Extreme Medicine (7 page)

Once recognized as “other,” foreign bodies are attacked by battalions of immune cells. These cells damage, destroy, and later engulf. Without this defense, the simplest of infections would prove lethal. But if you want a patient to receive an organ transplanted from another individual, these defenses work against you. The newly grafted organ is detected, attacked, and eventually rejected by the body.

During World War II, plastic surgeons were aware that skin grafts taken from donors related to the recipient survived longer than those taken from unrelated individuals. Precisely why this should be the case was unknown, but it gave cause for thought. Archie McIndoe himself had observed that grafts could be exchanged between identical twins without fear of rejection. Today donor and recipient are matched as closely as possible with respect to specific marker proteins expressed by their cells. The closer your genetic code, the more likely these proteins are to match. These proteins are like flags on the mast of a ship at war, announcing its sovereignty and distinguishing it from the naval vessels of a hostile foreign power. For the cells of the human body, exhibiting the wrong surface-marker proteins is akin to flying hostile flags and provokes attack.

Matching surface proteins as closely as possible provides a degree of protection, but ultimately it only delays the onset of rejection. To ensure graft survival, the recipient's immune system must be suppressed, risking overwhelming and potentially fatal infection. Pomahač's many appeals to the IRB at Brigham and Women's Hospital had opened the door, but each case would still have to be decided on its individual merits. Pomahač began a search that would lead him to Dallas Wiens.

Pomahač first heard of Dallas at a meeting of the American Society of Plastic Surgeons in 2009. The surgeon was due to present case reports of successes that he had had with partial face transplants. But speaking before him was Dr. Jeff Janis, a surgeon from Texas, who told the story of a man who had suffered the nearly total destruction of his face by high-voltage electric current. Dallas Wiens had been helping to paint a church in his hometown. He had climbed into a cherry picker in order to reach the roof. What happened next remains unclear. As the basket containing Dallas rose from the ground, he appears to have gotten close enough to a high-voltage power line for it to discharge through his body for many seconds, nearly long enough to kill Dallas and more than long enough to burn and almost completely destroy his face.

Dallas was resuscitated in the emergency room of the Parkland Memorial Hospital in Dallas, Texas. The scenes would have been distressing even for seasoned health-care professionals. Electrical burns are caused by the heating effect of the current as it passes through tissues. The resultant burns run deep, and electrical involvement of the heart can lead to immediate cardiac arrest. The power line had discharged through his head, heating and then burning the full thickness of skin over his entire face. The charge running through his body cauterized his face, reducing it to a coagulated mass.

Dallas was close to death when he arrived at Parkland. The resuscitating surgeons wondered how hard a fight for life they should mount. Seeing how completely his appearance had been destroyed, they initially wondered if anyone would want to survive in such a disfigured form.

A face fulfills a role that goes well beyond appearance. Its orifices form the conduits through which air is conducted into our lungs and through which food begins its journey down into our digestive tract. It is the sole seat of three of our five senses: sight, smell, and taste. From what the resuscitating team could see, much of that had been utterly obliterated. Even if Dallas could be resuscitated, what quality of life could this man possibly hope for?

Nevertheless, they continued, and later Jeff Janis's plastic-surgery team would cover Dallas's head by raising large, free flaps of tissue from his back and moving them up onto his face. But Janis was open about the fact that this effort was a lifesaving measure whose goal was to cover and manage the wound left by the electrical burn. Even after this work had fully healed, it was clear that Dallas would need a more radical solution if any meaningful reconstruction were to be realized.

In the presentation that Pomahač saw, Dallas looked as though he had been massively injured. A huge featureless graft had been pulled into place where his face had once been. Pomahač remembers thinking to himself that the man in the slides was so completely disfigured that he no longer looked human.

