Images of a nose implanted on a man's forehead have been all over the Internet, like ads for some creepy horror film you probably don't want to see. Almost as jarring are pictures of an ear protruding from a woman's inner arm.
They're not from some horror movie—they're real science. The nose-on-the-forehead photo depicts a nose repair in progress in China. The photo of the ear on an arm was published in the September 19 issue of the New England Journal of Medicine. Such surgeries are examples of new approaches to standard reconstructive techniques that may cost patients a few months of psychological discomfort but will eventually allow their facial features to be repaired.
Patrick Byrne, director of facial plastic and reconstructive surgery at Johns Hopkins Health Care and Surgery Center in Green Spring Station, Maryland, believes his innovative ear reconstruction pictured in the NEJM was one of the first performed in the world. Growing noses on foreheads or ears on arms before transplanting them to the conventional locations is based on surgical reconstruction techniques going back hundreds of years. But modern-day applications are truly revolutionary, as Byrne explained in an interview with National Geographic News.
The photographs look like some sort of cruel joke. Is this a serious procedure?
Yes, it certainly is. It's called prelamination: Tissue that's going to be used to rebuild an area is constructed in multiple layers. In the case of the ear, I was trying to solve a difficult problem. [The woman had advanced basal cell carcinoma, a skin cancer. Treatment, including radiation, damaged the area too much to allow for a more traditional reconstruction.]
What are the layers, and why is each layer important?
Take the nose, for example. If the damage from disease or injury goes all the way through, then all three layers must be replaced: the skin on the outside, the cartilage, and the soft lining inside. The forehead skin tends to be the best match for the outside skin from an area called the paramedian forehead flap, described in medicine as early as 700 B.C. [Reconstructive surgeons have been using skin from this area of the forehead for nasal reconstruction for centuries.] Cartilage creates a three-dimensional form that will resemble a nose, and the choice to take it from the rib cage is pretty straightforward. A lot of nuance and challenge comes from the internal layer, the lining of the nose. If you don't have a pretty good blood supply nourishing the nose from the inside, over time it will fail. You'll be left with a mess of tissue that could be a deformity worse than the one you started with.
So how do you help ensure a good blood supply?
Prelamination, or implantation of tissue or cartilage to a skin flap while preserving blood supply, provides that inner layer. You put a skin graft on the undersurface of the skin flap, then allow it to heal under the surface of the forehead, so you've created two layers. You can then split the layers and put cartilage grafts inside, like a sandwich.
What did you think when you saw the forehead/nose photograph circulating on the Internet?
In reconstructive surgery we're always trying to provide creative solutions. I'm impressed with the creativity of surgeons worldwide, but with a clear caveat. I personally have a healthy dose of skepticism as to whether or not this was necessary and was the optimal choice. Why they chose to do it in the forehead instead of the usual way—construct it right there where needed on the nose and then transplant skin from the forehead—we'll never know. Perhaps they had some concerns about the blood supply. With something as complicated as nose or ear reconstruction, there's really no particular standard of care or defined solution. When it comes to how you take living tissue to re-create something close enough to make people feel it's a real nose or a real ear, there are endless feasible strategies.
Where do we go from here with this type of reconstructive surgery?
I believe that it's a realistic possibility that at some point in the future we can take samples of cells and we'll be able to grow composites in the laboratory. It would be the same strategy, constructing a three-layer body part but out of cells taken from the patient. That's the holy grail. But before that, maybe cartilage can be grown in the lab, and from there, use the forehead flap.
How do patients react to such bizarre, if temporary, placement of a reconstructed body part? Even though few have full noses on their foreheads, a fairly common reconstruction requires a flap of skin running from the forehead and attached to the nose to stay in place while healing for several weeks or months.
The range of coping strategies is all over the map. I've seen people continue their professional work. Others won't leave the house until the procedure is complete. The woman with the ear reconstruction on her arm was lucky. She could cover up the growing tissue and cartilage with a sleeve. And she had some fun with it. "She was playing with her kids, and if they got in trouble, she'd roll up her sleeve and say, 'Tell it to the arm,'" said Byrne.