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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.
00:08I think back just being absolutely terrified looking in the mirror for the first time.
00:13Her nose and her jaw was torn out.
00:17People shout out obscenities or say nasty things.
00:22Because of her facial paralysis, she's unable to close her eyes fully.
00:25And eyelids are incredibly important to protect the eye from debris, scratching the cornea, losing your vision.
00:33I was actually born with some fibromas.
00:36Elizabeth has hundreds of tumors on her face and neck area.
00:40We have a surgery for this.
00:41It's like something that you wanted your whole life and it's handed to you.
00:46This tumor goes pretty deep.
00:48It's like a little dynamite that's about to explode. That's what's inside right now.
00:51Sometimes they do pop out like a pimple.
00:53I'm about to pop.
00:55I'm just worried about the support from inside the nose.
00:58It's way worse than I imagined.
00:59There's nothing there.
01:09So I got this patient. Her name is Josephine Shattuck.
01:13And when she was five years old, she unfortunately had this horrific dog bite to the face.
01:18Oh, dog bites are so hard, especially in kids.
01:21They're right at face level with the dog.
01:23She's 22 years old now.
01:25She has multiple scars on her face.
01:30You can see super crooked nose.
01:34It's got the reverse C shape deformity.
01:36When approaching plastic surgery of the face, you first have to consider the function.
01:40Are they going to be able to move their face better?
01:42Are they going to be able to breathe better?
01:44Are they going to be able to close their eye?
01:46The inner part of the eye is way lower on the left side than the right side.
01:51She has a little bit of scarring down of the lid.
01:54Oh, gosh, yeah.
01:55Wow.
01:56There it is.
01:57Yeah.
01:58Yeah, that's definitely full paralysis on that side of the face.
02:00Every emotion you have, you can see through the face.
02:03When somebody has some kind of facial difference, whether they like it or not, sometimes that
02:08could be misinterpreted.
02:09We're designed to communicate with the face, and not being able to do that from human to human
02:15has got to be so difficult.
02:17We see a lot of dog bites, but this is definitely one of the worst ones I've seen.
02:21Yeah, I think this is the worst dog bite I've seen.
02:24Absolutely.
02:25This injury is devastating.
02:28I can't, there's no better word for it.
02:30She's had to deal with a lot growing up, obviously.
02:33And by restoring the way she looks, we're hoping to restore the way she feels.
02:37What we're looking at here is really complicated.
02:40It's going to be a challenge for sure.
02:41I agree.
02:42Yeah.
02:47I prefer when people ask, you know, what happened rather than what's wrong.
02:51Because there is nothing wrong with me.
02:56Like, I'm just as much human as anybody else.
03:01It's just that I'm different.
03:10You know, most girls get to look in the mirror and say, oh, my hair looks silly today,
03:14or makeup smeared on my face.
03:16That's not what I see.
03:21When I look in the mirror, the first thing I see is all of my insecurities.
03:37You know, oh, that scar looks dark today.
03:39Or my eye is watering today.
03:41Nothing on my face is symmetrical.
03:43My nose is crooked.
03:44I notice all of the little things that most people don't have to notice.
03:49I don't put makeup on every day because it is a lot of work.
03:54It sucks.
03:55Like, it's a long process.
03:56I use the color corrector on my scars to kind of take down the redness.
04:05My eyes is definitely all mascara.
04:08Sometimes I do eyeshadow, but the thing with eyeshadow is it's hard because this eye doesn't close.
04:15I actually avoid lipstick at all costs because my lips are not symmetrical.
04:20So then it just looks funny.
04:22I was only five when my accident happened.
04:27A dog attacked me.
04:32I remember being thrown against the wall.
04:35And when I had started crawling away, the dog had grabbed my leg and pulled me back.
04:41I do remember my skin flopping in the air.
04:48My face felt cold.
04:51I do remember, like, looking at the dog.
04:54And I remember, like, seeing the blood, like, in its fur.
04:57I was told that, you know, the dog had ripped off the tip of my nose, like the cartilage part, and that somebody was sent to go retrieve that piece and bring it back to see what could be done.
05:12I think back on waking up in the hospital, just being absolutely terrified, looking in the mirror for the first time.
05:21It was purple skin, bandages, absolutely terrified.
05:37My boyfriend's name is Alec.
05:38We've been together for five years, and we actually went to the same preschool, and we have a picture together.
05:43So that's super fun.
05:45He told me that, like, he fell in love with me for how I look right now.
05:50He reminds me every day that I'm beautiful and that he loves me for who I am, which means so much.
05:58It's so hard to find somebody that genuine.
06:01He's amazing.
06:09Hey, Joe.
06:10Hi, Mom.
06:11How's it going?
06:12Good.
06:13Kinda nervous, but more excited.
06:16Yeah.
06:17We'll have to leave here shortly.
06:18Got lots of stuff to pack.
06:20Five years ago, with my last surgery, the doctors told me that nothing else can be done at this point.
06:26You know, that we've done everything that we could from Wisconsin.
