In November 2005, a group of French doctors shocked the world. In a dramatic news conference, they announced that they had successfully completed an operation that sounds like something one would read about in a sci-fi novel: transplanting a face belonging to a dead donor onto a living recipient. Its as if I was reborn, said the then-28-year-old recipient, Isabelle Dinoire. I am now capable of walking around among people without hiding or feeling embarrassed. I can walk about on the streets. Im free. Nearly seven years have gone by since, and just 21 face transplants have been performed, most of them in France and the United States. The last operation was done two months ago in Maryland. Despite the advances in science and technology, the process by which doctors remove the face of a person deemed brain dead and attach it to another person is considered to be the longest, most complex procedure in medicine. It can take anywhere between 24 and 36 hours. Nonetheless, Israel will soon join the exclusive club of countries where face transplants are performed. Over the course of the last few months, two of Israels most renowned surgeons have been preparing to perform the operation. Dr. Eyal Gur, director of the Plastic Surgery Department at the Tel Aviv Sourasky Medical Center (commonly known as Ichilov hospital), and Dr. Arik Zaretsky, who heads the Micro-Surgery Division of the Plastic Surgery Department, will be aided by an extensive staff of dozens of doctors and nurses who will bear an assortment of logistical and medical responsibilities. The operation will be the most extensive medical venture ever undertaken in an Israeli hospital for the sake of one patient. The preparations include procuring the necessary permits from the hospitals ethics board as well as increasing cooperation with the Health Ministry and the National Transplant Center. We have an organizational, medical, and ethical responsibility, said Dr. Gur, who is helming the project. This is a task that requires preparation on the scale of a military operation. We can already sense the tension and the excitement that is beginning to mount in the division and in the entire hospital. The candidate who will receive the new face has yet to be selected, but two of the finalists are children. If one of them is chosen, then the Israeli medical team will not just establish a national precedent, but a global one. It will be the first ever facial transplant performed on a child. The people being considered are holed up and isolated in their homes, Gur said. They do not allow themselves to go outside because of their appearance. I hope that we can help them change their lives dramatically with the help of another person whose life came to an end and whose family was generous and courageous enough to donate his organs for the sake of rescuing another human being. Last week, this reporter was granted exclusive permission to accompanying Gur and Zaretsky while they attended a special continuing medical education seminar devoted exclusively to facial transplants. The event was held at the University of Pennsylvania in Philadelphia. The doctors who came to the seminar watched simulations of facial transplants performed by some of the brightest minds in orthopedics and plastic surgery. The group, which was headed by L. Scott Levin, a physician at the University of Pennsylvania who is widely considered one of the top doctors in the U.S., includes surgeons who have already performed facial and hand transplants. Indeed, this reporter was the only member of the media in the world to be in the room during a facial transplant. Burns, bites, and wars The scene in the classrooms was quite macabre. The heads of 10 dead people and 10 arms were laid on operating tables. Each table was surrounded by a group of between four and five surgeons. Above the tables hung a video screen that showed images of the operation performed by the head surgeon. Levin, who was unquestionably the impetus behind this extraordinary gathering, made the rounds to each table, reminding the participants that they were a part of history. You are the new pioneers of the medical world, he told the 24 expert surgeons who had come to Pennsylvania from numerous countries, including France, Germany, Sweden, Spain, Italy, Canada, the U.S., Brazil, Colombia, and China. There were even doctors from Saudi Arabia. One can liken this group to the Sayeret Matkal, the elite IDF reconnaissance unit, of medicine. The bulk of instructions were given by two doctors who have thus far performed over half of the facial transplants since the procedure was introduced to the world. Professor Laurent Lantieri, who oversaw seven such operations in France (and who holds the world record for performing the most facial transplants), and Dr. Bohdan Pomahac of Brigham and Womens Hospital in Boston. Pomohac has performed six facial transplants. These two men introduced the seminar participants to new techniques and sophisticated methods that are designed to help doctors carry out the procedure. It is considered one of the most complex, difficult operations to undertake since the organ being transplanted the face contains a unique combination of tissue that cannot be found anywhere else in the body. They include layers of skin, fat, muscle, and bones. The tremendous complexity of this surgery is compounded by the difficulty in removing the face from the donor and affixing it onto the recipient. This process is followed by a long, grueling recovery and rehabilitation phase from a physical, psychological, and social standpoint. This explains why facial transplants are intended for those whose appearances have been disfigured severely and irreparably to the point where there is no other option but rehabilitation via replacing the face with that of a donor. It is believed that there are dozens, perhaps hundreds, of potential transplant patients in every country on the globe, including victims of war and terrorism, victims of shooting accidents, burn victims, or those who have been mauled. According to the Pentagon, there are 200 U.S. soldiers who suffered wounds during combat in Iraq and Afghanistan who could potentially qualify for facial transplants. Medical officials in Israel estimate that there are dozens of candidates here who could be in line for new faces after theirs were disfigured. Dissimilar