Risky decision saves transplanted face
Face transplant surgeon Bohdan Pomahac stopped by Carmen Blandin Tarleton’s hospital room early one morning in March and pulled a chair close to her bed. Instead of bringing his entire medical team as usual, Pomahac was alone.
Something is up, she thought.
Tarleton’s immune system was rejecting the donor face she had received in February at Brigham and Women’s Hospital. For more than a month, doctors had desperately tried drug after drug and a special dialysis-like procedure to stop the reaction. Nothing had worked.
“I don’t know if there is much more I can do,’’ she recalled Pomahac saying. “We have done everything. We have given you everything.”
Soon, he said, they would have to consider removing the new face and leaving her with the horribly disfigured one it replaced.
Tarleton, whose face had been burned beyond recognition in an attack by her estranged husband, said, “I have gone too far, and I am not going back.’’
More than a month later, it is clear she made the right choice. Her body ceased its all-out assault on the face, after doctors devised a plan to give her a potentially dangerous drug.
The 44-year-old is the only person to have received a transplanted face or hand, though her body was primed to attack donated tissue. Doctors believe they have succeeded in subduing her immune system.
Tarleton, recuperating at home in Thetford, Vt., is set to reveal her new face publicly during a press conference at the Brigham Wednesday and on “The Doctors” television show.
In an interview last week, she cried quietly as she recalled that March morning when her prospects looked bleak.
There was one medicine the doctors had not tried, since it had a 10 to 20 percent chance of killing her, since her immune system had been weakened by other drugs she was taking. Pomahac and his colleagues were uncomfortable with such extraordinarily high odds, in part because the face transplant was not a life-saving procedure.
“I told him I would want that medicine regardless of my risk of death,’’ Tarleton said.
When Pomahac left her room, he decided to call Brigham’s Center for Bioethics. “How much do you let a patient dictate even if their therapy means death?’’ he said in a recent interview.
The drug — alemtuzumab, a monoclonal antibody — would nearly shut down Tarleton’s immune system for one to two months, leaving her wide open to serious infections.
By that afternoon, Dr. Anil Chandraker, medical director of kidney and pancreas transplantation at the Brigham, had developed a compromise that would satisfy both doctors and patient. He would give her one-quarter the normal dose.
Within days, Tarleton’s antibodies stopped attacking the donor face. The swelling receded. The redness faded.
Chandraker said he is “extremely excited’’ the drug therapy worked. While alemtuzumab is routinely used for transplant patients, it is rarely usedwith other drugs Tarleton was taking and for the type of rejection her body mounted.
Pomahac and Chandraker plan to report the results in a medical journal. They said her case could help other patients who are considered too much at risk in a transplant because of strong immune reactions or whose transplant fails for some reason and are thought to be too sensitized to donor tissue for a second transplant.
Dr. Terry Strom, codirector of the Transplant Institute at Beth Israel Deaconess Medical Center and a founder of the American Society for Transplantation, said the Brigham doctors may have helped “solve a missing piece’’ for the 10 percent of transplant patients who produce antibodies against donated organs, resulting in acute rejection.
“The human story was unbelievably compelling,’’ said Strom, who advised Pomahac.
Tarleton, a former transplant nurse who recently wrote a memoir, had gambled more than once during her transplant and recovery from injuries inflicted by her estranged husband, Herbert Rodgers.
On the day of the 2007 attack, she was at home with her two girls — Liza, then 14, and Hannah, then 12 — when Rodgers forced his way inside. After battering her head with a baseball bat, he squirted industrial-strength lye from a dish-soap bottle onto her arms, legs, back, and face, burning more than 80 percent of her body and leaving her legally blind, according to police accounts. She has no vision in her right eye, but can see somewhat with her left eye and reads with a magnifier. Rodgers is in prison.
After Brigham doctors performed a partial face transplant on James Makiof Fitchburg in 2009, the first face transplant at the hospital and the second such transplant performed in the United States, Tarleton became eager for the surgery.
Doctors put her on a waiting list for 14 months.
It was hard to find a good match because she had received dozens of blood transfusions following the assault, leaving her immune system primed to attack any transplant.
Even when her donor’s family came forward in February, doctors debated whether it would work. The risk of rejection was as much as five times higher than usual, but Tarleton persevered.
She had her first close call within a week of surgery; her skin swelled and turned red. Doctors were able to reverse the symptoms with a new drug.
Soon afterward, Tarleton asked to see her face, and a nurse held up a small mirror for her. “I was just really happy to look in the mirror and see . . . a normal face,’’ she said. “Everything was an improvement.”
About a week later, her condition deteriorated. Pomohac sent samples from her neck, which was also transplanted, to the lab. Under a microscope, pathologists could see antibodies were infiltrating her face.
Doctors tried a half-dozen drugs; none stopped her body’s rejection of the face. Pomahac knew her antibodies would soon cut off the blood supply to the transplanted tissue.
He could return her face to the scarred condition it was in before the transplant, so she wouldn’t have lost anything. That is what he and Tarleton had agreed to before her surgery, so he was shocked that she would put so much at stake to keep the face.
Advisers Pomahac consulted at the bioethics center said they would wait to step in unless and until it became necessary to give her the full dose of alemtuzumab.
After giving her the reduced dosage of the drug, Pomahac sent tissue samples to the pathology lab every day. “The pathologists were saying we can’t tell if there’s a change. You guys have to calm down a bit,’’ Pomahac recalled.
Over several days, Tarleton’s face began to look normal.
“In my heart of hearts, I knew it would work out,’’ she said. “I knew this would benefit others down the road. I knew it would benefit me.”
Now, she said she feels “really good,’’ although she gets tired more easily than before surgery. She no longer has pain in her neck, because Pomahac removed scars that severely restricted movement of her head. She also has eyelids; her own were burned off by the lye.
In December, before her transplant, she began taking piano lessons from a teacher in Lebanon, N.H. They are now dating.