06:29So my stepmom and I are going to Los Angeles to meet a couple new doctors to dive in and see what they can do.
06:38I'm excited to meet the doctors.
06:40I do.
06:42It would be interesting to see what they say.
06:44Yeah.
06:45I guess technology has changed so much that now they can do so much more.
06:48This is it.
06:49This is it.
06:50I have been through every surgery with Josie, at least 14, for sure.
06:57And as a parent, it is hard to watch your children struggle.
07:02You kind of always have that little fear in the back of your head, like, okay, what can still go wrong?
07:10I don't know if this is the last chance, so we'll see what happens.
07:14Mom.
07:15OK.
07:21Are you missing me, correct?
07:31Hi.
07:32Hi, I'm here for my appointment.
07:33Sure.
07:34Go ahead and sign in, please.
07:35If these doctors aren't able to do anything more for me or improve anything, then I would be broken.
07:42and I would be shattered like glass.
07:56Given that Josie's problems are so intense,
07:59I will be teaming up with Dr. Rustayan.
08:01He's a recognized nasal reconstruction expert,
08:03and I will address the facial paralysis issues.
08:07Hi. Hello.
08:08All right.
08:10So, Josephine, I want to just start off by asking you
08:14what went on with all this exactly.
08:16Do you recall any of it?
08:17I think it was July 28th.
08:19July 28th.
08:20Of 2005.
08:21I was five years old.
08:23It was a family friend's dog.
08:25It lunged at me, and I could kind of remember
08:27the feeling of air, you know, like the coldness
08:29of air hitting whatever it was hitting.
08:33She was torn left to right.
08:36As you can see, the tear marks.
08:39Her nose and her jaw was torn out, and then she was off to surgery.
08:44So tell us your wish list.
08:46If we were the two genies in the bottle, I guess.
08:50You might be.
08:51Let's hope we are.
08:52Like, what would be your number one wish?
08:54To start off, it would be my eye.
08:56It's just, like, constantly watering, super droopy.
09:00I can feel the pain and the burning in my eye from the tears.
09:05I guess additionally, too, like, my dream as a little girl has always been, like, a perfect nose.
09:10So let's talk about the eye.
09:13Can you close your eyes as best you can?
09:15Nice and comfortably.
09:16There you go.
09:17Now, I've just followed my finger with your eyes here.
09:20Because of her facial paralysis, she's unable to close her eyes fully.
09:24And eyelids are incredibly important to protect the eye from debris hitting it and scratching
09:30the cornea, losing your vision, drying out, tearing.
09:33Okay.
09:34So you have a little bit of a drooping of the lower eyelid.
09:39It's the result of your nerve to the face was injured.
09:42Now, as far as the rest of the facial paralysis goes, the immediate thing that you see is the
09:47smile is missing.
09:48There's no movement happening at the corner.
09:50You know, in terms of the nose, should we take a look on the inside, see what's going on?
09:54Is that all right?
09:55Yeah.
09:56Yeah?
09:57I got a little instrument here.
09:58Came all the way from Wisconsin?
09:59We're not going to look in your nose?
10:00Yeah.
10:01It might be gross.
10:02You mind if I just stand on this side?
10:04No, not at all.
10:05How's your breathing?
10:06Maybe easier to breathe in through this one.
10:08Let's take a look on the inside here.
10:11When I examined her, I saw an extremely crooked nose.
10:15You know, your septum in the front curves into the left side, but as you go further back,
10:20then it goes back to the right side.
10:21So it's kind of going in every direction.
10:23You know, never grew normally on one side because the dog injured it so bad that all that scar
10:29tissue, you know, prevented it from healing normally.
10:32That is absolutely going to be a huge challenge.
10:36I have a patient coming in.
10:38The problem that these tumors form is incredibly life-altering.
10:42So we got your 3D images up.
10:45I'm able to make alterations to the image and actually simulate it in front of their eyes.
10:49Yes!
10:50That was me with a perfect nose.
10:52The big ones have to be cut out.
10:54You definitely want to stay away from the jugular here.
10:57The jugular vein is a very large vein.
10:59So if we nick it, the person dies.
11:16So now I would really like to take some 3D photography.
11:20We use it, you know, to get standardized views, get idea volumetrics, and just gives us more information essentially.
11:27The nice thing about 3D imaging is that it gives you some ability to give them a taste of what you're talking about.
11:33So I'm able to make alterations to the image and actually simulate it in front of their eyes.
11:38So we got your 3D images up and we want to take a little bit of this convexity, but it's also about getting this tip out for you.
11:45So I kind of simulated this for you, so let's see if we can see the results here.
11:49Yes!
11:52So this is the before and now the after.
11:54All right.
11:55Oh, that's awesome.
11:56I always used to say as a little girl I wanted a perfect nose, and when I looked at that picture, that was me with a perfect nose.
12:04What I would like to do next is talk about what our plan should be.
12:08Okay.
12:09For the eye, when you have paralysis, what we do is we go back in there and we have to bring it back up.
