Quebec man reacts to his new face
While the donor was transferred to Maisonneuve-Rosement Hospital, one of the people Dr. Daniel Borsuk called was Virginie Bachand. A special effects makeup artist who normally works on television and film, he had hired her to create a lifelike silicone mask for the donor.
Borsuk, the doctor overseeing Canada’s first face transplant, didn’t want the donor leaving the operating room without a face.
Bachand had only 24 hours to craft what normally takes her a month. She had spent months practising on her husband’s face, calculating every single minute, searching for techniques to make it faster.
She was 40 weeks pregnant and due to give birth when Borsuk had called to say the transplant was on. She almost fainted.
But she was determined to see it through. “Let me speak to my obstetrician friends here so that if, God forbid, you come in and do the mask and go into labour we can deliver the baby here,” Borsuk told her.
At 6 a.m. the next day, Borsuk and earnose-and-throat surgeon Dr. Tareck Ayad performed a tracheostomy on the donor, and wired his jaws together.
They couldn’t remove the face if it was still attached by a tube in his throat to a ventilator. They made CT scans of his head and sent the images to a team in Michigan to create a virtual surgical plan, allowing the team to practice one last time before surgery.
When Bachand walked into the ICU several hours later, she would have sworn that, if not for the breathing machine and beeping monitors, the donor was sleeping. She remembers thinking how handsome he looked. She made two impressions of his face, gently spreading silicone paste on his skin. She bent down and whispered close to his ear, “I’m sorry. This will feel a bit gluey and sticky.” They told her he was clinically dead, “But I told myself that some part of him heard me, somewhere.”
Bachand took the moulds home to her studio. It was then a race to mix the paints and build the mask — the veins, the capillaries, the translucent skin. Bachand attached real hair. She attached eyelashes. The donor had a light tan when he died, so she gave the skin the same kiss of sun. “He had so much life in his face.”
Meanwhile, Maurice Desjardins, the transplant recipient, had arrived from Gatineau so they could start the immune suppressant drugs.
At 4 a.m. the next morning, Desjardins was ready to be wheeled into the OR. Among the surgical teams was Dr. André Chollet, chief of plastic surgery at the University of Montreal. “Maurice, this is a new beginning,” he told him. “You are starting a new life.”
Desjardins’ wife looked scared. She leaned over the stretcher. “Don’t leave me,” she told her husband. “You are going to get out of this surgery.”
The doctors started on Desjardins. It would take longer to remove his face, to clean things up, because of the multiple reconstructions. They would have to work through thick scar tissue and all the old screws and plates.
The surgeons made the first incision from Desjardins’ lower eyelids, across the bridge of his nose through the temple region, then around his ears and down to the bottom of his neck.
Desjardins has almost no vision left in his right eye; any manipulation around the left eye could have cost him more sight, and Borsuk knew if he could get a perfect colour match there was no need to take off the forehead.
At 11 a.m., the second team gathered in the donor’s operating room. Before a scalpel was lifted, Borsuk gave thanks to the donor and his family, and led the room in a moment’s silence.
The plan was to start with the vessels in the donor’s neck. “We go through skin, we go through muscle to find the veins, the jugular veins and the carotid arteries,” said Chollet. At least one artery and one vein would be needed to keep the face alive.
Next, they followed the arteries to the tree-like branch of nerves that animate the face and activate the muscles that make us smile, talk, eat and drink. As they went, they stimulated the nerves with an electrical current.
The surgeons took turns. Dissecting, then assisting. Dissecting, then assisting. Everyone focused, concentrating on minimizing the bleeding.
They went deeper still, exposing the bone and the facial skeleton: the nose and upper jaw, complete with palate; the lower jaw. They used cutting guides as they went through the bone with saws and blades. The structure of the face is like a pyramid, Chollet explained. It holds onto the base of the skull with pillars, and in between the pillars are thin, bony walls that can break as easily as an eggshell.
