Dr. Bohdan Pomahac was on late call at Brigham and Women’s Hospital when the emergency room urgently paged him around midnight. A man had fallen face-first onto the electrified third rail in the Ruggles subway station, and was near death.
Pomahac, who at 34 was just a year out of training, had rarely seen such a horrible burn injury; the middle part of the man’s face was gone. Somehow the patient, James Maki, pulled through and Pomahac brought him to the operating room a week later, in July 2005, for the first of 13 surgeries he would perform to try to reconstruct Maki’s face.
But despite the hours of meticulous work, Maki, a disabled Vietnam veteran who grew up in Amherst, still did not have a nose and his speech was barely understandable. Conventional surgery had limits, and Pomahac was frustrated he couldn’t do more.
Then, in February 2006, French surgeons unveiled the world’s first face transplant patient, Isabelle Dinoire, who had been mauled by her dog. Pomahac stared in disbelief when he saw the before and after pictures of Dinoire on the Internet. She looked so normal. She had a nose. She had lips.
I could operate on that woman 100 times and never get close to those results, he thought.
Pomahac knew what he wanted to do: Give disfigured patients new faces. Give them entirely new lives.
It was an audacious idea for such a young, unproven junior surgeon. Pomahac would have to coax a cautious Harvard teaching hospital to embrace an almost fantastical new procedure, one that was the focus of international controversy.
He needed millions of dollars to pay for the surgeries and to assemble a team of dozens of doctors and nurses. He had to persuade the region’s organ donor agency that families would consider the unthinkable, donating the face of a loved one to a stranger. And perhaps most daunting, Pomahac would have to nudge his way into the elite community of established New England transplant surgeons, who were afraid that lifesaving donated livers, kidneys, hearts, and lungs would be rendered unusable if there was a delay to remove donors’ faces, for a procedure that at the time many considered cosmetic.
It took more than two years, but in May 2008, the hospital’s ethics board approved a face transplant for Maki. Since then, the Brigham has done a total of four, surpassing the Cleveland Clinic as the leading program in the United States and becoming the second busiest center in the world after a French team.
Along the way, Pomahac has ruffled some feathers, both by operating on patients other programs won’t take and because he has not done basic research on face transplantation, the traditional starting point for specialists at academic medical centers. Still, most in the medical community have been won over by the confident but unassuming surgeon, and by his early success.
When senior managers at the Brigham first approached her about Pomahac’s proposal to do face transplants, then-chief operating officer Kate Walsh said, “My first thought was ‘Who’s Bohdan Pomahac?’ ’’ Now Walsh, chief executive of Boston Medical Center, said: “This guy really moved a conservative medical institution to do something that was very brave.’’
Research is the currency of Harvard Medical School and its affiliated teaching hospitals. Publishing papers in top journals and winning large grants earn doctors promotions, lab space, and prestige. They often develop treatments in the lab for years before trying them out on patients. When Dr. Joseph Murray, a Nobel laureate, performed the first ever successful kidney transplant at the Brigham in 1954, it was only after extensive related research.
So at first, some senior Brigham surgeons discouraged Pomahac and advised him to build funding for his lab and publish his results in journals. His research into wound healing had little to do with transplantation, however.
I’ll never get this done, he thought. It could take 10 years.
‘This guy really moved a conservative medical institution to do something that was very brave.’
He decided to ignore those colleagues’ advice.
Pomahac, who grew up and attended medical school in the Czech Republic, doesn’t dominate a room like many surgeons with bold personalities. He wears wire-rimmed glasses and speaks softly, his words retaining a trace of his native accent. He keeps tight control of his emotions, a vital trait in the operating room. A former Brigham colleague tells of watching Pomahac, who took up golf after coming to the United States, smash the ball into a sand trap. There were no expletives; he just marched forward and took another swing.
A similar quiet determination brought him to this country in the first place. Pomahac knew that as a foreign student, he stood little chance of being accepted into the Brigham’s elite surgery training program. So he wrote a letter to Dr. Elof Eriksson, the hospital’s chief of plastic surgery, whose name he found in a course catalogue, asking for a job in his lab. Eriksson replied that he had no jobs.
Pomahac flew to Boston anyway, bringing his entire savings - $3,000 - and offered to work for free. Eriksson was impressed. Pomahac is from Ostrava, a large city near the Polish border. A doctor there may think “maybe one day I can get a job in Prague,’’ Eriksson said. “From Ostrava to Boston is a big jump. That takes special focus.’’
Soon, Eriksson began paying him a small salary, and after two years, Pomahac won a spot as a surgical resident.
