Flatline to Lifeline With Dr. Long
Consider a world where increasing survival rates in patients typically deemed dead on arrival could be the norm. Is dead actually dead? Is it an assumption or a fact? In Flatline to Lifeline we explore the very real potential for survival within the medical field of trauma and near-death experiences.
During his 50-year career, Dr. Long and his team radically altered the approach to trauma care by applying simple principles in profound ways. We hope to educate the general public and inspire medical practices worldwide to acknowledge and adopt these life-saving approaches to trauma care, because when the need is greatest for the patient, saving time saves lives.
Flatline to Lifeline With Dr. Long
Shot in the Face Part 1: A Miraculous Survival Story with Dr. Potter
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Caution: Graphic Medical Content. Listener Discretion Advised
A shotgun blast to the face at close range should've been fatal. Everything between her eyebrows and upper teeth was gone—eyes, nose, mid-face—yet somehow, a 17-year-old girl survived. This is the first episode in a three-part series exploring one of the most remarkable and complex facial trauma cases in medical history.
The secret to her survival? An extraordinary collaboration between specialists who weren't afraid to challenge conventional medical wisdom. Dr. Bill Long and Dr. Bryce Potter take us through this remarkable case where quick-thinking EMTs, who stuffed her facial cavity with sterile dressings to staunch the bleeding, innovative airway management, and revolutionary reconstruction techniques came together to save and rebuild a life.
What makes this story particularly fascinating is the counterintuitive approach to facial reconstruction. The maxilla, or upper jaw, was completely free-floating, no longer anchored to the base of her skull. In contrast, the mandible (lower jaw) remained attached. This meant the team had to begin by using the intact, still-connected lower jaw as the starting foundation to anchor and rebuild the entire face. The early placement of a tracheostomy, performed with a small incision in her neck to protect her airway, was a decision that faced significant criticism from other specialists. Yet, it proved transformative by allowing unrestricted access to the facial area for complex repairs and preventing her from drowning in her own blood.
This case also involved a unique collaboration between the trauma team and Oral and Maxillofacial Surgeons, as correctly aligning the mandibular and maxillary teeth was crucial to stabilizing the unstable maxilla. This was a pivotal step, as at the time, few plastic surgeons or ENT specialists had the training to perform this type of alignment. The old adage, "you can't sterilize the oral cavity," was a major challenge due to the high risk of infection in the open, bacteria-laden wounds.
The patient’s journey spans decades, from initial survival through multiple debridements to clear dead tissue and free flap reconstruction using the non-weight-bearing fibula bone from her lower leg. This graft was used to stabilize the critical upper mid-face bony structures and eventually rebuild the entire mid-face. This procedure, which involved an orthopedic and microvascular surgeon, required the detached flap to be brought to a new location and reconnected to the patient's artery and vein. The trauma team was also able to stabilize her blood pressure with transfusions, a crucial initial step to manage shock and prepare her for the long road of reconstruction. Her journey also included eventual prosthetic facial restoration using titanium plates and screws and magnets. Her two destroyed eyes were enucleated, and her case contributed to technological advances in 3D modeling that continue to benefit patients today. Most remarkably, she not only survived but went on to marry and have children, demonstrating the profound human impact of these medical innovations.
This episode illuminates how breakthrough medical approaches often emerge at the intersection of specialties when practitioners value patient outcomes over rigid adherence to established protocols. This is the first of three episodes on this incredible case, so stay tuned for the next two parts.
To learn more about these life saving strategies and techniques, look for Dr. Long’s upcoming book, Flatline to Lifeline.
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Producer: Esther McDonald
Technical Director: Lindsey Kealey, of PAWsitive Choices
Editing and Post Production: Adam Scott of Atamu Media Productions
© Flatline to Lifeline 2025
Introducing Flatline to Lifeline
Speaker 1Welcome to Flatline to Lifeline with Dr Bill Long . For three seasons , this podcast has explored unexpected survival outcomes within the field of medical trauma and how Dr Long and his team of trailblazing nurses and doctors began to replicate these unexpected outcomes by applying available technology and principles in new and profound ways . The pursuit of these outcomes became a mission for Dr Long's team over his almost 50-year career . We hope to educate those listening from any walk of life and to inspire those in the medical profession to consider and life-saving techniques and approaches we share here , Because when the need is greatest for the patient , saving time saves lives . Saving time saves lives . Welcome back to Flatline to Lifeline with Dr Bill Long . Dr Long , how are you this morning ?
