How much of that has to go in the vehicle?” asks the pilot, pointing at the mass of tubes, cables, monitors, and machines that surround my patient.
“All of it,” I tell him. The intensive-care side room looks cramped. Its contents must somehow be transferred to the roof of the hospital and crammed into the back of a medical-evacuation helicopter.
The pilot sucks air through his teeth, doing the mental arithmetic. It’s a warm day; the air is thin. His engines can generate only so much lift. The more weight we have to carry, the shorter the range of the helicopter and the more hazardous the takeoff.
“How much has to be in the cabin with us?” he asks.
“All of it,” I repeat.
More air-sucking sounds.
“How much do you weigh?” he asks, looking me up and down.
“About 155 pounds,” I tell him.
“How about her?” he says, nodding indelicately at the nurse.
The man in the bed before us was caught in a house fire and is badly burned. The trauma team estimates that perhaps the full thickness of skin over as much as 50 percent of his body has been destroyed by fire, though it’s hard to be sure. Underneath the char and the blisters, it is difficult to know what remains viable. Time is ticking by. Keeping him stable has taken all our efforts, and we are at the end of what we can offer here in this general intensive care ward. To give him the best chance of survival, he needs to be moved to a specialized burn unit.
We pour fluid into his veins, trying to keep up with the massive evaporative losses caused by the absence of skin cover. Protein is leaking from his vessels into his tissues; the osmotic pressure is taking more fluid with it. The alveoli of his lungs are filling as a protein-rich slush—leaking from his blood vessels—exudes into them. Those tiny, all-important sacs—which allow air to be brought into contact with blood and oxygen to be exchanged for carbon dioxide—are becoming waterlogged. Things will get worse before they get better. We must move now. Tomorrow he may be too sick. But the closest specialist bed is more than two hundred miles away, too far for a safe road transfer. We’ll need an aircraft. That’s why the helicopter pilot is here, still doing sums in his head, weighing benefit against risk, as the patient slowly drowns in his own juices.
—
WE DO NOT THINK OF SKIN as an organ in the conventional sense. It lacks the solidity and the discrete locus of the more familiar viscera. That elastic but porous covering stretched over your frame, folds of flesh and imperfections that you know well enough to take for granted, fulfills an essential task. It is no less important to your continued survival than a heart or a pair of lungs.
It is tempting to think of skin as if it were simply a barrier, a line of separation between you and the world outside, a convenient way of preventing your viscera and tissues from sloshing about in an unsightly way.
It does indeed protect, but as a description of purpose and function, that is the grossest of understatements. It does much more than act as a bulwark against the abrasive world outside: It is the first line of defense against the microbial hordes massing on its surface; it prevents the excessive evaporation of the body’s precious fluids; it harbors an exquisitely sensitive array of detectors that warn us of harm and allow us to respond fast enough to avoid further injury; and it thermoregulates to keep us warm when it is cold or cool us down when it is hot.
Skin is deeper than you think; in some areas of the body it is up to a fifth of an inch thick. The stuff at the top is dead, a keratinized layer that serves the purpose of physical protection. Below that layer is living, moist tissue that needs nutrients and a blood supply and is vulnerable to attack and injury.
If you take a microfine slice vertically through skin and examine it under a microscope, you can see the cellular structure of its layers. The specimens must be stained, otherwise the cells are largely clear and colorless. This is histology, the study of the microscopic anatomy of cells and tissues.
In my first year at medical school, I spent many hours staring into microscopes, trying to make sense of what appeared to be little more than washes of pink and purple abstract art. At the end of the course, we were supposed to be able to identify any number of organs and tissues from their microscopic appearance alone. It was like trying to identify different nations from close-up, unlabeled photographs of their fields and pavements. Sitting in long rows along laboratory benches stacked with microscopes, we strained our eyes to link the lecturer’s elegant verbal descriptions to the purple mess visible through the eyepiece. Some of the slide material was pink with wavy strands, like streaky bacon, and we were assured that this was a perfectly acceptable descriptive term for that tissue. In time, and with a little help, the underlying structure began to make sense—though not to everybody. One of my colleagues famously failed the first-year, one-hour histology exam, having written only the desperate words “It all looks like bacon to me!”
When you finally get your bearings, you can see that the skin is organized into distinct strata. The topmost layer, the epidermis, forms the tough barrier with which we feel so familiar. The cells of the epidermis are densely packed and further subdivided into layers. The base layer consists of stem cells that boast large purple-staining nuclei. These cells mature, eventually losing their nuclei and acquiring filaments of keratin, making them more rigid. As they develop, they ascend through the epidermal layer toward the surface, finishing at the top to form a tough protective layer of dead cells.
That layer tends to reinforce our image of the epidermis as a durable but passive barrier to the outside world. Yet it is anything but passive. The layers of epidermal cells, constantly being born and marching forward, are like a never-ending conveyor belt of foot soldiers throwing themselves at the wire. They mount a spirited defense: They create a dry and acidic environment hostile to bacterial growth; their tentaclelike appendages seek out and destroy foreign bacterial cells, and they secrete enzymes and fatty chemicals to further deter would-be colonists. The fight at the surface is fierce—a war against perpetual mechanical, chemical, and biological attack. Consequently the rate of attrition among these cells is high. For a single epidermal cell, that journey—from birth in the basal layer to combat maturity on the surface of the epidermis—takes something like six weeks. The rate of replacement must match the rate of loss, and the entire epidermal layer turns over every forty-eight days.
But the epidermis, the layer that we casually refer to as our skin, represents only what we can see. The epidermal layer is relatively uniform in appearance: stacks of purple-staining polyhedral cells topped by a paler weave of pink. Beneath this there is the dermis, which under the microscope looks like a vertical section through a chaotically planted vegetable garden. There are microscopic structures here that look like the cut surfaces of onions. That baconlike connective tissue is found here, dotted with strange-looking whorls, blood vessels, and tubes. Here the skin becomes more recognizable as an organ, run through with a network of glands and vessels and studded with organelles. It is from this layer that the skin derives both its elasticity and its supply of blood and nourishment.
