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About Face Season 1 Episode 4
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#AboutFace
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Short filmTranscript
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. I do get stares. It makes people uncomfortable.
00:14I just so happened to go out one night, living my life, and boom, it happened.
00:21Monkeypox was definitely a shock. The nose is being pulled through the scar that goes all the
00:27way down to light my shoulder. I really want to help him with that, but he has so much scarring and
00:33it's so severe. He is going to be an extremely tough case. My concerns about treating him are going in
00:41and futzing around with a lesion that we're not that familiar with. The amount that I'm going to
00:47have to take out is fairly large. It's a deep wound. It's a critical step because this has to work.
00:52There's no going back. If you don't take the right amount, it's game over at that point.
00:57So I have a patient coming in, real severe burn. It happened at two years of age, I believe,
01:08and now he's in his 20s. So this is Sergio Reyna. I really want to help him. He's the most severe
01:14burn patient I've seen, at least. I mean, the burns can be so devastating. I mean, you guys both know
01:19they are some of the most difficult cases. And that scar tissue doesn't behave like normal skin. No.
01:25It's thick. It's not pliable. It doesn't stretch. I mean, as you go through his photos,
01:30he really has a tail of two faces almost. You can see one side, amazingly good looking kid.
01:37And then on the burn side, the scar contracture just prevented him from ever developing the right
01:44side of his face.
01:45It's not just aesthetic. It's function, too.
01:50It's functional. When approaching plastic surgery of the face, you first have to consider
01:55the function. Are they going to be able to move their face better? Are they going to be able to
01:58breathe better? Well, Jason, my concern with you doing the nose is what are you going to do about
02:04the scar on the center part of his face? That scar band is going to want to pull it back to the side.
02:11Your reconstruction is not going to hold. Yeah. I mean, you're absolutely right.
02:15I got to replace a ton of skin there with blood supply so that it can actually heal. And any graft
02:20or any flap may fail. These things are tough. They're hard because everything could go right.
02:25Yeah. You know, but it may still not give enough movement. Yeah.
02:29It's going to be a challenge. This stuff is not a chip shot by any means.
02:32Let's get them out here, take a look in person, and see how we can help them.
02:36Absolutely. I agree.
02:47When I'm out in public, I do get stares.
02:51I can't separate myself from my scars. They made me who I am.
02:59The 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. And the way the eye looks, it makes people uncomfortable.
03:16When 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.
03:27And I'm just going to continue to fight on.
03:32One of the things I always say is that I'm like a Picasso painting.
03:38I'm worth a million dollars. And I look like art.
03:45When I was two, I was in a house fire. It 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.
04:10I 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. What are you doing?
04:26Just finishing up packing.
04:28OK.
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. Ruenstein.
04:36My sister, Olivia, is tagging along to take care of me and also be there for support.
04:40OK, so are you ready to get all the pictures for social media?
04:43Oh, yeah, definitely. Hopefully you're good with the camera.
04:47I'll try.
04:47When I was graduating from Texas A&M, I simply just took some photos of myself and also with my parents,
04:54and I put it on social media. When I first was posting, it was a little nervous, but that post
04:59went viral. Got 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 to
05:11measure me in Fahrenheit. I'm technically hotter than most of you.
05:17You know how, like, I've seen you since you were little. Like, 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. Each one of
05:28those times, they might do, like, three to four different surgeries. So I'm probably in the hundreds.
05:33What are you hoping for? Like, 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, you know,
05:42it just stretches everything, the mouth, the nose, and the eye, all the way down to, like, my neck and shoulder area.
05:48So you got that scar that, like, connects to your shoulder.
05:51Yeah. Yeah. Basically, 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 tugging on my face.
06:10I know you've, like, been through a lot and, like, you kind of manage it, but I don't really care,
06:18like, about how you look. It's just, like, the quality of life.
06:21Yeah.
06:21Having Sergio as a brother is pretty cool, you know? Sometimes I wish I had some of his confidence.
06:27He has inspired me, um, to be my best selves. He also, like, provides emotional support for,
06:34like, us, like, whatever we're going through. He knows how to help.
06:39This is also probably going to help just a little bit with dating. Uh, you know, uh,
06:43everybody always wants to go out with someone that's cute. Because of the way I look, I know I
06:47definitely, uh, get shot down quite a bit more than other people.
