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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.
00:07All my life, people would always stare, they would always ask them, why isn't he getting
00:11that fixed?
00:12What's he doing here?
00:14I can't close my eyes.
00:16Go all the way up.
00:17The hardest is like just dealing with the pain.
00:19I don't want to cry.
00:22People with this type of syndrome have lumps and sometimes when they get really large they
00:27cause real havoc.
00:29These eyelids are extremely complicating, muscles that are a millimeter or two thick.
00:35There's really no room for error to make this thing work.
00:37You're going to be awake during this, a little bit drowsy but awake.
00:40Are you waking up for me?
00:41Yes.
00:42There you go.
00:43She better not twitch or move or flinch when I got this scalpel near her eyeball.
00:47It's kind of a massive crater and what I'm worried about is that the facial nerve that
00:52controls all your motor function to your face, this is right in the area of the divot for
00:56then.
00:57And if I cut the facial nerve, I could paralyze his face.
00:59So I have a patient coming in from Chicago.
01:10His name's Patrick Gannon.
01:11It's a neurofibromatosis case.
01:13We do get these.
01:14They're tough.
01:15They're tough.
01:16And he had a tumor and it really went deep into the face.
01:21So he had a couple of surgeries not too long ago to remove and debulk this tumor.
01:28And now he's left with a pretty significant deficiency in the left side of the face.
01:34Look how much it really divots in there.
01:35You can see it's centimeters deep.
01:37Yeah.
01:38Where his divot is, it's only accentuated because the rest of that tumor is larger.
01:43Sitting here.
01:44Yeah.
01:45What a stark difference from the operated side to the unoperated side.
01:48Oh my god, yeah.
01:49This is two different people.
01:50Right.
01:51And the area where we want to treat is right where the facial nerve is.
01:55The facial nerve controls all your motor function to your face.
01:58So your ability to blink, to raise your forehead, to smile, to purse your lips.
02:02And if I damage one of these nerves, I could paralyze his face.
02:05I cannot, I do not want to injure that in this process.
02:08Right.
02:09Especially in the light, in light of having had previous surgery.
02:12I mean, things could have been moved.
02:14It's very easy to kind of move a branch of a nerve up or down a few millimeters from where
02:18you think it should be.
02:19Yeah.
02:20That is definitely going to make this more challenging and more risky.
02:23But if he's willing to take that risk with me, I think it's, it's a reasonable thing
02:27to try to help him.
02:28Absolutely.
02:29I agree.
02:30I don't like being a hermit.
02:40I like being out and about and I like socializing.
02:44But with the facial deformity, it makes it hard.
02:55How you doing?
02:56What do I do?
02:57Two coffees, please.
02:58Open it up.
02:59When I look in the mirror, the first thing I see is the crater on my face.
03:02The ear is sticking out too much.
03:04You got the droopy big old ball on the bottom.
03:07And it's very painful.
03:10So how are you doing today?
03:11Not as bad as it was yesterday.
03:12I was having a bad pain day yesterday.
03:14I saw you were having trouble eating.
03:16Yeah.
03:17I just, I just gotta be careful and maybe eat smaller meals.
03:23Or, you know, eat things that are softer.
03:25You know, I can't always go eating steak.
03:27No, I know.
03:28I have neurofied bromatosis type 1, or NF1 for short, that causes tumors to grow on the nerves anywhere throughout the body.
03:52This one started to grow, I wanna say I was about eight, nine years old, maybe 10.
03:59My parents were always told, it's not cancerous, we're not gonna touch it.
04:04But as an adult, it got to the point where the doctors were like, okay, this has to come out now because it did so much damage and took out this entire side of my jaw.
04:14I remember when you had teeth, how much it hurt and how much pain you used to have.
04:23Yeah.
04:24Never knew how much pain I was truly in until they were gone.
04:26I've technically had three full surgeries.
04:29The first surgery was for my teeth.
04:31I had to get all my teeth pulled because the tumor had fingers that came across and just started destroying all my teeth.
04:37I don't know how you managed your day to day.
04:40Looking back, I don't know how I did it either.
04:42I really don't.
04:43The second one was the first major debulking of this big tumor that I had here and it was the size of a grapefruit.
04:50Probably where a lot of that pain came from was just that tumor just putting pressure on everything.
04:55And then the last surgery, he helped with your ear.
04:58The tumor crawled up and was crushing your ear canal.
05:01Which is kind of scary.
05:04I almost lost hearing on that side.
05:08They say, God doesn't give you anything that you can't handle.
05:11But he must think I'm a superhero sometimes.
05:15I've had a lot of tough things happen to me and I'm still standing.
05:22When you take our son out places and people stare at you.
05:27It hurts.
05:28I see the looks.
05:29I feel them.
05:30I've seen them.
05:31And I get angry.
05:32I get angry.
05:33I try to ignore it.
05:35But on the inside, it always stings a little.
05:38Because I was picked on at school.
05:40I was tormented and tortured for years.
05:43I never wanted to go to school.
05:45Because I knew that I was going to get picked on on a daily basis.
05:51From almost everybody.
05:53I mean, just constantly picking on me and throwing things at me.