Speaker 1I'm doing fine , thank you and we have the incomparable partner in crime , dr Bryce Hopper . Thank you for joining us again , good morning . We're going to talk about somebody whose day was not perfect Quite the opposite . At the very beginning , dr Long expressed so many different concepts the field , hospital , the army , all these intricate things how , all of a sudden , the trauma center becomes this brick and mortar place where , as you said , it became really hard to die there . This is an awesome way to encapsulate it . We're protecting life . In this scenario , we go back all the way to the beginning , where Dr Long is talking about the race against time to stop the bleeding . You have this golden hour , but it's what's going to kill you first and in this particular case , this
Shotgun Trauma to the Face
Speaker 1young girl . She takes a shotgun blast to the face and ostensibly , it removes her nose and her eyes in one fell swoop . Dr Long and Dr Hopper , take it away from here , please .
Speaker 3She was a young gal that inadvertently got shot in the face with a 12-gauge shotgun at close range . Shot in the face with a 12-gauge shotgun at close range and it essentially avulsed everything below the skull Her eyes , nose . Did leave the upper part of the jaw , the maxilla , intact with the teeth , so she was missing , essentially the part below the skull and above the teeth . Everything was gone .
Speaker 2Eyebrows down .
Speaker 1Yeah , there's a picture on it . We'll put it in the show notes or at least links to some of this Warning . It is a very gory photograph . It almost looks like somebody took an ice cream scoop from the base of the nose , where it touches the upper lip , to right at the eyebrows . Like dr long said , it just looked like somebody scooped out that portion of the skull . It's incredible to think that this person survived and essentially separated her face from the skull it's crazy to me that this first love .
Speaker 1I didn't think this was an option . I thought when you miss that much of your face , I thought you'd expire , but nonetheless she survived . So we're going to take it through this . So it's the maxilla , or the upper part of the jaw and all the way to the eyebrows , I guess . Take me through the story . She shows up at the only place that we've talked about . They can save her .
Speaker 3There's not anything really life-threatening missing those parts . As long as you can maintain the vascular volume and ventilate the patient , the rest can be reconstructed .
Speaker 1All right , I'll believe you . I'm going to need some context more than yeah , you can do that .
Speaker 2Okay , dr Long , you had something to add yeah , the face has a lot of blood vessels , the facial arteries has a lot of blood vessels , and so when you take a patient like that and you lie her on her back , all this blood is pulling in what's called the pharynx , it's the space behind the palate of her maxilla , and it goes down to where your trachea begins and it goes down to where the esophagus is and pulls back there .
Speaker 2She's drowning in her own blood . The question is how did they protect that airway ? Bryce would know I wasn't there when all this
Securing the Airway and Controlling Bleeding
Speaker 2occurred . I saw later on as things evolved , but I'm just astounded that she didn't drown in her own blood .
Speaker 3This seems like a case of logistics EMTs that got there in time to pack off her face just with direct pressure controls the bleeding and stops it from going down into the parents , and then , when they got to the hospital , they were able to put a tube into her airway , into her trachea , which prevented the blood from going down into her lungs , and so , at that standpoint , everything is doable .
Speaker 1Huge applause to the EMT crew . They were the ones who got her stabilized enough that she could survive .
Speaker 2Correct . Again , from a person who spent about 35 years involved with EMT , I am astounded that they would know enough to try to pack her mid-face with bandages and those get soaked with blood and it might stop some of the bleeding , but it still is going to pull somewhat with blood and it might stop some of the bleeding , but it still is going to pull somewhat . But the trauma anesthesiologist was able to do what's called an oropharyngeal approach . She had no nose so they couldn't put a nasal tracheal tube in , but they put an oral endotracheal tube in through the mouth by putting the ringoscope in , elevating the tongue , and then they could see the vocal cords and they passed the endotracheal tube down into the trachea so they can ventilate her and stop the bleeding and oozing going down into her lungs Right .