After they got off the stage, Janis and Pomahač got to chatting. Having heard of Pomahač's pioneering work in the field of partial facial transplants, Janis suggested that perhaps Pomahač's team at the Brigham could help Dallas. But Pomahač was pessimistic; he was unsure how much of the structure of the face remained intact underneath the graft. To be reconstructed, Dallas would need a full face transplant and for this the underlying blood vessels would have to be intact. Judging by the details of the medical report and the photographs of Dallas that Pomahač had seen, he doubted that this could be the case.

Still, he decided to investigate further. Pomahač brought Dallas to Boston and began to assess him. Many aspects of his injury were at least as bad as he had feared. He was blind and had lost one eye. The structure of the nose had been entirely destroyed; he had no lips, and where there should have been a mouth, there was only a slit. Dallas was reduced to drinking through a straw, and when he ate, he had trouble keeping food in his mouth. He could just about speak, but the words were sometimes muffled and difficult to comprehend.

But as Pomahač came to know Dallas better, he couldn't help but be won over by the force of his personality. Here was a patient who remained positive despite the accident and open about the disfigurement he had suffered. He was also realistic in his expectations and clear about his motivations. The injury had left Dallas blind and so, one might assume, less conscious of his facial features. But the opposite was true. In conversations with Pomahač, Dallas explained the profound discomfort he felt in sensing the reactions of others to his appearance—the silence that fell in a previously busy restaurant when he sat down to eat and the hush that filled rooms in his presence. He was acutely conscious of all of this. But most of all, he worried about how his young daughter would cope with questions and comments from friends as she grew older.

While this didn't alter Pomahač's technical decisions, it certainly shifted his emphasis. He wanted desperately to help this man, a feeling that went beyond the ordinary duty of care.

Pomahač had been preparing for the possibility of performing a full face transplant for more than two years, assembling a crack team from various medical disciplines. He knew that the surgery itself was just the centerpiece; a host of clinicians and other health-care professionals would be necessary to make Pomahač's ambition a reality. For this plunge into the unknown, he would have to make sure that his team was meticulously prepared. This responsibility he gave to his friend and colleague Tom Edrich, an anesthetist.

By this stage, the team was on call twenty-four hours a day, waiting for the phone to ring summoning them to action. Meanwhile, there was plenty to think about. Where should the intravenous lines be sited? What degree of immunosuppression would protect the graft from rejection without running unacceptable risks? For Edrich there was the question of how to prevent the patient's airway from closing and suffocating him after the anesthetic had taken effect. Normally he would insert a tube through the mouth and thread it into the windpipe. But with burn patients, mouths were often too badly distorted to allow this to happen.

Meanwhile, the question of whether or not Dallas could be a candidate for facial transplantation depended upon the state of the blood supply that remained. Pomahač's team set about conducting an extensive mapping of his vascular anatomy, injecting liquid opaque to radiation into Dallas's veins and performing computerized tomography (CT) scans and magnetic resonance imaging (MRI) to reveal the delicate network of vessels woven below.

After many weeks of assessment, Pomahač's team decided that, despite the apparent damage, the key blood vessels remained intact. There was a good chance that Dallas would be able to receive a face transplant. Pomahač began working him up as a candidate, profiling his immune type so that the transplant teams could begin their search for a donor who was a suitable match. All that then remained was for them to find a donor whose immunotype was a close enough match.

They waited for several months. Then one day Edrich's phone rang. It was Pomahač, and though his voice remained level, Edrich could detect more than a hint of excitement. “We've got a face,” he said.

—

F
OR THE NEXT TWO DAYS,
nobody involved in the face transplant slept very much. Dallas was told to make his way from his home in Texas to the Brigham and Women's Hospital in Boston as quickly as he could. Meanwhile, Pomahač set out aboard a jet aircraft to retrieve the face from its donor. He was not the only transplant surgeon on the retrieval mission. Under ordinary circumstances, organs are retrieved in a carefully orchestrated sequence: first the kidneys, then the liver, and later the lungs. Once the other organs are taken, it is no longer necessary to supply the body with oxygenated blood, so the heart too can be removed. But in the years preceding this first attempt at a face transplant in the United States, Pomahač had agreed with the New England transplant coordinators that the retrieval of the face should happen first, despite the fact that it wasn't a lifesaving organ.