05:56And pushing me around.
05:58It was bad.
06:00I would like the indent in my face to go away.
06:03I mean, a crater was left.
06:05Because the tumor is now mostly gone.
06:07And maybe to get my ear pinned back a little.
06:10Kind of make it look a little more normal.
06:12So it kind of looked like jumbo.
06:13Hmm.
06:14I don't see it.
06:17And my eyes are perfect.
06:19Mm-hmm.
06:20But I know that a surgery would make you so happy on the inside.
06:25Yeah.
06:26I'm getting ready to fly out to California and meet with Dr. Rustine.
06:29If he gets my ear back and he gets rid of the crater on my face, I think it'll just make me a happier person inside and out.
06:37We're hoping for goodness.
06:39Yeah.
06:40Hope and pray for the best that these doctors can do.
06:52Hello.
06:53Hi.
06:54I'm here to see Dr. Rustine.
06:55Perfect.
06:56If you could sign in.
06:57My wife and I just flew out to L.A.
06:59And we are getting ready to go meet the doctor.
07:01All right.
07:02If you'd like to follow me back.
07:04I am anxious because I'm not too sure what he is going to be able to do for me.
07:09I'm very anxious and very scared, but my hopes are very high at the same time.
07:19So we'll see what he says, you know?
07:21We're almost there.
07:22Mm-hmm.
07:23And whatever he says, we'll figure it out.
07:25Mm-hmm.
07:26You got this.
07:27It's over.
07:28Yeah.
07:32Hi, Patrick.
07:33How's it going?
07:34Good.
07:35Hi, Doug.
07:36Good to meet you in person.
07:37Nice to finally meet you.
07:38How are you doing?
07:39That's your lovely wife, I assume.
07:40That's my lovely wife.
07:41What's your name?
07:42Vanessa.
07:43Vanessa.
07:44Nice to meet you as well.
07:45Nice to meet you.
07:46So tell me more about your medical history now, if you don't mind.
07:48I have neurofibromatosis, type 1.
07:49Right.
07:50The tumor on the side of my face, I had to have started 9, 10.
07:54I was really, really, really young.
07:56Mm-hmm.
07:57As it got bigger, it pulled the skin down and then it was like, just this lump just kind
08:01of hanging there.
08:03And over the years, it just got bigger and bigger.
08:06Do you remember roughly the size of it?
08:08You know, the size of a baseball or?
08:09No.
08:10The size of the tumor was probably roughly the size of a small grapefruit.
08:13Okay.
08:14It went up into his ear, crushed the ear canal, and went onto his eardrum.
08:20And it actually started rotting the teeth out from underneath.
08:23Okay.
08:24So the first surgery, I got rid of my teeth.
08:26And then the second surgery was to debulk most of the tumor.
08:30Mm-hmm.
08:31The third surgery, we built my ear canal.
08:33And now we're here.
08:34Okay.
08:35Let's pretend I was the genie in the bottle.
08:37You get all your wishes, all right?
08:38We got three, at least.
08:39Okay.
08:40What's number one on that list?
08:41Um, number one, I would say if you can't take out the indent that I have over here,
08:47and then get rid of whatever bulge is here.
08:50You know, try to normalize the left side to the right side.
08:53Okay.
08:54I'm glad that is your number one, because I think that is, you know, an important goal.
08:58Um, what's number two?
09:00How the ear sticks out.
09:01I was always told I had big ears as a kid.
09:03Uh-huh.
09:04And I grew into them.
09:05Yeah.
09:06But it kind of feels like this one's sticking out again, and...
09:08Yeah, I agree.
09:09It has some room for improvement.
09:10So, again, try to give that fold back more, and get it in back a little bit more for you,
09:15so it sticks out less.
09:16I think that's a valid goal.
09:17Mm-hmm.
09:18Should we do a quick exam now?
09:19Yeah.
09:20All right.
09:21People with this type of syndrome have lumps all over their body and faces.
09:24And sometimes when they get really large, they get really distorting and invade into nearby structures
09:30and cause real havoc.
09:31And this is exactly what happened for Patrick, and I just hope we can help him with that.
09:34You can kind of see this in the area that's excess, and then it's very deficient here.
09:43Go ahead and open and close your mouth for me.
09:47Bite down for me.
09:49Relax.
09:50Now, when you first did this surgery, was this tissue all the way up there, and now it's kind of fallen down?
09:55Or what do you think?
09:56Um, no, it's kind of always, always been...
10:00Kind of bulky there?
10:01Yeah.
10:02Okay.
10:05It's a pretty noticeable difference where it really dips in.
10:09It's kind of a massive crater.
10:11And what I'm worried about is that the facial nerve that controls all your motor function to your face,
10:16this is right in the area of the divot for him.
10:18And if I cut the facial nerve, I could paralyze his face.
10:21Incision, this is a danger zone.
10:26There is a very real potential that the branches of Patrick's facial nerve are sitting right under the skin.
10:32And that's terrifying.
10:34Shoot.
10:35It's uneven.
10:36If we get the adjustment wrong, your symmetry's ruined.
10:41Uh...
10:51All right, let's take a look here.
