News Summary

SPRINGFIELD, Ohio — He's an assistant clinical professor of surgery at Wright State University and director of the cleft lip and palate clinic at Children's Medical Center in Dayton.

He's also both a reconstructive and plastic surgeon.

But what Dr. Steven Schmidt is best known for in this area is being the surgeon who took care of Dr. Johannes Christian after a rock thrown from a Clark County overpass smashed Christian's face and head and blinded the Columbus minister.

The Centerville-based surgeon and U.S. Air Force veteran gave us his take on work done by his colleagues from another era: The surgeons at Wakeman General Convalescent Hospital at Camp Atterbury, Ind., who treated the soldiers disfigured and maimed in World War II.

The case descriptions, photos and drawings he's evaluating come from an album belonging to Springfielder Carl Emory, (See article on Page B1.)

Schmidt's overall assessment?

"It really is amazing the stuff they did with limited technology."

But that's only touching the surface.

And for surgeons, it's what's under the surface that's most interesting.

Major burns

"Even though there's been a lot of advances ... this is one of the areas where these are still very difficult to deal with, Schmidt said, looking at a face disfigured in a fire. "He survived the injury, and now what?"

To help restore some sense of normalcy, the surgeon at Wakeman first tried to remove as much scar tissue as possible from the face.

Next, he tried to give the face a new coating of skin taken from the soldier's back.

The plan was to cut a big flap — what the surgeon at Wakeman described as "the largest that has been attempted."

The skin would remain attached to the back and face for a time so the blood supply from the back would keep it alive until new vessels started feeding it from the face.

Once bonded, the skin would be separated from the back and trimmed to fit.

"Burns like this are still very difficult to deal with today," Schmidt said.

Dancing skin

Moving skin from one spot to another is common in the Wakeman descriptions. Schmidt said the technique was called "waltzing" after the dance.

"I've never done one of these, because we do microscopic transfer," he explained.

In that current technique, he is able to take a portion of skin from any other part of the body, affix it to a new location, then immediately establish a blood supply by sewing a blood vessel in the new location to vessels in the skin taken from the old.

The "microscopic" part of the microscopic transfer is his use of a microscope so that he can see to do the surgery attaching the blood vessels.

A two-step waltz

For a Wakeman patient with a disfiguring injury on the right side of his face, a two-stage waltz was planned.

In the first stage, a role of skin from the abdomen was attached to the patient's arm.

Once the skin had an adequate blood supply from the arm, it was separated from the abdomen and "waltzed" up to the injured portion of the face. There, it again was held in place until it developed the adequate blood supply at that site.

The difficulty, Schmidt said, is that it takes weeks for the skin in each step of the waltz to establish a blood supply, making the repair a long, drawn-out process.

Another difficulty with the face injury case involves the damaged bone.

"We would have cat scans, and we would put those bones together" with plates and other hardware, he said. Lacking that technology, "they probably wired them together. It's not rigid, and it doesn't work as well," he said.

But it was what they could do.

A nosy Italian

A soldier whose perforated nose led the surgeon at Wakeman to fill the old with skin from the soldier's inner arm reminded Schmidt of a bit of technique history.

In part because of an Italian custom of the 1700s to cut off the nose of a person who offended you, an Italian physician named Tagliacozzi "figured out that using the skin from the inside of the upper arm" could be used to make such a repair.

"He did it on the inside of the upper arm and just tied the arm on and elevated the inner arm and sewed it on to the nose. It's a little uncomfortable for a couple weeks. But it worked, and it worked pretty well."

Schmidt himself used that technique on a nose injury caused by a self-inflicted gunshot.

The technique is "fairly versatile" and "fairly reliable," he said. "It just takes a really long time."

A bone bridge

"Back then, this is a tough one," Schmidt said, looking at a soldier whose chin was shattered by a sniper's bullet.

"His lower jaw is mostly gone. He probably has a little piece up in here," Schmidt said.

Even though the skin is intact, with the jaw gone, not only is eating a problem for the soldier, the missing jaw causes the tongue to sit at the back of the throat, threatening to obstruct the airway.

The first step is to waltz skin from the belly to the jaw to provide some tissue to bridge the gap.

"Then what you're going to do is put in a bone graft from the hip" into that skin to form a chin, Schmidt says.

The bone graft on top of the skin waltzing "is taking years." to execute, he said.

Not only that, the chances of successfully transplanting a large enough bone into the chin to bridge the gap were "marginal at best," Schmidt said.

For the bone to live, there has to be adequate blood supply, and establishing that over such a long gap can be difficult.

Today, the procedure has a much better chance because surgeons can transfer bone, skin and vessels together, then anchor them to existing bone with plates and hardware.

It's a "big day," Schmidt said — an 8- or 10-hour surgery he's done for people with self-inflicted gunshot wounds.

But the procedure works.

A lack of nerve

Although the chunk of skin blown off a soldier's arm on Utah Beach could as reliably been replaced in the 1940s as it is today, "his nerve isn't fixed," Schmidt said, examining the case.

Without the nerve repair, the soldier would have lost function in his fingers, and the likely would have started to claw, Schmidt said.

Today's tendon transfers and nerve grafts could address those problems, he said, and produce a better result.

Skull session

"This is kind of a tough case," Schmidt said, looking at a man whose skin had been burned away from a portion of his skull.

"You can't put a skin graft on bare bone," Schmidt said, because there would be no blood supply to keep it alive.

"So what they do is they take off the outer layer of bone, so the marrow is exposed, and that will grow some tissue, which will support a skin graft."

"We do that on occasion, but not very often," he said.

The solution today would be either to rotate the scalp to cover the gap or get tissue from elsewhere and establish a blood supply to it to make the graft work.

The old solution "doesn't look pretty," Schmidt said, but the patch was successful.

A fine mesh

For another soldier missing a piece of skull, the solution in those days was a titanium plate, Schmidt said.

"This isn't that different that we put in today," he said.

But there's an important variation.

Instead of using a plate, surgeons use a titanium mesh that acts as structure or lattice on to which new bone can take root.

"The bone can actually grow into it," Schmidt said.

When it does, the mesh is integrated into the body, something that cannot happen with the plate, which is large enough that it will always be, to the body, a kind of foreign object.

As good as it gets

"This actually is a really nice result," Schmidt said of a facial repaired after being hit by a rifle grenade.

"They essentially did a fat graft from the abdomen and just filled in the big defect."

Because it has a rich blood supply, "the face is about the only place you can do that easily," Schmidt said. "It's able to revascularize."

"This is as good as anything we can do now. We probably would have done something a little more elegant," he said, "but the end result is really good."

Contact this reporter at (937) 328-0368 or tstafford@coxohio.com