appearance The need for facial transplants is not cosmetic in the medical sense of the word. Potential recipients are usually ensconced in a state of deep social isolation. In most instances, they are almost incapable of having any type of social or interpersonal interaction with others. Often times, their situations are so dire that their family members and loved ones cannot stand to look them in the face. At the seminar, Pomahac recalled one case where a patient instructed his family to prevent his daughter from coming near him out of fear that she may be traumatized by his disfigured appearance. Damage to facial tissue prevents one from making facial expressions, which is one of the most fundamental tools used in human interaction. In years past, it was acceptable to think that organ transplants were something that needed to be done solely for the purpose of saving lives, said Prof. Abraham Shaked, an Israeli expatriate and a top surgeon who currently serves as the director of the Penn Transplant Institute. But after I met a number of patients who were in line to undergo the procedure, I reached the conclusion that facial transplants could save the patients quality of life, because society doesnt accept the patient in his or her current state. We have seen significant improvement in controlling the bodys tendency to reject transplanted organs, with excellent long-term results. The results of facial transplants that have already been performed indicate that the newly attached faces function quite well. They enable the recipient to make facial expressions and to communicate more effectively with others. The recipient is given a more humane, palatable look, even if it still somewhat unconventional. The face that the recipient gets looks different that the face before it was disfigured, since the tissue and skin provided by the donor is not identical. While the tissue and skin is attached to the bone structure that remains in place, the appearance is that of another person. Children ran away from her The best social indicator of the success spawned by facial transplants can be found in a 2010 study conducted in the U.S. As part of the study, a hidden camera recorded the reactions of passersby who walked alongside a person before and after he underwent a facial transplant. Before the operation, people who were waiting in line with the subject could be seen moving away as if they were repelled by him. The reaction to the patient after the surgery showed that the responses were completely normative. In last weeks seminar, Pomahac movingly told of how one of his patients reacted when his daughter was no longer afraid to come closer to him. In her first appearance after undergoing the operation, the first transplant recipient, Dinoire, said that she felt free to wander around without being limited by any unpleasant feelings. Ive resumed feeling things after the difficult trauma that I endured, she said. Dinoire was not given a full facial transplant. Her operation focused on the nose, lips, and chin. In 2006, a partial face transplant, which included work on one cheek, the upper lip, and the nose, was performed in China on a young man whose face was deformed by injuries he sustained from a bear attack during a hunting trip. In December 2008, the most comprehensive facial transplant was performed to that date. A patient in the United States had 80 percent of her face replaced. The patient endured humiliation and was verbally abused, said the Cleveland doctor who did the operation. Children ran away from her because of the damaged appearance of her face. Before the surgery, the woman was subjected to psychological testing, during which she was asked how she would feel if she would need to live with the face of a dead person. She was not permitted to see any pictures of the donor, since doctors did not want to mislead her into thinking that she would take on the identical appearance of another individual. In July 2010, we were introduced to the first person to ever undergo a full, facial transplant. Oscar, a 31-year-old man whose last name was not disclosed, was treated by Lantieri. Within two months of the operation, Oscar needed serious medical treatment after two instances in which his body rejected the transplanted face. Still, he was able to move some facial muscles and he resumed speaking. He also began growing facial hair just a week after the surgery, which was interpreted as a good sign that his body would accept the organ. He desperately wants to enjoy the little things in life, like walking down the street without people giving him odd looks and stares, Oscars sister said during the news conference that was held after his surgery. This past February, Turkey also welcomed its first recipient of a donated face, Ugur Acar, a 19-year-old who had suffered serious burns in a fire that broke out in his home when he was a baby. He reportedly received the face from a donor who was killed by an oncoming train. In late March, there were reports that the most extensive facial transplant surgery to date had been performed in Maryland. The recipient was Richard Norris, a 37-year-old American whose face was disfigured 15 years ago by an errant bullet. The accident made it difficult for him to perform basic functions like speaking and eating. More than 100 doctors took part in the operation, and they were assisted by dozens of other staff members. Norris donor remained anonymous. His transplant included new scalp tissue, a tongue, a jaw, and teeth. He would walk around with a mask because everybody looked away from his disfigured face, said the chief surgeon, Dr. Eduardo Rodriguez. Now they have a new reason to stare at him, but this time the reason in an amazing one. The preparations Facial transplants entail a unique set of challenges that doctors do not have to wrestle with when it comes to other organ transplants. These procedures are similar to heart, liver, kidney, lung, bone, heart valve, and cornea transplants in that they require a donor whose has already been declared clinically brain dead and whose family has given its consent. However, in the preliminary stage, both the donor and the recipient need to undergo simultaneous operations: The donor must have his face removed, while the recipient needs to have preparatory surgery to accept the organ. These two