Pomahac faced long odds, too, in establishing a face transplant program. A high school chess champion, he knows how to think three moves ahead, and he set out a careful strategy.
He began by enlisting the support of senior plastic surgeons at the Brigham, including Dr. Julian Pribaz and Eriksson. Fortunately for Pomahac, Eriksson had just had a crucial conversation with Murray about the first French face transplant case, and the criticism that Dinoire’s identity may have been harmed because of her drastically different appearance.
Eriksson happened to be driving Murray, now 92 and retired, to a lecture at Shriners Hospital.
“What do you think about all of this?’’ Eriksson recalled asking him.
“I think it’s just great,’’ Murray told Eriksson. “It’s no different than what we went through.’’
“That made me completely convinced, [the field] should not be swayed by naysayers,’’ Eriksson said recently.
Pomahac’s challenge was to convince people that face transplantation is not just cosmetic but profoundly life-changing for patients so severely disfigured they often became recluses.
He gathered dramatic photos of disfigured patients and of Dinoire, before and after surgery, to show the Brigham’s institutional review board- a group of physicians, nurses, mental health workers, and others who make sure experimental procedures are legal and ethical. And he took the rare step of requesting a personal meeting with its chairwoman, Dr. Elizabeth Hohmann.
She was concerned because patients would have to take potent drugs with potentially dangerous side effects for the rest of their lives to prevent their immune systems from attacking the donated tissue. This risk seemed warranted for a patient who needed a new organ to survive, but, she wondered, was it worth it for a patient essentially undergoing an elective procedure?
Afterward, Pomahac was still worried that concern over antirejection drugs would sink the project, so he decided to first propose partial face transplants on patients already taking the drugs for some other transplant. It was a gamble: While the chances of finding a face transplant candidate on these drugs were small, he believed once he got his foot in the door he could later expand the criteria to include patients like Maki.
“It felt like an easy way to get a controversial project off the ground,’’ he said.
But he couldn’t do anything without donors.
Pomahac drove to the New England Organ Bank in Waltham to see executive director Richard Luskin and a few others. He showed them the photos of the French patient that had so inspired him, but he recalls “a lot of stone faces.’’
Luskin was skeptical about whether families would agree to donate their deceased loved-one’s face. And if by some chance they did, an even greater issue loomed: Who would go first in the operating room to retrieve organs? Pomahac’s team or the teams taking organs needed to save people’s lives?
Luskin told him he would have to present his case to the organ bank board and four separate groups of transplant surgeons.
Pomahac felt deflated. The work Luskin outlined would take months, if not years. Are they doing this to test my persistence and wear me down, he wondered.
But later, after Pomahac presented his plan to the board, stressing his desire to help patients, Luskin told Pomahac, “Something about you makes us want to help you.’’
At Luskin’s suggestion, Pomahac arranged to watch an organ retrieval at the Brigham. Surgical teams from four different hospitals took turns removing the donor’s heart, lungs, liver, kidneys, and pancreas in a carefully choreographed five-hour procedure designed to keep all the organs functioning.
He realized right away that he would have to go first. There was not enough room around the table for all the transplant surgeons to take the organs at once. And he needed to go before the heart team, so the face would get enough blood to keep the tissue viable.
But to disrupt the standard pecking order, he needed agreement from New England transplant surgeons, some of the most formidable men and women in surgery.
There were “a lot of strong personalities in play’’ when Pomahac made his pitch at a series of meetings, said Dr. Douglas Hanto, chief of transplantation at Beth Israel Deaconess Medical Center.
The transplant doctors all asked the same question. If Pomahac took the face first - an operation that would take at least four hours by itself while a brain-dead donor was on a ventilator - what would happen if the donor became unstable and the other organs deteriorated?
“We are not going to allow the lifesaving organs to be ruined,’’ said Dr. Sukru Emre, chief of transplant surgery at Yale-New Haven Hospital.
Pomahac agreed to back away from the operating table if a donor became unstable and let the other teams in. With that assurance, Emre and other transplant surgeons rallied behind the program - and so did the organ donor bank.
“This wasn’t some arrogant prima donna,’’ Hanto said. “He was doing this because he deeply cared about the patients.’’
In May 2007, the hospital ethics board approved transplants for patients already taking antirejection drugs. But no such patients came forward. So Pomahac set out to persuade hospital officials to open the surgery to all disfigured patients who qualified - including Maki.
