The facial trauma team who can ‘rebuild you’

NEW YEAR’S EVE 2009 is one night David and Thomas Barry from East London won’t forget. Ironically, they can’t remember most of it. For in the space of a few minutes, their quiet celebration at a favourite Bethnal Green pub turned into a night from a horror movie, when the brothers were attacked – unprovoked – by a group of 30 men wielding hammers. Yet, if you see either of them now, you might imagine that it had never happened, and that the extensive facial injuries the defenceless men suffered – splintered cheekbones, jaws, eye sockets and teeth – were all just imaginary. As thanks to a brilliant facial trauma team at their local hospital, Barts and the London, both men have been put back together – without any obvious scars.

Consultant Simon Holmes

The brothers had two strokes of luck. Firstly, they were under the care of an extraordinary team assembled in the aftermath of the 7/7 London Terror bombings in 2003, who have a fairly unique approach to treating this type of injury. And secondly, the hospital had the latest CT scanning equipment which meant that lead consultant Simon Holmes, an oral and maxillofacial surgeon, could see in 3D exactly what bones had been broken and work out how to mend them so that it is now impossible to tell where the damage occurred. The emotional scars will take longer to heal however. As David, a 41-year-old communications engineer, who is married to 42-year-old Taylor and father to three children, explains. ‘We had just stepped outside the pub to have a cigarette,’ he recalls, ‘when we heard my nephew (Thomas’s 18-year-old son Christopher) scream out for help. So we went round the corner of the pub to see about 30 men swinging hammers and running towards us. It was very frightening; they were clearly looking for trouble – something the police confirmed later as it turned out we weren’t their first victims of the night.’

‘I don’t remember a lot after that. I know I was hit in the face with a hammer several times and then knocked to the floor where someone stamped on my face and body.  Apparently, I stood up and was able to walk to a friend’s house nearby, but then collapsed and was taken to hospital by ambulance.’

Thomas, 46, a French Polisher, who lives in Bow with 56-year-old Bridget, a PA at Homerton Hospital, and two children, can’t remember much either. He, too, was set upon by the thugs, beaten and kicked on the floor. In hospital, the two were stunned to wake up in next-door beds on New Year’s Day. ‘It may have been the morphine,’ says David, ‘but it made us laugh; we were quite light-hearted about it at the time.’

Their injuries were no laughing matter: David couldn’t speak as the roof of his mouth had been snapped in two, causing his top teeth to rest on his bottom teeth when he opened his mouth. The bones on the right-hand side of his face had been shattered by hammer blows – all his nerves had been destroyed. His cheekbones were broken, as was his right eye socket. Thomas had three fractures in his eye socket and the side of his face caved in.

At this point, they met Simon Holmes who had the tricky job of working out how to reassemble their broken faces. Initially he wired David’s mouth together so he could open it again. And then he submitted both men for CT scans of the face.

‘I was scared of what they’d find,’ says David. ‘But it wasn’t an unpleasant experience. You lie down and go into your own little tunnel. It was nice and warm.’

‘David’s injuries were difficult and he was bleeding from the nose and mouth,’ says Mr Holmes, ‘But I knew we’d get a great result and that we could get him back to normal. The brothers have quite lived-in faces, and that actually makes it easier. As does the patient’s spirit – and both men were positive.’

When a patient presents with a badly beaten or damaged face, it can be very swollen and bruised, even looking deformed. In the past, surgeons might have to estimate how the damage looked inside – or rely on single X-rays. But now a CT scanner can send X-rays through the head. The machine slowly rotates, taking a picture of a thin slice of the head and face every second. The scanner can tilt too taking pictures from different angles. Afterwards, the set of pictures are gathered together on a computer and collated so that they recreate the head in incredible 3D detail.

Mr Holmes was able to use the CT pictures to examine the exact damage and decide how to mend it. Precision is vital, he explains. ‘Tolerance in the face is very narrow. Imagine having a human hair stuck in your teeth and how irritating that is. We can’t afford to be out by a millimetre when we repair facial bones or mouths, or we’d leave the patient feeling deeply uncomfortable.’ He adds that piecing together all the fragments of bone in a shattered skull is like assembling Meccano: ‘you couldn’t end up with a few bits left over – that would mean the whole wasn’t finished and wouldn’t work perfectly.’

After looking at the scans on his Mac computer and examining the damage from three angles, Mr Holmes was able to make a plan. ‘There are strategic landmarks on the skull that we use to structure our repair plan such as the mouth and jaw. Then we can estimate almost exactly how many screws – 24-36 say – we’ll need to use when we plate the face back together.’

