Yes, that makes sense.
14:23Okay, perfect.
14:24So we also need to release all the scar.
14:27That whole band that you have that starts at the nose, continues down your cheek, and
14:31onto your shoulder.
14:32I want you to be able to look to the left side without, you know, feeling this tightness.
14:36I think that's so important for you.
14:38Yeah.
14:39All right.
14:39So I think we have a great plan here.
14:41I feel like you feel good about it.
14:43Yeah.
14:43Does that sound about right?
14:45Do you feel good about it?
14:45Yes, I definitely feel good about it.
14:47Perfect.
14:47I do trust the doctor.
14:49I know that Dr. Runstein is going to do a good job.
14:53If you have any other questions, just let me know.
14:55But it was a real pleasure to meet you.
14:57It was a pleasure to meet you.
14:58All right.
14:59Sergio is a complicated case, no doubt.
15:01He's going to take multiple surgeries to get done.
15:03But I'm really pumped for this because Sergio is a awesome, happy-go-lucky young man who just
15:11wants to, you know, further improve himself.
15:14And I'm really hoping we can help him with that.
15:17I am ready for this.
15:20This is kind of what I wanted.
15:21So we all know about chicken pox, right?
15:33And so a pox is a virus that creates these lesions throughout the body.
15:38And sometimes they can blister or they can erupt.
15:40But they do something that break the surface layer of skin.
15:44I have a patient coming in today.
15:45His name is Jeffrey Todd.
15:47And Jeffrey has recently acquired monkey pox.
15:51Monkey pox is characterized by these rashes that develop all over the body.
15:56And they're kind of spots or pox marks, if you will.
16:01Monkey pox is very contagious.
16:03You can contract it through the skin.
16:05However, once the wounds have healed and they're no longer open, then they are no longer contagious.
16:11There's not a lot known about monkey pox so far.
16:14We know in some ways it's closely related to smallpox, but it's definitely its own strain of disease.
16:21It's just, it's so brand new.
16:23We just don't have long-term follow-up for it yet.
16:26Jeffrey was one of the first cases in Los Angeles.
16:29He's left with these facial scars.
16:32I can see that he has this crater-like depression on the right side of his cheek.
16:39I have not seen a monkey pox case before.
16:42And so my concerns about treating him are going in and futzing around with a lesion that we're not that familiar with.
16:53I never thought that it would be me.
16:56People look at me.
16:58It's no secret that there's something lost.
17:01I'm hoping that there is some sort of answer to take me back to who I was.
17:11Hi.
17:12Here for Dr. Rovello.
17:13Perfect.
17:13Go ahead and sign in, please.
17:14Okay.
17:15Monkey pox was definitely a shock.
17:17I just so happened to go out one night, you know, and celebrated this gay pride.
17:21And I went to a dance and living my life.
17:26And boom.
17:29It happened.
17:30Go ahead and have a seat and the doctor will be right with you.
17:33When my lesion finally fell out, a huge chunk of my cheek fell off with it.
17:42I mean, you could see through.
17:43And that was horrifying because I thought, am I going to walk around now with a hole in my face?
17:49I was traumatized.
17:52I was looking in the mirror and I was like sobbing.
17:55And some people are really awful about it.
17:58Try dating and a person says to me, oh, I'm really grossed out by that.
18:03I feel like I'm mourning a loss every time I look in the mirror.
18:06I'm kind of nervous, actually.
18:07Yeah.
18:08Nervous that she won't be able to do anything.
18:10Well, I think she will be able to.
18:13I like your positive lookout.
18:16My biggest fear is that this is it.
18:21That this is what I'm going to be living with.
18:22I like your life.
18:34Knock, knock.
18:35Hello.
18:35Hi.
18:36Hi.
18:36How are you?
18:37I'm really good.
18:38How are you?
18:38Good.
18:39I'm good.
18:39Good to see you.
18:40Good to see you as well.
18:41Hi.
18:41I don't think we've met.
18:42I'm Diane.
18:43Melissa.
18:43Hello.
18:44Nice to meet you, Diane.
18:45Nice to meet you, too.
18:47How are you feeling?
18:48I'm feeling good.
18:49I'm excited to hear what we can maybe do.
18:52Yeah, absolutely.
18:54So take me back to when you were first diagnosed.
18:58Well, like in mid-July, I noticed an odd, like, pimple on my face.
19:04Then I had all these other symptoms as well.