Speaker 2It's an astounding . There's nothing in the training manual for EMTs we tell them how to pack a face . They can put a tourniquet on the extremity , they can pack a wound elsewhere , but in this , this situation , the face is a whole different world . I'm astounded they were able to do that okay .
Speaker 1So let me bring in the idiots of art , where I'm imagining an emt showing up at the scene and when you say there's no manual , you know , when we discuss elite level performances and sport and medicine , you've trained so many times over the very basic things that it's second hand . But they allow you to adapt . It gives you the freedom because you know exactly how to make this cut or throw this pitch or whatever it is . It's your specialty . But you show up and all hell breaks loose and I'm imagining just like I really ever being 12 years old , and you build a bike ramp and then everybody starts flying through the sky . Next thing , one of somebody's on the ground screaming and there's blood , and the first thing every kid goes . It says some leaves and everybody starts packing the wound with leaves . It's terrible because leaves are that for us , but that's what I'm just imagining . It's just been too good , I okay . Yeah , let's just cover that Seriously . Let's just put pressure there because there's no other option . We can't tie that off because there's no other option .
Speaker 3We can't tie that off . They did a good job because putting pressure on it actually stops the bleeding and to push the mint phase back up against , this packing actually controls the bleeding . It's pretty effective .
Speaker 1That's amazing .
Speaker 2So I'm serious , though , because you said leaves , you got to be careful . The leaves have been coming from poison ivy . There's a number of things to consider when you're talking about some of these .
Speaker 1I'm sorry , but the 12 year old EMT staff that I gathered on that particular day was not the most well trained . Now back to this . You dragged Dr Hopper all the way over here and now we're talking about a bike ride . They put the endotracheal tube in , they've controlled the bleeding and they get her to the operating room . Applause to the EMTs for packing this wound and ostensibly stopping the bleeding and giving her a chance to live . Who wants to take over from here ? She's now at a meeting .
Speaker 3At this point
Facial Reconstruction Fundamentals
Speaker 3we need to reduce her fractures and remove the packing . The first thing we need to do is change out the tube that goes into the trachea , the oral endotracheal tube , to tracheostomy and by putting in a tracheostomy then we can remove everything from the facial area , because we need to reestablish the relationship of the occlusion , the upper jaw to the lower jaw and once we get that done we can reestablish the continuity of the midface to the skull .
Speaker 1Okay , not to be a pun here , but that is just over my head a little bit . We're reattaching bones and reconstructing faces casually .
Speaker 3And what really is supercharged facial fractures is these small titanium plates . They are very strong and you don't need external fixation once you have those and you don't need external fixation once you have those .
Speaker 1You need to establish the dental relationship and then reestablish the midface and then , once you get the midface reestablished , you're going to reestablish the continuity of the midface to the skull . You're essentially creating a retaining wall , correct , okay ? And you're building it off the base of the maxilla . So that's your foundation . You've got to start with the jaw and any fracture relationship . Okay , so you're fixing the mandible first .
Speaker 3Articulate the upper jaw to the lower jaw and then you can move up , deal with the frontal skull fracture and put this complex back in relationship to the skull .
Speaker 2Okay , so in the early days it used to be , you would wire the upper teeth , the lower teeth on your mandible , the upper teeth on your maxilla , To make sure the occlusion was normal . They would pass wires joining the two so that they couldn't open their mouth or close their mouth , but the teeth were in alignment and that stabilized whatever facial fractures that you were dealing with . Do you say that's true ?
Speaker 3Yes .
Speaker 1Yeah , I remember probably back in junior high school when somebody break their jaw and you'd see them wired shut and they were on a liquid diet for a month .
Speaker 3Okay , wired shut and they were on a liquid diet for a month . Okay , the driving force is really the relationship of the upper jaw to the lower jaw through the dental occlusion and once you have the in place .
Speaker 1I asked real quick what inclusion is . Can you please explain that word ?