Together the epidermis and dermis form a waterproof but breathable layer. They have pores that are small enough to prevent ingress of water droplets but large enough to let molecules of water vapor out. Gore-Tex clothing attempts to do the same thing, but as a breathable and waterproof barrier, it achieves only the very palest imitation of skin.
But it is the sensory array that is perhaps the skin’s most remarkable feature. Able to resolve point contacts little more than a millimeter apart, it’s capable not only of registering heat and cold but also of differentiating between a lover’s caress and pain from a needle tip. Your skin is honed to provide a series of ever changing inputs in response to the cruel world outside, and these inputs shape your behavior in such a fundamental way that you are barely aware of the process.
That holiday in the sun that you seek, the sensation of warmth on your skin, is in part a product of the pattern of receptors that activate in response to incident radiation. Think of summer; think of winter; think of plunging headlong into a pool of water. Chances are that the first thing that enters your mind is that inexpressible pattern of skin receptor activation that we interpret as warmth, cold, or wetness.
The clothes that you are wearing right now are in part chosen because of the way they feel on your body. The receptors in your skin help you decide to move away from drafts, cause you to retreat from the roar of the fire, or urge you to get out of a chilly pool of water. Few sights, odors, or sounds could compel you to behave quite so urgently.
Consider this finely tuned early-warning system linked to a consciousness that understands both luxurious pleasure and intense pain. Then imagine setting it on fire.
—
THOUGH PAINFUL, superficial burns involving only the epidermis are little more than that. Reddened by the dilation of blood vessels beneath and the inflammation of the tissues, they are rapidly healed and restored by the perpetual marching of those regenerating epidermal cells.
Even burns that extend below, into the upper two thirds of the dermis, retain the ability to heal and cover with new skin. A patch injured in this way generates islands of new epidermal cells that spread and eventually coalesce, replacing what was lost. These burns leave the bulk of the sensory architecture intact and are exquisitely painful. Damage to the tissue around pain receptors leaves them constantly firing. Inflammation—the process that marshals cells of the body’s defenses to fight infection and deal with injury—retunes the pain receptors, making them hypersensitive. The same process brings fluid into the wound, which produces the blistered, weeping appearance, separating healthy tissue from that which is dead or irreversibly injured.
It takes great effort to survive a serious burn. Certainly they are among the most formidable injuries to manage in emergency medicine. After determined and skillful resuscitation, specialist burn treatment must follow. This care is complex. In addition to repairing and replacing damaged skin, it must also accomplish the difficult task of compensating for the failure of an essential organ.
—
THE MAN WE ARE TRYING to cram into the back of that helicopter has already been the object of frenzied medical attention.
Burned larynxes can swell and occlude; smoke inhalation can prevent the lungs from exchanging oxygen and carbon dioxide; and poisonous gases—carbon monoxide and fumes from burning furniture and building materials—can asphyxiate. All of these will kill victims of fires in minutes or even seconds, long before the consequences of any external burn injury can manifest.
Yet if the opening minutes of the injury can be survived, the damage to the skin leaves a formidable constellation of problems. The vapor barrier function is lost, and the body’s water evaporates uncontrollably from denuded body surfaces at a rate that is difficult to anticipate intuitively. The losses are both invisible and incredibly rapid. Without the cover of skin, your body dehydrates as surely as a wet sponge left out in the sun. And the burn itself triggers a severe inflammatory response in the body, compromising the integrity of the blood vessels, making them more porous and permeable, letting them spill fluid into surrounding tissues.
Such is the severity of this reaction that at the start of the twentieth century, victims with as little as 10 to 20 percent full-thickness burns over the surface area of their body would often die.
Thankfully, that has changed, but when it comes to burns, the extent of the surface area involved remains one of the key prognostic indicators. In the care of burns, we were taught a rule of thumb: the percentage area of body involved in a full-thickness burn plus the age of the patient gave the percentage chance that the patient would not survive. A sixty-year-old man with full-thickness burns over 40 percent of his body, for example, would not be expected to live. Today that is an outmoded concept; older people with more extensive burns are surviving against expectations, due in large part to the efforts of specialist burn units and the hard-won lessons of the twentieth century. Aggressive resuscitation with fluids, trauma systems, and early transfer to specialist units all helped to improve survival rates.
But in 1940 the medical fraternity knew little or nothing of all of this. For a pioneering generation of RAF fighter pilots, immolation was a risk they took every time they climbed into the cockpit. It’s their experiences that have shaped—and continue to shape—the scope and ambition of burn treatments to this day.
—
ON AUGUST 31, 1940, the Battle of Britain was reaching a critical phase. The Luftwaffe was mercilessly bombing the Royal Air Force’s airfields. Fighter Command was losing aircraft faster than they could be replaced, and the remaining pilots were fatigued. Throughout the south of England, fighter squadrons had scrambled time and time again to meet waves of German bombers escorted by Messerschmitt fighter planes. In the heat of that combat, the air was full of glowing munitions and crisscrossing aircraft. At RAF Kenley, on the outskirts of South London, thirty-two-year-old Tom Gleave had taken over command of 253 Squadron from Harold Morley Starr, who had been killed the previous day. Despite the ever-present danger, Gleave still found it impossible not to be captivated by the spectacle of the world as seen from the air. Scrambling from Kenley that day, he climbed quickly into a perfectly blue sky and dazzling sunlight. North of him lay the River Thames, glittering as it snaked its way through the London sprawl; to his south he could make out the Kent coastline shimmering in the summer haze. Below, unfurling at hundreds of miles an hour, rolled the patchwork quilt of the English Home Counties.
Having shot down no less than five Messerschmitt 109s while on patrol the day before, Gleave was in confident form. With reports of a large formation of enemy aircraft converging to attack Biggin Hill Airfield, Gleave turned with his section of three Hurricanes to assist in its defense.
Plowing north, Gleave searched the sky for evidence of the enemy. Suddenly he found the sky above him dark with aircraft: column upon column of Junkers 88 bombers. He and his section remained unseen, less than a thousand feet below and beyond them.
