Extreme Medicine (6 page)

Gallows humor became de rigueur for the Guinea Pigs. They recruited a treasurer with badly burned legs, so that he wouldn't run off with the petty cash, and a secretary whose fingers had been injured, so he couldn't keep minutes. At the start of World War II, the Guinea Pig Club was tiny. But with the onset of the bombing campaign, those numbers rapidly swelled, and by the end, its membership numbered more than six hundred. They were testing times that saw McIndoe and his team forced to refine their techniques as they went, learning from successes as well as mistakes. But these lessons would transform the field of plastic surgery.

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T
HE PRACTICE OF MILITARY MEDICINE
during the war focused principally upon the salvage of life and limb. McIndoe didn't save the lives of the Guinea Pigs, at least not immediately. That task was achieved by the hospitals that received them. But McIndoe's work and the experience of those he treated taught clinicians that there was something at least as precious as life that modern medicine might preserve.

Today plastic surgery has its own image problem. All too often we associate it with tummy tucks and celebrity nose jobs rather than the plight of burn victims.

But plastic surgery retains many of the values that drove McIndoe and his heroic club of Guinea Pigs. It is, in the main, still about the restoration of function and appearance to people whose lives have been cruelly and irreversibly altered by illness and injury. The fact that we, in modern times, have been able to move beyond the pursuit of simple survival is something to celebrate.

Plasticity, in the context of surgery, refers to the ability to mold and alter the appearance of the body. McIndoe was able to find areas of healthy skin and move them to cover those areas that had been destroyed by fire. More than this, he was able to achieve a result that was aesthetically acceptable. But there were limits. These waltzed skin flaps were supplied by an indefinite weave of capillaries and venules running through the layers of tissue. This blood supply was tenuous, and flaps of this type had to be limited in length and breadth if they were to survive. More extensive injuries were not so easily addressed using this technique.

Larger and thicker areas of skin need much greater volumes of blood flowing through them to keep them alive. In terms of blood supply, the situation is akin to the difference between the needs of a village that subsists on the trickle of dozens of mountain streams and those of a city built on the banks of a coursing river.

This problem could, in theory, be overcome if a block of tissue could be harvested along with the artery and vein that supplied and drained it. These vessels could then be connected to the body's core circulation at the new site to which the graft was being moved. By moving and then connecting a flap directly to the circulation in this way it could be perfused with a rich flow of blood and made viable more or less immediately.

If this could be achieved, then McIndoe's waltzing flaps would no longer be necessary. Instead free flaps of skin and tissue could be taken and moved in a single operation. No longer would the patient be forced to undergo countless operations and wait contorted for weeks while the tissue established a useful blood supply.

But the vessels that supply and drain such flaps of skin, though huge compared with capillary networks, are still vessels of tiny caliber, and connecting them demanded a level of surgical precision previously unknown. With the naked eye, no one could cut and stitch vessels whose diameter might be little more than a millimeter. For this they would need a new but familiar tool.

By the 1970s, microsurgery was an established technique. The skin, whose anatomy had been so well explored by histologists with microscopes, could now be manipulated surgically using the same tool. In time the use of optical aids to magnify the view of the surgeon became as essential to the art of plastic surgery as McIndoe's scissors or scalpel. The ability to operate under a greatly magnified field of view made finer procedures, including the connection of blood vessels and nerves, a reality. For the first time flaps of skin, muscle, and bone could be moved en bloc from one location to another in a single bound—the so-called free flap.

This development massively expanded the plastic surgeon's repertoire and gave rise to a plethora of important and exciting new techniques. But the selection of flaps that could be used was still relatively narrow. Though the grafts made available by this method could be moved quickly and could cover much larger areas, the aesthetic result was sometimes less than satisfactory. Authorities of the time referred to these early, free-flap grafts as “hamburgers of tissue” or “globs and blobs.”

To be of genuine value in aesthetic reconstruction, the library of skin and tissue flaps that plastic surgeons could draw upon needed to be greatly expanded. But knowledge of the vascular anatomy of skin—its relationship to the core circulation—wasn't yet at a point where this was possible.

In the 1980s, Australian plastic surgeon Ian Taylor recognized this and undertook a massive remapping of the circulation of the skin. In so doing, he reconceptualized the anatomy of human skin and its relationship to the circulation.

Prior to this work, understanding of the connection between the core identifiable vessels of the circulation and the supply of more peripheral structures was poor. The body has a network of named arteries and veins that are reproducible from one individual to the next with little variation. These divide ultimately to form more variable, less distinguishable vessels. By the time they arrive at the planes of tissue underpinning the skin, the network has degenerated into a complex weave of small and largely nameless tributaries.

This was fine if you were a surgeon operating on, say, the heart or the liver, where the principal vessels are generally constant in appearance, well mapped by anatomists and immediately recognizable. But for surgeons interested in moving units of flesh and skin around, it was like having an atlas of Great Britain that included only its highways and then trying to navigate a route to a remote farm in the Scottish Highlands.

Taylor injected radiopaque dyes into the skin of countless cadavers and took X-ray images. He generated stunning images of the network of small but remarkably consistent vessels that connected the core circulation to the skin and tissues above.

Understanding these connections and the routes that vessels took as they rose up from deeper structures, weaving between planes of muscle and fat, allowed him to deconstruct the body into a three-dimensional jigsaw puzzle. Taylor called the pieces of the jigsaw angiosomes, and together the pieces constituted a library from which units of tissue, skin, and bone could be drawn and reliably transferred to almost anywhere on the human body. But the battle between blood supply and beauty was far from over.

