Blending Back In

Ethan Monsalve has an air of confidence on the football field. When you meet him, the 10-year-old’s green eyes and bright smile get your attention—but it’s only a split second until you also notice the rough, wrinkled appearance of deep scars across his chin and neck. When he is running to catch a pass during football practice, his goal isn’t to stand out. It’s to blend in.

Like hundreds of patients who come to Vanderbilt University Medical Center every year, Ethan endured a sudden, awful incident that changed his life and set him on a journey of healing. In his case it was a bonfire accident that left him with severe burns over nearly 40 percent of his body at the age of 6.

For some, the change may come in the form of radical surgery after a cancer diagnosis. Others may be victims of abuse—or victims of circumstance.

Vanderbilt has the area’s only Level 1 trauma center and the state’s only burn center. With an active cancer center and pediatric hospital, reconstruction cases come in countless shapes and forms. A deep and varied team of experts in plastics and reconstruction come in right behind the life-saving work of the trauma, cancer and burn surgeons. While cosmetic plastic surgery is a thriving practice at Vanderbilt, reconstructive plastics account for well over half the cases.

What begins when families like Ethan’s arrive at VUMC is a journey. Patients, families and loved ones must work together with the skilled plastic and reconstructive surgeons at Vanderbilt to reach a place of both form and function—so people can be noticed for who they are, not for what happened to them.

Surgeons at Vanderbilt who perform reconstructive plastic surgery have come from many backgrounds. Some began in plastics, others in orthopedics or otolaryngology. Dr. Blair Summitt, assistant professor of plastic surgery, was there when Ethan arrived at VUMC by medical helicopter four years ago. He is also a member of the burn team at Vanderbilt.

“Once you are a burn patient, it’s a lifelong thing,” Summitt says. “We’re the only burn center around, so burns account for about 30 percent of what we do. We get countless adult patients, often men and line workers, who suffer severe burns from electrical contact. Every week we see probably two or three children who have been scalded. Most of them are accidents, but some are not.”

The surgeons say that plastic reconstruction work challenges them and is often the part of their jobs they love the most. While not the bread and butter of their careers, it gets to the very heart of what they do.

The Gift of Symmetry

Dr. Russell Ries, professor of otolaryngology and the Carol and John S. Odess Chair in Facial Plastic and Reconstructive Surgery, has a gift for symmetry. He says it comes with his somewhat obsessive-compulsive nature. He even admits to a bit of an obsession about faces. Dozens of mask-like sculptures and pop-art faces—items ranging from antique decorations to belt buckles and bottle openers—cover his office wall. It reminds him, he says, about what he loves about faces: Each is uniquely its own.

“Some people say they think you’d want a facial plastic surgeon to be an artist—but you don’t want an artist working on your face,” Ries says. “You want symmetry, not interpretation.”

One of the more remarkable surgeries Ries does on a regular basis is called the paramedian forehead flap. Ries rearranges the skin on the face and scalp to cover gaping holes left after Mohs surgeons—named after Dr. Frederic E. Mohs, who developed a technique called Mohs Micrographic Surgery—have removed skin cancers, often from the top of the nose.

Ries recounts the history of the technique, developed in Bombay, India, where the price of adultery in the first half of the 20th century sometimes included slicing off a portion of the accused’s nose. Photos from his many cases show that facial symmetry can, remarkably, be regained, even after a silver-dollar-sized piece of flesh—or larger—is lost to cancer.

Those who know Ries well also know the symmetry of his own life: Conscientious volunteer work and environmentalism define him as much as his surgical skill does. While Ries doesn’t talk much about his volunteer work, Carol Odess, his benefactor and friend, says she is happy to.

Odess explains that Ries and her late husband, Dr. John “Jack” Odess, had been friends, and she learned something a few years ago from Ries’ assistant that she’s never forgotten: Ries has quietly offered victims of domestic violence an opportunity to regain their faces—repairing broken noses, jaws and battered faces—without charge.

“[Ries’ assistant] told me that you can’t imagine battered women who don’t want anyone to touch them, let alone a man,” Odess says. “You can see the fear in their eyes. But he is able to work with them. I can see that as though I were sitting in the room. He is such a patient man, and then to be able to bring them back and take away their fear … well, when he is through, she told me, ‘You can see the light in their eyes again.’”

Ries has a simple philosophy. He likes people and likes helping them, and he focuses on what they want. “Most people don’t want to stand out. They want to blend in,” he says.