Keen to press the attack before the German turret gunners had a chance to fire, Gleave pulled the nose of his Hurricane up, took aim, and raked the fifth bomber in the line with cannon shells. The smell of spent cartridges filled the cockpit; the Hurricane’s nose dipped with the repeated recoil of the guns. Gleave pulled the control column, kicked hard on the rudder pedal, turned, and dived away. Leveling out, he began to climb again, attacking another bomber in the formation. For his third pass, he decided he would take on the lead aircraft, which had already begun its dive in preparation for a bombing run. But before he could maneuver into position, he heard the click of a round striking his aircraft and felt a sudden heat rising in the cockpit.
Gleave glanced down. Flames were pushing into the right side of the cockpit from below; the fuel tank buried in the root of his starboard wing was alight. He rocked the Hurricane hard and slipped it sideways in the vain hope that this would somehow quell the fire. But the flames only grew fiercer, wrapping round his feet and climbing to reach his shoulders. Plywood and fabric burst rapidly into flames around him, accelerated by fuel from the breached tanks. In a few short seconds, the center of Gleave’s cockpit had become the head of a blowtorch. The aluminum sheet in which the dials of his control panel were set began to melt. But he was far too high to ditch the aircraft; there was nothing he could do but attempt to bail out.
Gleave was still tethered to his vehicle by the oxygen mask and radio cord attached to his helmet. He reached down to rip these from their attachments, but the searing heat beat him back. With his arms outstretched he could see the skin of his hands bubbling and charring. He unclipped his harness and tried to raise himself from his seat, but could no longer find the strength. Trapped with his plane ablaze and falling from the sky, Gleave’s hand fell to the butt of his service revolver and momentarily he considered a quicker, less painful end.
However, there was one last chance. If he could open the canopy, pitch the aircraft forward and flip it over onto its back, then perhaps the maneuver would fling him out. Gleave tore his flying helmet off, severing his last connections to the Hurricane. He slid the canopy open, shoved the control column forward, and then everything around him exploded.
He found himself propelled for many yards, enveloped in a ball of flames, finally breaking free into thin air and then tumbling toward the ground. His burned hand now reached again, not for releases or a revolver, but for the D-ring of his ripcord.
Finding it, he pulled hard and felt the unfurling of his parachute and a comforting tug as its silk canopy inflated above him. The roar of his engine and the cockpit inferno had been replaced by silence and a serene view of the English countryside that oscillated gently as he swung to and fro beneath his parachute.
He hit the ground hard and fell onto his side, somehow managing to avoid further injury. Releasing his parachute, Gleave eventually found the strength to get to his feet. His boots and socks appeared to be intact and largely unburned. But that was where normality ended.
His trousers had gone except for a small patch protected by the parachute harness. Above his ankle, the skin over his right leg had blistered and ballooned along its whole length. His left leg was in much the same state, save for a patch of skin over his thigh which had been relatively spared. The underside of his arms and elbows were burned, and the skin hung in charred folds from his hands and wrists. His head and neck, too, had been exposed to the inferno, and his eyes were little more than slits. His nose had been all but destroyed.
Somehow he staggered across the field toward a gate on its far side, shouting for help as he went. “RAF pilot,” he blurted out. “I want a doctor.”
—
YOU CAN JUST ABOUT BEAR TO hang on to a mug of hot tea at 42°C. (108°F.). That’s just ten degrees higher than your normal core body temperature. It’s pretty unimpressive, really, but that is where the limits of human endurance lie. The sensation that forces you to drop the cup is set in motion by a clever receptor: a weave of proteins in the dermis attached to an ion-channel control that opens or closes depending on how hot the channel is. The proteins convert the sensation of heat into pain.
For a species so wedded to exploration, such a modest thermal tolerance seems strangely limiting. But the proteins that that receptor is built from, and those that stack together to build everything from your digestive tract to your DNA, start to fall apart at 45°C. (113°F.). That’s where the physiology of thermal injury starts. As temperatures climb, cells lose their capacity to self-repair; vessels begin to coagulate, tissues become irreversibly altered and later begin to die. All of this happens as you approach a temperature of around 60°C. (140°F.).
Aircraft fuel, properly supplied with oxygen, can burn at over 1000°C. (1800°F.).
—
TOM GLEAVE WOKE UNDERNEATH a bed in darkness. He was at Orpington General Hospital in the middle of an air raid; the bed was his makeshift shelter. He had survived, but the surgical teams at Orpington had little experience with such severe burns. They had covered his wounds in solutions of gentian violet and tannic acid, the former for its antiseptic properties, the latter as a kind of chemical dressing that would cover wounded areas and then harden as a supposed protective barrier to infection. As a therapy for significant burn injury these measures were at best ineffective. Worse still, they encouraged scarring and infection. The dressings, simple dry gauze and bandages, stuck hopelessly to Gleave’s weeping wounds, pulling off skin whenever they were changed.
Inevitably sepsis set in, and Gleave spent many days slipping in and out of consciousness, hallucinating and delirious with fever. But he rallied and survived this, too. After several weeks, the medical team at Orpington decided to transfer him to the Queen Victoria Hospital in East Grinstead, which had developed a reputation for plastic reconstructive surgery under the leadership of Archibald McIndoe.
When the orderlies arrived to prepare Gleave for the journey, they dressed him in full military uniform, shearing dressings from delicate, partially healed layers of skin. The fact that the medical staff at Orpington allowed this reflects how little was understood about the nature and therapy of burn injuries at that time. But the hellish, seventeen-mile road trip to East Grinstead delivered Gleave to the care of McIndoe and his team and the start of his reconstruction and rehabilitation.
—
WARD 3 AT QUEEN VICTORIA HOSPITAL was a wooden-walled hut linked to the main hospital building by covered walkways. Within resided a cadre of men disfigured by fire, and in 1940 the most severely injured of these were Hurricane pilots.
To the rear of the ward was an extension that housed a bath through which a warm, weak salt solution was circulated. The bath was arranged so that a flow ran through it, exchanging a gallon a minute. Afterward, drying was achieved by standing the men naked in front of large heating lamps, thus avoiding the abrasion of toweling. The pilots came to call this the Spa, and it was into this tub that Gleave, with some trepidation, found himself being lowered on the evening that he arrived.