If Mr Holmes makes it sound easy, it is down to experience. The facial trauma unit at Barts and theLondon is extremely busy. In the past three weeks, it has seen 54 emergencies. In theUK, there are about 250,000 facial trauma cases every year. The team – which includes an orthoptist and ophthalmologist from the eye service working with colleagues from the ear, nose and throat department, oral and maxillofacial surgery, neurosurgery and plastic surgery – are working on ever-demanding cases, as anaesthesia and accident and emergency care has improved so fast that many patients survive traumatic incidents such as road accidents and fights which might otherwise have cost their lives.

In east London, where the hospital also benefits from a helicopter ambulance service, many of Mr Holmes’s cases are a result of violence. He explains: ‘A blow to the face is like a physics experiment. A low-energy attack – like a basic punch – will break a bone in two. But a blow with lots of energy behind it – like that from a baseball bat or a hammer or a hand wearing heavy sovereign rings – can splinter the bone into pieces. It’s even worse if the victim is stamped on; all that power is directed on a small spot causing massive damage.’

Three days after they arrived in hospital, the Barry brothers were operated on by Mr Holmes and his team. For David, they operated up through his mouth and in through his eye socket – ‘we don’t like to leave what I call an audit trail,’ explains Mr Holmes. ‘You shouldn’t be able to see where we’ve worked.’

First they cut into the gum so that they could pull out the fragments of bone before replacing them correctly and using titanium plates to hold the bones together.  The left jaw had been shattered into six pieces by a hammer blow; the cheekbone above needed a plate too. In all, they inserted five metal plates and 22 screws into David’s face. And before they could close up their incisions, the team had to check his teeth would match exactly – that his bite still worked.

When they had repaired the eye socket – first popping out the eye ball, before again inserting a titanium plate – the team had to check his eyeball could still move in the space by gently rotating it. ‘After you’ve finished placing the bones where you want them, and checked the positioning, you re-drape the soft tissue back to where it was, and close up with stitches,’ says Mr Holmes. ‘I can’t make people better looking than before, although sometimes you end up taking away the bag under one eye – so then you need to do the other side, so they ‘‘match’’. Leaving them looking unscarred really helps with the psychological trauma.’ The operation took four hours.

Thomas’s face was slightly easier to rebuild and the operation was faster – he had three fractures to the eye socket, and the team to have to create an incision on the face through which to work. But again, mindful of the need to leave no ‘audit trail’, they worked along the hairline. They had to ‘tyre-lever’ his eye socket back out. Cuts to his scalp were treated with staples and superglue.

David and Thomas Barry. Pic: thisislondon.co.uk

Both brothers recovered well from the operations and were allowed home after just four days. Says David now: ‘The surgeon told me my face was so smashed to pieces it belonged on someone who had died in a car crash – that’s how bad it was. That he could actually see the indentations of the hammer blows. But he has done an amazing job. ‘I still have a bit of sight trouble – I am slightly disoriented, and I’ve no feeling on the right hand side of my face. The nerves were so badly damaged that I’m never going to get it back and I’ll have to live with it for ever. My elbow may be chipped and my neck is very stiff. I’m scared of my youngest jumping on me and hurting me. But the real damage now is psychological. Big groups of people make me nervous.’  Police investigating the attack on the brothers have arrested three youths. They have been released on police bail and no charges have been brought. He adds: ‘And I’ll need to find a new job – I was due to start a contract after New Year, but that’s gone.’

Thomas is also sanguine. His most lasting injury is a very sprained foot which is making walking difficult; his doctor has warned that could take three months to heal. But as he doesn’t like painkillers, he has rarely taken any since the incident. Both men cannot praise Mr Holmes and his team highly enough. ‘The surgeon was amazing,’ says Thomas, ‘you can’t even see what he’s done.’ Adds David: ‘I’d like to buy him a beer! He should have a medal.’

Mr Holmes is delighted with their progress, and admits: ‘I don’t think I could have been so brave.’ But mostly he is keen to stress how pioneering the work is of the whole team at Barts and the London. ‘We’re really pushing forward the boundaries here. I like to say we give W1 standards of care in E1. That our patients get the best Harley Street standards even though they come from one of the most deprived areas in the UK. But the work we do here is happening all over the UK, too.’

About the Author

Victoria Lambert has been a journalist for more than 20 years, and specialises in health and medical matters. She writes for the Telegraph, the Times, the Sunday Times, the Guardian, the Mail and the Mail on Sunday. She contributes to Saga, Geographical and First Eleven magazines – where she is the agony aunt.

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