July 8, 2015
Written by Anna Grace (class of 2014-2015)
I recently moved and misplaced my journal with my notes from Dr. Harken’s lecture, so I’ll just jump into the surgery. I don’t remember the medical name for this case, (getting “ostomy” and “otomy” confused…) but this procedure was to replace a section of a man’s skull that had been removed and stored…in his thoracic tissue!
Before the surgery got underway, I met one of the neuro PAs, Larry. He was so nice and after introducing himself, pulled up the patient’s CT scan so I could see what happened. “You might see brain, today!” he mentioned, in his usual cheerful demeanor. The surgeon said that I wouldn’t see brain, just dura mater. Anyway, this patient had a stroke several weeks ago that resulted in swelling of the brain, readily evident on his scan. A section of his skull was removed (the size was a little bigger than a deck of cards) to allow the brain extra room as it healed. A sunken in area was readily visible on the patient’s head.
The skull section was stored in the patient’s side. I am not sure if it was in dermal tissue or further down, but it didn’t seem very far down. This was to keep the bone tissue viable while it was separated from its usual spot. The patient recovered for several weeks (I can’t remember how long but I remember marvelling that it was quite a long time to be without a portion of one’s skull, let alone have a portion of one’s skull in one’s side). What a crazy concept.
The first part of the surgery was to remove the skull fragment from its temporary pouch, which the surgeon did carefully but speedily. Then Larry stepped in to suture this opening up as the surgeon (I think his name was Dr. Patel) set about on the skull. The process of opening the man’s scalp was actually pretty interesting. After shaving his head around the existing scar from the first procedure (the scar wrapped from the forehead area around the ear and down to the back side of his head), Dr. Patel cut along the scar. He placed curved plastic clips around the borders of the skin flap on both sides as he went and I silently wondered what they were for. At this point, another PA came in to assist Dr. Patel as Larry had finished his suturing and left the OR to go round on patients.
Once the scalp was pulled back, Dr. Patel set about fitting little metal plates to help secure the skull fragment as it grew back. This was a careful, slow process. The rep from the company that makes these custom plates talked a little about the technology involved. Scans are taken of the patient and many different plates are made to give the surgeon multiple options. The screws can also be self tapping, meaning hollow on the inside so you don’t have to pre-drill a hole. I explained this to my husband later that day as a wildly amazing piece of information. His dad is a contractor and he was like, “Oh yeah, self tapping screws?” He seemed way less impressed. It’s kind of amazing how many similarities there are between ortho/osteo surgery and construction. Anyway, after the holes were drilled and the plates were on, it was time for bone cement!
Everyone took a minute to verify the directions. There was a powder and a liquid, and the scrub tech had to mix the solution for a certain number of seconds, and then Dr. Patel had a certain number of minutes to apply the paste until it set. He shellacked it on with great skill (obviously) and the paste filled in the areas that didn’t make a complete seal. I wasn’t able to ask this question, but the fit of the skull wasn’t 100% and I think it’s because the body probably harvested calcium from the bone edges during the weeks of healing. Again, that’s just my very uneducated guess….Anyway, the bone paste helped seal everything up and apparently also promotes bone healing.
The last phase was to close the skin up, and here’s where the plastic bits came into play. They served as markers to help the surgeon suture up the skin as accurately as possible. Something very important for any surgery, but especially where the face is concerned. No facelifts for our patient today. Also the suturing process was pretty bloody. After all, you can’t make any tourniquets around the head or neck area…and that concluded another special and informative day in the OR.