10:56I have a patient, his name's Patrick Gannon, and he has NF1.
11:01He's most bothered by the left side of his face, where he has a large divot,
11:04and an area where the neurofibroma is still pretty prominent.
11:07Patrick's ear is something else that really bothers him.
11:09You can see his left ear stuck out a lot more compared to his right.
11:12I don't know if this was from the prior surgery or something he's always been born with.
11:16What I do know is that he's missing some of the normal architecture of the ear itself.
11:21If you notice, this ear is missing that normal fold.
11:24You know, you can see it in my ear.
11:26You see this fold?
11:27We call that the anti-helical fold.
11:29And it sits right here, and that's why this is more prominent,
11:32because this doesn't bend back normally.
11:34You see how that gets rid of all that bend?
11:36You see?
11:37I see.
11:38Yeah.
11:39So, and his other ear has it perfectly.
11:40If you look and compare his right ear compared to the left right now,
11:43you can see a perfect anti-helical fold, and that's why this ear is perfect.
11:47With the prior surgeries and all the ear surgeries he's had,
11:49it is possible that it kind of pulled things forward a little bit,
11:51so we want to set back this part of the ear as well.
11:54This is your helix.
11:55This is the anti-helix.
11:56He's missing this fold, and when this fold is flatter,
11:58it makes the ear stick out more.
12:00So I know I have to recreate that fold,
12:02but, you know, it's more complicated than just setting the ear back.
12:05You have to also change the architecture of the ear itself.
12:08And this is the beauty of the 3D camera.
12:10We're able to appreciate things in a different way with, you know, high definition,
12:14but you see that?
12:15Wow, look at that.
12:16You can see how the fold is the most important part right through here.
12:19It's missing there.
12:20And then obviously this is your main thing we're here for.
12:23Yeah.
12:24That's our number one, right?
12:25The creator.
12:26Yeah.
12:27So let's take some other, let's look at some other angles of that.
12:29You know, you can see this is kind of where the tumor ends,
12:31and that's our divot, right?
12:33Yeah.
12:34We're not even sure if this is really a tumor.
12:36I bet you in the last surgery, they took out the bulk of the tumor.
12:40They took out the grapefruit because it's probably just a mix of tissues and scar.
12:45And, you know, these are benign.
12:46I know we're calling them tumors and people associate the word tumor with,
12:49oh, that you got to cut it out.
12:51That's not true necessarily.
12:52Now, is this something we're going to know when you open him up?
12:55Yeah.
12:56If I see anything that looks abnormal, worrisome, you know, any question of cancer,
13:00we're going to send that off for pathology.
13:02But the chance of any residual problem cancer is exceedingly low and not where my focus is.
13:07My focus is on let's make this look as good as possible.
13:10Okay.
13:11I want to take as much of the tumor, bring it up to fill that divot.
13:14It's going to help us in this case.
13:16If I just cut it out, it's going to create more of a divot there.
13:19Okay.
13:20Any of it that I can use that has this bulk, I want to not just throw it away.
13:24I want to use it to our benefit and fill in that big divot because that's our main problem problem.
13:28That makes sense.
13:29So my plan is to do two main things.
13:31One, recruit from the area that's too excess below it, bring it up, right?
13:36And fill in the divot as much as I can with that.
13:38If it's not enough, we may need to add some fat back to that area.
13:41I also want it to be a nice smooth contour as much as possible to match the right side.
13:45So I may cut away some excess tumor down low or anywhere that it's excessive after I moved it up.
13:50Are you going to try to use the same scar that they used last time?
13:54Absolutely, yeah.
13:55Because you already have that scar.
13:56It healed well.
13:57It's in a favorable position.
13:59So we'll go through the same scar and do all our work through that.
14:03Okay.
14:04And then last step, we're going to do the ear, right?
14:07We're going to recreate the fold here and that should help make the ear less prominent.
14:11Risks.
14:12Great question.
14:13This is a white.
14:14Did you bring her?
14:15Yes.
14:16That's why I have my beautiful wife.
14:17She understands all the medical knowledge.
14:18Yeah, yeah.
14:19They tell her.
14:20She explains it to me.
14:21Yeah.
14:22So the main risk here is that right here is a really important nerve called the facial nerve that controls all your facial muscles.
14:29You had prior surgery.
14:31It is no doubt a little riskier because of that because I don't know if scar tissue has pulled it up in an unusual location.
14:37Or were you born with it in an unusual location?
14:40We'll look for it every step of the way.
14:42And, you know, that is to me, you know, one of the major risks that we have to be mindful of.
14:47A major focus on my end is going to be to avoid that.
14:50Trust is critical and it's a two-way street.
14:53We're taking a major commitment together.
14:55And the last thing I want to do is make them any worse off.
14:59So I've got to be very, like, laser focused and do my most meticulous work to make sure I don't injure one of the facial nerves.
15:05All right, well, I think we have a great plan.
15:07I look forward to doing this for you and hopefully this is it.
15:10I'm feeling really, really good about this.
15:12I'm excited.
15:13I'm nervous, but I'm excited.
15:14Good.
15:15And Vanessa?
15:16100%.