06:50Mm-hmm. Uh, getting a surgery on my face might improve that a little bit.
06:53Mm-hmm. Yeah.
06:55Yeah. Uh, who knows? Maybe I end up finding some girl and I'll bring her to mom and she'll start saying,
07:02you get married, I'm like, not yet. Give me a few more years. I'm like, I know you want grandkids,
07:06but not yet. Yeah, I mean, mom's kind of harsh. I'm not going to lie.
07:10I'm already extremely excited, uh, but I'm trying to keep the hopes down a little bit.
07:15I just hope he could help me.
07:26Hi, welcome. Hi.
07:28In the past, I've already felt that experience of a doctor telling me, no, I just can't help you.
07:36If, uh, the doctor says that he cannot help me, I'm definitely going to probably get depressed.
07:42And that's why I'm a little bit nervous right now. Hoping that they can, and we'll just have to wait and
07:46see.
07:46Hi, Sergio. How are you doing? Doing pretty good. It's good to see you.
07:55It's fun to see you. Hi, how are you doing?
07:57Doing good. And this is your sister?
07:59Yes, this is my sister.
07:59Okay, perfect. Nice to meet you. What's your name?
08:01Livia. Livia, very nice to meet you. So you made the trip.
08:04Yes, it's about time.
08:05And you, uh, came from Texas, or?
08:07Yes, it was Dallas, Texas.
08:09Awesome. Okay, cool. So, um, you know, again, thanks for coming all the way out here to meet
08:14me. And, you know, really want to try to help you. So tell me what you've gone through so far
08:19in terms of reconstructive efforts.
08:20Okay, so for facial reconstructive efforts, I've had some stuff worked on my lip, my nose,
08:27my mouth, and my ear. But most of that happened when I was still little.
08:31Okay. What can we do now to improve your quality of life in any way?
08:36Yeah, so right now, one of the main things I'm trying to focus on is releasing as many scars as
08:41I can, like, making my mobility improve. So, like, with the nose, it's being pulled through the scar
08:48that goes all the way down to, like, my shoulder. When I turn, it just pulls it really hard. And it
08:53pulls also the mouth and the eye and, I guess, the forehead to appear. Then I would also like to get
08:58some work done on the nose to, like, improve the structure and, like, make it a little bit more
09:04even. Is it okay if I do an exam and take a look inside your nose? Yeah, go ahead. 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. The depth of the burn, we don't know. It's hard to tell
09:25as far as, you know, whether it went all the way through the nose. It's really hard to see in there
09:30because the opening is so small. You know, for sure, I know it's shifted all the way over here
09:35because of the scar tissue, but go ahead and breathe. That's your good side, right?
09:39Mm-hmm. Okay. And then this side,
09:42if we get that totally covered, pretty tight, right? It's a struggle. You know, this I could really see
09:48it's really tight onto your upper lip. And turn that way. Let's see what happens. So you can feel
09:55that 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. And then if I turn it a little bit more,
10:06I start feeling it here and down here.
10:10So that's the band. It goes all the way into your shoulder, right?
10:12Yes. He has so much scarring and it's so severe. He is going to be an extremely tough case.
10:23Part of my cheek fell off. I have not seen a monkeypox case before. Exactly how deep this
10:30extends is hard to say. Jeffrey's going to be awake for this procedure. Can you feel any of that?
10:37I'm fractured. I'm working with the rib raft and all of a sudden it breaks. This sucks.
10:42It's game over at that point.
10:59I have a patient, Sergio Reyna. He got burned at two years of age. Extensive burns to most of his body
11:07and the right side of the face. And I really wanted to help him with that.
11:11Let's go over what we're seeing here, okay? You had the burn so young that that right side of your face
11:19never got the chance to develop, like, the left side of your face. And it's kind of frozen in time
11:23the way it would have been when you were younger. Yeah, because I'm blind from this eye. I also don't
11:28really know exactly how this side looks without doing, like, three different mirrors and doing all
11:34that. But when I look in the mirror, I can actually see, like, four-year-old or five-year-old me.
