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From Brigham surgeons, the gift of a new face

Partial transplant operation, which took 17 hours, is the first in Boston and just the second in nation

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By Kay Lazar
Globe Staff / April 11, 2009

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Sometime in the next couple of days, the man who just became the nation's second face-transplant recipient will wake up and see his new face. When he does, odds are that he will recognize himself, the surgeon who performed the delicate operation at Brigham and Women's Hospital said yesterday.

There is a 60 percent chance that he will look much as he did before he was disfigured, said Dr. Bohdan Pomahac, leader of the 35-member medical team that on Thursday performed the partial face transplant, New England's first. The man's new face will not resemble the donor's because his underlying bone structure is different, said the surgeon.

"He's still waking up. He's not seen himself yet," said Pomahac at an afternoon press conference - a day after the 17-hour operation in which doctors replaced the man's nose, roof of his mouth, upper lip, facial skin, muscles and the nerves that power them.

Hospital officials released no further details about the recipient other than that he is a US citizen. He remains anonymous at his request.

The only information about the donor came from a state ment issued by his family, which suggested that the donor had previously received some kind of transplant. It read, in part, "To go from being a recipient family to a donor family so suddenly has given us the opportunity to fully understand the power of organ transplants to give and transform lives. The fact that we were able to give this gift was a tremendous comfort in our time of grief."

No further details about the circumstances of the donor's death, or identity, were available. The face tissue used in the surgery was obtained through the New England Organ Bank after conversations with the donor's family, hospital officials said.

The recipient received two years of counseling and intense briefings to make sure he understood the risks in such a complex surgery, including the possibility his body will reject the transplant, officials said. He will continue to see a psychiatrist for sometime, Pomahac added.

By yesterday afternoon, the patient had already passed the first critical 24 hours, when clotting may endanger the sensitive nerve and circulatory connections, Pomahac said. For the next week, the danger of infection looms.

For Pomahac, a self-described "procedure-oriented" surgeon, the methodical was replaced by something closer to the emotional as the surgery progressed. He watched the newly connected veins fill with blood, turning the chalk-white transplanted tissue a healthy pink.

"It's surreal," Pomahac said in an interview after the news conference.

That was seven hours into Thursday's 17-hour painstaking surgery, which required two operating rooms - one to remove the tissue from the donor, the other to attach it to the recipient.

One of the trickiest parts of the surgery, he said, was reconnecting the nerves inside the patient's mouth. His injury had left him with no sensation or feeling, making it hard to even eat.

"A face is so unique," Pomahac said, "even a half-inch off affects the recovery of the tissue."

Now the most stressful part, he said, is "to know whether [the tissue] is going to live."

Brigham and Women's had announced plans to perform the procedure in 2007, which would have made it the first hospital to perform the procedure in the United States. But in December the Cleveland Clinic claimed that title; surgeons there replaced 80 percent of a woman's face in a 22-hour operation.

That woman is doing "phenomenally" well now, Dr. Frank Papay, a member of the transplant team and chair of the Dermatology and Plastic Surgery Institute at Cleveland Clinic, said yesterday. Before that transplant, he said, multiple attempts at reconstructive surgery had failed to restore her ability to talk, chew, smell, or even taste.

"She is eating now, her speech is improved, and she can smell and taste much better," he said "More important, her self esteem is much improved."

Doctors are starting to ease the amount of powerful drugs the woman is receiving to keep her immune system from rejecting the donor tissue, he said.

Face transplants have sparked ethical concerns because the potent anti-rejection drugs patients must take for life expose them to dangerous infections and an elevated risk of cancer, and the surgery is not life-saving, even if it is life-altering.

The face transplant at Brigham's is the seventh performed worldwide since the first in France in 2005 on a woman who had been mauled by her dog. Since then a Chinese man who had been attacked by a bear and a French man with a disfiguring genetic condition have had face transplants.

Brigham originally planned to offer face transplants only to people who were already taking anti-rejection drugs. That limited the candidates to people who had already received transplants, such as a kidney or pancreas.

But last May the hospital expanded its protocol to anyone whose deformity involves 25 percent of the face or all of a major facial part, such as the entire lip or entire nose. Burns, trauma, or benign tumors are common causes of this kind of disfiguring problem.

There are two reasons for the change, Pomahac said in an interview with the Globe in December: The first transplant recipient's return to function and sensation have been encouraging; and immune-suppressing drugs have been less problematic than thought. In more than 100 patients who had limb transplants, which are similar to face transplants because they also involve a combination of skin, fat, muscle, and bone, no cases of skin cancer or kidney failure have been reported, Pomahac said.

Still, he said yesterday, the physical and psychological healing has "just begun" for the world's newest face-transplant patient.

Kay Lazar can be reached at klazar@globe.com.