It came off as one piece. All the bones of the upper face, the maxilla, the entire mid-face and jaw, with the attached muscles and nerves and tissue beneath.
The room went silent. “There must have been 20, 30 people in the room. And there was dead silence,” Borsuk said.
For plastic surgeon Dr. Dominique Tremblay, for a moment, it didn’t seem real. Plastic surgeons raise free flaps all the time — skin and vessels and fat from a belly. “You’ve never raised a free flap so important and here it is, and it’s an entire face, the bone, the nose, the jaws, the teeth.”
At 12:10 a.m., the final vessels were clamped. Borsuk and Chollet moved to the next room. The donor face was white, its lips blue. Desjardins’ face was set beside it. They took photographs. Two faces without eyes. Old next to new.
Borsuk and Chollet checked Desjardins and made a few final adjustments. Then they laid the donor face over Desjardins’ skull, the nose first, then the cheekbones. They adjusted the plates and screws and, working with special lenses and microsurgical tools, began reattaching the carotid arteries.
At 2 a.m. they removed the clamps from the artery on the right side of his face. His lips and face began pinking up. Blood flow was coming in. The room erupted into applause. Dental surgeon Dr. Jean Poirier moved in to help align the jaws and make sure the teeth fit properly. Surgeons began working to stitch the sensory nerves together. But by now, there was no more need to rush.
The face was alive.
Maurice Desjardins was allowed his first look at his new face two weeks after surgery.
He was eased out of his druginduced coma slowly, softly, like landing a plane, to reduce any agitation or delirium. He was alone in his room with Borsuk, Chollet and Tremblay when Borsuk set a mirror down on the hospital bed.
Desjardins stared at his reflection like a child. He gingerly touched his nose, and his chin. “And then he looked at me and he grabbed me and pulled me in and wouldn’t let go,” Borsuk said. “It was one of the most poignant moments of my life.”
There have been highs and lows since surgeons gave Desjardins a dead man’s face. He is starting to feel some sensation. He is learning to swallow and to chew with someone else’s teeth and mouth. He can raise the hint of a smile on the right side. But he still can’t close his lips.
“I have high hopes he’ll be able to close his lips together,” Borsuk said. “It’s a question of time. We can’t rush these things. But does he like his face? Oh my god, he loves it. Yeah, he’s enjoying his face right now.”
At 65, Desjardins is the oldest recipient of a face transplant. He doesn’t look the way he did before the bullet nearly obliterated the lower half of his face, or the donor, but like a different man, a blend, a melding of the two. He wears a goatee now, his donor’s beard, the grey streaks and flecks of brown an uncanny match to his own eyebrows. The beard started growing the day after the transplant. Borsuk shaved his cheeks while Desjardins was still in deep anesthesia in the ICU.
Desjardins’ operation is the 41st face transplant performed since 2005, the year doctors in France gave Isabelle Dinoire a partial new face. She had swallowed an overdose of sleeping pills, and when she didn’t wake her pet Labrador frantically clawed and scratched her, mauling her nose, lips and chin. She was given the face of a woman who died by suicide, and when her before-and-after photos were released by the hospital they provoked equal parts fascination and repulsion. Bioethicists flew into a moral panic.
Since then, transplants have taken place in Turkey, China, Spain, Belgium and Poland. In the U.S., the “miraculous” surgeries have been performed on a Vermont woman whose husband doused her with industrial strength lye, a Mississippi firefighter whose respiratory mask melted into his face when a burning ceiling collapsed on him, a Connecticut woman mauled by her friend’s pet chimpanzee. The September issue of National Geographic chronicles the youngest recipient of a face transplant, 21-year-old Katie Stubblefield.
