Losing Face, Gaining Hope

"I said, 'What? What? Is he dead?' He said, 'He's not dead, but he's not doing good. He's had an accident with his gun'."
"I just fell down on the floor."
"I saw his eyes [bandaged in hospital] and I said, 'Yes, it's him."
"I'm always afraid of making a mistake. There are so many different types of medication. I have to pay close attention to what I'm doing. It's really a 24/7 job."
Gaetane Desjardins, Notre-Dame-de-la-Salette, Quebec

"I think if  you want to talk medically, things have been a success. We might have to put in different plates [holding the jaws in place]. It's not a big thing, but it's frustrating."
"His life before is not like his life now, with all the medical visits. It takes some time to adjust to it. He's impatient; I'm impatient. We want it to be perfect right away and unfortunately that's not how it works. It's going to take time to establish a normal life. It's not just in this case -- it's in all [face] transplants."
"I am close to my patients, but with him, it's another level. Maybe it's a bit too close? But that's on me."
"I know he'll get it back [jaw control]. It's like when you have a cast on your wrist: If you don't move your wrist for a month, it's going to be stiff."
"I think that we have a great public [health care] system and I think it works really well, but the problem with some of these transplant patients is most of them don't live near a transplant centre,"
"They have to leave their homes, get in their car, pay for parking, pay for gas, pay for medications, which aren't always covered. And so it ends up being a quite expensive year for these patients." 
Dr. Daniel Borsuk, plastic surgeon, Montreal

"We had to basically dismantle all the work we had done over the years."
"This was, for  us, kind of a grief. We had to dismantle all that we had done to be able to offer him a new face."
Dr. Akram Bahai, ear-and-nose surgeon, face-transplant team member

Desjardins, pictured here before his surgery in 2018, was severely injured in a 2011 hunting accident. (Jérôme Voyer-Poirier/Radio-Canada)

Maurice Desjardins had decided back in January 2011 to clean his hunting rifle, last used hunting caribou in James Bay the month before. He had stored it still loaded. Then on January 10, he removed the bullets before cleaning the rifle. "I cleaned it, I oiled it, and it was too oily", he said recalling how the gun had slid out of his hands and onto the garage floor, the butt shocked into jarring the firing pin. One bullet had remained in the rifle, when he thought he had emptied it of all ammunition.

What ensued was what is termed an "avulsion" injury; the bullet carving a pathway through his face hitting his jaw, mouth, nose -- with the entire anterior portion of his face pulled away. He considers it a miracle that he survived. The second miracle was enacted seven years later when surgery provided him with the face of a man who had been declared brain dead. A man whose pancreas, heart and liver went to others awaiting organs to preserve their own lives, including that of a dying baby.

His wife Gaetane happened to be off with friends for a holiday in Cuba, and she flew home directly she was informed by a police call that her husband was in intensive care in hospital. Nine months later her husband was discharged. It took a year-and-a-half before he could speak and then only by pressing the tracheostomy opening with his fingers. While he recuperated as much as was conceivable, his roofing business dissolved. People stared at the man with 'no face' when he left his house in the small village.

His destroyed face was left with two apertures where his nose should be and a mangled, puckered mouth he was unable to close. And without the tracheostomy -- a surgical hole in his throat he would be unable to breathe. Attempts at reconstruction were futile. And for seven years this is how he lived. Last May, then-64-year-old Maurice underwent a 30-hour surgical procedure which had nine surgeons -- who had practised on cadaver heads for two years -- perform the process that united the faceless man with a new face.

Dr. Daniel Borsuk and Desjardins share a hug. After a year of ups and downs since the surgery, the two men have grown close. (Charles Dagenais/Radio-Canada)

The team, led by Dr. Daniel Borsuk, was comprised of over 100 medical, nursing and support staff. Montreal's Maisonneuve-Rosemont Hospital saw the team of surgeons essentially surgically remove  a brain-dead man's face to place it over Maurice's faceless skull. A one-piece neck, chin, mouth, cheeks and nose including the upper face bones, the maxilla, midface and jaw. Maurice was able to retain his own eyes and ears and forehead.