procedures require massive medical staffs, and each operation can last anywhere between four and eight hours. There are also sensitive and complex aspects of this change that need to be dealt with aside from the actual physical dimension. The patient and the family are provided with psychological counseling in order to prepare the groundwork for the change in the recipients appearance. Face and hand transplants require that the donor and recipient be a match in terms of blood type. There are also cosmetic traits that need to correspond, such as skin complexion. Ostensibly the face of a white man would not be transplanted onto the body of a black man. Unlike the transplant of internal organs like the heart and the liver, facial transplants require the donor and recipient to be of the same gender. This is necessary so that a woman who had received a new face would be spared the embarrassment of having facial hair grow on her. The doctors also make sure to address the issue of the donors appearance, since it is customary to pay last respects to the dead with an open coffin memorial service. Surgeons devised a special procedure whereby they install a new face that is made of silicon and algae. The goal of the operation is to create an exact replica of the facial outlines so that it would look as complete as possible. In some instances, the doctors did not make do with preparing the mask. They also made sure to have artists who specialize in applying makeup on dead bodies do work on the donors. Lantier says that preparing the mask is a critical stage in the process, since in all cultures and religions, the face is a very significant part of the process of identifying the body and of the burial. Pomohac views things differently. He said that his staff does not attach great importance to the issue, and as such they use masks that were prepared ahead of time. Removing the donors face After the mask is prepped, doctors surgically remove the donors face. Surgeons remove layers of skin, fat, and muscle from the important sections of the face that are necessary for the transplant. They also remove part of the bone, usually from the bone in between the eyes. Doctors also remove a piece of skin from the neck area in order to allow for proper closure of the incised areas in case of excessive swelling. The extent of the removal from the donor depends on the extent of the recipients disfigurement. According to doctors who took part in the seminar, it is possible to remove facial muscles, lips, mucous membrane, the tongue, the muscles surrounding the mouth and the eyes, the eyelids, the nose, ears, the scalp, and even parts of the facial bone structure, including the upper and lower chins and, if necessary, teeth. Eyeballs are not replaced, so the color of the recipients eye is unaffected. During the seminar, the surgeons practiced the full, complete removal of the donors face. This is the most complicated procedure, one that has only been performed a select number of times. In Pennsylvania, I watched as doctors held the face of a human being in their hands, an unusual, rare sight. Once unattached to a body, human faces suddenly look like masks unto themselves. These faces were then sewed onto the head of another human being. After the facial removal, the face is brought into the operating room where the recipient awaits. Like other organs, the transplanted face is first put into a container where it is preserved by a special chemical solution. Removing the damaged skin from the recipient While surgeons remove the donor's face, another team of doctors works on shedding the skin from the disfigured face of the recipient. In some instances, skin is removed from the entire surface of the face. One of the most critical things in face transplant surgery is timing, said Dr. Zaretsky. This is part of the complexity of this surgery. Removing the donors face needs to be done while the heart is still beating and blood is being pumped to the face, and we want to minimize as much as possible the amount of time that the face is cut off from blood circulation. For this to happen, we need to prepare the recipient and to expose the area in which we want to attach the new face as well as the blood vessels in the neck. Only when the recipient is ready in terms of his blood vessels do we remove the face from the donor. The preparatory operation of the recipient just before the attachment of the face is considered especially complex, particularly since the faces of the recipients are usually quite disfigured. This stage alone can take between five and six hours. The transplant Upon the completion of both preparatory operations, doctors enter the critical stage, which is the longest and most challenging: the transplant of the face that was taken from the donor and attaching it to the recipient. This phase demands that doctors employ the highest level of surgical skills known to modern medicine, since the transplant process entails a slow, painstaking effort to match up blood vessels and nerves. To minimize the amount of time that facial tissue is deprived of blood flow, the first stage of attaching the face is the micro-surgical introduction of blood vessels, which is done with the aid of a surgical microscope. It entails connecting a blood vessel or two individual veins in the neck region. From there, doctors then concentrate on connecting sensory nerves in the lower and upper jaw, connecting motor nerves that will act as facial muscles, connecting nerves inside the nose, sewing eyelids and the mechanisms for opening and closing the eyes, sewing facial muscles, and, finally, sealing up the skin. Even after the face is successfully transplanted onto the recipient, the medical process is not over. The rehabilitation period is long and exhausting, and it entails further medical treatments. Like other organs, the recipient of a facial transplant will also receive doses of medication that will combat the bodys rejection of the organ. These medicines weaken the immune system and leave the patient exposed to illnesses. In practice, the human body never grows fully accustomed to a transplanted organ. Without medication, the transplanted organ ceases to function, which necessitates its removal. The assimilation of a complex organ like the face or hands is a much more complicated process than the acceptance of other