Surgeons Describe 1st U.S. Face Transplant
May 6, 2009 -- The nation's first full face transplant gave Connie Culp what dozens of painful plastic surgeries could not -- the ability to re-enter life.
Culp, a 46-year-old mother of two from Ohio, didn't die four years ago when her husband pulled the trigger of a shotgun aimed at her face. But she lost every semblance of a normal existence.
The middle of her face was gone. She lost one eye, her nose and sinuses, her cheekbone, her upper jaw, and the bone, muscles, and skin that hold a face together. Her facial nerves were torn away.
Culp couldn't breathe without a tube in her neck. She could not drink from a cup, smell, or taste. Despite the best efforts of reconstructive plastic surgeons, a tight and extremely painful shell of scar tissue grew over the wound.
Perhaps even more painful to Culp, people saw her as a monster.
"We tried to assimilate her into society, but she had a difficult time," Cleveland Clinic plastic surgeon Risal Djohan, MD, tells WebMD. "Kids ran away from her and people stared at her."
"Our patient was called names and was humiliated," Cleveland Clinic transplant team leader Maria Siemionow, MD, PhD, said at a news conference. "You need a face to face the world."
Culp now has that face, thanks to an anonymous donor and to Siemionow's 17-member surgical team. The donor, a woman of about the same age and complexion as Culp, died of a head injury that left her face and neck intact.
In an astonishing 23-hour operation, the team was able to remove the donor's face -- nearly the entire face except for the upper eyelids, forehead, lower lip, and chin -- and connect it to Culp's blood vessels and nerves. Although they'd practiced over and over again on cadavers, the team didn't know for sure that the operation would be a success.
That changed when Culp's blood began to flow into the transplant, and the pale white skin became a rosy pink.
"It was a joyful moment to see the lighting up of the face," Djohan said. "It was like the lighting up of a Christmas tree."
The big risk for any transplant is rejection of the new tissues by the body's immune system. Culp spent 12 days in intensive care, and 45 days in the Cleveland Clinic's post-transplant room. She was able to leave the hospital on Feb. 5 -- 58 days after being wheeled out of the operating room.
She can now eat solid food without restrictions, drink from a cup, breathe through her nose, and smell. Her pain, which she'd described as 8 on a 1 to 10 scale, is down to a 1 -- the lowest level of pain.
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The before-and-after pictures are amazing, but for the time being Culp's face is still a work in progress. The surgeons intentionally gave her much more tissue than she needed to provide room for swelling.
"More skin is easy to remove, but if there's not enough it's harder to put back on," Djohan says. "And remember, if we put the face on too tight it will restrict any possible facial expression."
Over time, Djohan says, the nerves in Culp's new face will regenerate. That takes time -- nerves grow about an inch a month. Doctors expect Culp's facial nerve to reach full length in about a year, giving her much more facial movement and function than she now has.
What will she look like? Doctors will remove the excess skin when it's safe to do so, and there will be more procedures to improve the results.
"We will try to get her close to her former appearance -- but this is a reconstruction, not cosmetic surgery," Djohan says. "She will not resemble the donor, and she will not resemble herself, but something in between."
Before undergoing surgery, Culp convinced her doctors that she understood the risks of needing immune-suppressing drugs for the rest of her life. Those risks include life-threatening infections and cancers. And there's always the risk of rejecting the transplant, although those risks diminish over time.
Siemionow says that what Culp has taught her team will be applied to other patients who suffer extreme facial deformities that have destroyed their lives.
"There are so many patients in their houses where they are hiding from the society, because they are afraid to go to the grocery store, afraid to walk the streets," she said. "We hope that this special group of patients will one day be able to go comfortably from their houses."
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