Now, a year following that surgery, his new face is beginning to move. Sensory nerves are in recovery mode. Maurie can move his lips. He can feel if his cheeks are pinched. He can identify the sensation of heat or cold if it touches his face. His mouth remains in a wide-open position. He was taught facial exercises in rehab. People no longer stop to stare at him in the rural Quebec village by the Lievre River where he and his wife live. "I'm still the same guy", he says.

Maurice and his wife travel regularly to Montreal for follow-up medical care. Maurice feels his new face has given him a second chance. Because of the non-rejection drugs, however, problems have arisen. And the many drugs he must take with his new condition are not all medications covered by insurance. The couple recently posted a GoFundMe page. Which elicited merely $100 in response up to the present.

Gaétane Desjardins said she had to give up her job, because taking care of her husband is too demanding. (Charles Dagenais/Radio-Canada)

A feeding tube still supports him because he cannot yet consume a full meal through his mouth; it will take further adaptation. The anti-rejection drugs leave him vulnerable to infections, to cancer, to diabetes and potentially a shortened lifespan. He underwent emergency surgery for diverticulitis, in response to infected pouches forming on his colon wall one of which which ruptured, spilling the contents of his intestines into his gut. Gaetane rushed  him to hospital in Montreal.

"He wasn't answering me anymore; he wasn't talking anymore. I was driving fast"; fast enough that she was stopped by police just outside Montreal. "I said 'Please, come with me, take me the way, bring my husband to the hospital, he's going to die". A $325 ticket for speeding resulted. "I called intensive care, I called the general surgeon and they operated on him that night", Dr. Borsuk recalled. And for the time being Maurice wears a temporary colostomy until his bowels can be repaired in three to six months' time.

Now, however, the man with a new face is slowly regaining strength. He no longer consumes alcohol. "He didn't want to live anymore, that's why he was drinking, and Dr. Borsuk said, 'You have to stop everything. Everything'," pre-surgery, Gaetane explained. Maurice had lost 32 kilograms after the transplant. When asked if he still considers the transplant a godsend, he responds: "Ah, oui."

Maurice Desjardins and his wife, Gaétane, have dealt with major infections, hospitalizations and financial stress in the past year. But they say it's been worth it. (Charles Dagenais/Radio-Canada)

The Perfect Female Body Image

"We are reporting an analysis of the largest prospective study to date on silicone breast implant safety. We are sharing critical information on complication rates and rare associations with systemic harms. This data gives women important safety information about silicone breast implants to have real expectations and to help them choose what is right for them."
"Despite abundant data collection, and open public access, the LPAS [large postapproval studies] database had not yet been analyzed and reported."
"These findings are associations compared to the general population and determining why these associations are observed or any causation requires further study."
"To resolve the remaining uncertainty in the evidence base, it is important that this data be analyzed in an unbiased manner. It remains the plastic surgery community's duty to provide definitive evidence for the risks associated with breast implants."
“This study did not report a direct link or causative effect between implants and these diseases. It is important to understand a limitation of the study was that some diseases were reported by patients and not necessarily diagnosed by a physician. This is important safety information for women to consider when thinking about cosmetic or reconstructive surgery with breast implants. It also underscores the need for more research in this area."
"It’s vital that women with implants be aware of the potential risks, so they can identify symptoms early and consult with their doctors. Fortunately, many of the diseases and conditions that have an association with implants are quite rare, so awareness is that much more important."
"Patients are seeking an assurance of safety. The FDA has deemed breast implants reasonably safe and effective, and being educated about potential complications is an important part of good health. All surgical procedures and implantable devices have potential complications and side effects. As plastic surgeons, it’s our responsibility to continually monitor the long-term safety of breast implants and make sure that all patients and physicians are aware of any possible adverse outcomes. This ensures that patients and their healthcare providers can weigh the potential risks and benefits together to make the best possible decisions on augmentation and reconstruction."
Mark W. Clemens, MD, University of Texas M.D. Anderson Cancer Center, Houston

What price beauty? For some there is no cost too dear. Women in Latin America in particular accept plastic surgery as a rite of passage as a woman, a desirable woman, a woman whose bodily features are to be admired, to gain attention, to be proud of herself. To these women their natural endowments need not necessarily represent the end result of what they can aspire to physically. It has become in many quarters, a classic formula when a teen enters her pre-adult years, to plan for breast augmentation surgery and for some, why stop there?