Speaker 3that's how the upper jaw , the teeth , articulate with the lower jaw the teeth , meaning how they fit together , that's where the dental degree comes in , because you know the direct relationship of the teeth and their articulation with the upper and lower jaw . So you have to have that correct . Once you have their articulation , the occlusion is stabilized , then you start with the lower jaw and get that framework secure and then you can move up to the upper jaw and then to the skull .
Speaker 1I have one question before I go to you , Dr Long . The mandible , the lower jaw , movable , connected by muscle . Why does that movable piece have to be set first before you do anything above the maxilla ?
Speaker 3The lower jaw drives the whole . You have to reestablish the foundation so that they bring the rest of their structures into alignment . So the lower jaw drives the whole reconstruction complex .
Speaker 1Now , when you say the lower jaw , it's just very interesting to me . I look at the head , I look at it almost like a house and the jaw is a door , and to think of a foundation , I think of the fixed point , not the part that opens . So why is this movable piece the foundation for things in the dental or maxillofacial world ?
Speaker 3If you do the bed face first , you don't know where to put it . The mandible articulates with the skull and the upper jaw articulates with the skull , but you don't know the relationship . You could put the upper jaw in any relationship and it may not fit with the lower jaw . You have to establish the continuity of the lower jaw first so that you could have the upper jaw relate to it in the proper configuration .
Speaker 1Okay , I see where you're going with this . Dr Long , you had something to add .
Speaker 2I was going to say . I'm going back to the early days when I was in the medical student . I used to see in the shock trauma center people who would come in with a fractured mandible and if you put that , you can put that back together . But if you don't align that , as Bryce talks about , their bite is not normal . Teeth don't come together and there is a major separation , and so we wire the teeth together , the upper and lower teeth together , to provide stability , just like you would basically put a cast on a fracture of a leg or on extremity a fracture of a leg or on extremity . So that part of it is basically is to stabilize surfaces of the teeth with each other , upper and lower , in order to allow the fracture to heal in a normal fashion .
Speaker 1So Dr Potter who for some reason on this episode I have referred to as Dr Harper and Dr Hopper , because apparently the word Potter just can't come out of my mouth you were saying that the foundation of all of this is the lower jaw and resetting it so that it articulates properly and fits together with the upper jaw , the maxilla that sets the foundation for the rest of the skull , so that the mid-face rebuilding process can begin . But you also said that there's a much more important part of this in the way that the endotracheal tube or the tracheostomy is that the correct term ?
Speaker 3Tracheostomy is put in the neck , the oral endotracheal tube is put through the mouth ,
Early Tracheostomy: The Key Innovation
Speaker 3the nasal endotracheal tube goes through the nose . Both the oral endotracheal tube and the nasal endotracheal tube would interfere with treatment of this case . By putting in an early tracheostomy , we're able to reduce the facial fractures at the lower jaw , upper jaw and articulate the facial complex of the skull lower jaw , upper jaw and articulate the facial complex of the skull . If you do a tracheostomy early on in trauma care , you could treat the facial fractures early and then the rest of the procedures can take place over several days , which is a step forward from where it used to be , where the facial fractures might be treated five to ten days out because of not having a tracheostomy in place .
Speaker 1Okay , so if that's the linchpin , when did you two discover that putting in that early tracheostomy was more beneficial and taking care of the facial reconstruction and the jaw fractures ?
Speaker 3When did you think that was better ? Due to my training head and neck ENT training that allowed me to do tracheostomies . A lot of specialties are hesitant to do a tracheostomy plastic surgery , oral maxillofacial surgery because they don't have a lot of experience with tracheostomy and it was second nature for me .
Speaker 1Okay , so this brings back the fact that you are a bit of a unicorn , in that you were dentally and oral maxillofacial surgery trained and trauma trained . So all of those come together where you're leading an approach which is not necessarily different . You're maybe doing it in just a slightly different order to benefit the patient .
Speaker 1And that's where we go into the theme of this whole thing , dr Long , even though he claims no credit for it , putting your team together was getting the right people who put the patient first , and doing everything that was available , but just reordering it and taking the principle and the ideology in a slightly different direction .
Speaker 3By putting the tracheostomy tube in at the start of the case , expedites the patient's care , allows the patient's fractures to be treated and then allows other specialties to come back and not have to worry about an airway . There's a semi-permanent airway in place for the rest of the patient care .