15:17Okay. Love it.
15:18All right. Bye, guys.
15:19Good to meet you. Thank you.
15:20You too, as well. Bye, guys.
15:21Yeah, of course.
15:22I know the risks.
15:23Boy, the risk is very worth it.
15:24I just got to keep my fingers crossed and pray for the best.
15:35Hello.
15:46I'm here to check in with Dr. Penosian.
15:49Perfect.
15:50The hardest is, like, just dealing with the pain.
15:53I've had this since I was little, and as I age, it's just gotten worse.
16:00I can't close my eyes.
16:02Even with blinking, it blinks, like, a lot slower than my right.
16:07I have to, like, brace myself, having to explain that all the time.
16:12My left eyelid doesn't work like a normal eyelid.
16:16I have a muscle deficiency.
16:18It's like a droopy eye.
16:20I'd rather not, like, go out and meet people.
16:22They're going to be looking at me and asking,
16:24what's wrong with your eye?
16:26I just thought I was, like, done with everything that I wanted to do with my eye.
16:30Because there wasn't really no change from the other surgeries.
16:33I've had two other procedures done before with little to no results.
16:37And I was trying to, like, mentally be okay with that and just trying to live with it.
16:41And even, like, with the pain.
16:43So I am just looking for a solution to ease the pain of that eyelid.
16:47What pain are you feeling right now?
16:49Like, on my eyelid, like, when my muscle is, like, strained.
16:52Mm-hmm.
16:53Because, you know, like, I get that pain in my eyelid, like, when it's, like, strained too much.
16:56Mm-hmm.
16:57And, you know, I stare at a screen before work all the time.
17:00Oh.
17:01So I am an accountant, so it causes me a lot of pain just staring at a screen.
17:07My left eye gets so strained.
17:09I have, like, a bad headache coming from it.
17:11You know, I don't think I've ever pictured my eyes looking the same.
17:16And, like, getting, like, a somewhat symmetrical face.
17:19And I feel like it would mean a lot.
17:21Yeah.
17:22Just I feel I would feel more confident.
17:24I've noticed you always tend to cover it up.
17:26Yeah, with my hair.
17:27Yeah.
17:28Because my face is not symmetrical.
17:30Mm-hmm.
17:31And then you can see it more.
17:32I try to hide behind my glasses, behind my hair.
17:35Or, like, when I look at people, like, I try to, like, turn my head or, like, you know, like, be at an angle where they probably won't see it as much.
17:42I can't even imagine.
17:43I don't even know what it would look like if it did look, um, at least kind of the same.
17:50Yeah.
17:51Yeah.
17:52I really hope that for you.
17:53Thanks.
17:54I didn't want to cry.
17:56I know.
17:57I'm glad you're here.
17:58I know.
17:59I'm really glad to be here.
18:00I know.
18:01I'm really glad to be here.
18:03I know.
18:04Thinking about just living with the pain with, like, the rest of my life is definitely, um, it sucks.
18:10I'm really excited for you.
18:15I feel really hopeful that, you know, he'll be able to do something about it.
18:22Yeah.
18:23With age, it's getting worse.
18:24I'm taking pain meds just, like, to get by and where, like, I can't really see from one eye.
18:33I guess just, like, thinking or, like, knowing that there might be something that somebody can't do.
18:42Mm-hmm.
18:43Uh, it makes me emotional.
18:45I know.
18:46I know.
18:47I know.
18:48So I have a patient coming in.
18:51Her name is Neris, and she has congenital eyelid ptosis.
18:57Basically, when she was born, for whatever reason, the muscles that are responsible for lifting and opening your eyelid didn't develop.
19:05When I look at her photos, I notice the immediate asymmetry of her eyes.
19:10Droopy eyelids can be common, but Neris has a severe version of it.
19:15And that's often the case when people are born with droopy eyelids.
19:19But these eyelids are extremely complicating.
19:22The delicate, finesse nature of eyelid surgery makes it incredibly difficult to treat.
19:28We're talking about muscles that are a millimeter or two thick.
19:32We've got to be able to navigate through these areas, and there's really no room for error.
19:45This program examines medical conditions and the procedures involved with treating them.
19:48Due to their graphic nature, viewer discretion is advised.
19:51Hello.
20:02Hi.
20:03How are you guys?
20:04Good, how are you?
20:05Good, how are you?
20:06Great.
20:07I'm Dr. Panosian.
20:08Nice to meet you.
20:09Nice to meet you.
20:10All right.
20:11So, tell me a little bit about what brings you in today.
20:13So, my left eyelid looks lower than the other eye, and also the pain that I get, just like trying to keep my eyes open.
20:19And I had to close my eyes, and it's like just a pain that I get like on my eyelid.
20:23That's like, um, my biggest issue.
20:26Mm-hmm.
20:27Okay.
20:28When you cannot properly open up your eyes comfortably, your eye is constantly sore.
20:33What happens is that your forehead muscle is overactive.
20:36You're trying to raise your eyebrow enough to pull the skin of your eyelid up because the natural lifting mechanism's not working.
20:42It's almost like you've gone to the gym, and you just can't stop working out because that eye is constantly trying to open up.