Still, it is in the United States that a greater percentage of women choose to undergo plastic surgery to amend errors that nature endowed them with. Simply put, the gold standard of plastic surgery is what takes place in the United States, followed by Brazil, and other countries where women see themselves not quite finished unless and until they have taken the necessary steps to pad their natural endowments so that their figures more closely resemble the ultimate ideal in female pulchritude.

Nearly all the cases of breast implant-associated anaplastic large-cell lymphoma have been linked to textured implants like this one.    CreditSouthern Illinois University, via Science Source

Silicone gel implants were associated with some horror stories in years past, from slippage to leaking, to infections and worse. A newly published independent analysis concluded with the suggestion that there are health problems associated more commonly with silicone gel implants; problems rare, it would seem, but troubling to no end for those unfortunate enough to be one of those whose breast implants are the cause of a medical condition.

Close to 100,000 women were included in the study published in the journal Annals of Surgery, representing the largest long-term safety analysis of silicone implants since 2006, the year the Food and Drug Administration permitted their re-entry on the American market following safety concerns leading to a 14-year gap. "We completely stand behind this study and we do feel it's our best data to date", assured Dr. Clemens, plastic surgeon, at University of Texas MD Anderson Cancer Center.

Women who have undergone breast cancer surgery with the removal of a breast understandably often choose to undergo reconstruction in an effort to resume a normal life and view of themselves as resembling how they had presented prior to surgery. Roughly 400,000 women in the United States choose to undergo surgical implant, mostly with silicone rather than saline. Of that number, three-quarters represent women who aspire to have larger breasts.

The website of the Food and Drug Administration warns women that "Breast implants are not lifetime devices", pointing out that up to 20 percent of women who have chosen to enlarge their breasts with silicone implants face removal within eight to ten years resulting from complications that include infections, wrinkling, scarring, pain, swelling and rupture of the implant. According to the FDA there is as well a small but increased rare lymphoma risk [type of cancer].

After learning she had breast cancer, Raylene Hollrah of Hermann, Mo., had a double mastectomy. But then cancer struck again — caused by the implants used to rebuild her chest.  Credit: Whitney Curtis for The New York Times

When the FDA approved implant devices from two manufacturers in 2006 it was with the proviso that the manufacturers conduct studies on how use of the implants affected women's lives. These reports contained in an FDA database were used by the researchers for their analysis. Women with silicone implants appeared to suffer greater rates of Sjogren syndrome, an immune system disorder, as well as a connective tissue disorder called scleroderma, and melanoma; skin cancer; albeit rarely.

Problems such as fibromyalgia appeared lower among women wearing implants, and birth defects and stillbirths were inconsistent and inconclusive. To add to the confusion a  higher rate of rheumatoid arthritis linked to one of the silicone brands, but with another a lower rate was seen. Dr. Andrea Pusic, plastic surgery chief at Brigham and Women's Hospital in Boston, president-elect of the Plastic Surgery Foundation was unimpressed with the report, considering its potential to create greater anxiety than insight.

That problems associated with silicone implants are real is beyond doubt, however. And that women are risking real inconvenience in their lives should they need to have serial implants over the course of their lives if they remain committed to breast augmentation, let alone facing the onset of some quite life-disruptive diseases, seems to make the choice for implants an irrational, rather than a considered condition of vanity.

Some of the complications and adverse outcomes of a boob job include:

• Additional surgeries, with or without removal of the device
• Capsular contracture– scar tissue that forms around the implant and squeezes the implant
• Breast pain
• Changes in nipple and breast sensation
• Rupture with deflation of saline-filled implants
• Rupture with or without symptoms (silent rupture) of silicone gel-filled implants

According to the FDA, as many as 20 percent of women who have a boob job need their implants removed within 8 to 10 years.

Um, Cinderella Surgery? 