Speaker 1And this goes to Dr Long the pit crew approach and sequential versus the doctors working at the same time Concurrent , concurrent , thank you . I lost that vocab word today , I don't know why . Okay , so we've established that this endotracheal tube , the early one , helps the situation enormously , allows you to do your work . And where do we go from here ?
Speaker 3I think , if we're going to proceed from here , we assume the patient came in with an oral endotracheal tube in place and the facial wound packed up and that allows us to do a tracheostomy , remove their oral endotracheal tube and address the facial fractures and by reducing the facial fracture actually helps control the bleeding . So fracture reduction helps control the bleeding and then you deal with the individual vessels as necessary .
Speaker 1Okay , now the vessels , as you say . You have arteries , you have regular veins , you have capillaries , the small veins inside of the bones that have blood supply . Which type of veins are you talking about actually reattaching or dealing with on a case-by-case basis ? Which blood vessels are you saying that you would need to treat individually ?
Speaker 3You have to understand that the structures these arteries and veins were going to are gone .
Speaker 1Right .
Speaker 3So there's no need for their blood supply to be coming up there , because you should know where to go . So you can clip off these vessels because they essentially are not important for reconstruction with a free flap . We have to have an artery in a vein in order to re-anastomose to a bone and skin that comes from the leg or back .
Speaker 1Okay , in this case , a bone fragment was taken from her fibula . Is that correct ?
Speaker 3Her fibula was remote , along with soft tissue and skin , so she had a skin flap , soft tissue and bone re-anastomose so that it's a living flap .
Speaker 1Is that the word you ?
Speaker 3used . Yes . Anastomosis of the arteries and veins .
Speaker 2Anastomosis means you search your one end of an artery to another end of an
Free Flap Surgery and Reconstruction
Speaker 2artery that goes to the flap . You search through the vein as well . So it's a vascular situation Okay , and the nerve does not enter into a free flap at all . But mainly you want a living tissue to be placed in that spot so that it will not die and have to be redone over and over again .
Speaker 3This one would be very difficult to impossible to reconstruct without the advent of the free flap . When we say free flap it means tissue , skin , muscle , bone that can be re-enastomosed so that when it's put in place it's actually a living piece of tissue . Anything short of that won't survive . You can't just put bone in there when you have no soft tissue covering . In other words , if you tried to just take a piece of bone and put it in there , all the soft tissue is gone , so she's missing everything . So you have to bring skin , muscle and bone to reconstruct that facial area .
Speaker 1Because you're having to fill in that cavity .
Speaker 3Yeah , the cavity is , everything is gone . But there are arteries and veins that can be reattached in that area to the free flap to make it survive .
Speaker 1And Dr Long , I'll come to you in just a second . Just for those people at home , you need to consider this . You'll see a sponge across this woman's face controlling the leftover bleeding , and it's approximately the size of a hot dog diagonally across . It's the amount that is missing , and then we're talking about reconstructing . So , as Dr Potter is saying , it's not just building a wall of bone and putting some skin over it . There's a great deal of area behind that .
Speaker 3Dr , Long .
Speaker 1You had something to add .
Speaker 2The mouth . Organisms in your saliva and in the mouth are the dirtiest . Most organisms are germs that you'll ever find anywhere , even more than your rectum , and the question is with open fractures of the mandible , where we call compound fractures , where they stick to the skin . They're sticking to the lining of your jaw and you have a fracture there . It bathed in saliva . It's amazing that this heals without becoming infected . You could not get away with this in basic orthopedic surgery or any other place where you're dealing with bones . You have to do that in a sterile environment . But you're treating something in an unsterile environment , bryce .
Speaker 3The reason that you could do that is the vascular supply , the blood supply to the head and neck . Every jaw fracture is contaminated with saliva and it's not a factor . You don't worry about that . General surgeons , orthopedic surgeons , worry about the contamination from saliva . Cardiac surgeons worry about it . It's a non-issue because the head and neck is so vascular you can get by with it and you can put a tracheostomy and they worry about infections from that . It's not a problem .