11:40Yeah. Yeah, it is stuck in time. It's stuck in time. The biggest challenges in Sergio is he has two
11:45sides to his face. On the left side, he has an adult face. And on the right side, it's more that of a
11:52child's face. And the nose kind of tells the story. He has a web of scar bands that are all attached to
11:59the nose. And I got to get all these scar bands released if I'm going to have any chance to get
12:04his nose in the middle. The good news is we have surgical options to make things better and
12:09straighter. I 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. Now I'm going to pull up the images that the 3D camera took.
12:18Okay. Okay, so... Oh, wow.
12:21You rarely get to see that right side of your face, I think you told me, right? Yes.
12:25So I think this was going to be really helpful so we kind of know our start point. And I wanted to show
12:32you the right side anyways, that this is really tethering that down. And you can see how small
12:39the hole really is there. But probably one of the most important things, notice, you know,
12:43you have a little bit of extra height here, but notice that there's no tip. The tip's soft cartilage.
12:49And it never got to kind of grow as well. That's why it's kind of pulled over to the right,
12:54because all this scar tissue, everything's pulled over to the right. Let's go to the other side.
13:00You can see it really shows up too. Yeah. Nothing's there.
13:03So here is the side-by-side of the direction I want us to go in. And, you know, that's a really
13:11handsome face. It really is. Yeah. Wow.
13:15I got excited. Being able to see an actual nose there is pretty cool. I'm not looking like Voldemort anymore.
13:23So let's go through the plan for you, okay? The nose is the most important for you. I know it's
13:29the start point for this inability for you to even turn your face over to the left. I want to get your
13:34nose straighter. I want it to breathe better. And I want it to look as good as possible and go in this
13:41direction, okay? Yeah, sounds good. The best source for the external skin of your nose is the forehead.
13:47Okay.
13:48Basically, we're going to probably take this left side for one really good reason. You have less hair
13:53right there that extends up. A forehead flap is this intricate complex procedure that's been done
13:59since, you know, the beginning of plastic surgery. We'll draw basically an upside down nose on the
14:04forehead, make those cuts, and then flip it down from the forehead onto the nose. There's a blood vessel
14:10that supplies this that comes from here. So we have to keep this part connected for about three weeks.
14:15This allows it to heal. Over time, your body grows new blood vessels into this, and then we could
14:20disconnect the two. Does that all make sense so far?
14:22Yes, that makes sense.
14:23Okay, perfect. So we also need to release all the scar, that whole band that you have that
14:29starts at the nose, continues down your cheek, and onto your shoulder. I want you to be able to look to
14:33the left side without, you know, feeling this tightness. I think that's so important for you.
14:38Yeah.
14:39All right, so I think we have a great plan here. I feel like you feel good about it.
14:43Yeah.
14:43Does that sound about right? Do you feel good about it?
14:45Yes, I definitely feel good about it.
14:47Perfect.
14:47I do trust the doctor. I know that Dr. Rubenstein is going to do a good job.
14:53If you have any other questions, just let me know. But 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. He's going to take multiple surgeries to get done,
15:04but I'm really pumped for this because Sergio is a awesome, happy-go-lucky young man who just wants
15:11to, you know, further improve himself. And I'm really hoping we can help him with that.
15:17I am ready for this. This is kind of what I wanted.
15:20So we all know about chicken pox, right? And so a pox is a virus that creates these
15:36lesions throughout the body. And 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. His name is Jeffrey Todd. And Jeffrey has recently acquired
15:50monkey pox. Monkey pox is characterized by these rashes that develop all over the body.
15:57And they're kind of spots or pox marks, if you will. Monkey pox is very contagious.
16:03You can contract it through the skin. However, once the wounds have healed and they're no longer open,
16:09then they are no longer contagious.
16:10There's not a lot known about monkey pox so far. We know in some ways it's closely related to
16:16smallpox, but it's definitely its own strain of disease. It's just, it's so brand new. We just
16:23don't have long-term follow-up for it yet. Jeffrey was one of the first cases in Los Angeles.
16:29He's left with these facial scars. I can see that he has this crater-like depression on the right
16:37side of his cheek. I have not seen a monkey pox case before. And so my concerns about treating him
16:44are going in and futzing around with a lesion that we're not that familiar with.