12:14And the plan is to take a little tissue from the roof of your mouth and then insert it into the space on the inner eyelid.
12:21And then finally, most people think of it as smile surgery.
12:23We use the temporalis muscle, which is another biting muscle, and pull it through the cheek and reattach it to the corner of the mouth and animate the smile.
12:32So in terms of the nose, you know, I want to shave down the bump a little bit, support the tip, get the nose as straight as possible by correcting the deviated septum.
12:41That's on my end.
12:42Okay.
12:43Yeah.
12:44So I don't know.
12:45How do you feel?
12:46What do you think about the plan?
12:47I'm excited.
12:48Yeah?
12:49Are you?
12:50Yeah.
12:51Awesome.
12:52And I have really high hopes for this surgery.
12:55If this doesn't work, then how is one supposed to move on with that?
12:59This is probably a bigger surgery in some ways, but I think really meaningful for you to hope.
13:04Oh, yeah.
13:05Josie's had a lot of surgery.
13:07She's got a lot of scar tissue.
13:08She's got a devastating injury.
13:09Quite honestly, we don't know what we're going to encounter until we're there.
13:13This surgery is absolutely going to take several hours and it's going to be a major challenge.
13:28So I have a patient coming in.
13:29Her name is Elizabeth Keller.
13:31She has a condition called neurofibromatosis.
13:35And what that results in is the development of hundreds of these tumors all over the body.
13:42They're kind of like little golf balls and marbles underneath your skin that can be quite painful, itchy.
13:50And it's a condition that I specialize in.
13:53So I often will get patients from all over the world coming here for basically tumor removal services.
13:59And in Elizabeth's case, hundreds and hundreds of them are present on the face and neck area.
14:05So you can't escape it.
14:06You can't hide it.
14:07The biggest challenge is the sheer number of these tumors and how concentrated they are.
14:14This is really severe stuff.
14:21People stare a lot when you go out.
14:24People shout out obscenities or say nasty things and you try to get used to it.
14:33But there's times where you just can't.
14:36It's so cold.
14:37Oh, gosh.
14:38I don't know.
14:39It's hot.
14:40Yeah.
14:41It is a little warm today.
14:42It is.
14:43Yeah.
14:44Oh.
14:45But it feels good.
14:46It does.
14:47But the hotter it gets, the worse they hurt.
14:49When I get too hot sometimes, the bigger ones that I have, they sweat and they become more painful.
14:58And it's like if you have a rash and it itches, that's what it feels like sometimes when it gets too hot.
15:03Is there anyone that like hurts specifically more or like?
15:06Um, my chest and my torso hurt the most.
15:08Yeah.
15:09But like the twins, you know, they hurt the most sometimes because my shirt will rub them.
15:12Oh, yeah.
15:13And the big one right here always hurts on my neckline or the one right there.
15:17Like I can't wear hats without them hurting or sunglasses because the sunglasses pushes pressure on them.
15:23A brush across it just, just the right way.
15:25It just is so painful.
15:26It's hard when it's a hot day and I have to have my hair pulled up because my hair is so thick.
15:30And then the ones on my neck will itch and they get itchy and it gets hot and they get sweaty and it's either be miserable or have people stare.
15:39I wish we lived in a world where people didn't judge you on what they saw instead of what you were on the inside.
15:44Do you like notice when people look at you? Do you feel like they're always looking?
15:48Yeah.
15:49Not always, but there are times where I can feel somebody looking at me or, you know, like you can hear.
15:54You can't hear them whisper, but you can see like them leaning and talking like this.
15:57Right.
15:58You know, just staring at me makes me mad.
16:00Right.
16:01You know, looking at me and just staring or whispering.
16:04Yeah.
16:05Just like them. Did you see? They just like stared as they went by.
16:08Yeah.
16:09It's old. I mean.
16:10Do you get tired of it?
16:11All the time.
16:12Yeah.
16:13You would think you would get used to it after a while, but you don't.
16:15And some looks hurt worse than others.
16:17Some looks hurt like somebody cutting you.
16:19Because you're different.
16:20Yeah, because I'm different, but you know, that just means I'm special.
16:22You're so human.
16:23You know, sometimes it just hits you differently.
16:25By the way, people are not trying to hide that they're staring or they're not, you know, they'll walk by and it's a group of teenagers and they'll bust out laughing.
16:32You know, they say sticking stones will break your bones, but someone just looking at you differently can hurt just as bad as a word.
16:38It cuts just as deep as a knife.
16:39You know, I'm at a point in my life where I would really love to have the surgery to remove some of them.
16:44Right.
16:45Just because the older I get, the more painful they are and it's every day.
16:48Yeah.
16:49You know, it's like being, it's like walking on pins and needles every day, but it's all over your body.
16:52I've had surgery once when I was in the eighth grade, I had a big one on my knee and it like swelled up to the size of almost a softball.
16:58And then in high school, I had a few removed that have grown back, but I have a lot more tumors now.
17:04I feel like I could not imagine.