He needn’t have worried. His wounds were bathed properly for the first time, and old dressings floated away without pulling skin with them. Later his cleansed wounds were dressed with Vaseline-coated gauze: an invention of McIndoe’s that covered the wound but kept the dressings from sticking.
A few days later, McIndoe came to Tom’s bedside and explained what needed to be done. It would take many months and dozens of surgeries, McIndoe explained. “You won’t like it,” he said, “but it’ll be worth it.” Something in the manner of this surgeon, standing there peering at him through horn-rimmed glasses, gave Gleave confidence. And for the first time since the inferno, he felt as though he had been thrown a lifeline.
Archie McIndoe was a New Zealander, originally invited to the United Kingdom to join the practice of his esteemed older cousin Harold Gillies. Here McIndoe had gotten a taste for the possibilities that lay in reconstructive surgery. Harold Gillies had pioneered techniques of plastic surgery during the First World War, when a sailor burned at the Battle of Jutland was the first patient to undergo this type of surgery. In retrospect, the cosmetic results of these surgeries look primitive at best. But at the time, the idea that badly damaged faces might be reconstructed in this way was revolutionary. It would fall to McIndoe to refine and advance these techniques, and the air war of the Battle of Britain would provide his defining challenge.
First, Gleave got new eyelids pinched from the unburned skin of his thighs. These tiny islands of skin were removed and sculpted into place. They were so small they could rapidly establish themselves at their new location on Gleave’s face, seizing upon the bed of vessels and perfused tissues that lay there waiting to be covered, like a minuscule sod of earth being transferred from one lawn to another. Oxygen and nutrients readily diffused into these small tokens of flesh. And the wounds left by taking these grafts were discrete enough that they could be left to heal spontaneously.
But larger patches can’t be moved in this way; their needs are more demanding. In plastic surgery, the battle, as Harold Gillies once put it, is between blood supply and beauty. A full-thickness flap of skin about the size of an adult’s palm, cut out and moved as a single slab, will die before it has a chance to pick up a new supply of blood.
To get around this problem, McIndoe would raise a flap of skin, leaving it attached at one edge like a trapdoor. This kept the flap alive, supplied by the vessels running through its attached edge, but left it fixed in position. McIndoe would then fold the sheet of skin into a tube, stitching its long edges to each other to protect its raw undersurface from infection.
To move this tube of skin, he would make an incision in the patient’s arm and form a pocket into which its free edge could be tucked. He would then stitch the flap into place, fastening arm to thigh in the process, and wait for it to heal into position. This healing could take weeks, during which the patient was handicapped by the strange new anatomical arrangement.
Once the flap had established itself in the pocket, its link with the thigh could be severed. This arduous process left a flap of skin, previously from the thigh, now drawing its blood supply from the patient’s arm and free to be moved to any location which the arm could reach. This process of walking a tube of skin end over end from one part of the body to another was known as waltzing. Gillies had invented the technique, but McIndoe brought it to maturity, waltzing flaps from larger areas than ever before. It provided the plasticity in McIndoe’s reconstructive technique, allowing him to address larger areas of burn injury by walking skin up from distant uninjured sites.
But aesthetic considerations were at the heart of McIndoe’s work. It was not enough simply to provide protective coverage; cosmesis was essential. Skin is indeed one of the principal organs through which we are able to experience the world. But McIndoe understood that it is also the means through which the world experiences us. When the war started and the toll of burned airmen began to become apparent, it was thought that the best thing you could do with the victims was to institutionalize them away from society with the intention of protecting one from the other. But McIndoe was unwilling to accept this fate for his patients, and his efforts in reconstructing the injured went far beyond surgical innovation. McIndoe would give them new faces, but they in turn would be expected to face the world again.
Ward 3 became famous for its feats of plastic reconstruction and notorious for the antics of its resident airmen. McIndoe resisted the militarization of the ward. The Queen Victoria Hospital was his—quite literally. The Air Ministry had seen that control of the facility was signed over to McIndoe, and it was run by his rules. Military discipline was relaxed, and rank ceased to have significance among the men in the beds—except, of course, when it came to McIndoe, whom they referred to as the Maestro, the Boss, or simply Sir. Beer kegs stood freely accessible on the ward, and at times it came to resemble something like a workingmen’s club.
All of this did something to distract from the grimness of the pilots’ reality. Not only were they assaulted by disturbing odors of char and infection, but they were also exposed to a series of strange new procedures that left them with arms stitched temporarily to thighs, abdomens, and faces, initially leaving them looking more bizarre than even their injuries had.
Confronted with long drawn-out weeks of suffering, with free beer as their only real comfort, the patients of Ward 3 set up a drinking club. At first they stumbled with the name, coming up with the Maxillonians, in reference to their ongoing maxillofacial surgeries. But they quickly realized that this was unwieldy and didn’t quite capture the spirit of their circumstances. They were a new breed of casualty patient under the care of a pioneer surgeon armed with groundbreaking techniques. They knew at heart that they were the subjects of experimentation—however well intentioned. And so the drinking party reformed under a new name: the Guinea Pig Club, with Tom Gleave the first and only chief guinea pig.
The club’s activities moved rapidly beyond drinking and singing around pianos to rehabilitation and support. McIndoe orchestrated trips to East Grinstead. There the soldiers were dispatched, often under protest, to mix with the local population. The people of East Grinstead grew to embrace McIndoe and his army of strangely reconstructed men. They would make every effort to accommodate them, removing mirrors from their pubs, cafés, and restaurants and taking care to give the lives of McIndoe’s Guinea Pigs a veneer of normality. In time East Grinstead became “the town that never stared,” and it served as the perfect preparation for the Guinea Pigs’ reentry into a world that inevitably would.
Gallows humor became de rigueur for the Guinea Pigs. They recruited a treasurer with badly burned legs, so that he wouldn’t run off with the petty cash, and a secretary whose fingers had been injured, so he couldn’t keep minutes. At the start of World War II, the Guinea Pig Club was tiny. But with the onset of the bombing campaign, those numbers rapidly swelled, and by the end, its membership numbered more than six hundred. They were testing times that saw McIndoe and his team forced to refine their techniques as they went, learning from successes as well as mistakes. But these lessons would transform the field of plastic surgery.
