Ground-breaking surgery leaves no unsightly scar

This ground-breaking surgery, which took place on August 27, 2009, was performed by Dr. Nabil Fanous, Associate Professor of Facial Plastic Surgery and Head and Neck Surgery at McGill University and Université de Sherbrooke and by Dr. Sherif Emil, Director of the Division of Paediatric General Surgery at The Montreal Children's Hospital and Associate Professor of Surgery at McGill University.

The surgery proved more complicated than anticipated. After the endoscope and attached camera were introduced inside the upper face, the tumour was nowhere to be found! To locate it, the lead surgeon Dr. Fanous had to probe the forehead using special instruments. As it turned out, the tumour was hidden under a bony shell that had grown over it. The shell was thin in the middle, much like an egg, but thicker on the sides. Dr. Fanous had to delicately pierce the shell to excise the tumour, and then pull it out via the tunnel leading to the child's scalp.

Believed to be a first

The tumour was the size of a large blueberry (it measured about one by one centimetre) and was sitting in a deep bony crater that looked on the computer screen a bit like a small volcano. Dr. Fanous smoothed down the contours of the crater and filled the indentation with bone wax to make sure Jayden's brow would be perfectly smooth. The Montreal Children's Hospital believes this is the first time an endoscopic procedure has been used in Canada to remove a facial mass on a child's face through a tiny scalp incision. As well, this is the first reported case of such a tumour being covered by bone.

The child was discharged about an hour after surgery. He has recovered rapidly and fully since.

"We were extremely surprised to learn the tumour was covered by bone," says Dr. Fanous. "Despite this hurdle, the surgery went extremely well. This type of surgery requires a relatively simple technique, but the surgeon has to be careful because the face contains a dense 'forest' of nerves, muscles and vessels. The surgeon has to 'navigate' around all of these elements to get from point A to point B. If the surgeon inadvertently damages one of the important nerves or muscles, he risks permanently affecting or even paralyzing the child's upper face."

How it all began

Dr. Sherif Emil was the first surgeon to examine Jayden in late 2008. He determined the toddler had a congenital tumour, possibly of the type called 'dermoid cyst'. While this type of tumour is benign, it has to be removed because it may grow as the child ages and could rupture, causing serious infection and scarring. Traditionally, these types of tumours are removed by simply cutting through the skin and muscle directly over the tumour. However, this technique leaves a scar, one that Dr. Emil wanted to avoid at all costs since it would be in the centre of Jayden's forehead. Also, the scar would have gotten larger as Jayden got older, especially since the little boy has dark skin. People with dark skin are known to have much higher risk of scarring. Thanks to the use of this new endoscopic technique, Jayden will be spared an unsightly scar. Instead, he has a tiny scar hidden by his hair.

"I had read about the endoscopic excision of benign forehead masses in the Journal of Paediatric Surgery. Paediatric surgeons at Stanford University had used the technique," says Dr. Emil. "I knew right away Jayden was a perfect candidate for this procedure. I wanted to do everything possible to prevent the child from having a scar in the middle of his forehead."

Because this technique had never been used in Canada to remove a facial mass, Dr. Emil began to search for a surgeon with enough experience to attempt it. He finally reached Dr. Fanous, a renowned facial plastic surgeon. While Dr. Fanous had never performed this surgery on a child, he had done it hundreds of times on adults during facelift surgery. He readily agreed to perform the surgery and to provide the necessary equipment to The Montreal Children's Hospital.

It took eight months from the first time Jayden was seen by Dr. Emil until the day of his surgery. During the surgery, the anaesthesia team headed by Dr. Pierre Fiset, Director of Paediatric Anaesthesia, secured the child's safety. A number of surgeons and surgical trainees filled the operating room in order to witness this ground-breaking procedure. The nursing staff prepared tirelessly for the operation, assuring a calm and safe environment for the patient.

"We had complete confidence in both Drs. Emil and Fanous," says Ron Cambridge, Jayden's dad. "We also appreciate the fact that Dr. Emil went to all of the trouble to make sure my son wouldn't have to live with an ugly scar on his face. I really feel he went the extra distance and, for this, my wife and I are very grateful."

"Jayden is an example of the unique care that can be provided by the Montreal Children's Hospital and McGill University," says Dr. Emil. "Medical and surgical experts from diverse disciplines can collaborate to provide the best care for life."

Source: The Montreal Children's Hospital

Source: Mcgill University Health Centre

Source: The Montreal Children's Hospital Foundation