Face transplants cost an estimated $350,000 U.S., not counting the cost of a lifetime supply of anti-rejection drugs or follow-up revisions. That’s equal to about half a dozen reconstructions, surgeries that can leave faces patched together like quilts, with grafts and flaps of skin that often end up looking distorted or immobile. It is complex, radical surgery, and the consequences, if things go wrong, are horrific: Death in about 16 per cent of cases, or if the vessels clot, the loss of the entire graft, leaving the patient worse off than before, with no face, no bone. Just an open cavity.
Even successful surgeries come with serious trade-offs. The toxic anti-rejection drugs needed to pound down the immune system and keep the transplant from being rejected increase the risk of cancers, infections, diabetes, and kidney disease. Dinoire, who died of cancer in 2016, began rejecting her face ten years after surgery, and lost partial use of her lips. Richard Norris has had three bouts of acute rejection. He’s on dialysis for chronic kidney failure and is on a waiting list for a new kidney.
For the severely disfigured, the goal is to have not just a new face, but a functioning face. A face that allows them to breathe properly, to blink, to smell, to drink from a cup. A face that’s unremarkable. “We are bringing them to a certain normality so that others can accept them,” says French surgeon Dr. Laurent Lantieri.
Organ donation is anonymous in this country. But the family of Desjardins’ donor will know who wears his face when the story becomes public, because it’s the first face transplant here, and the only one.
It is also, according to Lantieri, who has known Borsuk since he was a young fellow in Baltimore, among the best.
An hour before wheeling his patient into the operating room, Borsuk called his French men- tor: “He asked if I had any advice to give him,” Lantieri said. “I told him, ‘You’re trained. You know how to do it. Just climb the mountain. I know you can do it.’ And he did an awesome job. It’s perfect. What can I say? I think he had the perfect transplant.”
Today, you can still make out the incision that runs across Desjardins’ face, just beneath his lower eyelids, and down around his neck. His lips are still paralyzed and his face still feels mostly frozen, as if he’s just come from the dentist. He can’t close his mouth, and so he has a surprised look, as if he still can’t quite believe his physical transformation. His gunshot accident had left a wide-open wound in the middle of his face. It’s astonishing he didn’t die. Borsuk said he doesn’t know the circumstances surrounding the accident. “The story wasn’t very clear. He hunts a lot. To this day, I still don’t know, exactly.”
When he saw his new face for the first time, Desjardins thought he was looking at a picture of another man. “I didn’t think it was mine,” he told me through his wife. His tongue has atrophied. He hasn’t used it properly in seven years, so it’s smaller than yours or mine, because we don’t stop talking. With time, it’s going to regain volume. He’ll be able to swallow again, to speak.
Desjardins was not at the press conference announcing the transplant. Borsuk said he wants to protect his patient as much as he can. He sees Desjardins at the plastic surgery clinic at Maisonneuve-Rosemont every week. They’re checking his face for signs of rejection, taking tiny biopsies from his neck.
When I first met Borsuk at his clinic, he told me Desjardins had just left and that I almost certainly passed him in the waiting room but didn’t notice anything unusual about the man.
When I finally met Desjardins last week at Maisonneuve-Rosemont, it was picture day. They were preparing him for the “after” photos. Plastic surgery resident Dr. Gabriel Beauchemin carefully trimmed Desjardins’ goatee with an electric shaver. Desjardins breathed through his mouth. When Chollet entered the room, he and Desjardins embraced. “Smile,” Chollet said. “Close your mouth,” he said, gently pushing up on Desjardins’ chin.
As he left the examination room, Desjardins walked slowly into the outer waiting room. He turned to look for his wife, who was waiting to take him to the photographer.
People bustled around him. But there were no looks. No stares.
He was just another face in the crowd.
Then he looked at me and he grabbed me and pulled me in and wouldn’t let go. It was one of the most poignant moments of my life. — Dr. Daniel Borsuk
Dr. Daniel Borsuk discusses the face transplant surgery at Maisonneuve-Rosemont Hospital in Montreal on Wednesday.
Dr. Daniel Borsuk and Maurice Desjardins, two weeks after surgery.