17:05Oh, and that's why I'm going to Los Angeles so I can meet with Dr. Panosian and get this surgery and make my life change just even a little bit for the better.
17:14I've known about Dr. Panosian for a couple of years now.
17:17I've been watching his stuff thinking, man, I wish somebody was like that in Kentucky that could do this.
17:21He's the best.
17:22That's why I'm so excited.
17:23Hello.
17:24Hi.
17:25My name is Elizabeth.
17:26I have an appointment today.
17:27Oh, perfect.
17:28Go ahead and sign in.
17:29Okay.
17:30I'm feeling so anxious and excited and nervous.
17:44If you could put all your emotions in together for one thing that you've wanted for so long and it's like a little dynamite that's about to explode, that's what's inside right now.
17:51I'm about to pop.
17:53I'm just ready to be able to go and not have the pain, the itchiness, the stares, the points, but just to be pain free is the main thing.
18:02I'm going to have to take a run and jump for this thing.
18:04I know.
18:05Too short.
18:06There we go.
18:07Come in.
18:08Hello.
18:09Hey.
18:10How are you?
18:11Good, and you?
18:12I'm Dr. Panosia.
18:13I'm Elizabeth.
18:14Good to meet you.
18:15I'm Heather.
18:16And how do you know each other?
18:17We're best friends.
18:18Best friends.
18:19Okay.
18:20So I understand you have neurofibromatosis.
18:21Yes.
18:22Okay.
18:23I was born with it.
18:24I was actually born with some fibromas.
18:25You did.
18:26Okay.
18:27Okay.
18:28And how many surgeries have you undergone since then?
18:29Maybe four, just to have little ones removed, but they were removed incorrectly.
18:33So the ones that I did have removed have grown back around the scars.
18:36Okay.
18:37And as I got older, they became more profound when I was pregnant and they were more noticeable.
18:41That is a frequent theme.
18:43Yeah.
18:44I was totally controlled until I got pregnant.
18:46Yeah.
18:47And all of a sudden it just exploded.
18:48Yeah.
18:49Tubers everywhere.
18:50Yeah.
18:51When you're pregnant, you have such a flood of hormones throughout the body.
18:54Those hormones can also impact this condition.
18:57Yeah.
18:58So let's move on into a little bit of an exam.
19:00Okay.
19:01Let's see what we're up against.
19:02Okay.
19:03If you want to pull your hair back a little bit, I'm just going to kind of come in and
19:06take a close look at all these areas.
19:11Mm-hmm.
19:12And we've got a big one here.
19:15In my exam, I'm seeing she's got various types of tumors.
19:18You've got these very large ones, and some of them look very angry on the surface, red,
19:23raised, also very tender when you touch it.
19:26And obviously it goes down on your chest and probably up onto the abdomen and all that.
19:31Then you've got these little flat ones, and there's hundreds of those little flat ones,
19:35almost coalescing with each other, kind of combining to form like this general textural change in the skin.
19:42How many there are, how big they are.
19:45Her photos leading up to this didn't give it justice.
19:48It is a very severe problem.
19:50This program examines medical conditions and the procedures involved with treating them.
19:57Due to their graphic nature, viewer discretion is advised.
20:02So you can see as you kind of, let's go pull the hair back over.
20:06And you've got a large one back behind the ear.
20:08Some of these are sort of deeper underneath, almost like an iceberg on the surface.
20:12It's tiny, but if you feel it, there's a bit of a root to it.
20:16What other tumors really bother you?
20:18The twins.
20:19The twins?
20:20Let's see.
20:21Look at that.
20:22There were two little ones and they started getting bigger to the point where they're almost all the way touching now.
20:25Yeah.
20:26Let's talk about what we can do.
20:27Okay.
20:28The good news is, we have a surgery for this.
20:31We can help you out here, which is great.
20:33Yes.
20:34The surgery itself.
20:35I know, right?
20:36I know, huh?
20:37What we do is essentially remove as many of these tumors as possible.
20:41I think we can get virtually every one of them on the face and the neck.
20:46Sometimes I have to make sort of judgment calls during surgery about leaving one or two behind if I'm creating too much of an injury to your skin.
20:56Okay.
20:57There are different ways of taking these tumors off.
20:59The big ones have to be cut out.
21:01But you have lots of little ones.
21:02Yes.
21:03So, we do something called electro-desiccation.
21:06Electro-desiccation is basically burning these tumors.
21:10Okay.
21:11Or cauterizing them.
21:12What we do is use a device that will burn the tissues.
21:15It's got a little needle-tip probe to it.
21:16Okay.
21:17We burn the tissues and we move to the next one and we do that pretty rapidly.
21:20Okay.
21:21There is another thing that we end up doing during surgery and that's a combination of electro-desiccation and excision.
21:28Okay.
21:29So, some of these tumors are like an iceberg.
21:30Yeah.
21:31On the surface, they're kind of teeny.
21:32Mm-hmm.
21:33But you don't even get the sense of how big that root is underneath.