Speaker 2I love it , we're just building somebody's face back .
Speaker 1I love it . One thing that Bryce somebody's face back , I love it .
Speaker 2One thing that Bryce taught me years ago when doing heart surgery some of these people had a difficult airway . He said put a tracheostomy in . I said I've just got a fresh incision in the sternum . I had to saw the sternum in half to get access to the heart , and that's by five millimeters or an inch away from the tracheostomy tube . We don't want to have a sternal infection . He said don't worry about it , and he was right . Other heart surgeons didn't worry about it and did not want to do a tracheostomy for that reason . But he said trust me , it will not get infected , and he was right .
Speaker 3Bill and I closed a lot of sternal dehiscence because the cardiac surgeons when they opened the chest damaged the blood supply to the sternum . So this necrosis electrocautery . So you have an open wound exposing the heart . We would put a tracheostomy in and thenized flaps to close that defect . Bill was a little nervous at first when I started doing tracheostomy but it's not a factor .
Speaker 1Okay , then Dr .
Speaker 2Lund keep going . Well , this is where the interplay people that you work with every day and you're basically trying to address certain clinical problems that come up what to avoid , what not to avoid and this dialogue that went on between Bryce and me changed the way we dealt with certain issues and didn't have the complications that were predicted when we started . We took a lot of criticism for doing this .
Speaker 1Now I would like you to tell me why you took so much criticism .
Speaker 2Because these heart surgeons were trained in their various institutions . This was wrong . You do not want to have an open external fracture or an incision contaminated potentially with saliva , because they'll get infected and then you'll have a dehiscence and then you'll have to sit there and get plastic surgeons in and to correct the whole problem . And it's a mess . But he showed me . This is what was thought . They always thought this was going to happen because they were taught that .
Speaker 1And how did you learn it , Dr Potter ?
Speaker 3Years of experience with tracheostomy and placement in all sorts of wounds cancer wounds , we had open chest wounds , not for the heart to get muscle to close , defects in the facial area before the advent of fairy flaps , and it was just not a problem . The orthopedic surgeon that I worked with will tell you our first encounter where he was worried about a bacteremia . But it just doesn't happen . It's a factor but non-factor .
Speaker 1So now that we've established that the mouth is the dirtiest area and the training that the heart surgeons had was not in line with your training and experience , and they're following the book and you're following your experience and we go back to this young woman and what is the next step with her ?
Speaker 3To remove the oral endotracheal tube , do a tracheostomy , get that out and then we can deal with their facial fraction . And we need to reestablish the relationship of the upper and lower jaw , wiring the teeth together so we can't have a tracheotomy . And then , once the upper jaw is related to the lower jaw , we can start plating the fractures with many little tiny plates with screws . That will re-establish rigid fixation in the face . I think you'll see from the x-ray that there is separation of the facial structures from the skull . With this blast they no longer articulate with the skull and so you need to put these back together .
Speaker 3Remove as much as pellets as you can you don't have to get a bone out , but you need to get a lot of them out and then re-articulate the upper jaw to the skull . And also you have to obliterate any of her sinuses of her left , like her frontal sinus has to be obliterated . She has no more sinus cavities at all . Her ethmoids and frontal sinuses are gone . She still will have sinuses in her upper jaw , the maxilla , and you have to put drainage tubes so that they can still function . But you have to then bring in reconstructive tissue from the leg bone , soft tissue , skin amazing .
Speaker 1In the paper we're talking about , I see here in the chapter , there's an image of what's called stelz's facial prosthesis , where it , where it attaches to the front of the face with magnets
Titanium Implants and Facial Prosthesis
Speaker 1, actually .
Speaker 2So here's what he's talking about the titanium metal implant screws in the facial bones and pellets of her face so they can put a mask on .
Speaker 3Wait , that is Dirk's reconstruction . That doesn't deal with her reconstructing face .
Speaker 2So that will be phase two when we talk about this later on . We're just trying to set the stage how we've controlled the bleeding and guaranteed her airway to get her to the next phase where , as she begins using the free flap that was put in place , there's now , then , how you're going to rebuild her face so that it's presentable , so she had to wear a mask over her face for a period of time because it was so unsightly .
