Chapter 141 138. New materials, new methods

The essential difference between oral and maxillofacial surgery and other surgeries is the destruction of appearance.

For patients, broken hands and feet can still be replaced with prostheses, but facial defects are difficult to repair. If it is just pathological damage, forget it, but oral and maxillofacial surgery is to treat deep-seated lesions.

It was so destroyed that many people find it difficult to understand.

The maxilla is the largest bone in the face, and surgery is already very troublesome, with life and death uncertain. Even if you survive the surgery, your face may become deformed due to scar tissue.

If it weren't for Waterman's position and the guarantee of the patient's recovery after a previous mandibulectomy, the patient would rather endure the pain of rotten teeth than agree to have half of his maxilla removed.

The final diagnosis was still osteomyelitis caused by deep infection caused by severe dental caries. The patient's face had been slightly deformed, and the left side of his face was slightly raised. It should be edema caused by inflammation. The surgical procedure was tentatively scheduled as "maxillary resection", but in the end it was

Partial resection, subtotal resection, total resection or extended resection has not yet been decided.

The surgery quickly got into the topic.

The patient sat during the whole process. After anesthesia, his limp body was supported by soft cushions under the armpits and crotch, and his head was tilted back on the cushion above the chair: "Because it is a maxillofacial surgery, we need to make a tracheotomy first to prevent bleeding.

Backflow into the nasal cavity can cause suffocation."

Waterman's tracheotomy was not much more skillful than Ignatz's. He simply cut in directly and inserted a hollow tube into the trachea, with straps on both sides fixed around the patient's neck.

Because there is no separation and hemostasis, the procedure itself will cause blood to pour back. But this is a trivial matter to Waterman, as long as the patient is still alive.

"The tracheotomy is completed, and the air is avoiding the mouth and nose and flowing in and out of the patient's lungs smoothly."

The two assistants began to "correct" the patient's head, placing the left face at the top, opened the patient's mouth with a pressure plate and a retractor, and began to confirm the scope of the lesion:

"Considering the patient's insistence on his appearance, I need to determine the scope of surgical resection. If there is only a small area of ​​maxillary infection, you can try to make an intraoral incision, so that there will be no damage to the appearance. Give me a scalpel."

One assistant opened the patient's mandible, and another used two retractors to open the upper lip to create a surgical field for Waterman.

The scalpel was quickly cut through the labio-gingival and buccal grooves [1], and the bleeding was simply stopped. The infected area was immediately discovered: "The scope of the lesion is not small, and the intraoral incision field is too small. The partial resection promised to the patient before was impossible."

Waterman and the two assistants cooperated very well. As soon as he finished speaking, the scalpel and several retractors were all withdrawn from the mouth: "We switched to extraoral incision. The main purpose is to expand the scope of the operation to gain enough fields of view. We chose

Make a longitudinal incision from the center of the upper lip to the base of the columella and then make a transverse incision around the nose wing." [2]

Following the rhythm of his speech, the scalpel drew a vertical line on the patient's upper lip, and then extended it along the side of the nose to the bottom of the inner canthus (inner corner of the eye). The other side also needs to follow the upward arc of the smile at the corner of the mouth.

Make an oblique incision directly in front of the ear.【3】

Waterman's maxillofacial surgery techniques are indeed superb. He does not hesitate with every cut and the depth of each cut is under his control.

"We have made the incision." After the two assistants used gauze to stop the bleeding, they began to help him slowly incise the upper lip. "We will incise the upper lip first. The blade needs to reach the bone surface. The technique must be decisive and don't be afraid.

Bleeding. If you keep worrying about bleeding, the operation will take more than three hours to complete."

Although the words were well said, Waterman was still affected by the "sequelae of quick hands" before the onset of anesthesia.

His rough technique is only faster than Ignatz's, and he can make the separated facial skin and muscles look like shoveling pancakes. I'm afraid there are only a few people in Europe.

Of course, what the director said about not caring about the bleeding does not mean that the bleeding is completely stopped. Necessary hemostasis is still needed: "Quickly ligate the large blood vessels, let all the other small blood vessels go, and just rely on the patient's self-coagulation. Then we open the side of the nasal cavity

The mucosa of the wall is connected downward to connect the nasal cavity with the skin incision on the side of the nose. Then the skin-muscular flap is opened." [4]

Kawei had no experience in maxillofacial surgery, so he couldn't help but squeeze forward while holding a telescope.

From where he is now, he can already see some not-so-good things. The bone surface that should be smooth is actually a large, hard lump that swells outward: "Why does it feel like a tumor?"

Waterman heard Kawei's voice and also heard the surprises of other viewers: "Dr. Kawei made a good judgment. I already discovered it when I was doing bone surface separation. The infection only exists in the gums and gums, and the scope is not included."

Big. Our real enemy is the maxilla, oh no, it may have affected the zygomatic bone, it is a bone tumor."

"The scope of surgery needs to be further expanded," Kawei said.

"Yes, the entire maxillary and zygomatic bone must be removed. As for whether to do an extended resection, it depends on the condition after the resection."

Expanding the scope of the resection will be wider, with the eyeball upward and the pterygoid process, ethmoid sinus, and sphenoid sinus inward. By then, the scope of the operation will be larger, and it remains to be seen whether the recovery will be possible after the operation. But Waterman does not seem to be too concerned.