16:53I never thought that it would be me. People look at me. It's no secret that there's something
17:01a block. I'm hoping that there is some sort of answer to take me back to who I was.
17:11Hi. Here for Dr. Rivello. Perfect. Go ahead and sign in, please.
17:14Okay. Monkey pox was definitely a shock. I just so happened to go out one night,
17:19you know, and celebrated. It was gay pride, and I went to a dance and living my life, and boom,
17:29it happened. Go ahead and have a seat, and the doctor will be right with you.
17:32Thank you. Thank you.
17:38When my lesion finally fell out, a huge chunk of my cheek fell off with it. I mean,
17:42you could see through. And that was horrifying because I thought, am I going to walk around now
17:48with a hole in my face? I was traumatized. I was looking in the mirror, and I was like sobbing.
17:55And some people are really awful about it. Try dating, and a person says to me, oh, I'm really
18:02grossed out by that. I feel like I'm mourning a loss every time I look in the mirror.
18:06I'm kind of nervous, actually. Yeah.
18:07I'm nervous that she won't be able to do anything. Well, I think she will be able to.
18:13I like your positive look out. My biggest fear is that this is it.
18:21That this is what I'm going to be living with.
18:22Hello. Hi.
18:36Hi.
18:36How are you?
18:37I'm really good. How are you?
18:38Good. I'm good. Good to see you.
18:40Good to see you as well.
18:41Hi. I don't think we've met.
18:42Hi. I'm Diane.
18:42Melissa.
18:43Jeffersville.
18:44Nice to meet you, Diane.
18:45Nice to meet you, too.
18:46How are you feeling?
18:48I'm feeling good. I'm excited to cure what we can maybe do.
18:52Yeah, absolutely. So take me back to when you were first diagnosed.
18:58Well, like in mid-July, I noticed an odd, like, pimple on my face. Then I had all these other
19:05symptoms as well. I had, like, bumps all over my arm and on my back. And the symptoms really started
19:10changing rapidly. And so the little pimple with, like, the raised ring around it. And luckily,
19:17I found a doctor that is an infectious disease specialist. And he saw the pictures. He understood
19:23exactly what was going on.
19:24Good.
19:24I got tested and found out, you know, that it was officially monkeypox.
19:30Wow.
19:30I think when I got tested, it was, like, 75 cases in Los Angeles. So it really wasn't on the radar
19:37that much. Yeah, very scary. But what happened here was that it ate away at the tissue inside
19:44of my cheek. So when it fell off naturally, part of my cheek fell off. I had, like, a hole the size
19:52of, like, a pea.
19:53Oh, that must have been disturbing.
19:55It was startling. Very shocking.
19:57And it's so prominent. And 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. So it's just, like,
20:04reliving it over and over again.
20:06Yeah. The 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. Let me take 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. It's flat.
20:32There's a little tiny bit of a divot in the center, but 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.
20:52Mm-hmm.
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.
21:02Uh-huh.
21:03What 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
21:16underlying muscles and soft tissues of the face.
21:18In terms of getting you treated, the treatment would be doing a scar revision,
21:23making 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've 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,
21:57Uh-huh.
21:57That'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.
22:05Does that sound like something you might want to do?
22:07Yeah.
22:09You can do that.
22:10Yeah.
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
22:22a little bit deeper to get that deeper involved tissue.
22:26Exactly 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
22:34in 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.
22:59Good luck.
23:00Oui.
23:01Dr. Panossi and I are going to be tackling this surgery together.
23:10My 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.
23:17And then Andre's going to work on releasing the scar tissue on the face, neck and shoulder.
23:24I think just cut along the border, actually.
23:25Yeah.
23:26I 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
23:31the normal nose skin.
23:33Yeah.
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.
23:49I'm just going layer by layer through this really thick scar.
23:51Very 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
24:01we can move it where we need to.
24:02Okay.
24:03Um, so...
24:04Everything's pulling that way.
24:06I think it's scar down there that's tugging it over at the base.
24:09It's a double tether.
24:10There's one there.
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.
24:16So 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
24:25start working on the delicate structure of the nose, I don't want that to cause it to
24:30get 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 that when we release these scar bands, it's almost like
24:45you just cut a rubber band and it just snaps open and it's big.
24:50That 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 form and get some of that tension released.
