Article: Injuries About The Head And Face

The following is reprinted with permission from Handling Accident Cases and first appeared in print in February 1987. Copyright © West Group. Please go to http://www.westgroup.com/ for information about this work.

Injuries About The Head And Face

Testimony of Plastic Surgeon

As noted in the main text, testimony of a plastic surgeon may be essential in detailing the consequences of injuries to the face. Perhaps no more dramatic example of the effectiveness of such testimony is a case where the injured plaintiff is an attractive young woman who is left permanently disfigured by her injuries.

The following excerpted testimony occurred at a trial in which a woman age 17 at the time of an automobile accident sued for damages that included conspicuous and permanent facial scarring as well as nerve damage. Her case was handled by Denis H. Mark, EsQ. , William C. Waller, Jr., EsQ. and Jersey M. Green, EsQ. , of Denver. Plaintiff was able obtain a $3.05 million jury award, due in part, no doubt, to Mr. Greens skillful examination of the plastic surgeon who performed the reconstructive work on plaintiffs face. Among the highlights of this testimony was the care taken by counsel and the expert to exhibit plaintiffs injuries to the jury and to explicate exactly what medical procedures were performed and how far such procedures could go to restore plaintiffs appearance.

Additional material drawn from this case appears in the supplements to Volume 2 (at chapter 21, section 210) Shielding Traumatized Plaintiff from a Witness) and Volume 7 (at chapter 118 Psychological Effect of Facial Injuries on Teen-Aged Girl).

The transcript has been lightly edited for clarity and to remove proper names.

Direct Examination of Plastic Surgeon

[Questions regarding the name, address, qualifications, and awards of the witness were asked and answered.]

Q. Have you ever been qualified as an expert witness in the field of plastic surgery?

A. Yes.

Q.(Plaintiff) is your patient?

A. Thats correct.

Q. When did you first see her as a patient?

A. Allow me to get out my chart, if I may, so I can give you some precise dates.

I first saw her the date of the accident, which was (date).

Q. Where was that?

A. At the emergency room in __________ Hospital.

Q. What was her condition at the time?

A. I was called in because at first glance it appeared that her facial injuries were the worst problems that she had. So I arrived shortly after she arrived in the emergency room.

And when I arrived, it soon became obvious her blood pressure began dropping and that she had severe problems not only with the face, but elsewhere.

MR. GREEN: May I approach the witness, Your Honor?

THE COURT: Yes.

Q. (By Mr. Green) Handing you what has been marked for identification as Plaintiffs Exhibit F, can you identify that, please?

Hold that down so the jury cant see it until its admitted, please.

Yes. This is a photograph that I took in, I believe, the emergency room when I first saw (Plaintiff).

Q. Does that truly and accurately portray that condition it purports to depict?

A. Yes.

MR. GREEN: We offer whats been marked as Plaintiffs Exhibit F for identification.

DEFENSE COUNSEL: No objection, Your Honor.

THE COURT: F is received into evidence.

MR. GREEN: At this time may we have the photograph presented to the jury?

THE COURT: You may do so.

(Whereupon, the jury viewed the photograph.)

THE COURT: The jury has completed viewing the exhibit. You may proceed.

Q. (By Mr. Green) What did you do?

A. Well, at the time that I reached the emergency room, we, of course, evaluated the facial injuries, made certain the airway was open so that she could breathe, and then began evaluating in terms of other potential problems. After we had gotten the blood pressure back, Dr. W________ proceeded to close the incisions while I closed the cuts on her face.

Q. Were there any other lacerations that she received besides this cut thats shown on her face?

A. Well, that particular picture shows the right side of her face. And there were some cuts on the left side that I dont think are totally shown in that picture.

Q. Besides that surgery and the emergency room, did you perform any other surgery? Had you performed any other surgery on (Plaintiff) since that time?