—
THE PRACTICE OF MILITARY MEDICINE during the war focused principally upon the salvage of life and limb. McIndoe didn’t save the lives of the Guinea Pigs, at least not immediately. That task was achieved by the hospitals that received them. But McIndoe’s work and the experience of those he treated taught clinicians that there was something at least as precious as life that modern medicine might preserve.
Today plastic surgery has its own image problem. All too often we associate it with tummy tucks and celebrity nose jobs rather than the plight of burn victims.
But plastic surgery retains many of the values that drove McIndoe and his heroic club of Guinea Pigs. It is, in the main, still about the restoration of function and appearance to people whose lives have been cruelly and irreversibly altered by illness and injury. The fact that we, in modern times, have been able to move beyond the pursuit of simple survival is something to celebrate.
Plasticity, in the context of surgery, refers to the ability to mold and alter the appearance of the body. McIndoe was able to find areas of healthy skin and move them to cover those areas that had been destroyed by fire. More than this, he was able to achieve a result that was aesthetically acceptable. But there were limits. These waltzed skin flaps were supplied by an indefinite weave of capillaries and venules running through the layers of tissue. This blood supply was tenuous, and flaps of this type had to be limited in length and breadth if they were to survive. More extensive injuries were not so easily addressed using this technique.
Larger and thicker areas of skin need much greater volumes of blood flowing through them to keep them alive. In terms of blood supply, the situation is akin to the difference between the needs of a village that subsists on the trickle of dozens of mountain streams and those of a city built on the banks of a coursing river.
This problem could, in theory, be overcome if a block of tissue could be harvested along with the artery and vein that supplied and drained it. These vessels could then be connected to the body’s core circulation at the new site to which the graft was being moved. By moving and then connecting a flap directly to the circulation in this way it could be perfused with a rich flow of blood and made viable more or less immediately.
If this could be achieved, then McIndoe’s waltzing flaps would no longer be necessary. Instead free flaps of skin and tissue could be taken and moved in a single operation. No longer would the patient be forced to undergo countless operations and wait contorted for weeks while the tissue established a useful blood supply.
But the vessels that supply and drain such flaps of skin, though huge compared with capillary networks, are still vessels of tiny caliber, and connecting them demanded a level of surgical precision previously unknown. With the naked eye, no one could cut and stitch vessels whose diameter might be little more than a millimeter. For this they would need a new but familiar tool.
By the 1970s, microsurgery was an established technique. The skin, whose anatomy had been so well explored by histologists with microscopes, could now be manipulated surgically using the same tool. In time the use of optical aids to magnify the view of the surgeon became as essential to the art of plastic surgery as McIndoe’s scissors or scalpel. The ability to operate under a greatly magnified field of view made finer procedures, including the connection of blood vessels and nerves, a reality. For the first time flaps of skin, muscle, and bone could be moved en bloc from one location to another in a single bound—the so-called free flap.
This development massively expanded the plastic surgeon’s repertoire and gave rise to a plethora of important and exciting new techniques. But the selection of flaps that could be used was still relatively narrow. Though the grafts made available by this method could be moved quickly and could cover much larger areas, the aesthetic result was sometimes less than satisfactory. Authorities of the time referred to these early, free-flap grafts as “hamburgers of tissue” or “globs and blobs.”
To be of genuine value in aesthetic reconstruction, the library of skin and tissue flaps that plastic surgeons could draw upon needed to be greatly expanded. But knowledge of the vascular anatomy of skin—its relationship to the core circulation—wasn’t yet at a point where this was possible.
In the 1980s, Australian plastic surgeon Ian Taylor recognized this and undertook a massive remapping of the circulation of the skin. In so doing, he reconceptualized the anatomy of human skin and its relationship to the circulation.
Prior to this work, understanding of the connection between the core identifiable vessels of the circulation and the supply of more peripheral structures was poor. The body has a network of named arteries and veins that are reproducible from one individual to the next with little variation. These divide ultimately to form more variable, less distinguishable vessels. By the time they arrive at the planes of tissue underpinning the skin, the network has degenerated into a complex weave of small and largely nameless tributaries.
This was fine if you were a surgeon operating on, say, the heart or the liver, where the principal vessels are generally constant in appearance, well mapped by anatomists and immediately recognizable. But for surgeons interested in moving units of flesh and skin around, it was like having an atlas of Great Britain that included only its highways and then trying to navigate a route to a remote farm in the Scottish Highlands.
Taylor injected radiopaque dyes into the skin of countless cadavers and took X-ray images. He generated stunning images of the network of small but remarkably consistent vessels that connected the core circulation to the skin and tissues above.
Understanding these connections and the routes that vessels took as they rose up from deeper structures, weaving between planes of muscle and fat, allowed him to deconstruct the body into a three-dimensional jigsaw puzzle. Taylor called the pieces of the jigsaw angiosomes, and together the pieces constituted a library from which units of tissue, skin, and bone could be drawn and reliably transferred to almost anywhere on the human body. But the battle between blood supply and beauty was far from over.
—
THE FACE DERIVES ITS BLOOD SUPPLY from a branch of the carotid artery. This divides low in the neck into a deep internal branch and one that runs more superficially. It is from the superficial division that the face gains its blood supply. From this there are branches aplenty, enough that we as doctors in training employed a variety of mostly obscene mnemonics to help remember them.
Run the tip of your finger gently back along the line of your jaw until the point just before it turns up toward your ear. At this point you can feel the pulse of the facial artery as it runs just below the surface of the skin.
From here it breaks over the surface of the face, with smaller vessels running above and below the lips and branches that run alongside the nose and then up to the eyes. And this shower of arteries joins with other branches of the external carotid artery that also creep across the face. This arrangement supplies both the facial skin and well over a dozen muscles that are involved in eating and facial expression. Surgeons had feared that the complexity of the arterial blood supply might prove an insurmountable challenge when it came to attempts at full face transplants. But more recently doctors discovered that the blood vessel connections required to supply and drain the face might be fewer and simpler than previously thought. This realization took the full face transplant from a thing of science fiction into the realm of science fact.