20:48But it's magnified in Nerys' case.
20:50What sort of things does this interfere with?
20:54Are you able to drive okay?
20:55I do, like, have to turn my head with the driving just because, like, my vision is limited because my eyelid doesn't open all the way.
21:01I don't even think about driving, honestly, but it makes so much sense.
21:05So, there's a real functional need to get this fixed too, right?
21:08Yeah.
21:09When I close my eyes sometimes, uh, it's like a little gap where it's open now.
21:14But, like, I can't, like, when I look up, like, it doesn't, like, move up either for, like, my vision.
21:19The inability to close the eyelids can dry out your eye.
21:22You can get debris flying in and scratching your cornea, which can ultimately lead to irreversible scarring and blindness.
21:28This is really severe stuff.
21:30So, let's do a little exam.
21:31I'm gonna just grab my ruler real quick and I'm gonna come right around again.
21:35Here we go.
21:39I like to measure out the degree of the drooping.
21:42Let me have you take your glasses off.
21:44And first things first, I'm just gonna have you keep looking at my nose and then sorta look up.
21:57And relax.
21:59Good.
22:00Now, I'm going to put a little ruler.
22:03It's gonna be a little weird to kind of get a sense for how much lifting we are seeing or not.
22:09Look all the way down.
22:10Good.
22:11And now, go all the way up to the sky.
22:15Good.
22:16Excellent.
22:17When examining Nerys, I'm basically gonna see how well her eyelid works.
22:20So, I'm measuring how much movement she's gonna gain out of just simply looking up to the sky.
22:25And in Nerys' case, it's not much.
22:28So, there's a bit of a gap, too, between how much this rises up and what it looks like at rest.
22:35Even when you're trying to look all the way down, this eyelid doesn't even come down all the way as well.
22:40So, there's a few muscles in your eyelid currently.
22:43There's one that is responsible for lifting the eyelid up.
22:46And that's the one that's not really working in your case.
22:49We call that congenital eyelid ptosis, which is a fancy word for a droopy eye.
22:54So, the fix for that is going to come by way of reconstructing this eyelid ptosis or droopy eyelid that you've had since birth.
23:03What's been done for this over the past?
23:05I've had two surgeries on my left eyelid by two different doctors.
23:09But with the other surgeries, there was, like, no results, really.
23:15Yeah. So, doing the same things that were done before is not gonna be a smart idea here.
23:20And so, what we need to do is sort of think a little bit outside the box when it comes to this stuff.
23:25Because we have to kind of recruit a different muscle to pick up the slack of the muscles that aren't working.
23:31So, we're gonna use this forehead lifting muscle right here that raises your eyebrows.
23:37We just take a little strip of it, we release it so that it travels down to the edge of the eyelid,
23:42and then we sew it there at the right height.
23:44When you're trying to really kind of open your eyes really widely,
23:48you're gonna end up activating those forehead muscles anyway.
23:51And in Eris' case, she's gotten used to that, so it's sort of intuitive.
23:55I didn't even know we had a muscle on our forehead.
23:58I mean, I don't know. I don't think about it.
24:03A lot of times, we like to do this under local anesthetic.
24:07With a little bit of sedation just to kind of calm nerves.
24:11So, like awake during the time.
24:14Yeah.
24:17It's a lot to absorb, right?
24:18Yeah, it's a lot.
24:20It does sound a little bit nutty trying to work on someone's eyelid while they're awake,
24:24and having all the instruments come at you, seeing everything.
24:26But I think if you look at the big picture, it's the way to go.
24:31We do it so that we can sort of ask you to open your eyes and close your eyes
24:35and see how we did on the adjustment, a little bit more fine-tuned adjustment.
24:39When she's awake during surgery, she can sort of follow instructions.
24:42She can look up to the sky, look down, look to the sides,
24:45so that I can see the other eye simultaneously.
24:48I want to get that symmetry just right.
24:50When people are asleep, I have to guess.
24:53And I don't like guessing.
24:57Um...
24:58I am very nervous.
25:01I totally get where you're coming from.
25:03Sometimes some people have a little bit of anxiety with it,
25:05and then we can kind of go to a more sleepy state at that point.
25:09Okay.
25:10All right.
25:11I think we can do that all today.
25:12That's our plan.
25:13That sounds good.
25:14That sounds great.
25:15So you're ready to get this done?
25:16Yes.
25:18Let's do it.
25:19All right.
25:20There's really no room for error to make this thing work.
25:22The eyelid's very thin.
25:24There's not much space or tolerance for bad surgery.
25:27Literally, the opening incision is going to be our toughest thing.
25:29Okay.
25:30Awesome.
25:31It's happening, Jen.
25:32All right.
25:33Excellent.
25:34We'll get you into the operating room.
25:36All right, you.
25:46I'm nervous.
25:47Yeah.
25:48You got this.
25:49Today's the day of my surgery.
25:50I'm nervous.
25:51I'm scared.
25:52I'm excited.
25:53All kinds of emotions going on at the moment, which I think is to be expected.
26:08You're in good hands.
26:09He knows what he's doing.
26:11Hey, good morning, Patrick.
