The rare tumor that was taking over Daniel Smith's lower jaw made his left cheek look as if it held a fat wad of chewing tobacco. His chin and lower lip jutted, giving him a sullen pout that belied his doleful eyes.
Smith, 30, tended to keep his chin lowered so the tumor would be less noticeable - or so he wouldn't see other Haitians staring at him.
But there was no shrinking from notice in early July at Thomas Jefferson University Hospital. Four surgeons examined, photographed, and X-rayed his splayed teeth, oozing gum, and the tumor, a non-cancerous but aggressive growth called ameloblastoma. It had made Smith's jaw so fragile that he was at risk of a fracture that could be disastrous, especially in devastated, poverty-stricken Haiti.
Kristen Hertzog, 38, of Ephrata, Pa., looked on with anguish and excitement.
Smith is a student at Haitian Connection Network, a tuition-free, online vocational school that Hertzog and her supporters set up outside Port au Prince two years ago, soon after the earthquake that decimated the country.
With the help of many Samaritans, she had brought Smith to the United States, where Jefferson and Holy Redeemer hospitals were underwriting $100,000 worth of surgery and physical therapy.
Smith seemed overwhelmed. He kept asking whether the tumor would grow back, as it had twice before after operations in Haiti.
Robert Diecidue, the maxillofacial surgeon who persuaded Jefferson to pay for the surgery, explained that this time would be different. Instead of scraping the abnormal bone out of Smith's jaw, the doctors would replace most of the jaw with a bone from his leg.
Hertzog spoke to Smith in Haitian Creole: "Ou konprann?" ("Do you understand?")
He did, but confessed, "I'm really scared."
The Haitian doctors who operated on Smith when he was 15 and 22 performed "curettage," shaving away as much of the tumor as they could.
Given their limited technology, reconstructive surgery was out of the question.
But curettage left tumor cells behind. Like cancer, ameloblastoma can grow from a few remnant cells, although it rarely metastasizes.
Smith said the doctors never gave him or his parents a diagnosis.
"My mother told me I had a bad tooth that grew," he said.
Ironically, she was right. Ameloblastoma forms from leftover developmental cells that normally become tooth enamel. It afflicts about two people in a million.
Smith, a devout Christian, was tauntingly called "crooked jaw" by fellow Haitians who speculated that he was a victim of evil spells, spirits, or a truck accident.
Instead of becoming bitter, Smith focused on education. In a country where half the population is illiterate, he graduated from high school, studied English, and was one of the first to qualify for Haitian Connection, where he expects to earn a computer science degree next year.
Still, Hertzog could see that his tumor was a torment. So about a year ago, she asked Keith Price, a Warren, Pa., family physician, to look at it.
"I had no idea what it was," recalled Price, who had gone to build desks at Haitian Connection.
Back home, Price queried colleagues, including Anthony Coletta, chief medical officer of Holy Redeemer Health System. They had shared a tent while helping in Haiti after the earthquake.
Coletta sent an e-mail blast that reached Diecidue, Jefferson's chief of maxillofacial surgery.
Diecidue could help, but he needed a tumor sample, or biopsy, to make a diagnosis and plan treatment. If the tumor were cancer, the care would be even more complex.
In February, Coletta, a surgeon, got the biopsy and was bringing it to Philadelphia for analysis - when he was stopped by U.S. Customs in Miami. He didn't realize the U.S. Centers for Disease Control and Prevention had to clear the unusual import.
"This was a Sunday, but they [Customs] were very good," he said. "They called the CDC. Luckily, they didn't confiscate it."
On July 25 at 7 a.m., Smith lay anesthetized on an operating table.
Diecidue and Daniel Taub, another maxillofacial surgeon, huddled at Smith's head.
Two facial reconstructive surgeons, Howard Krein and Ryan Heffelfinger, stood over Smith's lower left leg, where they would harvest the fibula, the long bone at the back of the calf.