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THERE IS SUCH A THING as life after death. It’s called transplant medicine. After death a patient’s heart, lungs, liver, and kidneys can be donated to give the gift of life. Many lives can be saved or improved by that single act of generosity. But death must come first.
In the United States more than one hundred thousand people are currently waiting for an organ transplant. The list is growing quickly; on average a new name is added every twelve minutes and demand outstrips supply. Each day in the United States eighteen people die waiting for an organ transplant. It is possible for patients to receive an organ, removed from a donor, after the heart has stopped beating. This is called non-heart-beating organ donation and it has greatly increased the numbers of organs available for lifesaving donations.
But waiting until the heart has stopped beating before beginning the transplant process means that the organs become deprived of a fresh supply of blood and oxygen. Once that has ceased, the organs begin the process of dying, and there is a greater risk that they will fail to function properly after transplantation.
Some organs are more resilient than others. Kidneys in particular can endure long periods of little or no blood supply and still be resuscitated. But organs with higher metabolic demands, such as the lungs and the heart, fare less well. It is because of this that a new definition of death was coined around the time of the first heart transplants, to give surgeons the best chance of obtaining a heart that might survive the transplant process and function well.
After severe head injuries, the brain can sometimes be so damaged that its higher functions are lost, leaving only the most essential reflexive processes intact. The intrinsic rhythms that drive your heart or the automated activity that drives your digestion, for example, can continue even if everything that is essentially you has ceased to be.
This is brain-stem death: the irreversible and permanent loss of consciousness and cognition. It is as final as the state that accompanies the standstill of a heart and the arrest of breathing. A heartbeat may remain, and breathing might be supported artificially, giving the outward appearance of life, but the elements that define a human being are no longer present. The organs continue to be supported by the beating heart that remains, even though death has already occurred. But it is from these tragic losses, usually from accidents or massive strokes, that the best hope of new life can come. Brain death allows organs to be given in the best possible condition.
The conversations that we have with the relatives and close friends of patients, in softly lit rooms on hospital corridors, are among the hardest in all of medical practice. For the team that approached a recently bereaved family somewhere in New England in March 2011 to ask for their consent to donate not only a heart or a liver but also a face, the task must have seemed impossible.
The doctors took their time, talking over the intricacies of the procedure. They told them that it was among the first of its kind in the world—and in that respect as experimental as much of McIndoe’s early work. There could be no coercion, only openness.
There were, however, reassurances. The transplant team made clear that the recipient of the donated face would not resemble their loved one. Once transplanted, the face, laid upon a new underlying structure of bone and tissue, would be as unique in appearance as any other. Neither identity nor appearance would be transferred.
But there were also difficult realities to confront. After the retrieval of a face, efforts are made to reconstruct the appearance of the donor. Casts of the face are taken, and silicon masks are sometimes fashioned. But none of these restores the donor’s appearance enough to allow the body to lie in state in an open casket. All of this had to be understood and accepted. After deliberation and despite the magnitude of the request, the family members gave their consent.
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THAT DAY, PLASTIC SURGEON BOHDAN POMAHAČ was sitting in the back of a private jet taxiing on the runway at Boston’s Logan Airport, waiting to take off. He was leading a transplant team, making ready to retrieve a donor organ. The plane was one of several regularly chartered by the hospital’s transplant service. Hearts, lungs, livers, kidneys, and other organs were ferried urgently across the United States in this way. But this mission was different. That evening Pomahač was going out to retrieve an organ as a prelude to a procedure that the United States had never before seen: the transplant of a complete face.
Pomahač had waited a long time for this opportunity and had fought hard just to gain permission to attempt the operation. At the time, only one other full face transplant had ever been carried out—by a team in Spain a year earlier. Pomahač was nevertheless convinced that this procedure offered the only real hope for people who had suffered catastrophic facial injuries. But not everyone was of the same mind. He petitioned the institutional review board (IRB) at Brigham and Women’s Hospital repeatedly. The board, tasked with making sure that both the science and ethics of the proposed procedure were sound, was supportive but took some time to be convinced. The difficulty was that, unlike other transplant surgery, the transfer of a face did not ameliorate life-threatening illness. The review board had to weigh the very real risks of the procedure against its perceived aesthetic benefits.
It wasn’t just the surgery that might present a threat. To be able to accept a transplant from another individual, the recipient’s immune system must be heavily suppressed to stop the newly grafted organ from coming under attack. For ordinary organ transplants, the tissue type of the donor organ must be matched as closely as possible to that of the recipient. Part of the body’s formidable defense against infection is its ability to distinguish foreign proteins and tissues from its own—a function fulfilled by the white blood cells patrolling in our circulatory system.
Once recognized as “other,” foreign bodies are attacked by battalions of immune cells. These cells damage, destroy, and later engulf. Without this defense, the simplest of infections would prove lethal. But if you want a patient to receive an organ transplanted from another individual, these defenses work against you. The newly grafted organ is detected, attacked, and eventually rejected by the body.
During World War II, plastic surgeons were aware that skin grafts taken from donors related to the recipient survived longer than those taken from unrelated individuals. Precisely why this should be the case was unknown, but it gave cause for thought. Archie McIndoe himself had observed that grafts could be exchanged between identical twins without fear of rejection. Today donor and recipient are matched as closely as possible with respect to specific marker proteins expressed by their cells. The closer your genetic code, the more likely these proteins are to match. These proteins are like flags on the mast of a ship at war, announcing its sovereignty and distinguishing it from the naval vessels of a hostile foreign power. For the cells of the human body, exhibiting the wrong surface-marker proteins is akin to flying hostile flags and provokes attack.
Matching surface proteins as closely as possible provides a degree of protection, but ultimately it only delays the onset of rejection. To ensure graft survival, the recipient’s immune system must be suppressed, risking overwhelming and potentially fatal infection. Pomahač’s many appeals to the IRB at Brigham and Women’s Hospital had opened the door, but each case would still have to be decided on its individual merits. Pomahač began a search that would lead him to Dallas Wiens.
