A MEDICAL FIRST FOR CANADA
Quebec man gets face transplant
It took 12 hours to remove the face, four surgeons working from early morning into the night, cutting through skin, muscle, blood vessels, nerves and bones, until it was lifted from the man’s skull.
It was a beautiful face. The flesh smooth and plump, the mouth and lips generous and full. It was still attached by two arteries and three veins to the donor’s neck. His heart was still beating strong, his body warm to the touch. His skin flushed pink with blood.
But when the surgeons cut and clamped the last five vessels, freeing the face entirely from the brain-dead organ donor’s body, it instantly began to turn white as his life drained from it.
Dr. Daniel Borsuk cradled the face in his cupped palms, carefully washed away the blood and injected the arteries and veins with a preservation fluid. Without a blood supply it would survive only two to three hours.
In the next room, Maurice Desjardins was almost ready. His old face, the mutilated one, was gone, disassembled over 17 hours by a second team of surgeons. Only his eyes, upper eyelids and forehead remained.
Seven years ago, a bullet from a hunting rifle destroyed Desjardins’ nose, lips, teeth and upper and lower jaws. Surgeons had tried rebuilding his shattered face over the years, using plates and screws and bone chiselled from his fibula. But he was still left with two holes where his nose used to be and a mangled and puckered mouth that he couldn’t close, which meant he couldn’t eat properly and drooled constantly. He breathed through a hole in his windpipe. He was in chronic pain from the rigid scar tissue and the loose, disconnected nerves floating in his skin.
On the rare occasions Desjardins left his rural home outside Gatineau, Que., he wore surgical masks. He lost his roofing business. He had lost his former self by the time he was sent to Borsuk, a plastic surgeon in Montreal adoring patients refer to as “un magicien du visage.” The doctor told him he had only one real option left, something never before attempted in Canada: a face transplant.
The stakes were incredibly high. There was a chance Desjardins, then 64, could die from blood loss on the operating room table, or from his body’s rejection of the new face afterwards. There was a significant chance he could end up with a lethal cancer because of the drugs he would need to take for the rest of his life to keep his body from rejecting another man’s face. But it was a possibility, a coin toss — an opportunity at a second chance in life. When Borsuk informed Desjardins and his wife that he was willing to try, if they were, the couple wept.
It took five years of planning, nine surgeons, five anesthesiologists and more than 100 other medical, nursing, support and technical staff. But last spring when Borsuk finally carried the donor’s face to that second operating room and placed it over Desjardins’ skull, it snapped into place perfectly, like a puzzle piece.
Desperate people find Borsuk. At 40, the Montreal native is a skilled surgeon known by his older mentors as a boy wonder. He’s a perfectionist, with zero tolerance for incompetence, but a leader who can bring people together and make magical things happen. Borsuk has always been drawn to the face — its beauty, its structure, “the whole window-to-thesoul thing.” The way it’s tied to our identity, our personality. His own face is handsome, his stubble beard neatly trimmed, that perfect, signature 5 o’clock shadow look.
Borsuk experienced an almost religious calling to plastic surgery. He was a first year MBA student at McGill University when Dr. Chen Lee, the then newly appointed head of plastic surgery, called the business school. Lee was looking for volunteers to help find the delays, the bottlenecks to rapid care for people who needed accidentally amputated body parts reattached.
One day Lee called Borsuk. “Dan, come to the operating room,’” he told him. A 14-year-old had amputated his arm in a wood chipper. Lee wanted the young business student to see what microsurgical replant surgery could do. Borsuk arrived at the Montreal General in his suit and tie. He was taken into the operating room, “and there’s an arm and a kid and it’s the most incredible thing. I was standing there in shock. I didn’t realize you could literally attach an arm and the nerves and the tendons. It was so complex and wild. It was like Star Wars.”
“This is what I want to do,” he thought. “I want to do this.”
What he does today are heavy, complex cases — children born with neurofibromatosis, or socalled “elephant man” disease, kids and adults with malformed jaws, orbits and skulls. Children with cancers or burns, or lips and cheeks sheered off by pit bulls. Adults with faces pulverized by bullets. One of those faces belonged to Richard Norris, who, in March 2012, underwent what was then the most extensive human face transplant ever at the University of Maryland. In 1997, Norris had shot himself in the face when, after an argument with his mother, he cocked the barrel of a rifle under his chin. He said he didn’t know it was loaded. Borsuk, a fellow in Baltimore at the time and the only Canadian on the surgical team, helped cut away Norris’ mangled mask of scar tissue and prepare him for the face of a 21-year-old brain-dead organ donor named Joshua.
Four months later, Borsuk returned home to Montreal, where he was named head of plastic surgery at Sainte Justine. He divides his time between the children’s hospital and Maisonneuve-Rosemont, both University of Montreal teaching hospitals. Borsuk started building a practice, but the university was interested in building something more: Its own program for vascularized composite allo-transplantation — transplants that involve not just a single organ, but muscle, nerves, bone and skin. Transplants like hands and arms. Transplants like faces.
In the United States, the military has supplied millions of dollars in grants to surgical masterminds with the goal of helping Iraq and Afghanistan combat veterans with faces demolished by crude homemade bombs. In Canada, no one was handing out that kind of money. To help offset the cost, to make face transplants more palatable to the public, Borsuk started looking for outside support.
He approached Johnson & Johnson, whose drill bits and plates and saws he used in his cranio-facial surgeries. “What if, hypothetically speaking, I was to try to do a face transplant in Canada? Would it be something you guys would want to help fund?” he asked them. Through a generous product grant, the company provided enough instruments, implants and wound closure products to fill two floor-toceiling OR cabinets.