24:57It's huge.
24:58You kind of feel it yourself as you're doing it.
25:00Better?
25:01It's providing some relief already.
25:04It's no longer tugging on that nose.
25:05That's a win.
25:06Okay.
25:08My next step is then to work down the nose, take it all apart, and then rebuild it with the rib
25:14cartilage.
25:15This is cadaver rib that we're using right now.
25:19What we're doing in this step is bracing that structure so it doesn't collapse in on itself,
25:23and it simultaneously reforms the top of the nose.
25:30Um, you think that's good enough?
25:32No, it's not enough.
25:34No, it isn't.
25:36Huh?
25:36You should reposition that piece right there.
25:38Let's give that a hole.
25:42It fractured.
25:43It broke in half.
25:48I'm working with the rib graft, and all of a sudden it breaks, and this sucks.
25:52It's a total challenge, and I got to figure out a way to make it work.
25:57Now I 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 just got to figure out a solution.
26:08The rib's just too brittle.
26:09It's not working.
26:10Um, the rib.
26:12Yeah, I think maybe what I'll do is actually do this.
26:14Yeah, put those together, yeah.
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,
26:23because the rib was not long enough and strong enough before.
26:26You're taking little fragments from this cartilage that he harvested,
26:29and we're going to splice it together, basically.
26:31Now 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.
26:42I hope it does what we need it to do.
26:44I think it'll work.
26:47So now I'm trying to put it back in the pocket.
26:49Is that all right?
26:50Yeah.
26:51The two pieces of septum I sewed together seems to be working, so I'm happy about that.
26:57It's holding up well.
26:58That looks 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.
27:05It's a good-looking nose.
27:07I'll take it.
27:08I'll trade, actually.
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 template out the forehead flap now?
27:19All right.
27:20Let's keep going.
27:20So we release the tension, and now I can start working on the forehead flap
27:24and getting the 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,
27:42but I have to draw it onto two dimensions on the flat forehead.
27:45Okay.
27:46Mm-hmm.
27:47We use tinfoil as the flat kind of template that we literally use
27:51to draw an upside-down nose on the forehead itself.
27:54Yeah.
27:55And then maybe just go on the inside of this line,
27:58and then outside of this one.
28:00Mm-hmm.
28:01Yeah.
28:03Once we draw out the shape of his nose, we're going to lift this forehead skin,
28:07and then we'll turn it over and, you know, reconstruct this whole side.
28:10So this would be the shape of it, and it would be right there.
28:13That'll work.
28:16This procedure is one of the coolest in plastic surgery,
28:19and one of the ones that drew me into plastic surgery,
28:21because historic records show it's been done since 500 B.C. in India
28:25by a doctor by the name of Shushrata.
28:27It's probably the oldest procedure in plastic surgery,
28:30which is crazy to me that there was a guy
28:32that 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...
28:42This has to work.
28:42I just want to double try.
28:46You're happy with everything, because you only get one shot.
28:48Okay, ready to cut it.
28:55There's no going back.
28:57And if you don't take the right amount or the right shape,
29:00it's game over at that point.
29:07This 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.
29:26This is the most critical, difficult part of the surgery,
29:29because there's no playbook of how and where to move this tissue and how to make it look good.
29:34It's all in your eye, and you've got to shape it until you feel like it's the right shape.
29:38But it takes time to do that, and there's no way around it.
29:44It's been many hours already, and there's still more to go.
29:54My biggest concern is just that he's okay.
29:58I don't know, I just can't wait for it to end and see him already.
30:01I just want to see him.
30:05So here's the tipped portion, right?
30:07That goes there?
30:08Yeah.
30:08Yeah, that's there.
30:09That's great.
30:10Yeah.
30:11Almost there.
30:13So right now, we got the forehead flap.
30:15As you can see, we got it flapped down.
30:17It made it.
30:18The blood supply to it's good.
30:20I feel really good about that.
30:22So now we're just what we call insetting and kind of suturing it into place,
30:25so it's going to heal right where we want it.
30:27There's a big hole where the forehead was,
30:28so now Andre's working on getting that closed.
30:31We're coming to the finish line here.
30:33Oh, look at that.
30:34Boom!
30:35Done.