19:05I had, like, bumps all over my arm and on my back.
19:09And the symptoms really started changing rapidly.
19:12And so the little pimple with, like, the raised ring around it.
19:16And luckily, I found a doctor that is an infectious disease specialist.
19:20And he saw the pictures.
19:22He understood exactly what was going on.
19:24Good.
19:25I got tested and found out, you know, that it was officially monkeypox.
19:30Wow.
19:31I think when I got tested, it was, like, 75 cases in Los Angeles.
19:35So it really wasn't on the radar that much.
19:39Yeah, very scary.
19:40But what happened here was that it ate away at the tissue inside of my cheek.
19:45So when it fell off naturally, part of my cheek fell off.
19:51I had, like, a hole the size of, like, a pea.
19:53Oh.
19:54Unless it had been disturbing.
19:54It was startling.
19:56Very shocking.
19:57And it's so prominent.
19:58And it's, like, I look at it every day.
20:00Yeah.
20:00And I see people look at it when I, you know, when I'm out in public.
20:03So it's just, like, reliving it over and over again.
20:06Yeah.
20:06The question remains is, what are we going to do about this?
20:08Yeah, what are we going to do about this?
20:09Yeah, what are we going to do about this?
20:10Well, let me take a look.
20:11Let me answer a look and tell you.
20:12Okay.
20:13It's clear that this experience was incredibly traumatizing for him.
20:18These lesions are such an obvious reminder to other people, to himself, of what he went through.
20:24And he just doesn't want that there anymore.
20:27So this one is pretty much healed over.
20:31It's flat.
20:32There's a little tiny bit of a divot in the center.
20:35But it's mostly just a little bit light pink-red.
20:38And then let's look at this one here.
20:41So this one, you can see sort of the remnants of a crater that used to be there.
20:46And underneath it, it's still quite firm.
20:49So that's all that scar tissue that's still in there.
20:52But there's definitely still a divot where that old lesion used to be.
20:59And I can feel it sort of is even larger beneath the surface.
21:02What you see on the surface is actually a lot smaller than what's happening below.
21:08You can't just remove that surface layer.
21:10I would have to dissect down to under the scar and release all of the deeper adhesions to the underlying muscles and soft tissues of the face.
21:18In terms of getting you treated, the treatment would be doing a scar revision, making a little incision over that crater that's there, excising it, and then closing it back up.
21:28When we do the scar revision, that hole gets cut out.
21:32You lost probably some of the natural tissue that sits under there.
21:36The lesion and the infection ate it up.
21:39Yeah.
21:39So we're going to do a little bit of fat grafting.
21:42I have a fat from your tummy just to fill in that concavity.
21:45And then when we close it and bring it back together, it's going to be flat.
21:49You'll still have a scar.
21:50There's no way around that.
21:51Okay.
21:52But if we can make it a thin line that maybe fits into a natural line of the face anyways, that's less noticeable and more ideal than something that's a little bit wide.
22:02Right.
22:03And then indented.
22:04And indented.
22:05Yes.
22:06Does it sound like something you might want to do?
22:08Yeah.
22:09You can do that.
22:12My plan for Jeffrey is to excise the lesion below his left ear and then just close it.
22:18On the right side, I'm going to do the same thing, but I'm going to have to take that excision a little bit deeper to get that deeper involved tissue.
22:27Exactly how deep this extends is a little hard to say.
22:30This definitely makes things more difficult because the last thing we want to do is go in there and start cutting around where there could be actual nerves.
22:37An injury to facial nerves can result in paralysis, and that's terrifying.
22:41Good luck.
23:00Dr. Panossi and I are going to be tackling this surgery together.
23:09My part is to focus on the nose.
23:12For sure, I know I'm going to do the forehead flap and get the nose straight, and then Andre's going to work on releasing the scar tissue on the face, neck, and shoulder.
23:21I think just cut along the border, actually.
23:25I think that's a good plan.
23:27Okay, so the first step here is to cut along the border between the really burned skin and the normal nose skin.
23:33Lift up all the skin off of the structure of the nose and see what's going on in there.
23:41Incision, guys.
23:42Yeah.
23:46Yeah.
23:46I'm just going layer by layer through this really thick scar.
23:52Very tethered here.
23:53A lot of warping.
23:57I'm trying to get all the anatomy released from the scar, like kind of unleashing it so we can move it where we need to.
24:03Okay.
