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- November 28, 1983
- Vol. 20
- No. 22
The Kindest Cut of All
A Virtuoso Toronto Surgeon Offers Disfigured Kids a Precious Gift: Normality
For Sandy, the five hours of surgery that lie ahead at Toronto's Hospital for Sick Children offer hope for a normal life. During the past five years, the Sackville, Nova Scotia youngster has suffered from fibrous dysplasia, a nonmalignant bone tumor whose wild growth has swelled the right side of her once pretty face into an ugly, misshapen mask. The rare disorder, whose cause is unknown, has destroyed her right sinus, pushed one eye upward and outward, and threatens to crush an optic nerve. Six earlier operations, in which doctors cut away at the abnormally growing bone, have brought no improvement, so last year Sandy's parents—Harold, a printing plant supervisor, and Linda, a housewife—contacted Dr. Ian Munro, 44, a wiry Englishman who heads the Toronto hospital's cranial-facial surgery team. Munro's group of doctors is one of some 15 such teams in the world today and, with its nine-month waiting list, one of the busiest.
In 12 years Munro has performed 2,000 cranial-facial operations, moving children's eyes when they were too far apart, creating chins where none existed, fixing faces injured in auto crashes or made monstrous by genetic defects. For Sandy, a battery of tests by Munro's team of orthodontists, ophthalmologists, speech pathologists and others had indicated a need for especially radical surgery. Munro would have to peel the skin from the top of her head down to her cheeks, cut away more than 20 cubic inches of diseased bone and reconstruct her face using bone grafts from four of her ribs. Munro had done this specific operation only twice before and admits privately that "on the table you could kill her easily or blind her. All kinds of things can go wrong." When he outlined the operation in detail to Sandy and her mother two days before surgery, the young girl had buried her head in her mother's shoulder and sobbed.
While English madrigals from a local radio station pipe through the operating room, 16 gowned and masked people gather round the patient. Among them: visiting surgeons from the U.S., Taiwan, India and Italy who have come to study Munro's techniques. By 8:45 an oral anesthesia tube has been inserted through Sandy's mouth and down her windpipe to help control her breathing. Munro cuts and peels the facial skin away from her skull. Then he frees her right eye and its optic nerve, which remains attached to the brain, and moves them safely to one side. "Everything is floating in the breeze," he announces cheerily.
Despite the brutal work before them, the surgeons banter through much of the operation. Then, at 9:15, Munro discovers that the diseased bone has invaded Sandy's eye socket. "Oh, gosh," he says. "That makes it considerably more awful." While an assistant finishes removing four of the child's ribs, leaving the periosteum, or bone sheaf (the bone itself, at her age, will grow back in six months), Munro orders the radio tuned to a symphony, then starts to carve away at the unhealthy bone. Most of the time "I can put my hand out and get the right instrument without asking for it," he boasts to his visitors. "The nurses are looking at what I am doing, and I don't have to take my eyes off the table. I don't have to worry about that or whether the machines are going to be working. If they aren't working, the people responsible get their asses kicked." Says nurse Pauline Keenan, a four-year veteran of Munro's team: "Ian is a vocal, aggressive person during surgery. You have to roll with that. But he knows what he is doing." Moments later Munro puts on a headlight to illuminate his work and asks for a specific Tessier surgical instrument. It is named after Paul Tessier, the Frenchman who pioneered this surgery in the late 1960s.
Munro spent six summers in Paris observing Tessier's operations and says the surgeon deserves a Nobel Prize for his contribution to medicine. Munro has modified his master's approach, developing a procedure which, while a little more time-consuming in the initial surgery, reduces the need for follow-up operations. "I am trying to get people back into society so they won't be stared at," says Munro. "I have too long a waiting list to have to go back and fiddle around."
Except for his preschool years in England—when as a little child he was made to sleep under an oak dining table in case of Nazi bombing raids—Munro seems to have approached life on the offensive. The youngest of three children of a Portsmouth physician and his actress wife, he decided on a science career "because it is a nice, tight intellectual discipline." He eventually attended the Cambridge University Medical School, where he captained the golf team and had to "cram like hell" to pass his annual exams. In 1964 Munro moved to Canada, where a less rigid medical establishment permitted him to practice plastic surgery years earlier than allowed in England. "There was no concept of the welfare state in Canada as we have now," he says. "The government was small and solvent, and the people worked."
