Challenging cases today. The second patient was a nasal reconstruction following a motorcycle accident. His nose was crushed so deeply that we had to use rib cartilage to reconstruct. Motorcycles are very popular in Honduras, with reliably warm weather and terribly congested streets. It took 90 minutes to drive about 3 miles from the hospital last night at rush hour. Seat belt laws are enforced only for front seat passengers. The limit of four passengers in the bed of a pickup truck is widely ignored, with riders typically standing or perched on the outside rail. Walking is not an option in the city, which is heavily secured against crime. Most homes are built right on the sidewalk, with an enclosed garage. There is an 8 foot wall topped with razor wire. Despite the prison-like surroundings of each home and business, the vistas of the mountains from second story windows are breathtaking. We especially enjoy the rooftop bar on the 7th floor of our hotel, which has a 360 degree view of the city and mountains. The sun rises during our morning devotionals.
The first patient was a Furlow palatoplasty for a recurrent cleft in a teenager who has had multiple prior surgeries. The opportunity to create normalcy in children born with severe deformities is a blessing.

After a long morning with plastic surgery at Hospital Escuela, I was taken back to the Social Security Hospital for the most difficult case of the week, a 59 year old woman whose nose started falling apart at age 29. It was cancer, and she has had multiple failed attempts to rebuild her nose. She has a one inch hole on the left side of her face, but she cannot breathe through the right nostril. The left upper lip is paralyzed and her dentures can be seen through the hole in the nose. She cannot open her mouth more than a fingerbreadth due to scarring in the cheek mucosa. We took her to the OR with a prayer, but no certain ideas of what we would find or accomplish. Under anesthesia, I was able to lift the tip of her nose about 2 mm, which may help her breathing on the right. The upper jaw bone was chronically infected, with bits of dead bone like splinters in the floor of the nose. We cleaned out the infection and tried to cover the living bone with her paralyzed upper lip, leaving her with an unsightly snarl. The most useful procedure we accomplished was to release the cheek scar and get her mouth open. We repaired the defect with a flap of tissue from the tongue.

Meanwhile, my roommate Paul was dissecting the facial nerve of a 4 year old in order to remove a 3 inch long wooden skewer that had entered his left eye and came out behind the ear. Previous surgeons had attempted to remove the stick, but it broke off inside the eye socket. Now, nearly a year later, He has swelling in his left eye and pus behind the left ear. The stick was located behind the facial nerve, cut into smaller pieces, and pulled out without injury to the eye.  Ray has stayed busy all week with chronic ear surgery, and Chris has been performing several rhinoplasties a day.