A New Face After Traumatic Injury

Think about all the functions your face performs: In so many ways, it allows a person to interface with the world — and not just to interact, either. “It’s your identity, you chew, you breathe,” says Dr. Dan Ceradini, an assistant professor and director of research in the Hansjörg Wyss Department of Plastic Surgery at NYU Langone Health in New York City.

In so many ways, what’s processed in the brain is expressed through the face, and we receive so much of the information from the world, including the social environment, via the face. “Through the eyes we see, and we look at people and we express emotion through the face and the facial muscles. We smell, we taste,” says Dr. Frank Papay, chairman of the Dermatology & Plastic Surgery Institute at Cleveland Clinic. “We produce the most complex thing that any being on earth does, and that’s to communicate in a social manner. No other animal does that as much as we do, and we have to articulate that speech.” While much happens internally, of course, via everything from the lungs to the vocal cords, the face — with so many vital functions — fronts these key operations.

That can make serious facial injuries resulting from gunshots, car accidents, burns or tumors that need to be removed all the more devastating and profoundly impactful. That’s fueled extensive expert efforts to rebuild what’s lost.

Papay recently led a team of dozens of clinicians in performing a face transplant on the youngest face transplant recipient in the U.S. to date, 21-year-old Katie Stubblefield. Only about 20 such procedures have been performed worldwide, relying on donor tissue — as an organ transplant would — to complete the experimental surgeries, which have also been performed at NYU Langone and the University of Maryland Medical Center in Baltimore. For many other patients, facial reconstruction procedures are done to repair bone and replace soft tissue and skin using their own tissue.

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Justin Mulligan landed at the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center after sustaining a self-inflicted gunshot wound to the face two years ago.

“I remember sitting on the bed with the gun, and that’s the last thing I remember,” Mulligan, who lives in Hagerstown, Maryland, recalls of that dark moment. That night, he says he had been arguing with his wife, Trish Winters, and drinking. He was depressed and upset. Winters said he was in the room after they argued, and things seemed to have settled. “I thought he might have went to sleep and everything was calmed down [when] the noise went off,” she recalls. Though he doesn’t have much memory of the incident, Mulligan says he had the shotgun under his chin, intending to take his life, and pulled it away at the last second when it discharged. “If I would have had it directly under my chin, I probably wouldn’t be here,” he says. The blast traveled up through his chin and the left side of his face taking half of his nose, he says.

Many facial reconstruction procedures late, Mulligan is getting back to what clinicians describe as a new normal. When injuries are particularly severe, the point of facial reconstruction — and face transplant, in rare cases — is not, experts say, to precisely replicate the face a person had before. Rather, these surgical interventions allow a person “to function, to present themselves in society, to increase their functions of the face, which are all the sensations — hearing, speech, eating, smelling, breathing,” Papay says.

In fact, even before facial reconstruction can be done, patients are checked for life-threatening and internal issues that need to be addressed immediately, from brain bleeds to breathing difficulties. Once a patient is stabilized, facial reconstruction can often begin early on in recovery, as in Mulligan’s case. For others, immediate emergency care is delivered but facial reconstruction starts much later. In either case, with major facial injuries, experts say it’s a good idea to at least start discussing options for facial reconstruction — or a face transplant in cases where injuries are so extensive that reconstruction isn’t possible — early on.

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“I think the best thing to do is find … a medical center that deals with a lot of the facial injuries,” says Dr. Arthur Nam, an assistant professor of surgery at the University of Maryland School of Medicine, and a plastic surgeon at the R Adams Cowley Shock Trauma Center, who performed Mulligan’s facial reconstruction procedures.

Especially with severe facial injuries, a wide range of specialists — from plastic surgeons to ear, nose and throat doctors, and oral maxillofacial surgeons to speech therapists — are needed to handle all that goes into not only surgery, but ongoing care and rehabilitation. “After they sustain an injury, you would advise everybody to go and be evaluated by a skilled surgical team in facial injury — it’s usually plastic surgeons, but it can also be ENTs or oral maxillofacial surgeons,” Ceradini says.

Given the deeply personal and intricate nature of the work, experts say, it’s key patients are not only confident they’re in capable hands but able to talk through questions and concerns. “The patient-doctor relationship is also very, very important,” Nam says.

Adds Mulligan: “Find the surgeon that you trust, and just fight through it and eventually it will work itself out,” he says. “I never thought I would get back to where I’m at.” Mulligan and Winters see that as a testament to Nam’s surgical skill in repairing extensive damage to Mulligan’s face. “I think he looks amazing,” Winters says. “I didn’t think he would be looking like [himself] as much as he does — that’s how good of a job Dr. Nam did.”

[See: 8 Ways to Reduce Hospital Readmissions.]

To be sure, the long process is still ongoing — with the next steps being reconstruction of his nose. “I have my days. But overall I’m good,” Mulligan says. “I tell myself, and my family and wife tell me, that I’m here for a reason, and I honestly believe that now because … I’m very lucky to still be here, and Dr. Nam has done a wonderful job.” He adds, “I’m just anxious to see, what more can he do.”

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A New Face After Traumatic Injury originally appeared on usnews.com