A. Yes, several operations.

Q. How many times?

A. Six times.

Q. When was the first time after the emergency room surgery?

A. The emergency surgery was on the (date). The next time I operated on her was (6 days later).

Q. For what purpose?

At that time I did some more work on some of the cuts on her face. At the time we initially closed the cuts on her face (Plaintiff) was in very serious condition. There was a very real question as to whether she was going to survive at all, and if she did survive, as to whether there would be any brain function left because of the extent of the period of time that she did not have a blood pressure. And she was still very unstable.

And so at the time we initially closed the wounds, we did so as rapidly as possible in order to get her up out of the operating room and up to the Intensive Care Unit.

As I recall the reason for doing that particular surgery is that some of the wounds had developed some bleeding and formed blood clots, and some of them had opened a little bit, so we went back and reclosed those. At that time she was more stable. I could take a little more time in doing that.

Q. What was the nature of the surgery that you performed on this occasion?

A. Reclosing some of the wounds.

Q. When was the next time that you performed surgery on her?

A. The next time was (4 weeks after the accident).

Q. Where was that?

A. That was in _________ Hospital operating room.

Q. And for what purpose?

A. At that time we repaired some of the nerves that go to the muscles of the face known as the facial nerves.

Q. Why wasnt that done sooner?

A. That is an extensive procedure. This particular operation required approximately five hours, has to be done under very controlled conditions. We use a microscope for most of this time in order to find the nerves and repair them as accurately as possible. And so this is not the sort of procedure that one would do when the patient is very unstable and has no good blood pressure. Its a lot better to wait until everything is stabilized, the patient is otherwise in good condition, and then go back and then you can take the time necessary to perform an accurate repair of these nerves.

Q. During the surgery what do the nerves look like to the naked eye?

A. Many of these nerves are almost impossible to see with the naked eye, and theyre very small. And this is why we have to use the microscope for most of this work. Theyre very difficult to find. Its like finding a needle in a haystack. We have some instruments that help with that, a nerve stimulator, and this helps us to home in on where the nerves are located. But theyre very small and difficult to pick out from the other blood vessels and other tissues that are in the area.

MR. GREEN: May I approach the witness, Your Honor?

THE COURT: Yes.

Q. (By Mr. Green) Doctor, I am handing you whats been marked for identification as Plaintiffs Exhibit T-6. Can you identify that, please?

A. Yes. This is a picture that we took at the time of this surgery on (date).

Q. Does it truly and accurately depict that which it purports to portray?

A. Yes.

Q. I am showing you whats been marked for identification as Plaintiffs Exhibit T-7. Can you identify that, please?

A. This is another picture that was taken at the time of the nerve repair, with little arrows showing some of the nerves that were repaired at the time.

Q. How did you determine the location of the nerves?

A. Well, after making the incision, we go down to the level where the nerves should be located. We then use a nerve stimulator. Its an instrument that has a very small electrical current, and by placing this instrument in various areas, when it comes close to a nerve it stimulates the nerve and makes the muscle twitch so that with the instrument we can tell when were fairly close to a nerve. Then we look in that area further to actually identify the nerve itself.

Q. Is this the photograph with the plastic points a true and accurate photograph?

A. Yes.

Q. The white plastic arrows that are shown in Plaintiffs Exhibit T-7, are those where the nerves were located, or what are they?

A. The tip of the arrow in each case indicates where a nerve is located.

Q. How difficult is it to sew the nerves back together again, to get them back where theyre supposed to be?

A. Well, its very difficult. This is one area where theres been a lot of improvement in medicine, but its an area that still leaves a lot to be desired

At the present time we use techniques that are very delicate and very much better than we had five years ago. In particular, we use microscopes that are fairly high powered rather than trusting the naked eye. We use stitches that are literally one-third the diameter of a human hair, almost impossible to see without a microscope. But, nevertheless, were still only do you have that?

Q. Would that assist you?

A. Yes. We have a model that might help. Is that a fair and substantial model of a human nerve?

A. Yes.

Q. Now, this is in colors, color-coded, so to speak. Is Mother Nature so accommodating?

A. Not quite.

Q. Is this a fair representation of the size of the human nerve?

A. No.

Q. Whats the difference? How large is a nerve?

A. This is many times larger than a human nerve would be.

Q. We were testifying as to the difficulty of sewing back together a nerve properly.

A. Yes. The facial nerve is divided into a number of branches. Each of these branches has some nerve bundles in them. And this little model shows that if this is one branch, there are several bundles, nerve bundles within that branch. And within each of these nerve bundles there are some nerves represented by the little wires.