26:12How are you doing?
26:13Vanessa.
26:14How are you guys doing?
26:15We're doing okay.
26:16Yeah?
26:17Yeah, nervous.
26:18Yeah.
26:19It's totally normal.
26:20I'm going to get a marking pen in, actually, so we can kind of mark things out.
26:25Yeah.
26:26Okay?
26:27Patrick Gannon has neurofibromatosis type 1.
26:30He had prior surgeries that caused a large divot in his face.
26:34My plan today for Patrick is to fill the divot, move that tissue up where it kind of sticks
26:39out in an unusual way, and get rid of any excess skin.
26:42Then I'm going to move on to the ear, give him the fold, get rid of the prominence that's
26:46causing it to stick out.
26:47All right.
26:48Ready to go back?
26:49Yeah.
26:50Yeah?
26:51And I'll come talk to you as soon as we're done with the surgery, okay?
26:53Okay.
26:54All right.
26:55It's going to take some time, of course, but we'll take great care of him.
26:57This is a tough case.
26:58Dr. Ravallo is going to come out and he's going to give me a second pair of hands, and I think
27:02we can make a big difference, but by far the most critical portion of this surgery is
27:06to make sure I don't injure one of the facial nerves because that could be a devastating injury.
27:10It's game over at that point.
27:12Wow.
27:13Room with the view.
27:14Look at that.
27:15Oh, yeah.
27:21We do a lot of neurofibromas, and each one's a little bit different in terms of where it
27:25is and what it involves.
27:27This case is unique because it's in a very tricky area.
27:31Incision.
27:37This is his old incision.
27:38I'm going to go ahead and use that.
27:42First step is lifting up the skin flat.
27:46And this is a danger zone.
27:47I don't know how much depth I have, and I have to be really careful.
27:50If I cut the facial nerve, I could paralyze his face.
27:53Well, he doesn't have much soft tissue, does he?
28:06No.
28:07No.
28:08Because of Patrick's previous surgeries, the gland that usually covers the facial nerve is gone.
28:14So there is a very real potential that the branches of the facial nerve are sitting right under the skin.
28:21And that's terrifying.
28:22I'm trying to stay above it so that we can make sure if we got close to the nerve, we would see it jump.
28:29Nice.
28:33Do that.
28:34Do you think we're good?
28:38Yeah, I think so.
28:40So far, so good.
28:41And I don't think we've had any issues with the facial nerves.
28:43I'm really happy about that.
28:44So the next step is I move that tissue from below that was too prominent up into the upper face and fill that area of the divot.
28:52It's a mix of normal tissue with some neurofibroma.
28:55It doesn't look cancerous.
28:57So I'm really happy about that.
28:59Kind of see, like, move all that up like that because it's a good secure point.
29:02Yep.
29:03I think that looks like a good start point for me.
29:05That looks great.
29:06I was worried it was going to be hard to get it to all the way smooth and look good.
29:09But I think it came together pretty nicely.
29:11It's looking really good.
29:14More reasonable?
29:15Yeah, it looks good.
29:16Great.
29:17Next up, I want to tackle the ear.
29:19All right.
29:22I'll set it out.
29:25Should we set it like that?
29:28First thing is to figure out where to place the sutures to give them a more natural fold.
29:33This is what I'm trying to create.
29:34Something like this.
29:35You see, when I create this bend, it causes this part of the ear not to stick out that much.
29:40So I made an incision behind the ear so I can get access to the cartilage and put some needles in there to kind of hold the shape that I want.
29:48And then I secure it with sutures once I know it's in the right shape.
29:53That's good, huh?
29:54Yeah, that's a little better.
29:55That's just better.
29:56Yeah.
29:57That's just better.
29:58The ear looks great.
29:59It looks so much more flush against his face.
30:01I think he's going to be really happy with that part.
30:03We're closing, and I just hope this heals as smooth and perfectly as possible for him.
30:09Hi, Vanessa.
30:10Okay, so we're all done.
30:11I think it went very well.
30:12Goal number one, which was the face.
30:13I was able to move some of that excess tissue he had below and got it all the way up to fill the valley, right?
30:24I didn't injure any of the facial nerves, so I'm really happy about that.
30:28And then the ear, it's less prominent and kind of nice and flush against his head so it doesn't stick out.
30:34And honestly, it's almost a little better than the other side, so you may be jealous or want this one to get a little better.
30:39Awesome.
30:40I'm excited to see you on that.
30:41Yeah, yeah, absolutely.
30:42It should be any minute.
30:43Thank you very much.
30:44I appreciate it.
30:45See you, hon.
30:46All right, bye.
30:47Thanks.
30:56I can't believe this is happening.
30:58I know.
30:59Don't leave.
31:01Has it hit you yet?
31:02No.
31:03I feel a little hopeful, but I don't want to be too hopeful just because I've been disappointed from the other two surgeries.
31:10But I am excited just because it won't be the same procedure I've had, so I feel like there will be a difference this time.
31:20Can you eat right after or no?
31:22Um, I don't know.
31:23Hello.
31:24Hi.
31:25All right.
31:26How you doing?
31:27The moment of truth is here.