Speaker 2She's blind , she can't see it , but others with that , so the mask was presentable . You'll sometimes see this , and sometimes people walk on the street who've had a cancer removing and they had to remove part of her face . They wear basically almost a sheet over their face , basically almost a sheet over their face .
Speaker 1So , dr Long , you told me offline that the facial mask or this prosthesis was done not only for her benefit , but actually more so for others , because of the size of the wound , and she wanted to look more presentable . I feel like that's what you were trying to get across .
Speaker 2One of the pictures that we'll have in the show notes shows the furrow going through her face , which is gross . The second one shows that , with the free flap in place , with both of her eyes closed , basically with the flap covering both of the lower portions of her eyes and her midface . That will give the reader an understanding of what we're talking about , because the pictorial display offsets what , the ambiguity of the words we're saying to describe this particular type of engine , what we're dealing with yeah , I don't think any words .
Speaker 1we have do justice until you can see the pictures .
Speaker 3Actually her reconstruction with the free flap was initially pretty gross , but long-term was fairly cosmetic .
Speaker 3And then she was able to wear a black mask like the Lone Ranger and actually appeared cosmetically very well . But she had children and she wanted a reconstruction of her face so her children could deal with that . That was one of the primary goals . Okay , and what has come around with the advent , from the time she first had this injury to the time that she was reconstruction , are titanium implants and they're the same implants that are used to reconstruct teeth . As you look at the picture of her skull , you see these little pegs sticking out and those are actually titanium implants that integrate into the bone , the fibula that we put in there , so they can put it into the skull and into the fibula flap . That then allows the facial structure , the prosthesis , to be attached to these titanium implants .
Speaker 1Gotcha . So how long between the initial what you have referred to as the flap ? So the initial covering for the injury that you said was initially pretty gross but then ultimately became rather cosmetic . How much time between that initial fix and then the times you had children and requests for the prosthesis ?
Speaker 3I think it was 10 to 15 years . Oh wow , it was a while .
Speaker 1Okay , and there's one thing in there that it attaches with magnets , so is it something for you to just take one hand and put it on ?
Speaker 3Yeah , the titanium implants . If you look at the x-ray from the side , the cephalometric film you'll see three titanium implants sticking out of the skull and two to three implants on each side sticking out of the fibula . Those titanium implants allow magnetic attachment so she can put her prosthesis over the top .
Speaker 2That's incredible . So people who are going to now door now get teeth tooth implants because for cosmetic reasons and the screws of the tooth implant has the enamel at one end . On the other end is a titanium screw which they screw into the bone and that is well tolerated . But it's the same principle . They use these things put magnets on the end the one as opposed to enamel for a tooth to help to put a mask on . That would hold the mask in place . Okay , we'll talk about more in the second phase when we talk about the reconstruction of her face .
Speaker 1Okay , since we are doing that further episode , I feel like we should wrap this up and look at the results . Fantastically , the results are a success . There's no other way about it .
Speaker 3What's critical is survival of the free flap . There's no other way about it . What's critical is survival of the free flap , and Buehler is probably the best free flap surgeon in Oregon until he retired and our success rate was phenomenal . He was able to bring this bone and soft tissue on and without that free flap in there you could not have reconstructed this gal's face . Free flap in there , you could not have reconstructed this gal's face . She would have a horrible defect in her face without the soft tissue bone reconstruction and that has phenomenally changed head and neck surgery .
Speaker 1The whole process is phenomenal to me . I can't even fathom it . But yes , the work of each of these individuals obviously contributes to this very successful case , and we already alluded to the fact that she got the prosthesis because she wanted her kids to see her face in a certain regard . So we know that she has survived , she got married , she has a child . But there's one comment that I think is very important from all of this that I think we end on , and it says this , I'll just read it verbatim mouth or under the chin , destroying the entire face . It led some of your team to work with companies to develop software that allows the CT scanner to form 3D images . Planning for patients that need future facial reconstruction . Cases like this started turning into pre-planning 3D models . Who is responsible for that ?
Speaker 3It's a component of everybody that's involved the people that make the titanium implants , the surgeons and the 3D scanner that allows these things to be reconstructed appropriately .