They were about to undertake a surgical tour de force: repurposing that long, straight, inflexible leg bone to replace the hinged, contoured, multipurpose jaw bone.
Such a feat was barely imaginable until the 1970s, when microsurgical techniques enabled doctors to cut and then reconnect tiny blood vessels. Bones, like all organs, will die if deprived of their blood supply for too long.
Initially, jaws were rebuilt with a shoulder blade or arm bone. Much later, in 1989, the fibula was first used.
It turned out to have distinct advantages, beginning with the fact that the leg works fine without it.
The blood supply is another plus. A sizable artery and vein run alongside the fibula, feeding an intricate web of vessels inside the bony matrix. As long as the bone has an external blood supply, wedges and segments of the fibula can be cut to shape it into a jaw. In the mouth, these segments fuse together in about six weeks.
The fibula also provides up to 11 inches of graft tissue, twice as much as other bones.
Smith needed a bit more than half that length: about three inches to replace the tumor-ridden left side of his jaw; 1.5 inches for his chin; and 1.2 inches for the right side of the jaw, where three molars would be saved.
Along with these segments, the surgeons would take a flap of leg muscle and skin to fashion a new gum.
By noon, the surgeons were ready to cut the bones.
"Where are the jigs?" Heffelfinger asked as nurses fetched plastic molds.
The molds, which snapped onto the mandible and fibula at spots predetermined by the surgeons, had slots to guide an electric saw - like a carpenter's jig.
The jigs were made by Medical Modeling Inc. of Colorado as part of a computer-aided, three-dimensional, pre-surgical planning program created with Smith's CT scans. Diecidue got the company to donate the $15,000 "virtual surgery," which is not routine; insurers don't cover it. By expediting the measuring and cutting, the jigs shortened the surgery and reduced the time that the fibula was without a blood supply.
Diecidue also persuaded KLS Martin of Jacksonville, Fla., to donate the custom-shaped strip of titanium that held the fibula sections in place in Smith's mouth.
Wielding screwdrivers and self-drilling screws, the doctors affixed the strip to the remains of Smith's mandible. Then the fibula was fastened to the strip with 10 more screws.
Finally, around 4 p.m., they connected the leg bone's artery and vein to vessels in the neck that had supplied Smith's jaw - and tumor.
As the 10-hour operation wrapped up, Krein chatted. He had heard Smith say he hoped to see the White House before returning to Haiti in November.
"My father-in-law is Joe Biden," said Krein, who married the vice president's daughter Ashley in April. "I told him I have this patient and he said, 'Let me know when Daniel is available and I'll get him a tour.'"
Smith's recovery has been smooth and swift - although he didn't think so at first.
He spent four nights in intensive care, then moved to a regular hospital room where Hertzog visited him.
Glassy-eyed and miserable, he still had a feeding tube down his nose, a tracheostomy tube in his neck that kept him from speaking, and a steady trickle of drool from his swollen-open mouth. His leg throbbed, but the pain medication gave him nightmares.
"I thought I was trapped and covered with ants," he jotted on a note pad.
Just two weeks later, Smith limped into a Jefferson examining room. No crutches. Not even a cane.
His jaw was smooth, symmetrical and only mildly swollen. The scars on his chin and in a neck crease were barely visible. And his lower lip disguised his lack of teeth.
"How long has it been since surgery? Five weeks?" Taub asked.
"Three weeks," Smith said with a slight lisp.
"Wow!" Taub said. "You look fantastic. You're ahead of schedule."
He will need an annual checkup in Haiti, but the chance that tumor cells were left behind is less than 1 percent.
The only lasting side effect may be toothlessness. When Taub explained that a conventional denture would not fit and tooth implants would cost tens of thousands of dollars, Smith was adamant.
"I don't need that!" he declared.
All he needed, he said later, was to find a way to thank his many benefactors.
"Every minute of every day, I think of a way to thank them," he said. "When I talk to them, I say thanks, thanks, thanks. But I have no words to express it. It is something I will never, never forget."
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