31:28Yes.
31:29Okay.
31:30Once again, you're going to be awake during this.
31:32A little bit drowsy, but awake.
31:33So we're going to lift up that eyelid to about the level that it is on the other side, okay?
31:38Okay.
31:39And then when I'm ready to actually adjust that muscle, I'm going to have you open and close for me, okay?
31:43Okay.
31:45Well, I'm going to get back in there and get things ready, and we'll see you inside.
31:48Okay.
31:49See you there.
31:50Give me a hug, Jen.
31:51Can I hug you in your scrubs?
31:53Yes, you can hug.
31:54Why?
31:55I don't know if it's, like, contaminating you.
31:57You're already contaminating from being in here.
32:04My name is Carlos.
32:05I want to be your nurse today.
32:06Hi, Carlos.
32:07Nice to meet you.
32:08So Dr. Ravella was helping me out in surgery today.
32:10The value of having another doctor is on the spot, on the fly collaboration.
32:14We're making sure we're getting the best result at the end of the case.
32:17So what we're going to start out doing is get you numbed up.
32:21After that, you're going to feel maybe a little tugging now and then, but you're not going to feel any pain.
32:25If you do feel pain, just let me know.
32:27Okay.
32:28So we're going to just draw a little bit of a line here.
32:32That's sort of where the flap will come down.
32:34So it goes like this, more or less at about the level of the eyebrow.
32:38Let me just get going then.
32:40All right, incision.
32:42Nurse, are you waking up for me?
32:43Yes.
32:44There you go.
32:45Nurse is completely awake during the surgery.
32:48You wonder, oh my gosh, we should better not twitch or move or flinch or do something where, when I got this scalpel near her eyeball.
32:58So we got to take our time, go slow and increase attention and focus.
33:03We're definitely above and into the forehead now.
33:06So I'm going to pull the muscle down now.
33:08What we're going to do is essentially take her forehead muscle and tunnel it underneath the eyebrow and attach it to the edge of the eyelid.
33:14There's just this little strip of tissue right through here.
33:19You can see the instrument going through.
33:21And then as we reach up in here, we'll be able to grab the muscle edge and we can pull it through.
33:28Boom.
33:29Like that.
33:30And then we're going to stitch it into the eyelid like that.
33:33We're getting to the point where we're going to actually attach this muscle to the eyelid.
33:37Now we've got to get Nurse involved.
33:39Hey, Nurse.
33:40Can you open your eyes for me?
33:42Good.
33:43Excellent.
33:44And then can you see that little keyhole up in the sky?
33:47You're just going to stare at that spot for me, okay?
33:49It's like in a big square, right?
33:51Yeah.
33:52Just kind of keep looking at that.
33:53I just want to see where we're going to lift this up to.
33:55It's going to be roughly about there.
33:57This is the moment where we have to anchor the muscle on the eyelid.
34:00It's a very important step to make sure that those stitches are placed as accurately as possible.
34:06If you over-tighten that eyelid and then she can't close it afterwards, we've got ourselves a problem.
34:12Okay, so let us start setting this muscle in.
34:16Can you try to close your eyes?
34:18Good.
34:19Excellent.
34:20And open.
34:21Good.
34:22Having an awake patient during surgery, that means she can open and close her eyes.
34:24So I can set that adjustment on that eyelid level accurately.
34:28Oh.
34:29You okay?
34:30I felt that bad.
34:31You felt?
34:32Okay.
34:33A little bit more local coming.
34:35Mm-hmm.
34:36Thank you, doctor.
34:37You're welcome.
34:38You're a very polite patient, doctor.
34:39I don't want to be too needy.
34:41You don't want to be too needy?
34:42You're not being needy.
34:44Don't you worry.
34:45You're doing great.
34:46She's doing a great job.
34:47So much so that she was joking during the surgery, which is always fun.
34:52Okay, so open your eyes, hon.
34:55No.
34:56I'm just going to do that one again.
34:58I'll tuck that up a little bit more like that.
35:00I think it's just enough tension.
35:02I don't want to overdo it.
35:04Now, can you try to look all the way at me?
35:07There you go.
35:09Shoot.
35:11It's uneven.
35:14It doesn't match.
35:16I don't like it.
35:19Uh, if we get the adjustment wrong, then your symmetry's ruined.
35:25And that's the problem that I'm worried about.
35:28Something something over here.
35:32I'm looking at the eyelid levels and it doesn't match.
35:47This stitch may be a little aggressive right there.
35:50Scissor, please.
35:51It's going to require a great deal of finesse to get the eyelid levels dead on.
35:56So what I want to do is sort of take a look at how those lashes go and sort of re-approximate it.
36:02I'm going to sort of tighten it down and we'll see the difference here.
36:05As this sort of secures down, this should allow the lid to right up there.
36:11So let's put a few more of these guys in.
36:17Now, let me have you open your eyes and look at that spot at the ceiling there, okay?
36:21All the way up, all the way up.
36:22And then really use your forehead to kind of make it go.
36:25There it is.
36:28It's pretty even.
36:30It's pretty good.
36:32So we're just going to start stitching this thing closed.