Even though I was overly worried, I still moved forward boldly.

"We'd better deal with the upper jaw first and use a small circular saw to cut the middle slit in the jaw." [5]

A nurse handed the saw to Waterman, and she stood by with pliers and gauze.

Bones have a rich blood supply. When the soft and hard palates have just been incised, the bleeding will be fierce. It is necessary to repeatedly stuff gauze into the patient's mouth to stop the bleeding. However, because there are no large blood vessels, the bleeding can often be stopped by tamponade for a period of time.

.

"The area invaded by the tumor is very large, and extensive local resection is required."

Waterman used his fingers to determine the growth area of ​​the osteoma. He used instruments frequently. After using the circular saw, he switched to an osteotome and a hammer: "We use an osteotome to cut the connection between the frontal process, the nasal bone, and the lacrimal bone. We still need to be careful here."

, the force of the hammer must be controlled well and not too excited, otherwise it will damage other tissues." [6]

duang,duang,duang

That is what he said, but judging from the movements of his hands, it was not careful at all: "Come down, come down, come down, this part is disconnected! Let's change sides and find the tumor boundary at the lower end of the outer edge of the orbit.

It should be right here”【7】

The two assistants continued to separate the skin and flesh, and Waterman made a simple positioning and placed the osteotome at the mentioned position.

duang,duang,duang

There was another breathtaking and clear thumping sound, and he was heard to say "Okay!". All the bone connections on the front had been cut open, and what was left was the gap between the maxillary tubercle and the pterygoid process of the sphenoid bone on the side.

The connection between.【8】

After incising the muscle, there were several more knocks of the osteotome, and the patient's left maxilla was completely cut off.

"Give me the pliers." Waterman clamped the patient's teeth with a pair of large pliers and slowly took out the bone fragment. "You try to stop the bleeding. I need to discuss bone reconstruction with Dr. Charles."

"Do I need suturing?" the assistants asked.

Waterman looked at the wound and bone section: "It's obviously too late to do it directly. You can polish the section clean and suture it directly. If you really want to do it, you have to wait for him to recover after the operation, and then do the second stage surgery."

"knew."

Although it was thought before the operation that the scope of resection would be expanded, the total resection was still a little beyond Waterman's expectation. Originally, he thought that a sub-total resection would be more likely, and he only needed to make a good incision during the operation, so that Charles could

Create an artificial dental tray that fits the patient's mouth.

Now that all the bones have been cut off and the supporting points have disappeared, it seems that just making a dental tray is not enough.

"Among my patients, there are also patients who have undergone total unilateral maxillary resection." Charles used a knife to remove the skin and flesh outside the bones while talking about his experience in broken French. "At that time, I only chose to make a palate similar to the soft palate.

The guard is placed into his mouth using the prepared material.

This will not only keep your mouth clean, but it is also very convenient to clean. However, it will attract a lot of attention after taking it off, so you need to avoid crowds as much as possible."

"Palate guard?"

"A very thin layer of solid material can be placed on half of the patient's soft palate."

"What material is it?"

Under his guidance, everyone became interested in this material. Charles stood in the surgery preparation area and took out a jar of mixed strange stuff from the box next to him:

"I chose gutta-percha shipped from India, a natural rubber from the Asian rainforest called gutta-percha. But this is just the most basic material. I also added many other ingredients to make it

I made a dental tray material with moderate hardness and softness. I named it after my own surname and called it 'Stent'." [9]

"Can it really be guaranteed to be strong?"

"Everyone, please believe in this perfect combination of Asian plants and European chemistry. This rubber can do anything."

Waterman knew that half of the purpose of his coming here was to advertise, and by inviting him here he acquiesced to this request. But now the operation has changed, and the omnipotent rubber will also encounter things that cannot be done: "Dear Dr. Charles, now

It seems that using this kind of rubber is not enough."

Charles was not discouraged: "You can try the palatal guard I mentioned first. It's very useful."

"What about the teeth?"

Charles dug out his dental forceps from the box again: "Pull them out one by one, throw away the bad ones, and insert the good ones when making the palatal guard. After they solidify, they will be perfectly fixed.

"

Waterman had to admit that this new material was very reliable. After all, he was asked to come here to make a good dental brace: "The palatal guard is really good, but now that the maxillary bone has been completely cut off, the rubber plate lacks fixation.

point."

Charles looked at the bone in his hand and fell into deep thought.

"Unless you can connect it to the pterygoid process."

"No, this is rubber. Even if it is fixed, it will be torn off due to bite." Charles cleared his throat, still not forgetting to advertise his material, "This thing is not cheap. If you hadn't written this letter

If you invite me to come to Vienna with this material, I'm afraid he will have to rely on his right tooth to eat."

"Now it seems that I can only eat with the right tooth if I only rely on the palatal guard." Waterman shook his head slightly, seeming to have made up his mind, "Now I not only need to make a dental tray, I'm afraid I also need to make another upper jaw bone.

To support the dental tray.”

"Make another maxillary bone???" Charles didn't understand what he meant, "Do you want to put this bone back again?"

"How is this possible? This is a bone tumor. It makes sense to put it back after finally cutting it off." Waterman said, "You can use new materials from Asia, and of course I can use Asian materials."

"What material?"

"ivory."
To be continued...