Joshua Lampert, M.D., a reconstructive and cosmetic plastic surgeon, talks about a unique series of surgeries utilized for nasal tip reconstruction that restores patients’ faces.
Is it that you don’t want to just be known as like the nose man, the breast man? Like you said, a lot of doctors in plastic surgery are known for one thing. What are you known for?
Lampert: I try to treat the whole patient. When I look at a patient, aesthetically, I look at their whole body. They come in. If they’re complaining of something, if it has to do with their face, their body or their breast, I look at them as a whole. I think that that is something that you’re trained to for your aesthetic eye as a plastic surgeon. Even before that, before I went to medical school, my parents encouraged me as an artist. I’m a sculptor really kind of out of practice with clay and plaster and doing that type of thing. I think you bring those same elements to a good plastic surgery practice. At least for me, I would be really bored just doing one type of operation every day. I would feel that I do enjoy operating on other areas of the body. I would miss that. I think that when you decide you’re not going to do that anymore, that’s hard, you know? I feel like a lot of people do that. Maybe they really only like operating on breasts or they really only like operating on noses, but sometimes people do that for financial reasons because they’re trying to push that and make that a more marketable thing, that they’re known for doing only one operation. I don’t think I would be happy doing that because I really enjoy operating as a whole. Sometimes, operating on the whole person affords you a way to benefit a different area and you’re borrowing sometimes from Peter to pay Paul. You’re making both areas look better. I think being a good plastic surgeon that operates on the body helps with my ability to operate on the face. Sometimes we’re harvesting a skin graft or fat grafting for aesthetic or reconstructive purposes and having an aesthetic eye of where to take that donor site and where to borrow from Peter to pay Paul helps.
Dr. Lampert, tell us about the nasal tip reconstruction. It is a unique procedure. First of all, what is it called and is it a specialty?
Lampert: I think it is a specialty to do nasal reconstruction. It’s something we learn in plastic surgery residency and training. What’s unique about the nose and one of the reasons I love it is it’s an important structure. It has a functional and aesthetic importance that’s arguably as important, if not more important, than other areas of the body. It’s a delicate structure. It’s a unique structure in its anatomy. It’s important for breathing. It’s important for how you look. Anyone who’s woken up before a big meeting or a date or whatever and had a pimple on their nose, right? It’s really hard to look in the mirror and deal with that. To have something a little bit bigger, whether it’s a small skin cancer or a larger defect or deformity – you can’t really hide that in general day to day conversations with other people. It does put a little bit more pressure on the surgeon or the team that’s delivering the procedure to get an excellent result. It does increase the technical challenges as you really have slim margin for error.
How many of these cases, Dr. Lampert, do you see here? In other words, like you mentioned, this can be for a number of different reasons. It can be for skin cancers. It can be for something more. We don’t think about the person having the tip of their nose bitten off by a dog or by a horse or an animal. How often does that happen?
Lampert: Most of the time these nasal reconstructions are for skin cancers. That’s the most common thing living down in Florida. They go out and they had a lot of sun when they’re younger and now they’re paying the price for it when they get a little bit older. I’m scared of the sun now, but I wish I avoided the sun when I was younger, but most nasal reconstruction has to do with skin cancer reconstruction. For younger patients, typically under the age of 30, most of these things are from traumatic injuries. A lot of times we’ll see nasal reconstruction in the form of a broken nose playing basketball, baseball hit them, car accidents – those are the most common forms of nasal reconstruction and they can be severe or little things. When you start seeing partial nasal amputation from an animal bite or a car accident or a gunshot wound, those things tend to be less common and obviously elevates the bar as far as technical difficulty.
I would certainly imagine so. In this case, we’ll talk a little bit about Valeria. We are going to be interviewing her. She’s a teenager who came to you. Tell us a little bit about her case when she came to you, and had she already had some treatment or a procedure done? What was going on with that?
Lampert: Valeria was an interesting case because I have treated younger patients with car accidents, gunshot wounds, and dog bites. What was interesting with Valeria was it was a horse bite. When I was a kid, I remember hold the carrot flat, the horse won’t bite you, that type of thing. They’re strong animals, but you don’t really think of them as having the mechanism to amputate a nasal tip or structure. In this circumstance, the horse unfortunately bit her in a way that amputated the tip of her nose. When I initially evaluated her, I was the plastic surgeon on call covering the emergency room and they had called me from another hospital asking if this was something that I could handle. We kind of knew a little bit of what was going on from talking to the E.R. doctor, but we didn’t really know the severity of it until she came in the emergency room.
