Nasal Reconstruction (2)
Consider the artery that travels straight up the forehead.
In modern Korean, we call it the supratrochlear artery, or hwalchasang-dongmaek... though hearing it out loud, it sounds rather pedantic. Perhaps it is because I learned medicine in English, but for whatever reason, medical terms in Korean always felt unnecessarily convoluted. In any case, in English it is the supratrochlear artery. Quite literally, an artery that arches over the trochlea. You can think of it simply as a blood vessel that emerges near the inner corner of the eye and courses straight up into the forehead.
"Do you see this?"
I placed two parallel incisions just under a centimeter on either side of the vessel, gently dissecting and lifting the skin flap free from the brow. Naturally, the base remained soundly tethered down below. The artery had to be preserved at all costs. Sever it, and the tissue is doomed to necrosis. Conversely, as long as it remains hooked up to that vascular pedicle, the tissue above will survive no matter how you fold, twist, or sculpt it. After all, blood still flows through it.
"Hmm... an artery. Well, one runs across it often enough during facial dissections. But to use it like this..." Blundell muttered without much conviction, eyeing my work with mild curiosity.
Liston, our great hope, was an entirely different breed.
"Ah... if you rotate it down like this...! It isn't fundamentally different from flipping a flap from the forearm, is it?"
"Precisely, sir."
The man might lack modern theoretical knowledge, and his surgical experience might lean lopsidedly toward raw brute speed, but his mind was exceptionally sharp. Even so, I hadn't expected him to grasp the core principle of a pedicled rotation flap the very second he laid eyes on it.
"The drawback is... given that it comes from the forehead, the available tissue must be rather limited."
"Quite true. However, a nose is not an exceptionally large organ to begin with."
"I know not about your nose, my good man, but mine is rather substantial."
"Well... it isn't as though we can reconstruct its original, pristine shape anyway, can we?"
"Restoring it to its original form would naturally be preferable, wouldn't it? But... well, I suppose that method remains quite out of reach."
To his credit, Liston was remarkably devoid of stubbornness when it came to pure surgical practicality. Look at him now. Wanting to rebuild a nose to its original symmetry was, in truth, an utterly reasonable and common-sense wish. Yet one glance at Colin's leather satchel—now half-dissolved and ruined by Joseph's carbolic bath—was enough to make him yield the point at once. He had firmly internalized the premise that no surgery should ever take place under conditions where proper antisepsis could not be guaranteed.
"Look, even doing just this."
I swung the crude flap I had just elevated down across the bridge and laid it over the severed stump of the cadaver's nose.
"Hideous."
To be frank, the reactions I had secretly hoped for were along the lines of 'Remarkable,' 'Brilliant,' or 'As expected of Pyeong.' Yet 'hideous' was undeniably accurate. How could it not be? It wasn't a neat, freestanding nose cleanly set upon the face; it was an awkward bridge of flesh still anchored to the forehead, drooping down like an elephant's trunk. The nascent nose itself was strange enough, but the pedicle tethering it to the brow was downright grotesque.
"What if we divide this bridge later on?"
"Ah, like the Italian method? Indeed... if skin grafted from a forearm can take root, why wouldn't forehead skin do the same? Hmm... done that way, it would certainly look far better than it does now."
'Better' was an understatement; it was nothing short of a revolution. Just think about it. Until now, they had strapped patients into barbarous iron-and-leather contraptions, tethering the arm to the head for weeks until people died of sheer exhaustion and infection. Swapping that torment for a local forehead flap that could be severed and set after a few weeks was a godsend. Setting aside the sheer difference in patient comfort, the actual vascular survival rate would be incomparably higher. Of that, I was absolutely certain.
"Well, say what you will, this certainly sounds vastly superior to the antiquated texts."
"Indeed it does."
"Brilliant, Professor Pyeong..."