24:04So...
24:05Everything's pulling that way.
24:07I think it's scar down there that's tugging it over at the base.
24:10It's a double tether.
24:10There's one there.
24:11There's one here.
24:11There's one here.
24:12As we're turning the head, it's tugging on the corner of the nose and the lip itself.
24:17So this is a continuous tether all the way down into the neck.
24:20We're going to have to release the distant scar tissue in the bands because before I start working on the delicate structure of the nose,
24:27I don't want that to cause it to get pulled at all from that scar tissue that's distant.
24:32All right.
24:33Let's cut this.
24:39The tension in the face was so tight.
24:41I think that when we release these scar bands, it's almost like you just cut a rubber band and it just snaps open.
24:47And it's big.
24:49That does not happen with normal skin.
24:51I may gap a little bit, but not that much.
24:53It's super satisfying to get that release for him and get some of that tension released.
24:58It's huge.
24:58You kind of feel it yourself as you're doing it.
25:01Better?
25:01It's providing some relief already.
25:04It's no longer tugging on that nose.
25:06That's a win.
25:08Okay.
25:08My next step is then to work down the nose, take it all apart, and then rebuild it with the rib cartilage.
25:15This is cadaver rib that we're using right now.
25:18What we're doing in this step is bracing that structure so it doesn't collapse in on itself, and it simultaneously reforms the top of the nose.
25:26You think that's good enough?
25:33No, it's not enough.
25:34No.
25:35It isn't.
25:36Huh?
25:37You should reposition that piece right there.
25:39Let's give that a hole.
25:42You're fractured.
25:43Oh, s***.
25:45Okay.
25:46The rib's fractured.
25:47The broken half.
25:48I'm working with the rib graft, and all of a sudden it breaks, and this sucks.
25:53It's a total challenge, and I've got to figure out a way to make it work.
25:57Now I've got to just roll with the punches, and this is very frustrating.
26:01Yeah.
26:04But bad things sometimes happen.
26:05You can't freak out.
26:06You've just got to figure out a solution.
26:08The rib's just too brittle.
26:09It's not working.
26:10You're going to re-anchor this.
26:12Yeah, I think maybe what I'll do is actually do this.
26:15Yeah, put those together.
26:15Yeah.
26:16I have a plan B, and that's going to be two pieces of cartilage from the septum.
26:21This is two pieces of septum I'm going to sew together, because the rib was not long enough
26:25and strong enough before.
26:26We're taking little fragments from the cartilage that he harvested, and we're going to splice it
26:30together, basically.
26:31And now I'm just hoping this works, you know?
26:33He's a good kid and deserves it.
26:35Yeah.
26:35Deserves the best.
26:36Yeah.
26:40I hope it does what we need it to do.
26:45I think I'll work.
26:47So now I'm trying to put it back in the pocket.
26:50Is that all right?
26:51Yeah.
26:52The two pieces of septum I sewed together seem to be working, so I'm happy about that.
26:57It's holding up well.
26:59Oh, it's good.
26:59Yeah.
27:00It's a nice-looking nose on this side.
27:01I'll be honest.
27:02I'm pretty happy with this side, right?
27:04It's a straight nose.
27:05Yeah, yeah.
27:06It's a good-looking nose.
27:07I'll take it.
27:08I'll trade, actually.
27:09You can.
27:10That's better.
27:11You see that?
27:11That's a little better supported there now.
27:14It's looking better.
27:15The makeshift thing worked.
27:17Should we tumble it out the forehead flap now?
27:19All right.
27:20Let's keep going.
27:21So we release the tension, and now I can start working on the forehead flap and getting
27:25the structure of his nose straight.
27:27We need a lot of width over here.
27:28Mm-hmm.
27:28Mm-hmm.
27:30Most of the tip is luckily going to be his native skin.
27:33Well, I think it's half, right?
27:34It looks like it's pretty much half.
27:36Yeah.
27:36I'm going to turn it this way, right?
27:37Yeah.
27:38It's got to be that way.
27:39The nose is a three-dimensional structure, but I have to draw it onto two dimensions on
27:44the flat forehead.
27:45Okay.
27:46Mm-hmm.
27:46That's a total.
27:47We use tinfoil as the flat kind of template that we literally use to draw an upside-down
27:53nose on the nose on the forehead itself.
27:54Yeah.
27:54And then maybe just go on the inside of this line and then outside of this one.