She came straight to you from the bite, right?
Lampert: Well she came straight to the emergency room, but I was pretty much waiting there for her.
How severe was her injury? Did the tip of the nose affect her breathing or the use of her nose? Like you said, this is aesthetic but it’s also the function that we need to breathe. How severe was her injury?
Lampert: With Valeria it was a severe injury. The horse bit off not only the outside layer of skin but also the underlying cartilaginous framework of the nose, the nasal tip, and also lining was missing. The internal lining of the nose is as important when you’re trying to reconstruct it. With all those layers of tissue amputated and missing, there was a defect on a very important part of her nose we call the soft triangle, which is the edge of the nostril. That’s a very serious injury and then it’s very important not only to try to make it look as good as possible on an attractive young lady, but also that she was able to breathe out of it as well.
How do you approach this? What is the technique that you do? Do you approach every single procedure like this differently? Like something would be different for skin cancer, but with her, what did you do?
Lampert: For minor injuries, for injuries that are more superficial, not super deep – injuries that are smaller – sometimes a small little skin graft is good to cover up to try to hide that and that can heal quite well. For larger injuries like this that are full thickness, that go all the way through, you can’t really put a little graft on space and have it look like the normal geometric anatomic structures of the nose. For something like this, the preferred method is to use the forehead tissue and a series of surgeries called the forehead flap. Frequently, when skeletal framework is missing, we do an intermediate procedure and take cartilage from rib or ear and use that to build up and recreate the skeletal framework of the nose. For amputated surgeries, large full thickness defects, most surgery or skin cancer or something like this, a bite wound that’s full thickness where tissue is missing, we need to bring tissue from somewhere else and recruit tissue. The optimal place is the forehead.
You do this with Valeria. You used tissue. You removed tissue from her forehead to recreate and rebuild her nose?
Lampert: Correct. With Valeria, because tissue was missing, I used tissue from her forehead based off an artery that comes out of the eye socket and I brought that down full thickness so that I had some bulk of tissue with which I could artistically shape. Now, I left it connected, which is customary to do that with the artery while the blood supply grows into it from the surrounding tissues. Once that surrounding blood supply grows in and is reliable, then we can trim that little artery and repair the forehead. Usually, the forehead heals very well. It’s difficult because the patient has to live with this forehead flap connected and it’s visible and it’s something that’s embarrassing to go out in public with, but the benefits and long term aesthetic outcome are far superior to any lesser surgery.
Right, especially for a teenager. Like you said, it’s got to be tough. How long did she wear that for? How long did she have that implanted and how many procedures did you need to do?
Lampert: With Valeria, I think we did four or five operations, but the current state of the art in nasal reconstruction for a large defect is what we call a three-stage forehead flap. This was really described by a plastic surgeon, Fred Menick, who has ties here in Miami and practices in Tucson. He’s written multiple textbooks on it. It’s the evolution of an ancient technique that goes back to 400 or 600 B.C. in India using forehead flaps to reconstruct nasal defects for criminals who had their noses amputated or lost their noses fighting with rapier combat each other. Nasal amputation back then was treated with no general anesthesia, using forehead flap tissue because of the similarities of the skin and tissue of the forehead and nose. Now this has evolved quite a bit, but we’re still using those same basic principles. It’s just become so much further refined. With Valeria, I did a three-stage forehead flap with initially bringing a thick, large, vascular piece of tissue measured off of the opposite side of her nose because I wanted the best possible symmetry. That then stays connected to that small artery for one month. After one month of that, I then lift that flap up, carve and shape it the best I can aesthetically because the blood supply is a lot better now, take a little ear cartilage graft, and then after I thin that flap, I put it back down. She’s got to go another month, unfortunately; but, the advantage of that second month with the flap connected is that I can greatly push my artistic sculpting. By doing an extra operation, I can work the tissue a little bit better because I’m worried with that first operation about the blood supply. Plastic surgery is what we call a battle between beauty and blood supply. After two months of having the flap connected with one intermediate surgery between, she then would have a third operation with the flap divided. I then performed a fourth operation to try to shape and do a little dermabrasion to improve scar tissue. With this type of injury, a lot of times it’s at least four operations.