organs. Those who do receive new faces must be closely monitored. Nonetheless, there has only been one instance in which a recipient of a face transplant died after the operation. In 2009, a French patient died after falling ill to bacterial infection. This was a month after he successfully underwent an operation that combined a face and hands transplant. Returning a smile to his face The two doctors from Ichilov, Gur and Zaretsky, have amassed the most experience in facial reconstruction surgeries that were performed on victims of road accidents and illnesses. Other doctors in the plastic surgery department as well as other divisions in the hospital took part in a number of reconstructive surgeries in recent years, including those with head and neck injuries. They utilized self tissue in these procedures, which are quite complex and which require a number of experts from various fields. Surgeons perform a number of intricate operations whose goal is to restore patients abilities to make facial expressions after having suffered paralysis of facial nerves. The end result is that the patient is completely regains the ability to make facial expressions and to smile. These complex surgeries are done by experts in numerous fields. These include neurosurgeons who specialize in head trauma, orthodontists, jaw experts, ear, nose, and throat specialists, anesthesiologists, and eye specialists. The operations are performed with microsurgery techniques, which are the only method capable of connecting blood vessels that measure no more than two millimeters. Doctors are capable of gently separating blood vessels that traverse the muscles. This is a delicate process that prevents extensive and unnecessary damage in the area from where transplanted tissue is taken. According to hospital statistics measuring data since 2002, doctors have performed 1,000 microsurgeries to revive organs in the body. Of those, 600 were done to correct head and neck injuries, with 95 percent of the surgeries resulting in the successful absorption of transplanted tissue. The 3-year-old candidate The medical staff headed by Gur and Zaretsky, including top micro-surgeon Dr. Ravit Yanko and deputy director of the Plastic Surgery Department, Dr. David Leshem, will perform the facial surgery at Ichilov the first such operation to ever be performed in Israel. The preparations for this groundbreaking operation are in full swing, and they are now concentrated on finding suitable candidates. Israel Hayom has learned that one of the candidates is a 3-year-old girl from southern Israel who suffered from serious burns to her face. Her injuries left her deprived of eyes, a scalp, lips, and a nose. Her doctors in Israel believe that there is no other way to treat her except for a face transplant. During the seminar in Philadelphia, the doctors from Ichilov showed Pomahac a picture of the girl. The doctor told the Israelis that there is no doubt the girl is in need of the operation. A face transplant can only be made possible if the donor is a girl of the same age who is clinically brain dead and whose organs were donated. According to the Israeli doctors at the seminar, a face that is transplanted onto a young girl will grow like it normally would on the donor. In recent months we have begun the search for suitable candidates, Gur said. We have already made initial contact with the families of two children who are in need of face transplants. The preparatory stage for both the recipient and the families is long and complex, and that is before we have begun dealing with the technical aspects. It includes a psychological assessment of the prospective patients ability to deal with the possibility that the operation will fail, to deal with the change in appearances and the way in which they perceive themselves and in the way in which the family will perceive the recipient, who has just received a new face from a dead person. At the same time, there is the ethical, medical, and moral dilemma of whether facial transplants should be performed on children, especially the first such operation in Israel. The rehabilitation process is not foreign to Gur, who was seriously wounded during the First Lebanon War from Syrian anti-tank fire. Gur served as an officer in the elite Sayeret Shaldag unit. As a result of his wound, his leg was amputated, and he was forced to undergo a grueling rehabilitation process. Today he is fully functional, and he has gained a reputation as one of the foremost experts in plastic surgery, with a special emphasis on facial reconstruction. The wound contributed greatly to me, and it really made me understand the patient and the disabled while enabling me to establish a more meaningful connection with them, he said. After returning from the special seminar in the U.S., Gur is convinced of his abilities and that of his staff to successfully perform such a complex operation, which has only been done on a few instances. Obviously this is something that we need in Israel, and if we need it, then it would be proper for us to do it, he said. There will be those who are suspicious of the doctors motives and their egos, but what drives us is the hope that we will be able to contribute to a dramatic change in the lives of one person and their family. I am leading a team of doctors that is akin to an elite unit, a rescue unit, a commando unit of the most talented people in the country from a surgical standpoint as well as from a planning and thinking standpoint, he said. This group has an exceptional ability to improvise, which is needed in these fields, and there are exceptional interpersonal ties and relationships. Its isnt just the virtuoso capability of each and every one of these people, but the power of this entire team, and it is what guides us to plan the first facial transplant in Israel. Israel's National Transplant Center is planning a public relations campaign about facial transplants, both to ask for donors in the event a person has been declared brain dead and to clarify to the general public the needs both medical and social of potential recipients. In addition, Ichilov's management on Thursday asked to clarify that "the [facial transplant] project is still in the initial stages of preparation. The hospital's management has not yet discussed this issue, nor has it yet authorized such a procedure."