30:35It's a good-looking nose.
30:36So surgery's all done.
30:38I'm really happy about that.
30:39It'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,
30:48which 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!
31:04All right, we're all done.
31:08Everything went great.
31:09Yeah?
31:10Yeah.
31:10The nose is straight now.
31:11Mm-hmm.
31:12That flap of skin's still connected right here,
31:14so that's going to be a little unusual looking, of course.
31:18But just remember, that's where the blood vessels are coming,
31:20and 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.
31:28Mm-hmm.
31:29Okay?
31:29Yeah, thank you.
31:30That's all good stuff.
31:31I appreciate it.
31:31Excellent.
31:32Of course.
31:32All right.
31:34This is a little bit smaller case than some of our usual,
31:51but sometimes that's a good thing.
31:54Sometimes that's okay.
31:58All right.
31:59There's the man of the hour.
32:00Look who it is.
32:02It's funny seeing you here.
32:05The plan for Jeffrey is to go in and excise that area of firmness
32:10that's creating this concavity 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
32:21that's going to be left behind.
32:22How are you feeling, Jeffrey?
32:33Oh, I'm good.
32:34You're okay?
32:34All right.
32:34Mm-hmm.
32:35Mm-hmm.
32:36Jeffrey's going to be awake for this procedure.
32:38It's a moderately invasive procedure and something that he can definitely tolerate under local anesthesia.
32:44What are your plans for Saturday night?
32:46I mean, you're looking at it?
32:48I think this is like a party.
32:50This is definitely a party.
32:52I mean, someone at the party's on drugs.
32:57The biggest challenge of this surgery is that I may end up too close to very small branches of the
33:03facial 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.
33:12So 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 the face.
33:20You'll feel me pressing on you and you may feel some pressure.
33:23You shouldn't feel a sharp pain.
33:25If you do, just let me know.
33:26Okay.
33:27I'll let you know.
33:28I have no doubt you will.
33:29No.
33:30Just don't punch me.
33:31That's all I ask.
33:31Oh, I won't.
33:33When they are awake, previously 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.
33:42All right, we're going to get started.
33:43Okay.
33:48Can 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 disease
34:01is very firm.
34:02It looks like the surrounding are firm.
34:09Sorry, did that tickle?
34:10No, no.
34:11Just the scent of it.
34:12Oh.
34:13Well, you're doing great.
34:15Everything's going well.
34:16I'm about to excise this scar and I'm concerned about how deep this excision is going to go.
34:22It doesn't take more than, you know, a thickness about this thick to potentially be in facial
34:28nerve territory.
34:29So we have to proceed very carefully.
34:39I am incising Jeffrey's right cheek lesion.
34:46You doing okay?
34:47Sorry.
34:48Jeffrey doesn't have a whole lot of extra tissue overlying these nerve branches.
34:53I'm concerned about how deep this excision is going to go.
34:56It's a little tugging.
35:01We're almost, we almost got it out.
35:03All right, your little friend is out.
35:09This was a huge piece of scar tissue and I was able to remove all of that firm,
35:14indurated, inflamed area.
35:16I feel good that we stayed away from the facial nerve.
35:20All right, let's go to the other side.
35:22After I excise the right side cheek lesion, I move to the left side.
35:27This is an area that's not as involved in terms of the deeper structures.
35:31It's very superficial.
35:32So I was able to just excise the superficial skin area and close it back together with some sutures.
35:42So now it's time to do our fat harvest.
35:46A little tugging here.
35:49The fat is held together with these fibrous bands.
35:52And you have to break up those bands when you do the liposuction
35:55in order to be able to smoothly remove the fat.
35:59And it's very violent.
36:01It's very aggressive.
36:06He seems relaxed, but what I'm doing to him is so barbaric, I hate to ask.
36:11Good call.
36:13Then we do that same technique with suction applied to harvest the fat.
36:19I don't need a lot.
36:20This might be enough.
36:22So now we're ready to inject.
36:24So we used sort of those same blunt instruments that we used to harvest to
36:28inject the fat directly into that empty space below his skin.
36:34All right.
36:34So we're all done.
36:35You did great.
36:36We filled in the deficit with some fat.
36:39That crater that he had here, that divot is definitely gone.