Restoring Futures

Helping a child blend in can go far beyond restoring form and function—it can save their future. Some of the cases Vanderbilt surgeons say are the most memorable involve children; after all, they have such a long time to live with their scars, defects or deforming tumors.

Dr. Kevin Kelly is associate professor and director of pediatric plastic surgery at the Craniofacial Surgery Center at Vanderbilt. He says the most severe cases he sees are children from poor or developing countries.

Recently, a young girl named Lan Kui came from China, brought to Vanderbilt by the Agape Foundation. A jaw injury had left her mouth painfully clenched shut for six long years. Lan Kui’s jaw joint simply melted into a solid strip of bone after a blow to the side of her face went untreated for several years. Kelly’s surgical skills created a completely new joint and gave Lan Kui the gift of a mouth that would open.

In the space of a few months, the shy preteen was rescued from devastating tooth decay and infections from teeth that were rotting away, unreachable by dental experts. She began opening her mouth to fit in her new favorite meal: big chicken sandwiches from Hardee’s. She is looking forward to returning home to a normal life.

For Lan Kui, what would be considered an essential and urgent surgery in the United States was a miraculous gift she had waited a very long time to receive.

“This is the reason we go into medicine, to help people,” says Dr. Steve Goudy, assistant professor of otolaryngology.

As a pediatric otolaryngologist, Goudy’s bread and butter involves a lot of ear tubes and tonsillectomies, but through the years, international travel and his firm belief that children can and should be helped have brought him several patients from abroad.

A recent case involved a teen from Guatemala named Marleny. When the Monroe Carell Jr. Children’s Hospital at Vanderbilt and the Nashville Shalom Foundation agreed to foot the bills to get her here, Goudy was on board to donate a tricky surgery with an uncertain future.

Marleny had a very rare, very aggressive tumor that was slowly consuming the right side of her face. Her nose and mouth had become grossly stretched as the fist-sized tumor bulged outward.

“It was taking over her whole face. She couldn’t go to school, and she never went out in public without a scarf over her face,” Goudy says. “Her whole life was on hold. It had taken over her life and her personality.”

The fist-sized mass was removed in March. Just two months later Marleny returned home without the scarf and went back to school. While it is unknown if the tumor will recur, requiring more surgery, Goudy firmly believes that giving her a chance to learn and live normally now is worth the risk. That belief is shared by those who brought her here, as well as by the others on Marleny’s surgical team: Dr. Christopher Wootten, assistant professor of otolaryngology, and Dr. Louise Mawn, associate professor of ophthalmology and visual sciences, and neurological surgery.

“That’s the thing about Vanderbilt,” says Goudy. “I can call on the best and brightest people I know for these difficult cases, to work together to improve the quality of someone’s life.”

Again and again, the word “teamwork” comes up. Plastic reconstructive procedures cross many disciplines and many different departments at Vanderbilt. Dr. Bruce Shack, professor of plastic surgery and chair of the Department of Plastic Surgery, says this collegial spirit is of considerable benefit. The fact that Vanderbilt is the referral center of choice for many states in the Southeast also means there’s a lot of work to do. On-call shifts for plastic and reconstructive surgeons to respond to trauma cases, 24 hours a day, are shared between disciplines and departments, among the individuals with the right skill sets.

One critical skill is microvascular surgery of the hand. Vanderbilt has become one of the top centers in the United States for hand surgery.

“In plastic surgery it’s not just the face but the hands that require careful attention to form and function,” says Shack, who is also certified in the art of microvascular hand surgery. “The face and hands are the parts that are visible, but we also communicate with them. People may not think about it, but we communicate a lot with our hands.”

Mending Hands

Dr. Doug Weikert, BS’83, MD’87, associate professor of orthopedics and rehabilitation, is director of the Division of Hand and Microvascular Surgery at the Vanderbilt Hand and Upper Extremity Center. When an injury like a finger or hand amputation occurs, Weikert often brings in others who have microvascular training, including Shack; Dr. Wesley Paul Thayer, assistant professor of plastic surgery; Dr. Jeffry Watson, assistant professor of orthopedics and rehabilitation; and Dr. Donald Lee, professor of orthopedics and rehabilitation.