Specifically within each of these nerve bundles theres somewhere between 500 and 3,000 of these little nerves.

Now, even with the highest power microscope and the best technique, its totally impossible to sew each of these little nerves back together. The best we can do is sew the nerve bundles back together and hope the little nerves get across the place where it was cut, and find their way back out the channels to the muscles that they used to get to.

And approximately 50 percent or so of these little wires will actually make it to the place where the nerve was cut. And if were lucky, 30 percent or so may find their way back to the little muscle portion that they went to before the injury. And so even with the techniques that we have available, if were lucky, as I say, only about 30 percent of these little wires will get back to the muscles that they are supposed to go to.

Q. How successful were you in getting all of (Plaintiff) facial nerves back together the way they were?

A. Well, there are quite a few of these branches of the facial nerve. And even in a five-hour operation with the microscope, its not possible to find all the branches that are cut.

On that particular occasion we were able to find five of the major, the larger branches and sew those back together. And there were other smaller branches that just couldnt be found.

Q. Would additional surgery be helpful?

A. No. In terms of trying to repair the nerve itself, your best opportunity to do that is at the time of the initial surgery. There will be additional scarring, for example, at this point, and it would be even more difficult to find those other little branches. And it wasnt possible to find them then.

Q. What is Mother Natures purpose in having nerves in the face?

A. Well, nerves in general serve two functions. They provide the communications for feeling. In other words, they go from the nerve endings in the skin to the brain and carry if you touch the skin it carries that signal from the skin to the brain, and its one purpose, sensation.

The other purpose is to cause muscles to work. As the brain sends a signal along the muscle or motor nerve to the muscle that signal causes the muscle to shorten or contract and in essence tells it when to work.

Q. Would it assist you in your testimony about how (Plaintiffs) nerves are affected or the muscles are affected in her face if you could testify with her as a model?

A. Yes.

MR. GREEN: Your Honor, may we ask the Plaintiff to stand in front of the jury or take a seat in front of the jury so Dr. T________ can?

THE COURT: She may do so.

THE WITNESS: Would you like me to demonstrate?

Q. (By Mr. Green) Yes. The full range of her expression and what is happening.

A. Do we have a chart of the facial nerve we might look at first?

Q. Yes.

Why dont you have a seat and we will authenticate this, lay a foundation.

Dr. T________, I am showing you whats been marked for identification as Plaintiffs Exhibit T-1. Is this a substantially fair representation of the nerves and muscles of the human face?

A. Yes.

Q. First, Doctor, could you identify for the jury what those lines are that are in the yellow?

A. Okay. Just a few landmarks. This is the nose, the eye. This is the ear, and, of course, the head in general. The facial nerve which is the nerve that goes to the muscles of the face, it comes out a little below the ear here and then branches into a lot of branches. And these are shown in yellow on the chart.

As I said, theyre various sizes.

In (Plaintiffs) case we were able to identify five of the larger branches. There were other smaller little branches that it just wasnt possible to find in her case.

These nerves go to the muscles of the face. Some of the branches up here go to the muscle right here which closes the eye. And so initially after her injury she was not able to close her eye. Her eye was exposed to the air and had a tendency to become very dry.

Some of these branches go to the muscles that are shown here that help produce the normal smile. They raise the corner of the mouth and help with the normal smile.

The branch in here goes to the muscles that control the nose, the wrinkling of the nose and the movement. And these muscles can almost actually help to some extent in controlling the air passage.

There are other muscles down in here that go to this muscle, which is the primary muscle that helps to close the mouth. And without these muscles one has little control of the mouth. Its something, you know, like you might experience after going to a dentist and having Novocaine, you cant control the mouth.