U.S. women have started a trend for so-called 'Cinderella surgery' which sees them having the size and shape of their feet surgically altered so they can fit into designer shoes

"Life takes its toll on feet. I get lots of requests to make feet smaller. It's really difficult for women who love glamorous shoes and are over a size 8. By shortening toes and removing bunions, Cinderella surgery can reduce feet by up to one full size."
"Everyone wants that perfect parabola, with the toes forming a smooth arch. Shoes are usually fitted to the big toe, so women with over-long second and third toes wear shoes that are too small, causing corns, swollen, painful joints and toe deformities."
"It's very important to have a specialist look at underlying causes before considering surgery."
"Some [women] never wear sandals; others won't go swimming, even on holiday or with their children. One patient told me she'd never shown her feet to anyone, even her husband of twenty years."
Jason Hargrave, consultant podiatric surgeon, Albany, New York

Some podiatrists, offer foot surgeries which include nail resizing, foot narrowing, a toe tuck - a surgical procedure to shorten the second toe, and toe obesity surgery that make fat toes thinner and more beautiful.

"Varicose foot veins can be removed via surgery or by injecting a chemical to close them down. Up to twenty percent of women have hidden varicose veins in their legs that affect blood flow. If they aren't treated, foot veins will recur."
"An ultrasound scan of the leg is necessary before surgery."
"Almost all vein procedures are now walk-in-walk-out, performed under local anesthetic, with minimal downtime, apart from two weeks of compression stockings after sclerotherapy."
Prof.Mark Whiteley, consultant vascular surgeon, Whiteley Clinic, Guildford, Surrey, GB

As a pioneer of "Cinderella Surgery" Dr. Hargrave is, unsurprisingly, a proponent of it; for its beneficial health effects in altering misshapen feet, of course. His surgical procedures include bunion removal resulting in foot slimming; toe shortening, shaving lumps and bumps and separating webbed toes, all of which conditions make women very aware of their imperfections and loathe to have anyone view them. The last word in elegance is fashionable footwear for women, with high heels and narrow toes, and they certainly take their toll of the wearer, over time.

There are surgeons whose specialties include bulging veins, and adding fillers to smooth out scrawny feet. Anti-aging techniques through plastic surgery of the face and various body parts to renew that lithe and youthful look that the middle-aged regret having lost remain hugely popular with a youth-transfixed society, so why not 'correct' the appearance of ungainly, misshapen feet to restore them to a more comfortable version of returning youth?

With the prospect of taking advantage of the availability of anti-aging foot-lifts there is also the delightful prospect of being able, once again, to fit that foot into those beloved designer shoes. Of course those same shoes whose constant stress on the foot caused the problems to begin with, will once again recreate damage to the foot, but in the meanwhile, the foot has gained the advantage of more time to flaunt its graceful appearance in a beautiful, ill-fitting shoe.

Got bumps on your instep? They "may be an overgrowth of bone above the first metatarsal-cuneiform joint", all very technical and medically professional, so don't sweat the terminology just be assured that the surgeon can correct that unsightly, uncomfortable, limiting situation for you. Bumps like that, be assured, have a tendency to develop in "people with high-arched feet". The bad news is that underlying osteoarthritis may be involved. Take your pick; alternately the bumps might only be a soft tissue lump caused when lubricating fluid leaks from a joint.

Shaving down bone may take only fifteen minutes, performed under local anesthetic, and all there is that attests to the procedure is a tiny, hidden scar. "Once healed, they feel much more comfortable in shoes day to day", assures Dr. Hargrave. The very descriptive, "Cinderalla Surgery" can be deceptive, however, masking the fact that the surgery represents a serious medical intervention with its own risks. Shortening of long toes require that a segment of bone be removed from the joint with a metal clip fusing it to the correct position ($5,843).

On the medical side, "This will also prevent a too-long toe becoming a hammer toe", assures Dr. Hargrave -- an intervention that can be performed under local anesthetic. Risks? Infection, thickened scars, failure of bone to heal, and the possibility of thrombosis. For at least three months following surgery, toes will be swollen and bruised. There are interventions for mallet toes and hammer toes; stunted digits to be elongated with a bone graft from the heel. "It's a complex procedure", the cost a cool $11,684, each toe.

A special boot must be worn for six weeks, recovery is in terms of months, and when all is said and done, the toe may not be perfectly aligned. Bunions? They form when the big  toe joint begins an outward slide, causing the toe to lean toward its partners. Bunions can make feet very broad since they can occur on both sides of the feet, and it becomes a trial and a tribulation to find shoes that will fit that broadened foot. Even so, their presence can cause pain wearing shoes and walking about.

New feet: Sandie Shaw shows off the results of her 'foot lift' which involved surgeons shortening and straightening her toes