36:43I'm really confident that he's not going to have that divot that I was concerned about afterwards.
36:48You did great.
36:49Oh, thank you.
36:57I'm following up with Jeffrey today.
37:03He sent him some photos, so I am looking forward to seeing how he's coming along.
37:07So this lesion he had before is completely gone, which is really exciting.
37:14So that area that to him was so obvious that everyone was looking at is just gone.
37:20It's not there anymore.
37:22My favorite thing is that this scar is so well hidden in his crease line,
37:27his natural smile line, which kind of frames the side of his nose there.
37:33I'm very happy with the result.
37:34I think it turned out really well, and I know Jeffrey is really happy with how things are going.
37:39Hello, hello, hello, Dr. Ravello.
37:43I just want to thank you for everything that you've done.
37:46All I wished was that I could have my face restored and be given back the confidence that I
37:54was lacking and had lost.
37:56So thank you, thank you, thank you for being my angel and helping to erase
38:04the nightmare that was monkeypox.
38:07It feels like a distant memory.
38:09Thanks.
38:09I have Sergio Arena coming in today, and his surgery was really complicated.
38:36I had to do it in multiple stages.
38:37First stage, we had to restructure the nose.
38:40Second stage, we had to shape that skin on top and then disconnect the forehead flap.
38:45Again, he has a right and left side that are never going to match.
38:48And his nose had no projection to it.
38:51Every nose, you know, projects on your face and you have a tip that sticks out.
38:55He didn't have that.
38:56I want to make sure his nose is straight.
38:57I want to make sure I was able to keep the projection of his tip and I want to make sure
39:01he's breathing.
39:02I'm really excited to see him and I'm really hoping that this all held up.
39:09Sergio, how's it going, buddy?
39:11Good to see you again.
39:12You're doing good?
39:12Great to see you.
39:13Look at this guy.
39:15Oh my gosh, it's been a while.
39:16Yeah, it has been a while.
39:17You look fantastic.
39:20I remember back then I said I had like a Voldemort nose.
39:23I don't think I do anymore.
39:24Not at all.
39:25It's improved.
39:27How's your neck treating you?
39:29The neck's a lot better.
39:30I actually can rotate a lot more.
39:32Before I think I would stop like around right here.
39:34Wow.
39:34I can almost look at my butt now.
39:38And what about the breathing?
39:39How's the breathing?
39:40The breathing is probably the thing that I've noticed the most.
39:42Really?
39:42Because now the wind just goes in there.
39:44I have like two cannons now.
39:46Just taking in oxygen.
39:47I'm very happy with your progress thus far.
39:50All our milestones, everything looks straight,
39:52it's breathing well.
39:53And I think it's just all good things ahead.
39:55And I'm really happy to see that.
39:57I honestly feel grateful for my two doctors.
40:00Anytime I'm walking down the street or something like that,
40:03I get less stares.
40:04With my new look, I feel like I have a bright future ahead of me.
40:08Overall, I feel like I'm doing a lot better.
40:10You guys got to remember Sergio.
40:22I mean, he's unforgettable.
40:23This is probably one of the most challenging cases I've ever done too.
40:27And his personality is awesome.
40:28So I know this video is going to just be awesome.
40:30So let's check it out.
40:33How's it going guys?
40:35Since I've had the surgery, my breathing has gone in so much better,
40:38which helps me do even more things.
40:41I started this year by going to Bolivia,
40:43to even the highest city in the world.
40:46But if it wasn't for my nose,
40:48I probably wouldn't even be able to last there for as long as I did.
40:51I met some llamas, ate some llamas.
40:54Honestly, the line was pretty good.
40:56I really appreciate everything you two have done for me.
41:00I also have this surgery done by two great professionals.
41:03I really appreciate it.
41:04What a great guy.
41:07I love him.
41:08Yeah, so that trip to Bolivia and going to the highest city in the world,
41:11which I think is like around 15,000 feet high.
41:14There's very little oxygen there.
41:15I mean, I don't know if I could last there.
41:17Yeah.
41:18I don't think he ever had any issues with his social life,
41:21but I think it's just going to take off.
41:22Skyrocket.
41:23Yeah.
41:24Skyrocket.
41:25Skyrocket.
41:26Skyrocket.
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