Speaker 1When did this initial injury occur for this young woman ?
Speaker 3Do you know the date ?
Speaker 2No .
Speaker 3It has to be 20 years ago , okay .
Speaker 2So , it'd be in the late 1980s , 1990s , okay .
Speaker 3She was 17 at the time and she's probably 27 , maybe 20 years ago .
Speaker 1Pretty incredible how long until these 3D models were available , technologically speaking , to plan for facial
Advances in 3D Modeling and Results
Speaker 1reconstruction .
Speaker 3I think they've really come into vogue in the last 5 to 10 years .
Speaker 1Okay , I think they've really come into vogue in the last five to ten years . Okay , you were doing by hand what these computers have only now been able to come up with in the last five to ten years .
Speaker 3Actually , they show prosthesis reconstruction by clay models and we would take a clay model and then have that used as a baseline to make a prosthetic reconstruction . And that was way back before 3D models . They don't need anymore because it eliminates that step .
Speaker 1Did you have ?
Speaker 2something to add , dr Lowe . Well , during this time period the University of Maryland myoma monitor , the head and neck surgeon , the plastic surgeon , did a total facial transplant on a person who had a badly disfigured face . They had a one-year celebration of that and John Hill , cardiothoracic surgeon , and I went back to hear that presentation , meet the patient and things like that . But that case was only soft tissue . It did not involve the bony reconstruction that you would need to do with a face like this , people who commit suicide .
Speaker 2I don't know if you ever saw the movie Shooter , yeah , mark Wahlberg . This guy takes a gun and basically puts the muzzle of the revolver underneath his chin . But Hollywood doesn't show the gore that's associated with an injury like that . We saw a number of people who attempted suicide by blowing their face off with a gun underneath their chin , pointing upward , going up to the mandible , up through the nose and , to the past , the forehead . We had experiences with dealing with those type of injuries , but we never did a facial transplant . I want to emphasize that we were able to reconstruct a face , but we never did a facial transplant .
Speaker 1I want to emphasize that we were able to reconstruct a face but we never did a facial transplant .
Speaker 1All I can think in my head is a terrible movie with Nicolas Cage and John Travolta called Face Off , and they trade faces . It's a terrible premise . So I'm glad to hear that you didn't do any facial transplants . That just makes my soul happy . In regards to the other items that we've talked about , is there anything before we close out and we're going to revisit this topic in greater detail is there anything about this particular case that needs to be brought to light ?
Speaker 3I think the main thing that is important with this case is there were the facial fractures and the trauma , but it's the facial reconstruction that was able to do because of the advent of free flaps and the advent of titanium implants that allowed you to use a free flap as a reconstruction for final aesthetics of the face for final aesthetics of the face .
Speaker 2The other thing I learned from Bryce is that basically they were using titanium to fix mandibular fractures and they had them angled to go to contour with the shape of the mandible and I was using to fix rib fractures and elsewhere on the chest stainless steel which is much heavier and thicker , and so when we first started doing rib fixation , I took the technology that Bryce was telling me about using titanium mandibular plates and putting them on ribs , before we finally developed through our lab , a custom-made way of pre-contoured titanium plates to fit on the surface of a rib . This cross-circulation of ideas and experiences with different specialties that you work with every day opens up a whole new horizon of what you can do .
Speaker 1Absolutely Just finding those intersections between specialties is hugely important .
Speaker 1It's
Cross-Specialty Innovation and Closing Thoughts
Speaker 1your training in two different specialties and Dr Potter's training in two different specialties that ends up making the magic here , beyond what you set up in a team atmosphere . So with that let's close and we hope you enjoyed this episode . We hope that you come back and listen . If you want to learn any more about this case study history of any of the items that we have talked about , please check out the show notes or Dr Long's upcoming book entitled Flatline to Lifeline . As we close , we remind you to imagine a world where dead isn't actually dead . We remind you that there are places and people who value the patient over the system . Flatline is not the end . A lifeline exists . Saving time saves lives . Thank you for joining us here on Flatline to Lifeline with Dr Bill Long . We'll see you again soon .