So did Munro. Spurning "face-lifts-and-boobs" cosmetic surgery as "incredibly boring," he began research on hypertelorism, a deformity in which the eyes are spaced too far apart. After experimental work on animals and cadavers, he successfully performed his first operation on a victim of the disease in 1971. The complicated, dangerous surgery took 13 hours, after which, Munro admits, "I got very drunk." Gradually, colleagues who had been skeptical of such daring cranial-facial cutting referred patients to Munro. He now performs five major operations a week, 40 weeks a year.
Patients like Sandy return for post-op evaluations by Munro's group until they are 18, a process of self-criticism he heartily endorses. "There is a tendency in medicine to go on doing the same thing year after year," he explains. "This way there is a constant stimulus to get better, quicker, more efficient."
At 10:15 an alarm goes off indicating abnormal breathing. Anesthesiologist Creighton readjusts the windpipe tube that has slipped out of place, and Munro resumes his work, now cutting through the child's mouth above her hard palate. "Multo dificile," mutters the visiting Italian surgeon. At 11:00 more blood is brought in, part of the almost four pints that will be used before the operation is done. Munro and his assistants change into new gloves and gowns.
Five minutes later Munro starts the toughest work, using rib bones that have been scraped and cleaned, to reconstruct Sandy's face. He drills holes into the ends of the rib segments so they can be wired into place. He places one five-inch-length section crosswise to create a cheekbone and uses smaller pieces to build the floor of the eye socket. At 11:15 another problem arises: The soft tissue of Sandy's right eye has been compressed so long that it has atrophied considerably. "How in the hell are we going to get it to stay in there?" Munro wonders aloud. Then he tries something new, experimenting with a different way of reconstructing the frame of the eye orbit. "You have to have great faith in bone grafts to do this. You wire bits to bits all the way down," he says.
By 1:05 Munro has reconstructed, almost from scratch, the right side of Sandy's face, moved her nose a half inch to the right and pulled up her facial tissue, reattaching it to the scalp with metal staples. The visitors leave the operating room, but the surgeon stands by the child's side for five minutes until the anesthesiologist brings her back to consciousness. "How many fingers am I holding up?" he asks, while covering her left eye. "Two," she says weakly, then falls back to sleep. "She's okay, "says Munro with a grin as he bounds out of the operating room to tell her parents.
A father himself, Munro keeps a portrait of wife Valerie and his three teenage children prominently displayed in his English Tudor home in Toronto. Mindful of the kids' schoolwork, he forbids TV watching and spends much of his own spare time taking the clan skiing and sailing. His 14-year-old son, Neil, does not live with the family. Retarded and confined to a wheelchair because of cerebral palsy, he has been institutionalized but comes home for weekly dinner and for holidays.
There is nothing the surgeon can do for the boy ("He needs a new brain," says his father), but Munro credits his son with making "me empathetic to other people, much more so than I would have been otherwise." Munro has recently operated on children with Down's syndrome and says that "one of the ways I judge whether I would do something for a kid is whether I would want it done for my kid. Anytime you get into the big stuff, you are taking a risk that something goes wrong." In 2,000 difficult cranial-facial operations, seven patients have died from complications arising during or after surgery. Earlier this month an Ontario court ordered Munro to pay $68,500 in damages and Iegal fees in the case of a woman who had lost most of her teeth after he operated on her to correct an overbite in 1978. Says Munro, "I still do not understand what happened [medically] in that case." The judge who handed down the decision—which Munro is considering appealing—went out of his way to cite Munro's "brilliant surgical talents" and his "well-earned international reputation" but concluded that in the case at hand the doctor had "erred, and must be held accountable."
Little has gone wrong with Sandy apart from a low-grade infection caused by one of the wires in her cheek. Although she will receive orthodontia to straighten teeth skewed by her disease, her face is once again balanced. By the time her postsurgery swelling subsided, eight weeks after the operation, she gave up her habit of hiding her face behind one hand. She runs and bikes with her sister, Kary, 7, and her friends, attracting no more—or less—attention than any other energetic child. "I think she is on cloud nine," says her mother. "She's just a different little girl. It used to be we couldn't go anywhere without someone coming up and asking, 'What happened to your face?' Now she is giddy, bouncing around. She has come out of herself." Munro is pleased but typically matter-of-fact. "The only thing that counts is the child," he says, after surveying his handiwork during one of Sandy's postsurgical visits. "Ultimately, everyone else is irrelevant."
- Giovanna Breu.
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