36:35I feel great.
36:36Yeah.
36:37Everything went well.
36:38We had a lot of length of muscle to use and we got her eye open.
36:41Mission accomplished.
36:42So now that she's got a functioning upper eyelid, she shouldn't have any more pain moving forward.
36:46All right.
36:47All done, okay?
36:48All right.
36:49Thank you, doctor.
36:50Okay.
36:51You did it.
36:52You did it.
36:53You made it through.
37:06I will be seeing Neris today.
37:07She's coming in for her follow-up.
37:09We did a droopy eyelid repair and I'm excited to see how the results have panned out.
37:14This is actually an incredibly difficult surgery.
37:18But what I'm hoping to see is both eyelids are on the same level.
37:22The second thing I'm hoping is that that pain with that area she was complaining of will forever be gone for Neris.
37:32Hello.
37:33Hi.
37:34How are you?
37:35Good. How are you?
37:36Long time no see.
37:37I'm going for the real thing.
37:38Here we go.
37:39We've already got real personal.
37:41I know.
37:42So fill me in.
37:43I mean, you look awesome.
37:45So fill me in.
37:46What's been going on?
37:47Well, I feel like it's definitely a lot more open and I haven't gotten that soreness at all, actually.
37:54So that's definitely a plus because just getting that pain was just like a lot.
37:58I mean, I love to hear this.
38:00This is exactly why we were doing this stuff.
38:02So let's do a little exam.
38:04Would you mind taking off your glasses?
38:06There we go.
38:07Excellent.
38:08I'm looking at how the bottom eyelid lines up, how the top eyelid lines up.
38:13I'm looking at it.
38:14It's pretty darn even up top.
38:16Then you're able to close completely.
38:18I mean, I am very happy for you.
38:21This is as great a result as I can hope for.
38:23And I think it's just going to get better with time.
38:27I really appreciate what you've done for me.
38:29It's definitely made a big change in my life.
38:31I am very, very grateful of Dr. Panosian.
38:35I never in a million years would have thought that I would have had an opportunity like this.
38:41And here I am.
39:01I have the follow-up for Patrick Gannon today.
39:03And I'm hoping to see that the contour is much better on the left side of the face.
39:07And then I just want to see that the ear doesn't stick out as far as it did before.
39:13Patrick.
39:14Hey, Doc. How you doing?
39:15How's it going?
39:16I'm doing all right.
39:17Well, thanks for making it again.
39:18Yes, thank you for having me out again.
39:20Yes, of course.
39:21So you look great.
39:22Thank you. I feel good.
39:23You feel good?
39:24Yes.
39:25Awesome.
39:26And the face just feels great.
39:27It looks great.
39:28Awesome.
39:29Yeah, the contour on the face is so much better.
39:32It's so much smoother than before.
39:34And let's take a look at the ear.
39:37The fold is definitely better than before.
39:40They look really good.
39:41Yeah.
39:42Yeah.
39:43It feels better.
39:44Awesome.
39:45It looks better.
39:46Lots of people tell me that.
39:47Awesome.
39:48And it's really good to hear.
39:49Yeah, all good things.
39:50All right.
39:51All right.
39:52Well, if you need anything else, please let me know.
39:53And don't hesitate to reach out.
39:54Thank you so much, Dr.
39:55Yeah, absolutely.
39:56All right.
39:57We'll see you next time.
39:58This experience has just been amazing and wonderful on so many different levels.
40:04I am so grateful to Dr. Bruce Dying for being able to do this for me and help me out.
40:09All right.
40:10I have Nerys Martinez.
40:11And she sent us this video.
40:12Just take a look.
40:13Let's see it.
40:14Hi, doctors.
40:15It's me, Nerys.
40:16I'm here at my home in South Carolina with my cat and my dog, Leia.
40:17It's a whole new world with my vision.
40:18She looks great.
40:19Like, I can see so much more.
40:20Before the surgery, I was always trying to hide my eyes behind my glasses because I didn't
40:25like how I looked.
40:26like how I looked.
40:27But now.
40:28Contacts.
40:29I'm not my contacts.
40:30Love it.
40:31Love it.
40:32Love it.
40:33I don't think I've ever imagined to be where I am now.
40:34And I'm very, very grateful for this opportunity.
40:35I'm not trying to hide my eyes behind my glasses because I didn't like how I looked.
40:40But now.
40:41Contacts.
40:42I'm not my contacts anymore.
40:43Love it.
40:44Love it.
40:45Now I'm on dating apps and I'm trying to get out there a little more and not trying
40:52to hide.
40:53And it's just been a great journey.
40:56I love that dog in the back.
40:57I don't think I've ever imagined to be where I am now.
41:01And I'm very, very grateful for this opportunity.
41:05And I'm just excited to see where I go from here.
41:08With my babies.
41:10I mean, she got upstaged by the dog, but I mean, wow.
41:15I mean, she looks great.
41:16She looks fantastic.
41:17How huge it is to be on dating apps.
41:19I mean, that's really putting yourself out there.
41:21She's great.
41:22It's like Clark Kent glasses off and now she's superwoman.
41:25So, right?
41:26Absolutely.
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