21:36Now, when we do electro-desiccation, that tumor swells aggressively if there's a little bit left behind.
21:42So much so that I can see it happening.
21:44Okay.
21:45When I do the treatment.
21:46So, when I see it, I kind of realize, ah, okay, there's a root under this.
21:50So, I will take a little tiny curette, which is kind of like an ice cream scooper.
21:54Okay.
21:55I'll go right through that electro-desiccation wound and I'll scoop it right up.
21:57Okay.
21:58And then, all of a sudden, magically, it goes flat.
22:00Oh, wow.
22:01Just like that.
22:02Good job.
22:03Very excited.
22:04Excited?
22:05Yes, very much so.
22:06Ready to do this?
22:07Yes.
22:08Let's go.
22:09Excellent.
22:10So, let's do that.
22:11Okay.
22:12Even though some of these tumors might seem really tiny on the surface, we really don't know what it's
22:13like underneath the skin.
22:14It doesn't mean that it doesn't have this big giant root underneath, kind of like weeds.
22:19And if you leave one of these roots behind, then there's a potential for that tumor to
22:24come back.
22:25I need to get all of it.
22:26It's going to happen.
22:27I can't.
22:28I'm so happy for you.
22:29I'm going to cry.
22:30I'm going to cry.
22:31I know.
22:32You keep telling me not to cry.
22:33I know.
22:34I know.
22:35I'm going to.
22:36This is something I've wanted for so long.
22:39Sorry.
22:42It's like wanting something that you've wanted your whole life and you never thought
22:46you'd get it and it's handed to you.
22:49I'm just very thankful.
22:59It's going to be great.
23:00You're going to feel beautiful.
23:01Aw.
23:02Can we get the pictures at the top of the bed?
23:15Okay.
23:16That's perfect.
23:17That's all we need.
23:18Yeah.
23:19It's going to be a challenge.
23:20That it will be.
23:21For sure.
23:22Today is surgery day and it's going to be an absolute game changer for Josie.
23:27Hey Josie.
23:28How are you doing this morning?
23:29Good.
23:30How are you?
23:31Yeah.
23:32You feeling ready?
23:33Yeah.
23:34I think I got the crying out of the way.
23:35Good.
23:36We're going to take really good care of you.
23:37Okay?
23:38We're all going to watch every step of the way.
23:39Pound it?
23:40There you go.
23:41All right.
23:42See you at surgery.
23:43I'll see you there.
23:44Goodbye.
23:45Love ya.
23:46Big picture, I'm going to work on the nose and Andre's going to take care of the eye
23:50and the face.
23:51But you get one shot to do this right because it's a disaster to try to go back.
23:55There's just more scar tissue and it's more challenging.
23:57All right, man.
23:58You're up.
23:59Okay.
24:00Incision.
24:01We're opening a lower eyelid.
24:05What I'm doing is essentially releasing the lower eyelid from its tether.
24:10And that's going to help the lower eyelid rise up.
24:13Now we've got to support that lower eyelid.
24:15I'm going to take a little piece of tissue from the roof of her mouth, splice it into
24:20the lower eyelid and essentially suture these tissues together.
24:23And that's going to help the lower eyelid stability.
24:27When we're working on eyelids, you can imagine these are very delicate structures and we have
24:31to have a whole different set of instruments that are much finer to work on eyelids.
24:36You better be on your game.
24:38Injury is only a few millimeters away.
24:40You cannot make mistakes.
24:42All right.
24:43Before this eyelid was further down like this and now it's sort of popping right back up
24:49to a better position.
24:51She's going to be able to close her eyes better now and give her a much more symmetric appearance.
24:56So now we're moving on to the cheek here to reestablish the balance.
24:59Where my finger is is where the muscle is and we're going to move it right back down like that.
25:03We need to restore some of that volume.
25:05But at the same time, we're going to actually move the temporalis muscle which lives all the
25:10way up here and slide it down through the cheek and connect it to the corner of the mouth
25:15right through here and animate the smile.
25:17Okay.
25:18Knife, please.
25:19I'm thinking probably the best bet is just go down that scar.
25:20Yeah.
25:21Today it's been pretty emotional.
25:35Your mind goes so fast and from emotion to emotions and is she going to be okay?
25:42Is it going to be painful?
25:43Yeah, this is it.
25:44We've got to just sort of swing that back into that spot.
25:47You want her to feel really good about herself like she does on the inside.
25:51It feels good.
25:52I mean, I think we've done a pretty good job here correcting what we set out to do.
25:57That vibrant, beautiful person and she looks in the mirror and sees that's who she
26:01is on the outside too.
26:06I'm working on the nose and I want to figure out how to get everything as straight as possible.
26:11But you can't know until you get in there and see the actual structural integrity of the
26:16cartilage, how much bone was there, exactly how all the pieces are going to come together.
26:21I have no idea.
26:22So it's making it look crooked there.
26:23Yeah.
26:24Right where it's bending is where it's all beaten up.
26:26Yeah.
