Que­bec man re­acts to his new face

Calgary Herald - - FRONT PAGE - Mau­rice Des­jardins’ face was dis­fig­ured in a gun­shot ac­ci­dent. A Mon­treal doc­tor helped give him a new one. In the sec­ond part of the exclusive story of Canada’s first face trans­plant, the surgery and its af­ter­math. Sharon KirKey

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

GRAHAM HUGHES / THE CANADIAN PRESS

Dr. Daniel Bor­suk dis­cusses the face trans­plant surgery at Maison­neuve-Rose­mont Hospi­tal in Mon­treal on Wed­nes­day.

GRAHAM HUGHES / THE CANADIAN PRESS

COURTESY CIUSSS EMTL

Dr. Daniel Bor­suk and Mau­rice Des­jardins, two weeks af­ter surgery.

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