After four operations, is there a very long recovery? For two months, Valeria had the connection. Then, you said by the third surgery, what was going on?
Lampert: With these operations, it’s usually the first stage to bring in the vascular blood supply from the forehead with a flap. We really want to make sure the blood supply is good so we keep that a little bit thicker. Then one month later, we elevate that flap. We can carve now like a sculpture the way we want it to look, specifically at the tip where her problem is. That’s one of the harder places to get an aesthetic result. Then after a month we put that flap back down so it stays reconnected for two months, which is sometimes difficult for the patient. That time, they have to be patient themselves, but the benefit of doing the operation with an extra stage allows us to more aggressively sculpt or shape the nasal tip to a better aesthetic result. Then after that second operation, now the second month goes by. Then we can with a third operation divide the flap and then reconstruct the forehead which usually heals very well. The forehead is a very good donor site. Scars typically fade very well and are hard to see and makes it well worth it because there’s really no other way to get a good three-dimensional reconstruction of the aesthetic nasal tip with such a good skin match.
If you had to go to a different part, you could go to the ribs, you mentioned?
Lampert: Well, in that intermediate stage, usually after the first stage but before the last stage where we divide the flap, that stage that’s the intermediate stage will a lot of times need a cartilage graft to rebuild the skeletal framework of the nose. That could come from the ear or the rib just depending on how much tissue and what type of tissue we need. The cartilage that comes from the ear or the rib – that’s really our skeletal framework. The resurfacing the quality of the skin from the forehead and the quality of the skin on the nose are very similar. So usually for good resurfacing of the outer what you see on the nose, the forehead is the best.
In Valeria’s case, how long did the entire process take?
Lampert: For Valeria’s case, there was a month between the first operation and the second operation. Then after the second operation, another month went by before the flap was divided. There are a couple months before that third operation. Now after the third operation we usually wait three to four months before doing any minor revisions. It’s usually smaller operations that we’re doing at that point.
By the end, how close would you say it looked to before the injury, before she was bitten?
Lampert: After we were done with the third stage of Valeria’s surgery, her nose looked very good. It was acceptable enough that she postponed that fourth smaller revision operation some time. She had some school things she wanted to do. She had her prom she wanted to do. That fourth operation I think is really important. I always want to do it a little bit sooner because I’m excited to get things to look more symmetric and better, but Valeria had a little bit of a social schedule which that always makes me feel good, too, to know that the patients are able to get back to the things that they wanted to in their activities of daily living.
As far as the function of her nose is, is she able to breathe normally? Is she able to smell? How is she today as far as that’s concerned?
Lampert: Overall, Valeria’s nose functions very well. She’s breathing out of it fine. It takes time sometimes, feels a little itchy, the sensation to the tip can take many years, and sometimes there is a little bit of numbness on the nasal tip compared to the other side, but overall, her aesthetic outcome has been excellent.
A procedure like this was mentioned that, thankfully, in her case, there was a charity that you worked with to help her get this procedure taken care of. Can you perform this type of procedure for different medical issues, like you said? What are the medical issues that would be used for this procedure, that fall under this nasal temporary ? construction?
Lampert: Well, nasal reconstruction is a lot of different procedures. It could be from a broken nose from a basketball game, could be from a car accident, could be from a skin cancer, maybe a dog bite. This was a horse bite, which is really not a common thing that we see. Nasal reconstruction really encompasses everything. We even see patients – sometimes they’ve had a bad rhinoplasty and they want a revision rhinoplasty and it starts to become nasal reconstruction because now we’re taking rib cartilage or ear cartilage to reconstruct something that was maybe a little bit overdone in the cosmetic surgeon’s hands. So nasal reconstruction really encompasses a lot of things. One of the really cool things I like about nasal reconstruction, about nose surgery in general, whether it’s aesthetic or reconstructive, is that every nose is different. Everybody’s nose is different. Everything that they want to achieve is different. It really makes no surgeries alike. There are no two same operations. Everything involves some artistic eye. It involves some creative thinking. There’s always a slight challenge, if not a bigger challenge, for the plastic surgeon. I think that’s why I like these operations. I think that’s why many of us really enjoy doing nasal surgery, whether it’s aesthetic or reconstructive surgery.
