Week 6 - Fibulas, fat, and facial paralysis

This week was one of my favorites so far. I had the opportunity to observe an incredible surgery and spent a lot of time in the clinic and research lab. It was a busy week, but I felt very accomplished and learned so much.

The surgery was a mandibular reconstruction with a fibula free flap, meaning a portion of the mandible is removed and replaced with bone from the fibula. This patient had cancer in their mandible and the only course of action was to remove the affected area. To give the patient a functional jaw and preserve their quality of life, the portion of bone that was removed was rebuilt with the fibula. I was quite invested in this patient as I was there for their initial pre-op appointment with Dr. Spector in the clinic and sat in on the follow-up surgical planning meeting with the other surgeons participating. The surgical planning meeting also included a biomedical engineer from Stryker who was simulating the reconstruction with their VSP Reconstruction software. This software uses data from the patient's CT scan to model the portion of fibula needed to fix the defect in the mandible. After a bit of back and forth between the surgeons and Stryker engineer, the surgical plan was finalized and a personalized cutting guide for the fibula was created. The cutting guide provides the exact location where each cut needs to be made on the fibula and placement of the dental implants.

During the surgery, the head and neck surgeon removed cancerous soft tissue in the mouth and the oral surgeon removed the cancerous portion of the jaw. Dr. Spector's team worked on freeing the fibula from the leg and fixed the cutting guide to the bone, ensuring the bone still had sufficient blood supply from the leg. After this step, the oral surgeons installed the dental implants on the fibula. The fibula was then cut according to the guide, attached to a metal bracket, removed from the blood supply, and fixed to the remaining portions of the patient's mandible. Finally, microsurgery was performed to connect vessels from the fibula flap to vessels in the patient's mouth. The surgery took about 11 hours and was a complete success! Two days later I was able to visit the patient in their recovery room and they were doing great. I am looking forward to the next visit to see how everything is healing. It's incredible to see how far we have come with surgical techniques, tools, and software to help patients recover from diseases that would otherwise result in severe defects or even death.

3D simulation of before and after the fibula-mandible reconstruction using Stryker's surgical planning software and the patient's CT scan. In the top images, the cancerous lesion is highlighted in red. In the bottom images, the fibula segments are shown in blue and dental implants are shown in red.

As for clinic this week, I saw many different patients including a post-op appointment for a degloved foot resulting from diabetes complications, pre-op appointment for a breast revision, and consultation for a fat transfer to the feet due to an autoimmune disorder. However, the most memorable case from clinic this week was an older patient who had experienced sudden facial paralysis on the right side of their face that began only a month prior. After a few doctor's appointments, the patient was diagnosed with squamous cell carcinoma that was situated on the facial nerve and carotid artery, causing the facial paralysis. There is no way to save the nerve with the way the tumor is positioned so the patient was meeting with Dr. Spector to talk about their options once the tumor is removed. Unfortunately, the patient is not a great candidate for a nerve graft due to their age but Dr. Spector offered a few other creative solutions. A browpexy will be performed to stabilize the patient's eyebrow to make it even with the left eyebrow. The patient is having a hard time keeping their eye shut when sleeping so a small 1.0 g gold weight will be inserted into the upper eyelid to help keep it closed. To reduce the amount of tearing that the patient is experiencing, Dr. Spector will also raise the lower eyelid. Finally, a fascia lata sling will be performed to bring up the drooping part of the patient's mouth so they can eat and drink properly. Despite the inability to do a nerve graft, the patient was happy to hear about their other options and will likely have great results from Dr. Spector's proposed surgery.

Lab was also a success this week. I performed immunofluorescence staining on sections of our collagen breast constructs so we could visualize human umbilical vein endothelial cell (HUVEC) migration using immunofluorescence microscopy. Continuing on with my image analysis training, I met with a technical support representative from Imaris and he provided great feedback and suggestions for analyzing HUVEC migration using confocal microscopy. I am looking forward to utilizing the new workflow in my data analysis. To conclude the week, I helped out with collecting adipocytes and stromal cells from breast tissue. I sectioned portions of the breast into adipose tissue and stromal tissue and used tissue digestion enzymes to break it down into single cell suspensions. These cells were then embedded in collagen and seeded with HUVECs to make the collagen breast construct. After 5 days, we will analyze the constructs for HUVEC migration.

Breast tissue from a breast reduction that was used to collect adipocytes and stromal cells.

Can't believe we only have two more weeks left here in NYC. Time flew by fast! Hopefully I can observe a few more surgeries and continue making progress on my research before my time here is up!

Kylie Persson