And early on, very often if these nerves are damaged and this muscle doesnt function, one cannot control the mouth, not only in facial expressions but also when eating. Try to drink, for example, and you cannot close that portion of your mouth. The liquid, the fluid will literally drool out or pour out of the corner of the mouth there.

So, if I could, can I show on here where the cut in (Plaintiffs) face went down in this manner and cut almost all the nerves to the eye, the nerves that help in smiling, the nerves that go to control the muscles in the nose, and most of the nerves that go to the muscles around the mouth on this side of her face.

MR. GREEN: For the record, the witness has indicated the cut as being in red magic marker on the exhibit.

Q. (Mr. Green) Before we get to (Plaintiff), you testified that she was unable to close her eye and that it was exposed to air. How long was it before she could close her eye?

A. I dont recall the exact period of time on that. Generally, in this sort of case it takes several months for the muscles to begin to work after the repair. And the repair was done approximately a month after the initial accident, so it would have a number of months after the accident that she had difficulty closing her eye.

MR. GREEN: Your Honor, may I move to the corner of the jury box so that I can see while I am asking my questions?

THE COURT: Yes. And if you want to, (Defense Counsel), you may do the same.

THE WITNESS: I might mention one other fact involved in repairing the nerves.

As these nerves, for example, if we repair a branch in here where we repair the main nerve, as the nerves heal some of those nerves will go out the correct branch. Others will go out the incorrect branch. So on (Plaintiff) we can demonstrate, for example, that when she closes her eye she has motion in the nose, which is not really appropriate, and that at the same time she does not have control of the nose muscles that she had before.

Shes also mentioned that when she yawns, for example, and some of these muscles down in here are activated, that she spontaneously closes her eye. And every time she yawns her eyes close.

There are a lot of little subtleties like this where the nerves dont work the way they used to after repair of this type.

Q. (By Mr. Green) You were mentioning sometimes the nerve grows out in the wrong direction.

A. Uh-huh.

Q. Its kind of a folklore, I guess, that nerves dont grow back. Can you explain that inconsistency in what is the general perception, and what in fact is the medical fact?

A. It used to be the case, before we had the microscopic techniques, it was very difficult if not impossible to repair those nerves; so, no, they didnt heal. If theyre not repaired, you will get no return. And if theyre not repaired if theyre repaired with some of the older techniques, you get almost no return.

With the newer techniques we do get maybe 30 percent return, but theres still a 70 percent deficit.

Q. Can you step over to (Plaintiff) and lets see how much has returned for her.

Maybe she should stand up so the jury can see that.

A. Again, her cut is through here. The facial nerves roughly branch out about the way a hand would on the side of the face. And so the facial serves that were cut went to her eye, her nose, and her mouth, down here. And she does have, as I say, some return, but its nowhere near as subtle or as accurate as it was before.

And this can be noticed in a number of different areas. Let me have you smile, if you would, please.

I think you can appreciate the fact that her smile is not a natural smile. Her two sides of her mouth do not move the same amount, nor do they move in the same form.

Can you whistle for us?

Again, her mouth function on this damaged side of her mouth does not function normally. She doesnt have the ability to control it nearly as well as on the normal side.

Now, close your eyes for us.

At this point if you can see this from there. She is able to close the eyes pretty well.

Close them real tight.

I dont know if you can see this from there, but when she closes real tight the muscles in her nose here move a lot more than they do on the other side of the nose.

Relax and then close your eyes real tight again. Now, open your eyes. Now, let me have you wrinkle your nose.

And here you can see that this side of the muscles react normally. On the other side she has almost no wrinkling of the nose, almost no control of the muscles in the nose.

Do that again for us.

I would have her yawn for you so you could see how her eye involuntarily closes whenever she yawns, but

Q. Go ahead and do that.

THE PLAINTIFF: I cant yawn.

THE WITNESS: The other problem that shes had, which is not unusual, again, with the fact that the muscles dont work normally, shes had some twitching off on this side. Actually, shes involuntarily demonstrating that for us a little bit. This is something she cant control. Its something she cant make happen. Its something when it does happen she cant control it. It can be a real problem.