Pomahač first heard of Dallas at a meeting of the American Society of Plastic Surgeons in 2009. The surgeon was due to present case reports of successes that he had had with partial face transplants. But speaking before him was Dr. Jeff Janis, a surgeon from Texas, who told the story of a man who had suffered the nearly total destruction of his face by high-voltage electric current. Dallas Wiens had been helping to paint a church in his hometown. He had climbed into a cherry picker in order to reach the roof. What happened next remains unclear. As the basket containing Dallas rose from the ground, he appears to have gotten close enough to a high-voltage power line for it to discharge through his body for many seconds, nearly long enough to kill Dallas and more than long enough to burn and almost completely destroy his face.
Dallas was resuscitated in the emergency room of the Parkland Memorial Hospital in Dallas, Texas. The scenes would have been distressing even for seasoned health-care professionals. Electrical burns are caused by the heating effect of the current as it passes through tissues. The resultant burns run deep, and electrical involvement of the heart can lead to immediate cardiac arrest. The power line had discharged through his head, heating and then burning the full thickness of skin over his entire face. The charge running through his body cauterized his face, reducing it to a coagulated mass.
Dallas was close to death when he arrived at Parkland. The resuscitating surgeons wondered how hard a fight for life they should mount. Seeing how completely his appearance had been destroyed, they initially wondered if anyone would want to survive in such a disfigured form.
A face fulfills a role that goes well beyond appearance. Its orifices form the conduits through which air is conducted into our lungs and through which food begins its journey down into our digestive tract. It is the sole seat of three of our five senses: sight, smell, and taste. From what the resuscitating team could see, much of that had been utterly obliterated. Even if Dallas could be resuscitated, what quality of life could this man possibly hope for?
Nevertheless, they continued, and later Jeff Janis’s plastic-surgery team would cover Dallas’s head by raising large, free flaps of tissue from his back and moving them up onto his face. But Janis was open about the fact that this effort was a lifesaving measure whose goal was to cover and manage the wound left by the electrical burn. Even after this work had fully healed, it was clear that Dallas would need a more radical solution if any meaningful reconstruction were to be realized.
In the presentation that Pomahač saw, Dallas looked as though he had been massively injured. A huge featureless graft had been pulled into place where his face had once been. Pomahač remembers thinking to himself that the man in the slides was so completely disfigured that he no longer looked human.
After they got off the stage, Janis and Pomahač got to chatting. Having heard of Pomahač’s pioneering work in the field of partial facial transplants, Janis suggested that perhaps Pomahač’s team at the Brigham could help Dallas. But Pomahač was pessimistic; he was unsure how much of the structure of the face remained intact underneath the graft. To be reconstructed, Dallas would need a full face transplant and for this the underlying blood vessels would have to be intact. Judging by the details of the medical report and the photographs of Dallas that Pomahač had seen, he doubted that this could be the case.
Still, he decided to investigate further. Pomahač brought Dallas to Boston and began to assess him. Many aspects of his injury were at least as bad as he had feared. He was blind and had lost one eye. The structure of the nose had been entirely destroyed; he had no lips, and where there should have been a mouth, there was only a slit. Dallas was reduced to drinking through a straw, and when he ate, he had trouble keeping food in his mouth. He could just about speak, but the words were sometimes muffled and difficult to comprehend.
But as Pomahač came to know Dallas better, he couldn’t help but be won over by the force of his personality. Here was a patient who remained positive despite the accident and open about the disfigurement he had suffered. He was also realistic in his expectations and clear about his motivations. The injury had left Dallas blind and so, one might assume, less conscious of his facial features. But the opposite was true. In conversations with Pomahač, Dallas explained the profound discomfort he felt in sensing the reactions of others to his appearance—the silence that fell in a previously busy restaurant when he sat down to eat and the hush that filled rooms in his presence. He was acutely conscious of all of this. But most of all, he worried about how his young daughter would cope with questions and comments from friends as she grew older.
While this didn’t alter Pomahač’s technical decisions, it certainly shifted his emphasis. He wanted desperately to help this man, a feeling that went beyond the ordinary duty of care.
Pomahač had been preparing for the possibility of performing a full face transplant for more than two years, assembling a crack team from various medical disciplines. He knew that the surgery itself was just the centerpiece; a host of clinicians and other health-care professionals would be necessary to make Pomahač’s ambition a reality. For this plunge into the unknown, he would have to make sure that his team was meticulously prepared. This responsibility he gave to his friend and colleague Tom Edrich, an anesthetist.
By this stage, the team was on call twenty-four hours a day, waiting for the phone to ring summoning them to action. Meanwhile, there was plenty to think about. Where should the intravenous lines be sited? What degree of immunosuppression would protect the graft from rejection without running unacceptable risks? For Edrich there was the question of how to prevent the patient’s airway from closing and suffocating him after the anesthetic had taken effect. Normally he would insert a tube through the mouth and thread it into the windpipe. But with burn patients, mouths were often too badly distorted to allow this to happen.
Meanwhile, the question of whether or not Dallas could be a candidate for facial transplantation depended upon the state of the blood supply that remained. Pomahač’s team set about conducting an extensive mapping of his vascular anatomy, injecting liquid opaque to radiation into Dallas’s veins and performing computerized tomography (CT) scans and magnetic resonance imaging (MRI) to reveal the delicate network of vessels woven below.
After many weeks of assessment, Pomahač’s team decided that, despite the apparent damage, the key blood vessels remained intact. There was a good chance that Dallas would be able to receive a face transplant. Pomahač began working him up as a candidate, profiling his immune type so that the transplant teams could begin their search for a donor who was a suitable match. All that then remained was for them to find a donor whose immunotype was a close enough match.
They waited for several months. Then one day Edrich’s phone rang. It was Pomahač, and though his voice remained level, Edrich could detect more than a hint of excitement. “We’ve got a face,” he said.
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FOR THE NEXT TWO DAYS, nobody involved in the face transplant slept very much. Dallas was told to make his way from his home in Texas to the Brigham and Women’s Hospital in Boston as quickly as he could. Meanwhile, Pomahač set out aboard a jet aircraft to retrieve the face from its donor. He was not the only transplant surgeon on the retrieval mission. Under ordinary circumstances, organs are retrieved in a carefully orchestrated sequence: first the kidneys, then the liver, and later the lungs. Once the other organs are taken, it is no longer necessary to supply the body with oxygenated blood, so the heart too can be removed. But in the years preceding this first attempt at a face transplant in the United States, Pomahač had agreed with the New England transplant coordinators that the retrieval of the face should happen first, despite the fact that it wasn’t a lifesaving organ.
