Transplant at Mayo Clinic replaces 85% of patient's face after more than 50 hours of surgery

March 5 had been a day of dread for the Pfaff family since 2014, when Lisa and Jerry found their 19-year-old son, Derek, bleeding in the snow from a self-inflicted gunshot wound that ripped away his face.

Not this year.

After 58 surgeries that kept him alive but disfigured, Pfaff underwent a transplant at Mayo Clinic in February that replaced 85% of his face with donor bone, tissue and skin. He wasn't allowed to look at himself for a month afterward. Mirrors in his hospital room in Rochester had been removed, and his mother took away his phone and iPad while he was swollen and tethered to drainage tubes.

Now a month had passed, and his doctor was handing him a mirror for his first look — 10 years to the day after his gruesome injury.

"What do you think?" Dr. Samir Mardini recalled asking him.

The anticipation in the room was tangible. Face transplants are tricky, requiring doctors to prepare bones and facial tissues from donors that precisely match the contours of the recipients, and rewire nerves so that patients' brains interface with the correct parts of their new faces when they blink, sniff or smile.

Less than 60 face transplants have occurred worldwide. Pfaff's face transplant was the second at Mayo, lasting more than 50 hours over three days in February and involving more than 80 medical professionals. Mayo waited until Tuesday to publicize the surgery's outcome.

"Most organ transplants are lifesaving. A heart transplant is lifesaving. A liver transplant is lifesaving," Mardini said. "With facial transplantation, it's a life-giving operation. You can live without it, but you are missing out on life."

An isolating injury

Pfaff almost died from his gunshot wound. He was transferred from a hospital near home in Harbor Beach, Mich., to a trauma center, where his parents were asked to consider donating his organs and tissue because he might not survive. But Pfaff hung on and was airlifted to Henry Ford Hospital in Detroit, where he underwent numerous reconstructive surgeries.

Most of his nose was gone, leaving a gaping but obstructed nostril in the middle of his face. There was a gap in the front of his skull and a titanium plate replacing the roof of his mouth, which was missing most of his lips and teeth. Pfaff struggled to eat, cry, smell or breathe through his nose. The former high school football star, who was studying nursing at Saginaw Valley State University, felt humiliation in public.

"People were always pointing at me," he recalled. "I stayed in my house most of the time."

Mayo approved Pfaff for a transplant because the nerves behind his face were intact and appeared capable of conveying signals from his brain to the transplanted tissue.

"If the nerves are not working properly, or would not connect to the donor nerves, then there is no point in doing the surgery," said Mardini, surgical director of Mayo's Reconstructive Transplant Program.

Psychological exams found Pfaff could cope with the consequences if the transplant failed, or adjust to a new cosmetic identity if it succeeded.

Pfaff had little competition in the search for a donor. The waiting list maintained by the United Network for Organ Sharing shows two people seeking head or neck transplants right now, compared to more than 90,000 seeking kidney transplants. The process still took four months, because Pfaff needed a precise match — a donor who was dying and on life support, but with the same facial structure, gender, age, blood type and skin tone.

Convincing families amid grief to support any organ or tissue donation is a delicate business, said Mary Prince, a donation liaison with LifeSource, Minnesota's organ procurement organization.

"You get one chance with these families," she said, and the decision has to be made quickly while a donor's organs and tissues are viable.

Asking them to consent to donation of something as personal as the face is on another level, she said, and requires an extra layer of permission, because it isn't covered under the standard agreement that many donors make on their driver's licenses.

Prince tried to anticipate every concern before approaching one grieving mother in North Dakota, who surprised everyone with her response.

"The first words out of her mouth were, 'That would be so amazing if I could see my son's face walking around!'" Prince recalled. "'I would be grateful and I would love to meet [the recipient].'"

Point of no return

Pfaff's surgery had been two years in the planning by the time his match was found. Mardini said it was among the most-rehearsed procedures in Mayo's history. His team figured out the precise amounts of bone and tissue to trim from Pfaff's face so the donor material would fit. They practiced the transplant 35 times with cadaver tissue and 3D models.

Pfaff's parents waited in a nearby hotel when the surgery started on Feb. 4 and received text updates every two hours. They had many questions.

"We had never seen a picture of the donor," his mother said.

In all, 18 nerve branches needed to be connected between Pfaff and his donor face, and each branch spilled out like tree roots into separate nerves.

Surgical teams in separate rooms electrically stimulated each nerve on Pfaff and his donor and recorded what part of the face it controlled. That created a precise manual for wiring the donor face to Pfaff's brain. The doctors also used 3D-printed guides to make precise cuts that matched the bone structures of the donor and recipient.

Mardini said he felt confident when the transplant passed the "point of no return" and his team removed Pfaff's existing face. At the midpoint, Pfaff's face was little more than exposed eyes, tongue and blood vessels. Doctors rebuilt the front of Pfaff's skull with bone and tissue segments, creating the framework over which his new face was draped. The surgery team stitched the new face to intact skin around the side of Pfaff's head to minimize noticeable scars.

The procedure presented unique challenges compared to Mayo's first face transplant in 2016, Mardini said, including a microsurgery to reroute the flow of Pfaff's tears so they would drip normally down the nose.

Color rushed to Pfaff's face near the end of the procedure, after blood vessels were sewn together between his head and the donor tissue.

Even so, the doctor remained nervous a month later, handing the mirror to his patient for a first look. It didn't help that Pfaff couldn't yet make facial expressions or offer visual cues of his emotions. A minute of silence passed in the room.

"Looks good," Pfaff replied.

"I guess you got your stamp of approval," Pfaff's mother said with a laugh to Mardini.

"Feels good," Pfaff added.

Adding up the cost

Pfaff needed follow-up procedures in August to improve the connection of the palates on the roof of his mouth and tighten up skin that had been left loose during the transplant to account for swelling.

The donor's teeth were in disrepair, and Pfaff may need them replaced. The family is delaying procedures that aren't urgent, though, while they figure out payment.

"We have an outstanding balance at Mayo," said the mother, who didn't want to reveal the cost.

Health insurance considered the transplant experimental and didn't cover it. Online fundraising netted $270,000, but more is needed.

Pfaff is gaining facial movements and sensations as nerves spring to life. He can exercise and feels comfortable going out in public again to football games and movies. His reshaped nose allows him to wear glasses so he can see clearly. Most of his pain is gone. He cuts himself every once in a while shaving his face, which sprouts a reddish beard every week. He will stay on anti-rejection medications for life to make sure his body's immune system accepts the donor facial tissue.

Pfaff said he is focused on reducing suicides. His self-harm occurred during college, when he felt the pressure of his own high standards, he said.

"If something is on your chest, talk to someone. Get it off," he said.

Someday he would like to shake the hands of the relatives who consented to the donation. The new face feels like his own.

"It's normal life. This is who I am," he said. "I can't be more thankful."

If you're feeling distressed or suicidal, you can seek support any time from the national Suicide and Crisis Lifeline by calling or sending a text to 988.