Q. (By Mr. Green) Why dont you go have a seat.

Anything else that you think you could demonstrate to the jury?

A. I think I pretty well demonstrated it.

Q. Doctor, using the diagram thats behind you, can you describe the surgical procedure that was undertaken to try to sew those nerves back?

A. The surgical procedure this is the original cut we had to reopen the cut and then having reopened the cut, as I say, there are several lawyers of tissue underneath, we have to go down to the appropriate layer. We then have to separate the skin from the underlying muscles and nerves so that we can actually open up the skin like this so that we can then trace out the nerves.

We use the muscle stimulator so that we know when were close to a nerve. And then we actually have to separate the fatty tissue, and in some cases the muscle tissue, to identify the individual nerves, and then sew the nerves.

Actually what we are sewing together in this model, we are sewing together what is rubber in this model. Theres no way we can sew it together, the individual nerves themselves. We just have to sew together the sheaves of the nerves and then hope that these little individual nerves can get to the place where we sewed them together and grow back out to the muscles.

Q. Following the surgery did you periodically have occasion to observe the healing process?

A. Yes. Its important to watch this quite closely.

Occasionally there will be a situation where a lot of scar tissue would develop at the point where we repaired the nerves. If theres a lot of scar tissue developing, then those little wires cant grow back out to the nerve sheaths. And if that happens, we have to go back in and remove some of that nerve and again try to get the wires to grow out.

Q. What was the appearance of the scar after surgery during the healing process?

A. The scars gone through a healing process of maturation which takes approximately a year or so.

During the early phases of healing the scars are very red. This is due to the new blood vessels that flow into the area to help with the healing. They are very red.

There is usually swelling in the scar. The scar tends to be thick and rather unsightly.

As healing continues, the scars tend to soften up, the redness fades, as those new blood vessels are no longer needed, and hopefully the scar will become flat. Sometimes instead of becoming flat the scar tissue will build up in the area, but early on theyre very red, very firm, very swollen.

Q. Was there any other coloring about (Plaintiffs) face following surgery besides the redness?

A. Under various conditions such as cold weather, and you all have probably observed this yourself, that these new blood vessels that help with the healing are not normal mature blood vessels and they do react to cold temperatures and other stimuli. And under those conditions can become a blue color or even sometimes a purple color.

Q. Okay, Doctor, you can have a seat.

MR. GREEN: May I approach the witness, Your Honor?

THE COURT: Yes.

Q. (By Mr. Green) I am handing you whats been marked for identification as Plaintiffs Exhibit T-3. Are these the medical records from the surgery?

A. Yes, they are.

Q. When was the next time you performed surgery on (Plaintiff)?

A. (14 months after the accident).

Q. For what purpose?

A. At that time we did further work on the scars on her face. And by further work, I mean scar revision, removing some of the scar tissue in part.

Q. What does that mean, scar revision?

A. Well, again, under life-threatening situations its important to close scars rapidly so as to not prolong the operations. And so these initial incisions were closed as rapidly as possible, as rapidly as possible to get a good closure, a good solid closure, but that doesnt produce the best appearance very often, and so these scars were very red, were wide, were thick, and these are the sorts of scars that can very often become painful scars. And so we went back, removed as much of the scar tissue as possible, and then performed a much more delicate but time-consuming closure which is designed to produce a very minimal scar, and generally do everything we can to make those scars as small and inconspicuous as possible.

Q. You mentioned in that context that the scar is painful. You mean emotionally or physically?

A. They very often can be painful physically as well as, of course, emotionally.

Q. Why is that?

A. The probable explanation for this is that some of the sensory nerves, those nerves that provide feeling in the area, actually get caught in the scar tissue and those nerves that are much more sensitive than they ordinarily would be.

Q. Is the surgery itself or the recovery afterwards painful?

A. Yes. As I recall, (Plaintiff) experienced a fair amount of pain and required more pain medication than some other patients that Ive worked on.

Q. Was scar revision the only process you used?

A. No. The other process that we used on some of the scars is known as dermabrasion. Its a sanding process. We tried to smooth off some of the scars and help them blend in more.

