All of Linda Hershey’s nose reconstruction surgeries were performed by Patrick J. Byrne, M.D., at Johns Hopkins. Grafts were taken from her forearm, ribs, ears, forehead and skull to create a new nose in the cavity left from the removal of her own nose.
Story and photos by Algerina Perna. Warning: Series contains graphic content.
Yet even for him, rebuilding Linda Hershey’s cancer-ravaged nose was a “colossal challenge.”
“I don’t think there’s a more difficult reconstructive procedure that exists than recreating a nose that looks close to normal,” says Byrne, 46. On the scale of difficulty from one to 10, “she’s a 10.”
The very shape of a nose — which he describes as a “complicated, three-dimensional structure suspended from the head into space” — creates problems. Its prominent location in the center of the face can’t be camouflaged as an ear can be with hair, or an eye can be with glasses. Because each side mirrors the other, any deformity is immediately apparent, unlike ears or eyes, which are separated in space. Recreating a nose that can breathe properly adds to the challenge.
Meanwhile, the fact that Hershey had smoked for more than 40 years and was an older patient who had experienced the “devastating effects of radiation therapy” increased the odds for complications, Byrne says.
“Not only was the skin gone, the cartilage gone, the lining tissue underneath the cartilage, but also the very support structure — the nasal septum that holds all of it up and together. … And probably the last kicker is, her surrounding bone was removed.”
The intricate process of building a nose from scratch requires precise surgical skill — and a degree of artistry. Just as a sculptor uses tools to form a figure from blocks of stone or clay, Byrne uses medical instruments to sculpt a nose from a mass of flesh and bone.
As a child in Salinas, Cal. — the birthplace of author John Steinbeck — Byrne began developing the artistic skills that would eventually serve him well as a facial plastic surgeon. In elementary and junior high school, teachers and students would enlist his help for art projects, and he won a regional art contest that landed him on TV.
At California Lutheran University, where he majored in biological science while on a track scholarship, Byrne’s interest gravitated to medicine. His older brother, Jim, who was in medical school at the time, was a huge influence. “I idolized him growing up,” says Byrne, who graduated from the University of California, San Diego School of Medicine in 1994.
Byrne who founded the nonprofit Face Forward Foundation to provide treatment for children with cleft palates and other facial deformities, recalls that he wanted to be a doctor “to make a difference in the world. … I thought it would be a valuable thing to do with my life.” His parents, he says, worked in soup kitchens and gave what little money they had to charity.
He chose plastic surgery because he loved that specialty and enjoyed the atmosphere in the operating room. Where else could one wear “pajamas” to work, listen to music and be with friends, he says with a smile.
Building a new nose for Hershey would require a couple of dozen grafts of cartilage, skin and blood vessels — for the bridge, tip, nostrils and side walls.
Unlike procedures with clearly established protocols, Byrne says, there’s no “textbook answer” to nose reconstruction. “We know the techniques. But which technique to choose and when and why depending on the particular patient’s situation is really difficult to call,” he says.
The first major step in the reconstruction came in April 2008, when Byrne took skin, veins and an artery from Hershey’s forearm to build a foundation of living tissue. A month later, he cut the skin of her forehead to prepare for a future surgery that would transfer it to Hershey’s nose to form the smooth outer skin.
He lifted the skin, leaving one piece attached at the bridge of her nose. He then stitched the “forehead flap” back into place. Separating the layers of skin and re-attaching them stimulates the growth of blood vessels that would be needed later to ensure a successful skin graft.
This was one of the few procedures when Hershey drove by herself to her clinic appointment. Afterwards, her head was wrapped in a gauze dressing.
“I looked like a train wreck,” she recalls. She joked with Byrne, saying, ‘If a cop stops me, can I give him your phone number so you can tell him I have permission to be behind the wheel of a car?’“
The first major problem — one that would lead to months of complications — arose following a three-part surgery in June 2008.
You don’t realize how short life is until you get older… When you’re 19, you don’t think about dying. … You don’t think about disease.”
Byrne took rib cartilage from Hershey’s chest to use as a support structure in her nose and used ear cartilage to shape the nostrils. He turned down the “forehead flap” to form the nose’s smooth outer surface.
But the cartilage, normally a firm yet flexible tissue, proved too brittle, and later broke down. “Regardless of where we take the cartilage from … there’s a risk. There’s an unpredictability to it,” Byrne says.
Hershey’s body was compromised by radiation therapy, smoking and her age — the older the person, the more calcified and brittle the cartilage, Byrne says. Radiation therapy, meanwhile, shrank the fat and muscle where part of the cheekbone was removed, contributing to the shift in her right eye’s position.
Hershey had smoked from a relatively early age. “You don’t realize how short life is until you get older,” she says. “When you’re 19, you don’t think about dying. … You don’t think about disease.”
Still, she doesn’t think smoking is necessarily the cause of the cancer. “We all breathe in toxicants everyday,” Hershey says, pointing out that everyone in her immediate family has been diagnosed with some form of cancer.
Complications caused by the unhealthy cartilage — and a painful recovery from forearm skin grafts and the removal of rib cartilage — were draining on Hershey. Another disheartening moment came two days after the June 2008 surgery.
She was in her hospital room in Johns Hopkins’ Weinberg building, waiting for discharge orders. A physician’s assistant came in with the resident and they said they had discovered a blood clot in each lung.
That meant more time in the hospital.
“I was expecting to go home, and that’s what I got instead,” she recalls. “I was not short of breath, I had no chest pain. I was very upset to get the news.” Doctors fitted a major vein with a filter to prevent more clots from traveling up to her lungs and heart.
The complexity of the nose reconstruction escalated with the failure of Hershey’s rib cartilage. When the cartilage graft dissolved as a support structure, the next option was taking bone from another graft site: her skull.
On Sept. 16, 2008, in Operating Room 10 on the third floor of the Weinberg building, an electric saw hummed and a mallet tapped on Hershey’s skull bone as Byrne and his team removed a section to place inside her nose. Classical, jazz and alternative rock music from Byrne’s iPod mixed with the beeps of machines monitoring Hershey’s status.
Byrne and his team retrieved two pieces of bone, each approximately one-half inch by two inches. Byrne then connected the pieces in an L-shape and placed the bone joint under the tip of her nose. The top of the graft was fastened to the nasal bone with a plate and titanium screws. The graft was further secured with nylon sutures.
The necessity of a skull graft operation prolonged nose reconstruction by several weeks — if not months.
For Hershey, handling the physical pain from 10 months of nasal surgeries was tough enough. But the major setbacks were beginning to burden her emotionally as well.
Tomorrow: 3rd in Series: Battling the emotional scars
To read Linda’s Journey: 1st in a Series, “Confronting cancer” click here