Liston and Blundell ultimately nodded in agreement, and Colin chimed in with quiet admiration. Joseph and Alfred hadn't spoken, but their silence signaled assent as well—though each was quiet for an entirely different reason. Alfred, possessed of hands utterly cursed by the gods, had attempted to mimic my incision on his own cadaver and promptly severed the supratrochlear artery clean in two. How on earth one manages to cut a vessel that runs in a straight, predictable line was an anatomical mystery beyond my comprehension.
And Joseph?
Joseph was busy disinfecting.
I really need to pull that lad back a bit soon.
Granted, in an era where nobody disinfected anything, and where the vast majority outside our immediate circle still scoffed at the practice, having a zealot obsessively policing cleanliness was undeniably necessary. But the problem was...
His hands are actually talented.
With Alfred, it didn't matter what he spent his time on. In fact, him staying as far away from an operating knife as possible was a blessing for mankind. I was human too, and I owed his father a debt of gratitude I had to repay. With enough grueling labor, I might just manage to train Alfred into a mediocre surgeon... but as the saying goes, graveyards are paved with the bodies of mediocre warriors. In swordsmanship, a mediocre warrior gets himself killed; in surgery, he gets other people killed. The mere thought of the mountain of corpses Alfred would leave in his wake made a sigh rise unbidden to my lips. His family was wealthy and well-connected to boot, meaning his blunders would likely be swept under the rug as unfortunate acts of God.
"Hmm... but look here," Liston began, interrupting my grim musings on Alfred and the future of London.
When it came to surgery, he was the most earnestly dedicated man alive. Even now, he was turning and twisting the forehead flap over the wound, scrutinizing every angle. A question from such a man was always worth heeding. At the very least, it held far more value than Alfred's surgical prospects. Besides, ignoring Liston when he addressed you was suicidal folly. Even if he hadn't beaten me to death after I feigned mild madness and cracked a bald joke at his expense, tempting fate twice was ill-advised.
"Yes, sir?" My reply slipped out on pure muscle memory. Whatever my soul felt, my flesh possessed an instinct for self-preservation. One has to survive. To die from a slip of the tongue after getting a second chance at life would be pathetic.
"What about the bridge? Your own nose may be small, but it stands straight and firm, does it not? If we merely drape flesh like this, the bridge will be entirely mush."
"Aren't you... perhaps obsessing a bit too much over aesthetic contour?"
"It is not an obsession! We must consider the patient. Consider his life in the days to come!"
Worrying about a patient's distant future seems rather presumptuous for a nineteenth-century surgeon, doesn't it? Shouldn't our primary concern be whether he survives the next three days without succumbing to sepsis?
Naturally, I kept that thought firmly to myself.
Well... it is a question worth considering.
I shifted my focus to genuine clinical problem-solving. My deliberation was not over what technique to invent from scratch, but rather whether the modern solutions I knew by heart were feasible within the limitations of this primitive era.
"Should we perhaps insert iron...?" Liston ventured.
"No, wait. Absolutely not."
"Why?"
Iron. Steel. It was certainly a marvelous material. History had an Iron Age, but no Mercury Age, Lead Age, or Arsenic Age. It was immensely useful and relatively stable, yes... but that hardly meant one could go shoving raw metal into living human flesh.
"Touch your own nose, sir."
"I will not."
"Why... on earth not?"
"Because then I should have to scrub my hands all over again."
"We are working on a cadaver anyway, aren't we?"
"Do you think Joseph will let that slide?"
"Well... fair point. Just picture it in your mind, then. The tip yields when pressed, doesn't it?"
"It does. And?"
"Exactly. The tip of a nose is soft. Look at the nose I just excised earlier. That framework isn't rigid like metal, nor is it hard like solid bone."
I picked up the severed nose and turned it between my gloved fingers. Though it was stiffening from post-mortem decay, it was still far from dense bone. Anyone who touched it would know at once. It was common sense.
"Hmm. But wouldn't it suffice merely to hold the shape? Surely the profile is what matters most."
His logic wasn't entirely baseless. In ear reconstruction, for instance, rigid frameworks were indeed utilized. A rigid protrusion might be prone to injury if bumped, but it didn't compromise the ear's ability to gather sound. A nose might follow similar logic, though being the most prominent feature on the face, an unyielding metal core would easily shatter the surrounding tissue under the slightest impact. Much like a rigid tree snapping before a gale while a supple one bent.
