Michele Giblin had cancer behind her eye, and surgery involved reconstructing her upper jaw with bone from her leg. (photo by William Mueller)
BY AMBER SMITH
In constant pain after two root canals and months of antibiotics that were no help, Michele Giblin of Binghamton finally received a diagnosis. She had a rare cancer called adenoid cystic carcinoma. Her oral surgeon referred her to a specialized otolaryngologist at Upstate: Jesse Ryan, MD.
Giblin liked him immediately.
“He was very sincere,” she says. “I felt like I really matter to him.”
Ear, nose and throat specialist Jesse Ryan, MD, was interviewed about jaw reconstructions on Upstate’s “HealthLink on Air,” a podcast/radio show that airs on Sundays at 6 a.m. and 9 p.m.on WRVO radio. Hear his interview at healthlinkonair.org by searching for “Jesse Ryan.” (photo by Jim Howe)
Treatment for cancer that is discovered in the jaw area may require an extensive operation that’s designed to both remove the cancer and reconstruct the area. Such surgeries require expertise and stamina from a team of surgeons, since they can take more than 20 hours.
Ryan estimates he’s involved in five to 10 such operations at Upstate each year, on patients with cancer or traumatic injury requiring jaw reconstruction. “This is rare,” he says, “but this has been a major problem for this subset of the population for centuries. Initially, there was very little that could be done.”
If the front portion of the jaw is removed, its absence will impact a person’s ability to speak and swallow. Techniques evolved in the middle of the last century to use a titanium plate across the gap of missing bone, which would then be covered with skin or muscle in an attempt to preserve some of the structure, Ryan says. Infections and plate exposure over time meant this was not an ideal solution.
Advances in reconstructive surgery in the 1970s had surgeons transferring tissue from one part of a patient’s body to another, with assistance from engineers to shape the bone. Those developments shifted into jaw reconstructions, and today success rates are about 95 percent, Ryan says. The biggest challenge is establishing adequate blood flow to the transplanted area by connecting arteries and veins that are so tiny they require sutures that are smaller than a human hair.
Ryan’s education makes him a natural for this type of surgery. His undergraduate degree is in mechanical and aerospace engineering from Princeton.
After graduating from Mount Sinai School of Medicine, he completed a residency in otolaryngology and head and neck surgery at the National Naval Medical Center and then a fellowship in head and neck oncology and microvascular reconstruction at the University of Michigan in Ann Arbor. He’s been at Upstate since 2015.
Computer model of Michele Giblin’s reconstructive surgery. The areas in shades of blue show what was rebuilt. (courtesy of Jesse Ryan, MD)
A leg bone that works in the jaw
Giblin spoke with Ryan before what would be a 19-hour operation in June 2017. “How do you feel about this?” she asked him.
“To be honest,” replied the surgeon, “I’m a little bit nervous.”
“Well, I’m not. I have faith in you.”
Giblin’s cancer started in a minor salivary gland in her left cheek sinus and involved her upper jaw and part of her nose. Removing it meant having to rebuild her upper jaw and palate. Replacement bone and skin came from her lower leg and was used to resurface both the inside of her nose and inside of her mouth. Then a thin layer of skin was taken from her thigh to cover the area of her lower leg.
Ryan explains that replacement bone typically comes from the fibula, a lengthy bone of the lower leg that most people don’t need.
Removing a piece of the bone may affect a marathon runner, but most people are able to walk normally afterward. “The leg bone fits pretty well in terms of the size and strength that’s needed to reconstruct the jaw,” he says.
Giblin spent seven days in intensive care. Then she spent several days on a regular hospital floor, recovering from the surgery. Later, she underwent radiation therapy.
She has some trouble eating, and must sip drinks, but two years after her surgery, Giblin feels good about the results. She was afraid she would lose the side of her cheek, but friends say she looks as she did before. Today she takes care of people with developmental disabilities as a house director for New York state. She has monthly appointments with Ryan, and she undergoes imaging scans every six months.
Computer model of Paul Desimone’s reconstructive surgery. (courtesy of Jesse Ryan, MD)
A skeptic who was impressed with his care
Paul Desimone, 52, of Sangerfield in Oneida County underwent a similar 20-hour surgery in October 2016. What he initially thought was a cold sore on his lip grew bigger, until he could not ignore it.
Doctors in Utica confirmed the growth was cancerous and referred Desimone to Ryan.
When Ryan proposed surgery, Desimone says, “I was skeptical. But I’m a skeptical guy. It had nothing to do with him. Trust me. I had not seen a doctor in 30 years.”
The sore on his lip was about 3 inches by 2 inches, and an affected lymph node had eroded through his lower jaw. DeSimone underwent two transplants in the same operation. First, Ryan used tissue from the forearm to re-create a lower lip. Then, he used bone and skin from the lower leg to re-create the jaw and external cheek skin. The surgeon used skin from Desimone’s hip to cover the forearm and lower leg.
Desimone went home from the hospital 16 days later. He wouldn’t undergo radiation or chemotherapy, and the cancer returned about a year later. At that time, he was willing to undergo radiation and chemotherapy, and he added two more doctors to his care team: oncologist Muhammad Naqvi, MD, and radiation oncologist Michael Lacombe, MD.
“What a pack of great guys. They really know what they’re doing,” Desimone says. He is in remission now.
This article appears in the spring 2019 issue of Cancer Care magazine.