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The world's first recorded surgery to resculpture a face without an upper jawbone took three phrases over four years. Liu Zhihua and Lu Hongyan report in Xi'an.
Zhao Jinlong, a maxillofacial surgeon with the Stomatological Hospital of the Fourth Military Medical University in Xi'an, the capital of Shaanxi province, remembers the first time he saw Wang Na.
"When the kid took off the scarf around her face, all the doctors and nurses were speechless," Zhao says. "We had never seen anyone like her."
That was in early 2006.
Wang, 23, was born without her upper jawbone. While growing up, the bones and tissues that should have grown onto the upper jawbone also degenerated.
When she came to the hospital, the middle part of her face looked like a pit. Her nose was tiny. She had no upper teeth, and her mouth seemed always ajar as her upper lip sank into the mouth, without support from the upper jawbone.
Her profile was u-shaped, which is how she got the nickname, "pit-faced girl".
The "pit" was filled after four years of free-of-charge treatment in the hospital, which included a dozen of operations and numerous examinations.
"We were reportedly the first in the world to successfully reconstruct a face without an upper jawbone," says Wang Limin, the political commissar of the military hospital, adding that more than nine departments and nearly 20 experts were involved.
"Although we had all the technology and expertise in the different departments, it was the first time we combined all the know-how in one single case," says Lei Delin, a maxillofacial tumor specialist, who was also one of the chief doctors for Wang.
Lei says they were initially quite clueless about where to start.
In early summer of 2006, the medical team conducted a series of examinations on Wang, held several seminars, and finally agreed on a three-phase operation plan.
Phase 1 was to lengthen and thicken Wang's cheekbones through distraction osteogenesis - to gradually move the two bone ends apart, allowing a new bone to form in the gap.
Phase 2 was to transplant an artificial upper jawbone made from Wang's calf bone.
And Phase 3 was to reshape the nose and lower jawbone and implant dentures.
Doctors used computer modeling throughout the process.
"The first phase is the most important, because cheekbones support the upper jawbone," says He Lisheng, a maxillofacial trauma expert. He notes the human skull is a whole connected only by sutures, and any change changes the forces among the bones.
Wang Na's cheekbones were very thin and, thus, were very close to the brain. If the distraction operation was not conducted precisely, both the brain and the eyes would be harmed.
Doctors faced another delicate challenge in making sure the soft tissues on the old bones would not add too much pressure on the growing bones and disturb the new bones' orientation.
Wang received her first major operation on Sept 5, 2006. Her cheekbones were cut open to place a tailored distraction osteogenesis device designed using computer modeling. The operation lasted about four hours and was a success.
The cheekbones projected about 0.7 mm per day. Seven months later, Wang's cheekbones were ready for the next stage of transplanting. Such a procedure is nothing new, but Wang's case was special.
"We created a whole upper jawbone and put it onto the cheekbones we had reconstructed, and there were a lot of challenges," He says, adding that the specialists had difficulties designing the shape and position of the upper jawbone because Wang's lower jawbone was also deformed.
After several discussions with painstaking attention to details, doctors decided to make a horseshoe flap of the bone, with the flesh and the skin resembling the upper jawbone, made from a 14-centimeter piece of fibia.
"That was the best method we could think of to ensure the safety of her leg and the success of the transplant," He says.
They faced other risks. Apart from the danger of infection, He says their major concern was the dovetailing of the blood vessels in the connecting parts.
"If the blood vessels failed to properly grow onto one another, the delivery of nutrients would be insufficient, and the tissues would likely die on large scale. That would mean the transplant's failure," He explains.
Although much preparation was done, the stitching of the blood vessels would largely depend on the experience and performance of microsurgical experts and cooperation among the medical staff.
The stressful and backbreaking operation took 11 hours on April 18, 2007. "Finally, we were able to breath," He recalls. "The kid recovered quickly, and she had a new look."
On March 14, 2009, as the artificial upper jawbone and tissues healthily stabilized, doctors put the dental implants into the bone, reshaped the lower jawbone and reconstructed the nose.
On May 17, 2010, Wang received her final operation. The hospital's president Zhao Yimin implanted her dentures.
As the treatment progressed, Wang became confident and smiled often. Nurses observed she would initiate conversations with strangers and even help care for younger patients.
Wang had more than a facelift. The once timid and introverted girl, who hardly spoke and would always tip-toe while avoiding eye contact, is a changed person.
"I'm happy with my look," Wang says.
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