I’m sure with Valeria and her case, it must have been very satisfying to know that you could help a young girl, a teenage girl, who had something so traumatic happen to her, and not just traumatic but traumatic with her appearance. For a girl that age, that’s a critical time for that. Like you said, she had prom and all these other things. It must have made you feel good to get her back to her face, to what you know what she would look like.
Lampert: Yeah. It makes you feel great as a surgeon. It really makes me feel great. Valeria is a unique individual because your typical teenage high school student doesn’t really fall into that. She’s an extremely tough individual. She’s very strong. I really can’t think of a time that she was flustered or frustrated. She was optimistic the whole time. I think that that’s really unique about her. I think for a lot of other patients that this is a hard thing for anyone to handle, you know? But with Valeria, she handled it in stride. When I look back, I don’t really ever remember seeing her shed a tear. I don’t remember seeing her get down. Sometimes those things happen at home and I don’t see them, but usually I see them. With her, she really is a tremendously strong individual. Just to see the photographs, her getting back to school, her graduating, her going to college, seeing her do those things and just doing things that every other kid her age is doing makes me feel great and would make any surgeon feel great.
I would imagine that you get to see patients just all over the country, all over the world depending on what the problem is. Do you see a lot from all over?
Lampert: We get patients that come from out of town. Miami is a big place, so we kind of become a little bit of a referral center for the state of Florida for nasal reconstruction. We saw a couple patients from the Gulf Coast area today. I think one really cool thing about the Internet and e-mail and being able to look at photographs of patients and have a video conference with patients and go over some other problems and what’s going on – it really helps a lot for patients to find the right surgeon. I think that that’s really better than it used to be. It’s getting more and more feasible to see and you really don’t want to give patients too much without examining them. Every patient, I want them to come in my office. I want to do a nasal speculum exam. I want to look inside their nose and see what’s going on, but the Internet, the video conferences – those things help us get a history from the patient. We can see what’s wrong, what are their options, maybe they should wait a little bit if they’ve recently had a surgery and the swelling is there and it’s not the right time to fly to Florida or wherever, or maybe they have a great surgeon in their neighborhood. I mean, if they’re in Tucson, I would send them to see Dr. Fred Menick who wrote the textbook on this. I think that it really is helpful, but it’s also a double-edged sword because sometimes patients will look at things like social media or the Internet and decide that someone’s an expert, but really, they’re more of a marketing expert. I think that that’s a difficult thing to do for patients as well. What we encourage patients to do is to make sure that their surgeon has hospital privileges at a good facility so that if there ever is a complication or problem, they’ll be treated at the appropriate facility. Safety is the most important thing and it’s very difficult for a patient to vet out and see the qualifications of their surgeon. The Internet and social media aren’t going to show them that. Most hospitals will do a better job of going through the credentialing required to make sure, if it’s a good hospital, that that surgeon has the right training and abilities to perform that operation. I think that that’s a very important thing for patients.
I’m glad you said that. Lastly, how many animal bites like that do you see?
Lampert: Okay, so we see a lot of animal bites as plastic surgeons. It’s probably one of the more common things when you’re on call is a plastic surgeon to get called. For a lot of times, it’s a smaller bite to the lip or the nose or sometimes there’s a little bit of tissue missing. Mostly it’s dog bites, and usually the larger breed dogs do the most damage. Sometimes even small dogs. We saw a Yorkie bite that was really terrible the other day. Those things are very common. What’s not common is that tissue is a large piece of tissue that is missing and it’s not common to be bit by a horse so severely. To see a partial nasal tip amputation from a horse bite makes this case unique.
Very, very unique. She was lucky to have you.
Lampert: Yeah. The other thing though that I’ll tell you that was really cool about Valeria is after this whole thing and everything that she went through, we had another patient who was a little bit younger and a teenager and Valeria offered to be a mentor to that patient. Valeria had a mentor, a very pretty lady in her 30s that had a large nasal defect from cancer and had a similar operation. One of the things that I think is really cool about this specific case and about this specific patient is she kind of paid it forward. I think that’s really unique, a cool little story inside this story.
Absolutely.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Joshua A. Lampert, MD, FACS
LampertMD.com
305-878-1920
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