26:27The bone is soft and unstable.
26:30She had no support for the nose.
26:31It was like a big squishy piece of skin.
26:34See, like on this side, there's really no bone.
26:36See, that's like gone.
26:38The bone is a point of structure, so when that's missing, that makes my job harder because
26:43parts of the nose are hanging off of that.
26:45Just worried about the support from inside the nose, so it's way worse than I imagined.
26:50See that?
26:51Yeah.
26:52See that?
26:53Yeah.
26:54Yeah.
26:55The bone's gone there.
26:56See, like this side's missing.
26:57This side's gone.
26:58When we're trying to straighten out a nose, you need something for structural support.
27:02But after I opened the nose, I noticed there was a major missing bone there.
27:03And, you know, that definitely, you know, the bone is missing.
27:04It's gone.
27:05When we're trying to straighten out a nose, you need something for structural support.
27:09But after I opened the nose, I noticed there was a major missing bone there.
27:10And, you know, that definitely, you know, took me by surprise.
27:16You just have to figure out what to do from there.
27:17Yeah, I'm just going to slide something right there and try to get it like that.
27:25And, you know, this is part of my job.
27:30I mean, you have to figure out what to do from there.
27:31Yeah.
27:32You can just slide something right there and try to get it like that.
27:41And, you know, this is part of my job.
27:43I mean, you have to go to this.
27:44How can you take that value?
27:46I mean, you have to problem-solve on the fly.
27:48Here, let me try it from here.
27:50Should we try the 30-degree scoop?
27:53It's pretty weak.
27:55OK.
27:57I think we're going to need the rib graft.
27:58And finally, I used a couple of tricks.
28:01We used a cadaver rib, because that's the best replacement
28:03for the bone of her nose.
28:04The rib is a nice straight piece of bone.
28:07Plaster the two together, and that's like a splint
28:10that straightens and strengthens the nose.
28:12And this is shaping the whole root of the nose.
28:16So I got the rib graft in there.
28:17And finally, after a lot of work and effort,
28:20it finally looks straight.
28:21Now I got to get the tip rebuilt.
28:24You know, how far to set out the tip,
28:27what rotation to put the tip at, that's all, you know,
28:30an artistic call.
28:32And your persistence to work at it until it looks
28:34as perfect as possible is so important.
28:41All right, man, I'm finally done.
28:42It's a, that was a battle.
28:44That was rough.
28:45It wasn't easy.
28:46But, but I think we accomplished our goals.
28:48So thanks, man.
28:50I really appreciate that.
28:51So probably a lot closer, more the cuter nose she was,
28:54you know, hoping for.
28:55It looks straighter.
28:56The bump's gone.
28:57The tip's in the right place.
28:59Looks a lot more symmetric.
29:00And it's going to breathe a hell of a lot better.
29:02I think she'll be happy with that.
29:03I really hope so.
29:05Put a lot of work into it.
29:06It feels good.
29:06I mean, I think we've done a pretty good job here
29:09correcting what we set out to do.
29:11We corrected the eyelid and moved the biting muscle over,
29:14correcting her smile.
29:15I'm feeling really good about it.
29:17From where she started to where she is now,
29:19it's just phenomenal.
29:20All right, man.
29:21Good.
29:22Excellent.
29:23Great job.
29:24So I have Josie coming into the clinic today.
29:38And the dog bite went, like, through the scars all.
29:42You know, she had a very crooked nose.
29:44And I'm just really, really hoping that it's straight.
29:49But most importantly, I hope to see a happy Josie.
29:54Hello.
29:57So good to see you.
29:58You look great.
29:59Nice, stranger.
30:00You look great.
30:01The tip, you know, is a lot better supported.
30:04Really happy to see that.
30:05It looks beautiful.
30:06And it's just going to get better and better from here.
30:08You know, you had what we call a major C-shaped deformity.
30:11It was really curved.
30:12Now it looks perfectly straight down the middle.
30:15Really happy to see that.
30:16It looks beautiful.
30:17And it's just going to get better and better from here.
30:19You know, there's still some swelling there.
30:21But already it looks great.
30:22And it's awesome.
30:23And it's awesome to see that.
30:24Give me a big bite.
30:25And relax.
30:26And look at that tug right there.
30:27You've got a lot of good movement there.
30:29The immediate thing that you see is the smile is missing.
30:32There's no movement happening at the corner.
30:34Now give me your best smile.
30:36Excellent.
30:37That is a smile.
30:38You have a smile.
30:40That's really fast.
30:41It's beautiful.
30:42And it's only going to get better from here.
30:43Yeah.
30:44It's really cool to see.
30:45Yeah.
30:46Yeah.
30:47So what's new in your life?
30:49What's been happening since the time of surgery?
30:51I'm getting married.
30:52What?
30:53That's a big one.
30:54Oh my gosh.
30:56Beautiful ring.
30:57Wow.
30:58Congratulations.
30:59I did in a way.
31:00I told him what I wanted and he did the thing.