Weikert, who has reattached all manner of fingers and hands, arms and even lower limbs, keeps in close touch with many patients. Kaitlyn Lassiter, a teen whose feet were severed in a horrific theme park incident, dropped by to see him recently to show off the progress on the foot Weikert had successfully reattached. Much like the treatment of severe burns, rebuilding extremities is a long-term process.

“It’s very challenging for me because I must be able to be a nerve surgeon, an orthopedic surgeon, a vascular surgeon and plastic surgeon all at the same time,” Weikert says. “I have to have a plan and a vision—not over days and weeks, but over months and years—about how to restore function.”

In one particularly awful case, a 3-year-old boy had been intentionally scalded by his own mother, who submerged the tot’s left hand in a pot of boiling water as a punishment. Burn program director Dr. Jeff Guy, MMgmt’09, began treatment, but it was obvious the boy would need a reconstructive specialist, so Weikert was called in. There was little flesh left for him to work with.

The boy, named Kevon, was quickly placed in foster care along with his older brother. The boys’ foster—and now adoptive—father, Robert, says Kevon had much to overcome. Because of concern about his mother, who was released from prison after serving a single year of her 26-year sentence, Robert asked that only their first names be used for this article.

“The first time I saw Kevon’s hand without the bandage, it was a real shock,” Robert says. “The extent of the damage was so great. We were learning what could be expected as far as best-case scenario, but that’s where Dr. Weikert and his staff were amazing. They exceeded all expectations.”

Kevon has required surgery every four months for the past two years. Muscles, bones, nerves and blood vessels first had to be protected while a plan was worked out to supply skin from elsewhere. A special graft material wrapped his digits together for months to preserve them, making Kevon look like he was wearing a thumbless mitten.

The real challenge for Kevon and his adoptive parents came when the then-4-year-old’s hand was literally sewn into his thigh. The active boy was placed in a body cast for three weeks to keep him from detaching something as the thigh skin and its blood supply “took” on his hand. The struggles with difficult toileting and dressing were worth it. Skin was permanently relocated from thigh to hand, giving Weikert enough to work with to rebuild Kevon’s hand—finger by finger.

“That was five surgeries. Last fall when he had one more web space to go, he looks up at me and says, ‘One more surgery and I can put on a baseball glove,’” Weikert recalls. “That just broke my heart.”

A love of sports often connects Weikert with his patients, especially the budding athletes like Kevon, who is already showing some skill. Three months after the final finger—Kevon’s pinky—was surgically separated from the rest of his hand, Kevon came in for a checkup. Weikert had a baseball glove waiting for him.

“The smiles and the joy he expressed getting that glove!” recalls Robert. “Now he’ll make us go out to play catch with him, saying it’s doctors’ orders.”

Shared Journeys

When the lives of plastic and reconstructive surgeons and their patients intersect, bonds can be built that are nearly as close as family. The journey certainly changes patients and families. Some say it changes them for the better.

Ethan Monsalve and his mother, Sara, are from Los Angeles; they had only been visiting friends in Tennessee at the time of Ethan’s awful burn injury. But that Thanksgiving visit turned into Christmas and New Year’s at Vanderbilt’s intensive care unit and burn unit. Now, four years later, the family has decided to move permanently to Tennessee.

“This is a journey, and I had to ask myself: Who did I want to make the journey with?” says Sara. “Dr. Summitt lets us know what the choices are, and the lines of communication are always open. I really respect his honesty. We make the choices together.”

Ethan still may have 20 more surgeries to go as his body grows under stiffened and scarred skin. Visits to the hospital are frequent, and are usually painful, yet Ethan says he likes coming to VUMC. Mostly, he says, that’s because it means 24-hour access to ice cream and PlayStation 3, but also because he trusts and likes Summitt—especially his dry sense of humor.

“He’s funny when he tells jokes,” Ethan explains. “He’s like my coach. He’s funny, but he’s not a laugher.”

Ethan is even developing a sense of humor about his injury. And his mom talks about considering nursing school because she found that she could stomach, and stay involved in, Ethan’s difficult skin treatments. But Ethan teases her about continually working on his skin and calls her a “picker.”

Sara says it’s good to come to a hospital where people speak their language, with humor. It feels normal. Their journey has taken them a long way toward healing.

Ethan says his most recent graft procedure—which took a flap from his belly to cover a tightening strip of scars on his neck—should qualify him for the Guinness World Records book.

“I’m the world’s youngest tummy tuck—a 10-year-old tummy tuck,” he says with just a hair of a grin. He’s not a laugher, either.