"Now, now! Would the Lord above have fashioned it this way without reason?!"
The words that burst from my mouth took an entirely different tack. Under normal circumstances, shouting at Liston was unthinkable, but invoke the Almighty, and the board changed completely.
"Ah... Lord have mercy."
Perhaps it was because his terrifying countenance made him feel destined for damnation whenever he looked into a mirror, or perhaps it was because his conscience carried a heavy burden of actual sins, but Liston was an extraordinarily devout man.
"I spoke out of turn. We shall dispense with the iron."
"Indeed. If we must insert a framework at all—though I believe doing without would be safer."
"Tell me your counsel. Is the Lord speaking to you even now? Is it a prophecy?"
"He is not whispering in my ear, but if an idea comes, you believe it is from Him, do you not?"
If he started viewing me as a Joseon shaman channeling the dead, things would become exceedingly awkward. My concern wasn't unfounded either; these fellows had recently taken to studying Joseon on their own. Thank the heavens that archival records on Korea were practically nonexistent in Britain. Had historical texts been plentiful, I would have been branded Master Wolha of Mount Jiri instead of Noble Kim.
"Naturally. Who else but the Lord could impart such profound truths?"
"Quite so. In any case, an inspiration has come."
"Oh? What is it?"
"We harvest cartilage from another part of the body. From the ear, for instance... or here."
"The ribs?"
"Yes. There is cartilage along the ribs as well."
"Ah... quite right. Give them a sharp rap, and they snap right off. Haha."
Coming from a brute capable of snapping a man's spine with a bare-handed strike, the remark felt distinctly unsettling. Still, his familiarity with costal cartilage was likely extensive. When a man spends his life cracking ribs, anatomical knowledge naturally accumulates by the heap.
"Though, regarding the ear... isn't that cartilage rather curved?"
While I was contemplating that, Liston had already sliced an ear clean off his assigned cadaver and, with uncanny manual dexterity, slipped the auricular cartilage straight out from the skin.
As expected... of Liston.
I was startled by his raw efficiency, but his surgical intuition astonished me even more. Auricular cartilage was far easier and safer to harvest than costal cartilage from the chest wall. Yet its inherent curvature was the problem. The nasal bridge required a straight, rigid strut.
"It may be better not to use it. Unless some remnant of the original nasal structure remains, of course."
"I see. Then it must be the ribs after all?"
"Still... is cramming foreign structural support inside truly our best option? Perhaps we should verify whether the forehead flap alone can succeed before complicating matters."
"You know, watching you, I am often hard-pressed to tell whether you are boldly progressive or terribly timid. What under heaven cannot be achieved through resolute effort?"
Well, sir... in the twenty-first century, they say that the capacity for effort is just another facet of innate talent.
Still, the nineteenth century was undeniably intoxicated with optimism. Setting aside the working poor, who lived in an entirely different world of squalor, men of comfortable station like those standing here believed that tomorrow would always be brighter than today. It was the British Empire, after all—the realm upon which the sun never set. An atmosphere of boundless, chest-thumping confidence was only natural.
Besides... if it's Liston, raw effort might actually take him all the way.
Bitter though it was to admit, the man's innate surgical genius surpassed my own. I didn't hold back from reining him in merely out of fear of getting battered. Truly, I didn't.
"Shall we practice once more upon the cadavers before calling in the patients waiting outside?"
"Aye. Let us do so."
"Though... they have been waiting a rather long time. Will they be all right?"
"What? They are being paid a daily wage just to sit and wait. Do you have any idea how dearly we paid for their surgical consent? It is no trivial sum. They only collect the full bounty once the operation actually takes place, so I imagine they are grinning from ear to ear."
The term 'surgical consent form' sounded uncomfortably close to a forfeiture of bodily rights, but I nodded nonetheless, consoling myself with the thought that under the care of our hospital and our hands, their odds of survival were far better than anywhere else on earth.