31:04I'm getting married to the love of my life and I'm feeling happiness, joy, all things positive.
31:11I'm just like extremely thankful for the both of you.
31:16You know, I'm extremely grateful from the bottom of my heart that they did an amazing
31:21job.
31:22I definitely want to use my smile at my wedding and show everybody how strong I am and that
31:28I've made it this far with a smile on my face.
31:31Well, thank you guys.
31:32Yeah, of course.
31:33All right.
31:34Let's bring it in for a big hug.
31:35Tribble hug.
31:36Tribble hug.
32:03Okay.
32:04Ready to prep?
32:05Let's do it.
32:06Today's the day for Elizabeth's surgery.
32:10So the plan is to remove as many tumors as we can.
32:14There's a lot of improvement that we're looking for which will restore her confidence, her inner
32:19personality and basically let her enjoy life more.
32:22Yeah.
32:23Let's put one up underneath her knees.
32:25My hope for the surgery is that I will be pain free and not have the itchiness, the stairs,
32:31the points.
32:32I'm ready.
32:33It's been a long time.
32:34I need it.
32:35I'm excited.
32:36I finally have it done.
32:37I'll do whatever it takes.
32:38I mean, these have got to be very uncomfortable for her.
32:41Yeah.
32:42Dr. Ravella will be helping me out today to remove as many tumors as we can and stay efficient
32:46with our time.
32:47There's pain.
32:48There's itching.
32:49There's clothes rubbing on these things.
32:51Interestingly, her cheek is pretty speared right here.
32:53Kind of.
32:54This is smooth.
32:55From both sides, which is great.
32:56She has a lot.
32:57So we have our work cut out for us, for sure.
32:58Yeah.
32:59For sure.
33:00We'll start with this big one on the back of the ear over here.
33:02She's got a tumor on top of a tumor here.
33:04So what I'll do is basically follow the hairline.
33:07Incision.
33:14A little incision.
33:15You can see that some of these are like pretty well compartmentalized.
33:24It would be nice if they were all like this, but I doubt it.
33:30There's one piece.
33:32I don't hold off.
33:35Hold on to them.
33:36Let's just see what we're doing with them.
33:38So we got the one off behind the left ear and now we're going to do electro desiccation,
33:42basically destroying these tumors by burning them.
33:45So we'll just kind of go through these.
33:47This is sort of the electro desiccation.
33:49So when I touch these smaller tumors with this cautery probe,
33:53it just basically destroys them and disintegrates it.
33:58So you can see it happening as you're doing it.
34:00And they flatten out, they tighten, they shrink as you do it.
34:04And these guys have a bigger mass under them.
34:23These tumors can sometimes be like icebergs.
34:25So if it looks a little tiny on the surface,
34:27doesn't mean that it doesn't have this big giant root underneath that.
34:31Give me a curette.
34:32A little one to start.
34:34If it has that bigger root underneath, we're going to see that thing swell.
34:38And if it swells, I immediately know that there's something under there
34:42that I'm going to need to scoop out.
34:44Sometimes they do pop out like a pimple.
34:46See if we can make it happen.
34:48That's all tumor.
34:50They kind of look like little boba balls, those little jelly balls
34:53that you put on top of your pink berry or in your drink.
34:56Yeah, those things.
34:58Go ahead and grab that and try to pluck it away.
35:01So it immediately goes flat once you get that root out.
35:06Should we do the twins?
35:08So Elizabeth has these two particular tumors on the front of her neck
35:12she calls the twins.
35:14I find it hard to cut on the neck with a knife.
35:18She's sitting.
35:22It's the first step.
35:29There's one piece and then this one's the other one.
35:34We're over halfway done with the surgery
35:36and now it's time to take that big one off her neck.
35:39All right, good.
35:40Give me a big nail.
35:41A curve.
35:42A curve nail.
35:43This guy's angry.
35:45It's red.
35:46You can tell it's been irritated.
35:48This tumor goes down to the muscle layer underneath.
35:51It's deep.
35:52It's pretty deep.
35:59That's part one.
36:01Now we're gonna peel out the rest of it.
36:04The last thing I want is this thing to grow back.
36:06And I'm gonna chase it down as deep as it goes
36:09so that I get the full root out of there.
36:11We need to get this thing off.
36:13We need to get it off completely.
36:15You definitely want to stay away from the external jugular here.
36:19The problem is that it's near the jugular vein.
36:22And I gotta be very careful not to nick that.
36:27A jugular vein is a very large vein.
36:29And one of its main functions is to drain all of the blood from the brain.
36:33And it brings it into the heart.
36:35So, yeah, when you cut it in a mob movie, the person dies.
36:41What's going through my mind is,
36:43please don't nick that jugular vein.
36:45If I do, I'm gonna be in serious trouble.
36:47I do definitely want to stay away from the jugular here.
37:06From underneath.
37:08I'm cutting off the tumor.
37:10And if I nick that jugular vein,
37:12I'm gonna create a bad bleeding situation
37:14right in the middle of this surgery.