“Once I had that, I approached the hospital, saying, ‘I’m coming already with some support,’” Borsuk said. “I didn’t want to take surgery away from someone who needs cancer surgery; I wanted to know I was not taxing the system.”
He then approached Transplant Quebec. Their approval was essential. “I’m going to tell you a little about myself and I’m going to show you some patients that I really have no options for,” Borsuk told them.
One of the photos was of Desjardins.
Borsuk ran through the case: Gunshot injury to the face. Permanent tracheostomy. No sense of smell through what was left of the nose. Tongue buried behind scar tissue. When Borsuk first met Desjardins and asked, “If I were a magician and could do anything in the world for you, what would you want?” Desjardins said he just wanted to lead a normal life. He wanted to walk outside with his granddaughter without hiding behind a mask. But he didn’t want any more painful reconstructions. His leg and heel still ached where surgeons pulled bone the last time they tried to build him a new mandible.
Borsuk told Transplant Quebec about his experience in Baltimore: He said he wanted Montreal — the first Canadian centre to perform a successful kidney transplant between identical twin sisters in 1958, the first place in Canada to perform a human heart transplant in 1968, the first in Canada to do a liver transplant — to be the first to give a man a new face.
“Clearly we were open to it. But we were very cautious,” said Louis Beaulieu, chief executive officer of Transplant Quebec. “We were concerned about the logistics, about the donor family, the ethics and how society would receive it. Because the face is bound to identity.”
Beaulieu also needed reassurance that Borsuk wouldn’t risk other organs while taking the face. Borsuk agreed that if the donor’s blood pressure began to plummet, if they began losing him in any way, he would stop until the other organs could be taken.
Transplant Quebec secured the necessary ethical and legal approval. Donor coordinators decided they should only approach families if they had already consented to give a loved one’s kidney, liver or other critical organ: You are so generous. There also happens to be this research protocol where we are doing a face transplant. Special legal consent forms were drawn up that state, in part, that the family member has “no knowledge of any hesitancy on the donor’s part concerning the donation I am about to make on his/her behalf.”
Borsuk started assembling his team: plastic surgeons, ear-noseand-throat specialists, anesthesiologists, kidney experts, microbiologists, physiotherapists and nurses. “I knew who my people would be.”
Desjardins was also sent to a psychiatrist. Borsuk insisted he spend at least a year in therapy to make certain he was sufficiently mentally prepared to handle what was coming — the risk of the face transplant failing, the risk of rejection, the media attention, the reaction of family and friends. Since kidney transplants were first performed in the 1960s, psychiatrists have warned about the psychosomatic challenges of integrating a new organ: Is it mine? Hers? Ours? How would patients’ body image adjust?
Dr. Hélène St. Jacques has worked with people receiving new organs. A face — not an invisible internal body part — adds an entirely new emotional dimension. When Borsuk first approached her about Desjardins, she wondered: “Am I the right person?”
“He was severely disfigured,” St. Jacques said. “He had to wipe his mouth constantly when he was speaking, and he was difficult to understand.”
“We had to discuss — and it was very theoretical — the potential identity change,” she said. “But he was a mature person who gave a very frank account of what happened. And he was very, very isolated. He lives in a very small village. People would stare. They would make comments. Adults. Something you teach children not to do.”
“Maurice said, ‘I have nothing to lose.’”
Over the next year, doctors tested Desjardins for any hint of disease that could derail the transplant — cancer, a heart murmur, the tiniest lesion in his lungs. “Every test comes back that this guy is in phenomenal shape,” Borsuk said. “There is nothing.”
Borsuk and his team of surgeons began rehearsing in the basement cadaver lab. They propped the cadaver heads up on steel tables and separated into two teams — one for the donor, the other the recipient — and practised, over and over: Should they get rid of this gland, or keep it? Is it easier to find the nerve that way, or harder? They worked through every possible manoeuvre and complication and mapped out their results. The day of the transplant, their notes filled white billboards in the operating room.
That day came two years after they started practising in earnest, and two weeks after their last runthrough on the cadavers. One morning last May, Borsuk’s cellphone rang. Bernard Tremblay, an organ donor coordinator with Transplant Quebec, was on the other end. He was calling from a small nearby hospital.
There was a brain-dead man in the ICU whose family had consented to donate his organs. A white male, the same blood group as Desjardins, good teeth, no scars on the head or neck, no signs of previous trauma to the head or neck and who seemed to have similar colourization.
Borsuk’s heart skipped a beat. “What are you saying?” he asked Tremblay. “I think you should come and evaluate the patient,” Tremblay told him.
The treating doctor agreed to let Borsuk into the ICU as long as he avoided any contact with the donor’s family. Borsuk arrived 15 minutes later. He had a digital scale in his pocket and 3D moulds of Desjardins’ face. He scanned the donor’s skin to make sure the tones matched. He laid the moulds over his face to check the height, width and projection of the donor’s facial skeleton.
“Everything is fitting, like it’s Maurice.”
The visit lasted three minutes. Borsuk left the ICU and called Tremblay. “It’s a perfect match,” he said. Tremblay said he would approach the family. He didn’t try to oversell the transplant. He didn’t push anyone’s agenda. He remained neutral. “I meet these families at the worst time in their lives,” he said. “They’ve just lost somebody and I will never have the time to fully know them. I want what they want.”
Tremblay explained the research protocol. He explained the process. The family told him that if it meant potentially helping someone else they were willing to let them take the face, too.
Tremblay left the room and called Borsuk. “We have consent.”
Borsuk summoned his team.
See PART TWO of Canada’s first face transplant in tomorrow’s paper
He was very, very isolated. He lives in a very small village. People would stare. They would make comments. Adults. Something you teach children not to do. — Dr. Hélène St. Jacques