Maki had seen Pomahac describe the limited transplant program on television and remembers thinking, “I wish I could be the one.’’ Later, he came to the Brigham for a routine checkup and his surgeon broke the good news: Doctors wanted to evaluate him for a face transplant. Pomahac called it an “unprecedented opportunity’’ but also cautioned Maki about the risks and the long screening process.
“I was excited,’’ Maki recalled recently. “I trusted him completely.’’
But expanding the program to include patients like Maki would be trickier from an ethical standpoint, and also from a financial one. Face transplants are not now covered by insurance, and while Walsh and Dr. Gary Gottlieb, then the hospital’s president, said the hospital would pay for the surgery and hospital stay - the initial estimate for Maki’s operation was $120,000 - they would not agree to take on the cost of lifelong antirejection drugs, which could reach $10,000 a year, or promise funds for subsequent patients.
“I did not want to get rid of something essential to our mission for something I didn’t understand very well and that was experimental,’’ Gottlieb said. A psychiatrist, he also worried about patients like Maki who had “suffered extraordinary trauma’’ and undergone multiple surgeries, having to endure a major recovery, rehabilitation, possible identity struggle, and publicity. “Does that person have the resiliency? Is this humane or not?’’
There was debate in Pomahac’s own department about whether Maki was an appropriate candidate for surgery because he had a history of drug addiction and hepatitis C - an illness that would have excluded him from the Cleveland Clinic program.
Pomahac requested a meeting with surgery chief Dr. Michael Zinner. They sat across from each other at the small round wooden table in Zinner’s sunny office. Pomahac could feel some skepticism.
“I am listening to him, and thinking this is never going to happen,’’ Zinner said later. “In our region, getting donors for regular organs is really hard. But getting a face? God, how are we going to do that? And if we failed, it would be as big as if we succeeded.’’
Then, Eriksson had a game-changing idea. A lecture honoring Murray was coming up in March and he suggested inviting charismatic French surgeon Dr. Jean-Michel “Max’’ Dubernard, a key player in Dinoire’s face transplant, to give it.
On the final night of Dubernard’s four day visit, about 100 Brigham surgeons and their spouses had just settled down for a grilled filet mignon dinner at Boston’s Harvard Club when Dubernard stepped to the podium to thank his hosts. Then, he pointed at Zinner. “You have to support this,’’ he urged. “This is the new frontier.’’
“I was a sponge,’’ recalled Zinner. “He made very convincing arguments.’’
Over the following months, the hospital negotiated with Medicaid to pay for Maki’s drugs, and the institutional review board reviewed Pomahac’s proposal to broaden the patient selection criteria. Dr. Paul Allen, an anesthesiologist and board member, said he and others wanted to know that if the operation failed, the patient would not die and would not end up looking worse.
“There had to be an exit plan; that was a deal-breaker,’’ he said.
Pomahac reassured them that Maki and other patients who followed would be his patients for life, not just for the operation. “I argued that we had been making decisions for patients for too long. They’re the ones living without a face,’’ he said.
The board approved expanding the pool of patients in May 2008, but took the unusual step of saying each patient must be approved individually.
Since then, the review board has approved three more patients - Mitch Hunter, Dallas Wiens, and Charla Nash. Nash had been rejected by the Cleveland Clinic because she is blind. Doctors there said she wouldn’t be able to monitor her own face for signs of rejection. Pomahac argued to the Brigham ethics board that family and friends could help watch for rejection.
Almost a year after Maki got the OK, the family of Joseph Helfgot, a Brookline heart transplant patient who died during surgery, agreed to donate his face. Maki’s surgery was scheduled for April 9, 2009, at 6 p.m.
At about noon, Pomahac sat down alone with Zinner. Pomahac was uncharacteristically worried about something going wrong, because a television crew would be filming a documentary in the operating room. “Calm down and do what you do best,’’ Zinner reassured him.
But shortly before 6, Pomahac got a page out of the blue from a radiologist. During a routine presurgery screening, he had found a spot on Maki’s lungs. It looked like cancer. If confirmed, the transplant would be off.
This is going to fall apart, Pomahac thought.
He got a second and a third opinion but no one wanted to make the final crucial call. At 9 p.m., he called Dr. Phillip Camp, a lung surgeon. Camp was exhausted after having done a double lung transplant that day, but he came back to work. He sent a sample to pathology. The result came back at 10:30: resolving pneumonia.
The surgery began at midnight and ended late the following afternoon.
It was a moment of triumph for Pomahac; it was something much more for Maki, who now feels able to go out to eat and shop.
“This was the chance for me to get my life back,’’ he said.Liz Kowalczyk can be reached at firstname.lastname@example.org.