37:16We got the tumor out.
37:17We didn't hit the jugular.
37:18And I'm feeling great about everything.
37:19Now we're ready to close it up and finish the rest of the surgery.
37:21All right.
37:22That's it.
37:23We are done.
37:24Wow.
37:25I think she's really gonna like it.
37:26We basically took off somewhere between 200 and 300 tumors on the face.
37:31I feel great.
37:32She's not gonna have that same level of pain.
37:33She's not gonna have those shooting sensations.
37:34This has been a longtime dream for Elizabeth to have this done.
37:35This has been a longtime dream for Elizabeth to have this done.
37:36I want her to have the confidence that she's always going to have that same level of pain.
37:41She's not gonna have those shooting sensations.
37:42This has been a longtime dream for Elizabeth to have this done.
37:43I want her to have the confidence that she's always wanted.
37:44She can open a new chapter in her life.
37:45And I think that moving forward is just,
37:46looking up.
37:47Well, she looks very darn good.
37:48Yeah.
37:49I mean, she will.
37:50She will.
37:51Exactly.
37:52I think she's really gonna like it.
37:53I think she's really gonna like it.
37:54I think she's really gonna like it.
37:55We basically took off around somewhere between 200 and 300 tumors on the face.
37:58I feel great.
37:59She's not gonna have that same level of pain.
38:00She's not gonna have those shooting sensations.
38:01This has been a longtime dream for Elizabeth to have this done.
38:04I want her to have the confidence that she's always wanted.
38:07She can open a new chapter in her life.
38:09And I think that moving forward is just looking up.
38:12Well, she looks very darn good.
38:13Yeah.
38:14I mean, she will.
38:15She will.
38:16Exactly.
38:17We got a little bit of a process ahead of us.
38:18For the next couple of weeks,
38:19she's gonna have a lot of tiny wounds all over her face.
38:21But it's gonna heal up nicely.
38:23Take it from looking kind of bumpy and red,
38:25to flat and almost pale.
38:27And she's gonna look great.
38:28Great job.
38:29All right.
38:30High five.
38:42We have Elizabeth Keller coming in for her post-op appointment.
38:44I'm excited to see what it's done for her just beyond the obvious visual appearance.
38:49I want to see how she's changed.
38:51Well, look who's here.
38:54Hello.
38:55How are you?
38:56Good, how are you?
38:57Looking in for the real deal here.
38:59How is it going?
39:00Good.
39:01Good.
39:02You look awesome.
39:03It's because of you.
39:05My collar doesn't rub certain ones anymore that hurt me before.
39:09And then you called one of them the twins?
39:12The twins.
39:13The one that was right there that you got.
39:14Oh, my God.
39:15There was two of them right there together.
39:16Oh, I can't even remember what it looked like at this point.
39:18Yes, the twins.
39:19That's so good.
39:20They were like together, so.
39:21What was it like you were feeling before?
39:22Oh, like the one behind my ear that was really bad.
39:24I can wear sunglasses with no problem.
39:26I can wear hats, headbands, anything like that.
39:29The ones that were hurting me the most, they're gone.
39:31Yeah.
39:32Less pain.
39:33Tell me, what's the last few months been like?
39:35It's been life changing.
39:36I, um, I'm happier.
39:39I don't have as many looks as I did before.
39:42And I'm just, I couldn't be more thankful than what I am now to have all this.
39:46And I can't thank you enough.
39:48And this has just been something I wanted.
39:50And I can't be more grateful.
39:52I thank you so much.
40:03So Josie Shattuck sent us a video.
40:09Okay.
40:10And, uh, she's got some changes to share with us.
40:13So let's take a look.
40:15Hello from Wisconsin.
40:18As you can tell, it is freezing outside.
40:20We have a little snow on the ground.
40:22I want to talk about my healing.
40:25Everything has gone super amazing.
40:28I healed up perfectly in time for my wedding, which was in September.
40:32Alec, you may kiss your bride.
40:38The most perfect day.
40:40Absolutely amazing.
40:41Gorgeous.
40:42I probably wouldn't have been as confident on my wedding day if it weren't for my amazing surgeons.
40:47I couldn't have chased this dream of being the most beautiful bride without them.
40:53Wow.
40:54Wow.
40:55Awesome.
40:56That's so cool.
40:57Some big updates.
40:58Just seeing her ability to smile, I mean, that was amazing.
41:01That was huge.
41:02To be able to smile for your wedding is an amazing, amazing thing.
41:07She is so happy.
41:08And the fact that she can express that, it really comes through.
41:12I know we saw her wedding and everything, but we got one more bit of good news for our young patient.
41:17Alec and her are having a baby.
41:19Oh, awesome.
41:20Oh, that is exciting.
41:21That great?
41:22Yes.
41:23Come on.
41:24Congratulations to them.
41:25It's wonderful.
41:26Hi, Mike.
41:27Give yourself a little bit.
41:41Let me know your bad heart.
41:42Say two more things.
41:43Are you supposed to be Bow we areparable?
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