After removal, an organ can be deprived of its blood supply for only a short time before it fails and dies. Measures are taken to extend that period for as long as possible, including ice boxes and preservative solutions. But even with these, the time that organs can survive without being plumbed into a recipient's new blood supply is limited to a few hours, so the timing of the retrieval of Dallas Wiens's new face was critical.

As other transplant teams from around the region geared up to perform their retrievals, Pomahač received a phone call. A patient in urgent need of a heart transplant had been identified, and there was no time to waste. The coordinators were clear: lifesaving transplants took priority. Pomahač was told to leave Boston within the hour and that, upon arrival, he would be racing the clock. As he scrambled his medical team in Boston, his heart sank. Earlier in the year, he had performed a partial face transplant; on that occasion, the retrieval had taken six hours. Today he guessed he would have not much more than two.

This presented a huge challenge. The retrieval of a donated face is in many ways a task far more complex than the removal of the more familiar solid transplant organs. It must retain form and function, and dozens of decisions must be made regarding what muscle, tissue, and bone to take and how.

Pomahač worked as fast as he could, with the other transplant teams beginning to circle. After two hours, they had no choice but to ask Pomahač to step aside. With the retrieval of the face only partially complete, the removal of the solid organs had to begin. Finally, when the heart-transplant team left with their vital organ in hand, they took with them the blood supply to Pomahač's donor face.

From this moment onward, the face was beginning to die. The team ran cold preservative solutions through its vessels to protect it, but this could buy only so much time. If they were not back at the Brigham with the new face connected to Dallas's circulation in less than four hours, all would be lost. Now the last surgeons left in the operating room, Pomahač's team worked furiously. When they finished, the face had been without a blood supply for over an hour and still had to be transferred by road and air back to the Brigham. It was going to be close.

—

B
ACK IN
B
OSTON,
E
DRICH WAS MAKING
his preparations. The team was assembled, the operating room ready, its microscopes and surgical sets prepared. Dallas, accompanied by his grandfather, was ushered into the operating theater suite. There was no time to lose; the face being brought by Pomahač would be fading. Dusky and starved of oxygen, its tissues were slowly dying. To survive, it needed a new host and a new supply of blood.

Dallas was anesthetized almost as soon as he arrived. Edrich sited drip lines in his veins through which to give fluids and drugs and another line in an artery to monitor the blood pressure directly, with beat-to-beat precision.

By the time Pomahač reached the Brigham hospital, the skin of the donated face was by now a dull thundercloud gray—the color of tissue and blood that has been stripped of its oxygen. It would not be long before it ceased to be viable at all.

Pomahač had to move quickly. He dissected out Dallas's external carotid artery. Having divided it, he pinched the free ends shut with an artery clamp. Then he began the delicate work of connecting that vessel to the face that he had just delivered. Working quickly, Pomahač threw stitch after stitch into place. Having made the connection, he released his arterial clamp. For the first time in nearly four hours, blood ran into the oxygen-starved tissues. The face blushed pink.

—

A
FTER TWENTY-ONE HOURS
of paring back tissue, stemming dangerous hemorrhages, and connecting blood vessels, muscles, and bones, the operation was finally complete. The orchestra of surgeons withdrew, and Edrich's anesthetic team handed the patient over to the intensive-care unit. But Pomahač, despite having been awake for nearly forty-eight hours, wasn't quite ready to go to bed. Once Dallas was settled in the ICU, Pomahač visited his room. After checking his patient's new face, Pomahač told the nurse that he was going to take a shower and change his clothes, but that he would be back to spend the night at Dallas's bedside.

“Dr. Pomahač,” she said with a smile, “I think we can take it from here.”