28:00Mm-hmm.
28:01Yeah.
28:02Yeah.
28:03Once we draw out the shape of his nose, we're going to lift this forehead skin and then we'll
28:07turn it over and, you know, we'll turn it over and, you know, reconstruct this whole side.
28:10So this would be the shape of it.
28:12That would be right there.
28:13That would be right there.
28:14That's all right.
28:15That'll work.
28:17This procedure is one of the coolest in plastic surgery and one of the ones that drew me into
28:20plastic surgery because historic records show it's been done since 500 B.C. in India by
28:25a doctor by the name of Shushrata.
28:27It's probably the oldest procedure in plastic surgery, which is crazy to me that there was
28:32a guy that was reconstructing nasal mutilation using the forehead that long ago.
28:36Now I have him drawn on the forehead.
28:38We're ready to raise it.
28:39And this is obviously a critical step because this is, this has to work.
28:43I just want to double try.
28:46You're happy with everything because you only get one shot.
28:49Okay.
28:50Ready to cut it.
28:55There's no going back.
28:56And if you don't take the right amount or the right shape, it's game over at that point.
29:03This program examines medical conditions and the procedures involved with treating them.
29:11Due to their graphic nature, viewer discretion is advised.
29:14I'm working on rebuilding Sergio's nose with the forehead flap.
29:25This is the most critical, difficult part of the surgery because there's no playbook of how and where to move this tissue and how to make it look good.
29:32It's all in your eye and you got to shape it until you feel like it's the right shape, but it takes time to do that.
29:39And there's no way around it.
29:41It's been many hours already and there's still more to go.
29:53My biggest concern is just that he's okay.
29:56I don't know, I just can't wait for it to end and like see him already.
30:01I just want to see him.
30:03So here's the tip portion, right?
30:07That goes there?
30:08Yeah.
30:09That's there.
30:10That's great.
30:11Yeah.
30:12Almost there.
30:13So right now, we got the forehead flap as you can see.
30:16We got it flapped down.
30:17It made it.
30:18The blood supply to it's good.
30:20I feel really good about that.
30:21So now we're just what we call insetting and kind of suturing it into place so it's going to heal right where we want it.
30:27There's a big hole where the forehead was so now Andre's working on getting that closed.
30:30We're coming to the finish line here.
30:33Oh, look at that.
30:34Boom!
30:35Done.
30:36Good looking nose.
30:37So surgery's all done.
30:38I'm really happy about that.
30:40It's a relatively straight nose.
30:41That nostril is in the right position on that left side.
30:45This one, you know, we have the bulk of the forehead flap there which we're going to debulk in that second stage.
30:50This is just step one though.
30:52We got to shape that forehead tissue in the next surgery.
30:55In about a month, then we can get it starting to look really good.
30:58So what do you think?
30:59How do we do?
31:00Looks good.
31:01I mean, this is as complex as it gets for nasal reconstructions.
31:04Boom!
31:06All right.
31:07We're all done.
31:08Everything went great.
31:09Yeah?
31:10Yeah.
31:11The nose is straight now.
31:12That flap of skin's still connected right here.
31:14So that's going to be a little unusual looking, of course.
31:17But just remember, that's where the blood vessels are coming and we have to keep it connected.
31:21And then we'll disconnect that later.
31:23And we'll get them back in and get it finished up.
31:25So I think we really made a lot of strides today.
31:27I'm really happy for them.
31:28Okay?
31:29Yeah, thank you.
31:30That was all good stuff.
31:31I appreciate it.
31:32Of course.
31:33All right.
31:34There's the man of the hour.
31:35Look who it is.
31:36It's funny seeing you here.
31:37It's funny seeing you here.
31:38The plan for Geoffrey is to go in and excite the man of the hour.
31:43The plan for Geoffrey is to go in and excise that area of firmness that's creating this
31:46concavity in his face.
31:47This is a little bit smaller case than some of our usual, but sometimes that's a good thing.
31:52Sometimes that's okay.
31:53All right.
31:54There's the man of the hour.
31:55Look who it is.
31:56It's funny seeing you here.
31:57The plan for Geoffrey is to go in and excise that area of firmness that's creating this
32:12concavity in his face.
32:13The amount that I'm going to have to take out is fairly large.
32:16It's a deep wound.
32:17And then do a little bit of fat grafting to fill in that irregularity that's going to
32:22be left behind.