Q. The dermabrasion, how is that done, with what kind of an instrument?

A. Its done with a special instrument which is a wheel that turns, and on this wheel is a diamond frays [sic] material that is somewhat similar to sandpaper, except that its much more exacting in terms of the nature of the material and how accurate it is and the standards that it has to meet. And this wheel turns and literally sort of sands off some of the outer layers of skin in order to try to smooth out the irregularities and decrease the contrast between the scar tissue and the normal tissue.

Q. How comfortable is that for a patient?

A. The procedure itself is done under general anesthetic so there is no pain during the procedure itself. However, after surgery this would feel similar to a rather severe scrape of the knee, if you can imagine that on the face, which is more sensitive and tender in the first place than the knee would be.

Q. Would you describe the healing process after one of these dermabrasions?

A. The first week or so there is a fair amount of scabbing, crusting. Theres usually use of an antibiotic gauze on the areas during that period of time. It takes about seven to ten days for this scabbing or crusting to get to the point where it comes off. After this the area that has been treated has a somewhat pink hue to it for a number of months, as much as sometimes six months. Again, this is part of that healing process that we talked about before and it takes a full year again or more sometimes for that totaling healing to take place in this area as well.

Q. What kinds of things did you tell (Plaintiff) to do to take care of herself after that surgery?

A. Initially during the crusting we use an antibiotic ointment which is applied to both decrease the risk of infection as well as to soften up the scabs and to help them come off in a less traumatic manner.

During the time that the areas are pink its necessary to avoid excess sunlight, so she needs to stay out of the sunlight somewhat, use a good sunscreen if she is going out in the sun. We will advise our patient to use a cover-up makeup so they can go about their normal activities, and there are good products that have cover-up makeup as well as sunscreens in them so that the patient can go about their normal activities sooner than they otherwise would be able to.

MR. GREEN: May I approach the witness, Your Honor?

THE COURT: Yes.

Q. (By Mr. Green) Handing you a photograph marked for identification as Plaintiffs Exhibit X. Do you know when that was taken?

A. My note on the back indicates that it was taken on (date), which would have been nearly a month after the dermabrasion scar revision.

Q. Is it true and accurate as she appeared?

A. Yes.

Q. When was the next time you performed any surgery or operation on (Plaintiff)?

A. The next procedure was (18 months after the accident).

Q. For what purpose?

A. At that time we did additional sanding or dermabrasion on her right cheek.

MR. GREEN: May I approach the witness, Your Honor?

THE COURT: Yes.

Q. (By Mr. Green) Handing you whats been marked for identification as Plaintiffs Exhibit Z-1, can you identify that?

A. That was taken just prior to this next sanding process.

Q. Does that truly and accurately portray how she appeared?

A. Yes.

Q. Why was the dermabrasion performed again?

A. Theres a limit to how deep you can sand at any one time, and so because of this, its not uncommonly the case that repeated treatments will produce a better result than a single treatment would. And so as in (Plaintiffs) case, we performed three treatments: Sand a certain level, let that heal, then go back and kind of sand a little more finely, let that heal, and then go back and sand as finely as possible.

Q. I note that the surgery was approximately (date), and the one prior, I believe you testified to was (4 months previously).

A. Thats correct.

Q. Why did you wait so long before sanding again?

A. You have to allow at least three months for the healing to take place before you go back and repeat the treatment.

Q. When was the next time that you performed any operation on (Plaintiff)?

A. The third sanding process was then (21 months after the accident).

Q. Did you expect to perform any other dermabrasions?

A. No.

Q. To what extent would dermabrasions have improved the appearance of the body scars?

A. Unlikely it would significantly improve it.

Q. How long is she going to have these scars that she has today?

A. The scars that she has today are permanent scars. Theres virtually nothing that can be done to improve them any further. They will be as you see them for the rest of her life.

Q. When will she be able to smile again like she was before?

A. Shell never have any better smile than she has now.

Q. What can medicines do to improve either her smile or her scar?

A. Nothing.

MR. GREEN: Nothing further, Your Honor.