David Bye's Reconstruction

David Bye’s injury resulted in a devastating loss of hard and soft tissues from his jaw and lower face.

Bye’s diaries describe the sequence of 15 procedures over 18months during which his chin, jaw, mouth and teeth are reconstructed. Sequential clinical images taken during the clinical records depict the process. He was given these images after the procedures were complete, and his family have now very kindly donated them to BAPRAS. The major procedures were undertaken by Plastic Surgeon John Grocott at Stoke, followed by dental work in McIndoe’s unit, the Queen Elizabeth Hospital at East Grinstead in Sussex.

By the time he was triaged for care in Stoke, David Bye had lived with his injuries for more than two months. Speaking and retaining food or saliva must have been very difficult. Grocott decided that the volume of soft tissue required to make up the deficit demanded transfer of a tube pedicle flap. This reconstructive technique was developed by Harold Gillies at Sidcup, Kent during the First World War.  In Bye’s case, Grocott first developed this flap in several stages from a donor site on the upper left chest wall. Staged or “delay” procedures, as Bye correctly refers to them in his diary entry of 3^rd May 1945, ensured the flap grew and was kept alive by a robust blood supply.  At the 6^th procedure on 17^th May 1945 the flap was detached at only the lower end and swung up to be sewn into the freshened raw edges of his facial defect.

It is likely that the 7^th procedure on the 21^st of June 1945 was a local anaesthetic procedure to finally divide the shoulder end of the pedicle, the flap surviving on blood vessel in-growth from surrounding lower facial tissues. The bulky flap would then form the basis for something which could be both formed or moulded– literally plastic surgery- into a functional chin and lower lip, whilst providing cover and blood supply for a subsequent jaw-reconstructing bone graft.

The 8^th procedure, carried out on 20^th August thus involved trimming and shaping the flap to make it look more like a chin. It is uncertain what “..and tissue from leg” at this operation refers to. It could have been a strip of fibrous tissue (fascia lata) taken to better suspend the lower lip margin. 

The 9^th operation, carried out on 22^nd October, was the bone graft, taken from the crest of the pelvic bone to bridge the gap in the lower jaw (mandible). This seems to have been successful, such that the subsequent operations 10-14 comprised forming a pink lower lip and an oral cavity. The cleft between lip and the jaw the two would be suitably deep enough to receive a bespoke set of false teeth. The clearing of existing teeth, whilst partly a fashion of the time would have facilitated the additional specialist dental work for which Bye had to travel to East Grinstead.

Click on the Gallery below to view the reconstruction sequence

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David’s family have diaries only for 1945 and 1946. Whether or not he kept a diary after that is unknown. He remained a patient at North Staffordshire Royal Infirmary until being discharged in November 1947, having undergone some minor scar revisions that year.

The whole reconstructive process was punctuated by occasionally cancelled operations, and hints of complications, such as the first infusion of Penicillin, still a recently introduced “miracle drug”, over three days in June 1945. Also notable is the regime of staged, early stitch removal, prevalent at the time. This was designed to reduce the formation of dot-like stitch mark scars whilst ensuring the wounds healed together.

By the standards of the reconstructive techniques available at the time however, this whole sequence, taking some 18 months, proceeded remarkably efficiently and successfully. Testament to the reconstructive skills of John Grocott.

The original series of clinical images depicting David Bye’s reconstruction were donated to the BAPRAS Collection by his daughters.