32:32How are you feeling, Geoffrey?
32:33Oh, I'm good.
32:34You're okay?
32:35All right.
32:36Geoffrey's going to be awake for this procedure.
32:38It's a moderately invasive procedure and something that he can definitely tolerate under local
32:44anesthesia.
32:45What are your plans for Saturday night?
32:46I mean, you're looking at it?
32:48I think this is like a party.
32:51This is definitely a party.
32:52I mean, some of the parties on drugs.
32:57The biggest challenge of this surgery is that I may end up too close to very small branches
33:03of the facial nerve.
33:04The facial nerve allows you to raise your eyebrows and close your eyes and make a smile.
33:09All of these things that are crucial to the facial expressions that we make.
33:13So that would be a huge problem.
33:14I don't want to go in there to remove a scar and then end up inhibiting the function of
33:19the face.
33:20You'll feel me pressing on you and you may feel some pressure.
33:23Mm-hmm.
33:24You shouldn't feel sharp pain.
33:25If you do, just let me know.
33:26Okay.
33:27I'll let you know.
33:28I have no doubt you won't let me know.
33:30Just don't punch me.
33:31That's all I ask.
33:32Oh, I won't.
33:33When they are awake.
33:34Previously, I've had patients punch me because what I'm doing to them hurts.
33:38And always, you know, they're very apologetic afterwards.
33:40I'm sorry.
33:41All right.
33:42We're going to get started.
33:43Okay.
33:44Can you feel any of that?
33:50No.
33:51Good.
33:52I am incising the right cheek lesion.
33:55As soon as I get through the skin, I can see that this area that's been involved by the
34:00disease is very firm.
34:02It looks like the surrounding fat, but it has a different feel to it.
34:07It's a lot more firm.
34:12Sorry, did that tickle?
34:13No, no.
34:14Just the sound of it.
34:15Oh.
34:16Well, you're doing great.
34:17Everything's going well.
34:19I'm about to excise this scar, and I'm concerned about how deep this excision's going to go.
34:25It doesn't take more than, you know, a thickness about this thick to potentially be in facial nerve
34:31territory.
34:32So we have to proceed very carefully.
34:46I am incising Jeffrey's right cheek lesion.
34:49You doing okay?
34:50Sorry.
34:51Jeffrey doesn't have a whole lot of extra tissue overlying these nerve branches.
34:56I'm concerned about how deep this excision's going to go.
34:59It's a little tugging.
35:04We're almost, we almost got it out.
35:09All right, your little friend is out.
35:12This was a huge piece of scar tissue, and I was able to remove all of that firm, indurated,
35:17inflamed area.
35:18I feel good that we stayed away from the facial nerve.
35:21All right, let's go to the other side.
35:24After I excise the right side cheek lesion, I move to the left side.
35:30This is an area that's not as involved in terms of the deeper structures.
35:34It's very superficial.
35:35So I was able to just excise the superficial skin area and close it back together with some
35:40sutures.
35:41So now it's time to do our fat harvest.
35:46A little tugging here.
35:51The fat is held together with these fibrous bands.
35:54And you have to break up those bands when you do the liposuction in order to be able to smoothly
35:59remove the fat.
36:01And it's very violent.
36:03It's very aggressive.
36:05He seems relaxed, but what I'm doing to him is so barbaric I hate to ask.
36:12Good call.
36:13Then we do that same technique with suction applied to harvest the fat.
36:20I don't need a lot.
36:23This might be enough.
36:25So now we're ready to inject.
36:27So we used sort of those same blunt instruments that we used to harvest to inject the fat directly
36:33into that empty space below his skin.
36:36All right, so we're all done.
36:38You did great.
36:39Oh, thank you.
36:40I'm following up with Jeffrey today.
36:41He sent in some photos.
36:42So I am looking forward to visiting.
36:43Oh, I'm really confident.
36:44You're ready for this.
36:45You're ready for this.
36:46You're ready for this.
36:47You're ready for this.
36:48And I'm really glad to see you.
36:49I'm really confident that he's not going to have that divot that I was concerned about
36:51afterwards.
36:52You did great.
36:53Oh, thank you.
37:01I'm following up with Jeffrey today.
37:06He sent in some photos, so I am looking forward
37:08to seeing how he's coming along.
37:10So this lesion he had before is completely gone,
37:13which is really exciting.
37:17So that area that to him was so obvious
37:20that everyone was looking at is just gone.