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T
HE FACE DERIVES ITS BLOOD SUPPLY
from a branch of the carotid artery. This divides low in the neck into a deep internal branch and one that runs more superficially. It is from the superficial division that the face gains its blood supply. From this there are branches aplenty, enough that we as doctors in training employed a variety of mostly obscene mnemonics to help remember them.

Run the tip of your finger gently back along the line of your jaw until the point just before it turns up toward your ear. At this point you can feel the pulse of the facial artery as it runs just below the surface of the skin.

From here it breaks over the surface of the face, with smaller vessels running above and below the lips and branches that run alongside the nose and then up to the eyes. And this shower of arteries joins with other branches of the external carotid artery that also creep across the face. This arrangement supplies both the facial skin and well over a dozen muscles that are involved in eating and facial expression. Surgeons had feared that the complexity of the arterial blood supply might prove an insurmountable challenge when it came to attempts at full face transplants. But more recently doctors discovered that the blood vessel connections required to supply and drain the face might be fewer and simpler than previously thought. This realization took the full face transplant from a thing of science fiction into the realm of science fact.

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T
HERE IS SUCH A THING
as life after death. It's called transplant medicine. After death a patient's heart, lungs, liver, and kidneys can be donated to give the gift of life. Many lives can be saved or improved by that single act of generosity. But death must come first.

In the United States more than one hundred thousand people are currently waiting for an organ transplant. The list is growing quickly; on average a new name is added every twelve minutes and demand outstrips supply. Each day in the United States eighteen people die waiting for an organ transplant. It is possible for patients to receive an organ, removed from a donor, after the heart has stopped beating. This is called non-heart-beating organ donation and it has greatly increased the numbers of organs available for lifesaving donations.

But waiting until the heart has stopped beating before beginning the transplant process means that the organs become deprived of a fresh supply of blood and oxygen. Once that has ceased, the organs begin the process of dying, and there is a greater risk that they will fail to function properly after transplantation.

Some organs are more resilient than others. Kidneys in particular can endure long periods of little or no blood supply and still be resuscitated. But organs with higher metabolic demands, such as the lungs and the heart, fare less well. It is because of this that a new definition of death was coined around the time of the first heart transplants, to give surgeons the best chance of obtaining a heart that might survive the transplant process and function well.

After severe head injuries, the brain can sometimes be so damaged that its higher functions are lost, leaving only the most essential reflexive processes intact. The intrinsic rhythms that drive your heart or the automated activity that drives your digestion, for example, can continue even if everything that is essentially you has ceased to be.

This is brain-stem death: the irreversible and permanent loss of consciousness and cognition. It is as final as the state that accompanies the standstill of a heart and the arrest of breathing. A heartbeat may remain, and breathing might be supported artificially, giving the outward appearance of life, but the elements that define a human being are no longer present. The organs continue to be supported by the beating heart that remains, even though death has already occurred. But it is from these tragic losses, usually from accidents or massive strokes, that the best hope of new life can come. Brain death allows organs to be given in the best possible condition.

The conversations that we have with the relatives and close friends of patients, in softly lit rooms on hospital corridors, are among the hardest in all of medical practice. For the team that approached a recently bereaved family somewhere in New England in March 2011 to ask for their consent to donate not only a heart or a liver but also a face, the task must have seemed impossible.

The doctors took their time, talking over the intricacies of the procedure. They told them that it was among the first of its kind in the world—and in that respect as experimental as much of McIndoe's early work. There could be no coercion, only openness.

There were, however, reassurances. The transplant team made clear that the recipient of the donated face would not resemble their loved one. Once transplanted, the face, laid upon a new underlying structure of bone and tissue, would be as unique in appearance as any other. Neither identity nor appearance would be transferred.

But there were also difficult realities to confront. After the retrieval of a face, efforts are made to reconstruct the appearance of the donor. Casts of the face are taken, and silicon masks are sometimes fashioned. But none of these restores the donor's appearance enough to allow the body to lie in state in an open casket. All of this had to be understood and accepted. After deliberation and despite the magnitude of the request, the family members gave their consent.

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T
HAT DAY, PLASTIC SURGEON
B
OHDAN
P
OMAHAČ
was sitting in the back of a private jet taxiing on the runway at Boston's Logan Airport, waiting to take off. He was leading a transplant team, making ready to retrieve a donor organ. The plane was one of several regularly chartered by the hospital's transplant service. Hearts, lungs, livers, kidneys, and other organs were ferried urgently across the United States in this way. But this mission was different. That evening Pomahač was going out to retrieve an organ as a prelude to a procedure that the United States had never before seen: the transplant of a complete face.

Pomahač had waited a long time for this opportunity and had fought hard just to gain permission to attempt the operation. At the time, only one other full face transplant had ever been carried out—by a team in Spain a year earlier. Pomahač was nevertheless convinced that this procedure offered the only real hope for people who had suffered catastrophic facial injuries. But not everyone was of the same mind. He petitioned the institutional review board (IRB) at Brigham and Women's Hospital repeatedly. The board, tasked with making sure that both the science and ethics of the proposed procedure were sound, was supportive but took some time to be convinced. The difficulty was that, unlike other transplant surgery, the transfer of a face did not ameliorate life-threatening illness. The review board had to weigh the very real risks of the procedure against its perceived aesthetic benefits.

It wasn't just the surgery that might present a threat. To be able to accept a transplant from another individual, the recipient's immune system must be heavily suppressed to stop the newly grafted organ from coming under attack. For ordinary organ transplants, the tissue type of the donor organ must be matched as closely as possible to that of the recipient. Part of the body's formidable defense against infection is its ability to distinguish foreign proteins and tissues from its own—a function fulfilled by the white blood cells patrolling in our circulatory system.