Today, the 38-year-old is not only alive, but his face has also been restored to near normal with the world’s latest reconstruction techniques. “It feels like a rebirth,” the FMCG company employee told TOI. It definitely is, because on September 3, 2020, when the bull’s left horn lacerated his lips, smashed his nose, gouged out the right eyeball and herniated upward through the front lobe of his brain, even the doctors at the local hospital he was rushed to could do nothing more than stem the bleeding and put in some big sutures.
Bishnoi was driving home with a friend when they slowed down the car to let two bulls cross the road. “But suddenly, one of the bulls turned back and charged at me, hooking its left horn in my face,” the man said. His friend, who wasn’t seriously hurt, went into shock at the sight of Bishnoi, but mustered courage to call relatives, who took the bleeding man to a local hospital.
Series of surgeries later, doctors worked on giving face emotions
At the hospital, besides packing the face to stop the bleeding, the doctors pleaded helplessness to do anything more. Deepak Aggarwal, managing director of Bikaji Group, the FMCG company in which Bishnoi is employed, made arrangements to airlift his friend to Max Hospital in Saket. Despite the pressure of dealing with Covid-19 patients, the hospital admitted him because this was a time-sensitive case.
By the time Bishnoi landed in Delhi, a team of doctors led by plastic surgeon Dr Sunil Choudhary and neurosurgeon Dr Bipin Walia was ready with an action plan. A high-resolution, 3D CT scan was done in the emergency section itself before the patient was wheeled into the operation theatre.
“When he came to the hospital, he was on ventilator support but his oxygen saturation level wasn’t stable,” recalled Choudhary, chief of plastic, reconstructive and craniofacial surgery at Max Saket. “We thought it was caused by foreign material or improper intubation, but investigation revealed that the ventilation was blocked by pulverised brain matter flowing out from his nose into the mouth. This was something we had never seen in a live person.”
The neurosurgeons immediately cleared the brain of debris and repaired the dura mater — the outermost of the brain’s three protective layers — with a patch of bone membrane taken from the back of his skull to stop the leaking of brain fluid.
With a portion of Bishnoi’s skull missing, it was imperative to provide the brain a bone cover. “Normally, we would use a titanium mesh as a patch. But in this case, we didn’t have enough time to get a customised implant of the dimensions required,” said Choudhary. “We, therefore, took a part of his remaining skull and split it into two layers, putting the inner layer back in its regular place and using the outer layer to patch up the defect.” This was the first major step towards the reconstruction of his face.
Next, to prevent the brain from herniating into the open eye socket and the nasal cavity, a part of the patient’s temporalis muscle was transplanted into the eye socket. “We couldn’t have used a bone graft there because first, the brain would undergo massive swelling and second, the bone graft itself could start pushing into the brain and damaging it,” explained Choudhary.
Now that the brain cavity was totally sealed off from the external cavity, the focus shifted to the face. Bishnoi’s nose and lips were crushed into 20 and six parts, respectively, by the blunt force. The plastic surgery team pieced them together while ensuring blood supply to ensure tissue survival. This surgery lasted almost nine hours.
Over the next two days, the doctors waited for Bishnoi to regain consciousness, hoping all the while that his cognitive abilities were intact. It took the ravaged patient around a week to gradually regain his memory, speech and mobility. “The only explanation for the neurological recovery despite such an injury was that the damage to the brain was limited to the right frontal lobe, whose functions are still not fully known,” said Choudhary.
In 10 days, Bishnoi was stable enough to be discharged. But the restoration of the face remained. “The face is the identity of a person. Even minor expressions on the forehead often reveal our emotions. If the patient couldn’t do any of this, he would feel less a human,” Choudhary said.
Normally, grafting of tissue is done between two ends of an injured nerve to re-animate the forehead. But that wasn’t possible in this case. The surgeons found only one example in medical literature of sutures as fine as human hair being used to connect the muscles of the two sides of a patient’s forehead via a bridge of three nerve grafts to enable the person to move the forehead. Bishnoi must be the second patient in the world to undergo this procedure, his medical team conjectured.
His nose was sculpted from a rib cartilage. The right side of the face was reconstructed using the thin casing of connective tissue surrounding the thigh to connect to his temporalis muscle in a technique developed by Choudhary. The volume loss on the face was made up by using fat harvested from Bishnoi’s abdomen. These procedures took nearly 10 hours.
Bishnoi had lost his right eyeball and the surgeons tried an artificial eye in the orbital cavity to improve appearance. However, this didn’t work because the eyelid couldn’t move. After the second surgery, Bishnoi was advised to practise mirror bio-feedback involving moving the forehead on the affected side periodically in front of the mirror. Bishnoi remembers spending hours doing this without much happening. After four months of regular practice, one day he felt that his right forehead moved a little “It was my eureka moment. From then on, I worked harder and there is now significant movement,” the miracle man smiled.
Kiran Bishnoi, the patient’s elder sister, is ecstatic at the developments. “The turnaround in my brother’s condition is unbelievable, thanks to the medical team which spent months planning his new life and also to Deepak Aggarwal, who arranged for his shift to Delhi in the middle of the Covid pandemic,” she said.