37:23It's not there anymore.
37:25And my favorite thing is that this scar is so well hidden
37:28in his crease line, his natural smile line,
37:31which kind of frames the side of his nose there.
37:35I'm very happy with the result.
37:37I think it turned out really well.
37:39And I know Jeffrey is really happy with how things are going.
37:42Hello, hello, hello, Dr. Ravello.
37:45I just want to thank you for everything that you've done.
37:48All I wished was that I could have my face restored
37:52and be given back the confidence that I was lacking
37:57and had lost.
37:59So thank you, thank you, thank you for being my angel.
38:04And helping to erase the nightmare that was monkeypox.
38:09It feels like a distant memory.
38:11Thanks.
38:12I have Sergio Arena coming in today, and his surgery was really complicated.
38:25I had to do it in multiple stages.
38:26First stage, we had to restructure the nose.
38:30Second stage, we had to shape that skin on top and then disconnect the forehead flap.
38:35Again, he has a right and left side that are never going to match, and his nose had no projection to it.
38:40Every nose, you know, projects on your face and you have a tip that sticks out. He didn't have that.
38:43I want to make sure his nose is straight.
38:44I want to make sure I was able to keep the projection of his tip, and I want to make sure he's breathing.
38:49I'm really excited to see him, and I'm really hoping that this all held up.
38:56Sergio, how's it going, buddy?
38:57Good to see you again.
38:58You're doing good? Great to see you.
38:59Look at this guy.
39:00Oh my gosh, it's been a while.
39:01Yeah, it has been a while.
39:02You look fantastic.
39:04I remember back then I said I had like a Voldemort nose.
39:06I don't think I do anymore.
39:07Not at all.
39:08It's improved.
39:09I'm really excited.
39:10I'm really excited to see him.
39:11I want to make sure his nose is straight.
39:12I want to make sure I was able to keep the projection of his tip, and I want to make sure he's breathing.
39:14I'm really excited to see him, and I'm really hoping that this all held up.
39:17Sergio, how's it going, buddy?
39:18Good to see you again.
39:19You're doing good?
39:20Great to see you.
39:21Look at this guy.
39:22Oh my gosh, it's been a while.
39:23Yeah, it has been a while.
39:24Back then I said I had like a Voldemort nose.
39:26I don't think I do anymore.
39:27Not at all.
39:28It's improved.
39:29How's your neck treating you?
39:31The neck's a lot better.
39:33I actually can rotate a lot more.
39:35Before I think I would stop like around right here.
39:37Wow.
39:38Look at my butt.
39:41And what about the breathing?
39:42How's the breathing?
39:43The breathing is probably the thing that I've noticed the most.
39:45Really?
39:46Because now the wind just goes in there.
39:47I have like two canyons now.
39:49Awesome.
39:50Just taking in oxygen.
39:51I'm very happy with your progress thus far.
39:53All our milestones.
39:54Everything looks straight.
39:55It's breathing well.
39:56And I think it's just all good things ahead.
39:58And I'm really happy to see that.
40:00I honestly feel grateful for my two doctors.
40:03Anytime I'm walking down the street or something like that, I get less stares.
40:07With my new look, I feel like I have a bright future ahead of me.
40:11Overall, I feel like I'm doing a lot better.
40:23You guys got to remember Sergio.
40:25I mean, he's unforgettable.
40:26This is probably one of the most challenging cases I've ever done too.
40:29And his personality is awesome.
40:31So I know this video is going to be awesome.
40:33So let's check it out.
40:35How's it going, guys?
40:38Since I've had the surgery, my breathing has gone in so much better, which helps me do
40:43even more things.
40:44I started this year by going to Bolivia to even the highest city in the world.
40:49But if it wasn't for my nose, I probably wouldn't even be able to last there for as long as I did.
40:54I met some llamas, ate some llamas.
40:56Honestly, the llamas was pretty good.
40:59I really appreciate everything you two have done for me.
41:03I also have this surgery done by two great professionals.
41:06I really appreciate it.
41:08What a great guy!
41:10Yeah, so that trip to Bolivia and going to the highest city in the world,
41:14which I think is like around 15,000 feet high.
41:17There's very little oxygen there.
41:18I mean, I don't know if I could last there.
41:21I don't think he ever had any issues with his social life,
41:24but I think it's just going to take off now.
41:26Skyrocket.
41:27Yeah.
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