After removal, an organ can be deprived of its blood supply for only a short time before it fails and dies. Measures are taken to extend that period for as long as possible, including ice boxes and preservative solutions. But even with these, the time that organs can survive without being plumbed into a recipient’s new blood supply is limited to a few hours, so the timing of the retrieval of Dallas Wiens’s new face was critical.
As other transplant teams from around the region geared up to perform their retrievals, Pomahač received a phone call. A patient in urgent need of a heart transplant had been identified, and there was no time to waste. The coordinators were clear: lifesaving transplants took priority. Pomahač was told to leave Boston within the hour and that, upon arrival, he would be racing the clock. As he scrambled his medical team in Boston, his heart sank. Earlier in the year, he had performed a partial face transplant; on that occasion, the retrieval had taken six hours. Today he guessed he would have not much more than two.
This presented a huge challenge. The retrieval of a donated face is in many ways a task far more complex than the removal of the more familiar solid transplant organs. It must retain form and function, and dozens of decisions must be made regarding what muscle, tissue, and bone to take and how.
Pomahač worked as fast as he could, with the other transplant teams beginning to circle. After two hours, they had no choice but to ask Pomahač to step aside. With the retrieval of the face only partially complete, the removal of the solid organs had to begin. Finally, when the heart-transplant team left with their vital organ in hand, they took with them the blood supply to Pomahač’s donor face.
From this moment onward, the face was beginning to die. The team ran cold preservative solutions through its vessels to protect it, but this could buy only so much time. If they were not back at the Brigham with the new face connected to Dallas’s circulation in less than four hours, all would be lost. Now the last surgeons left in the operating room, Pomahač’s team worked furiously. When they finished, the face had been without a blood supply for over an hour and still had to be transferred by road and air back to the Brigham. It was going to be close.
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BACK IN BOSTON, EDRICH WAS MAKING his preparations. The team was assembled, the operating room ready, its microscopes and surgical sets prepared. Dallas, accompanied by his grandfather, was ushered into the operating theater suite. There was no time to lose; the face being brought by Pomahač would be fading. Dusky and starved of oxygen, its tissues were slowly dying. To survive, it needed a new host and a new supply of blood.
Dallas was anesthetized almost as soon as he arrived. Edrich sited drip lines in his veins through which to give fluids and drugs and another line in an artery to monitor the blood pressure directly, with beat-to-beat precision.
By the time Pomahač reached the Brigham hospital, the skin of the donated face was by now a dull thundercloud gray—the color of tissue and blood that has been stripped of its oxygen. It would not be long before it ceased to be viable at all.
Pomahač had to move quickly. He dissected out Dallas’s external carotid artery. Having divided it, he pinched the free ends shut with an artery clamp. Then he began the delicate work of connecting that vessel to the face that he had just delivered. Working quickly, Pomahač threw stitch after stitch into place. Having made the connection, he released his arterial clamp. For the first time in nearly four hours, blood ran into the oxygen-starved tissues. The face blushed pink.
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AFTER TWENTY-ONE HOURS of paring back tissue, stemming dangerous hemorrhages, and connecting blood vessels, muscles, and bones, the operation was finally complete. The orchestra of surgeons withdrew, and Edrich’s anesthetic team handed the patient over to the intensive-care unit. But Pomahač, despite having been awake for nearly forty-eight hours, wasn’t quite ready to go to bed. Once Dallas was settled in the ICU, Pomahač visited his room. After checking his patient’s new face, Pomahač told the nurse that he was going to take a shower and change his clothes, but that he would be back to spend the night at Dallas’s bedside.
“Dr. Pomahač,” she said with a smile, “I think we can take it from here.”
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DALLAS’S NEW FACE WASN’T immediately perfect in appearance. The tissues were swollen and bulky, and the lines of surgical incision were evident. The face itself remained largely inanimate and without sensation. Pomahač had expected all of this. It would take time before the full benefits of this procedure would make themselves known. But even in those early days, it was clear that Dallas had been transformed. He bore almost no facial resemblance to the man who had been injured in that cherry picker more than a year earlier. But now, where there had been a blank canvas of skin, there were individual features: a nose, eyes, a mouth, lips, and the more definite bony contours that make a face recognizable.
Further sculpting of his features was necessary. Once the swelling had subsided, Pomahač trimmed excess tissue. Nerves and muscles needed time to become reeducated. But when Dallas returned many months later, it was clear to all that the surgery had been a great success. His appearance was improved to the point where he might enter a room without anyone giving him a second look.
More impressively still, the nerves had begun to establish themselves. Dallas could now begin to express himself once more—relearning how to smile and frown. He even regained his sense of smell. But most important of all, he gained sensation in the skin of his new face. For the first time since his accident, he could feel his daughter’s kisses on his cheeks.
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THE TALE OF DALLAS WIENS’S FACE tells us much about medical science’s most spectacular triumphs, but it is in burn units all over the world where the everyday battles against fire are being won by slow and painful increments.
Without McIndoe and his Guinea Pigs, the man lying in front of me now, body ravaged by burns, would have no hope of being restored to something of his former life. As it is, at least we can give him a fighting chance—providing we can get to the specialist unit in time.
We finally close the doors on our helicopter. The rotor blades spin up, the motors whining as they get up to speed. We rise backward from the helipad with the idea that, should the overloaded engines fail, we have an outside chance of crashing into the helipad rather than the streets below. The oxygen levels in my patient’s bloodstream continue to fall.
An aircraft alarm begins to ping in the cockpit. It is continuous and sounds malignant. I look around at the patient buried in wires and tubes, at the equipment we have jammed into the rear of the vehicle. The cabin is packed. We have wedged the gear in around the crew, me, and Louise, the nurse. I imagine the strain on the engine and rotor blades. The ping of the alarm persists. It is, at this early point in the flight, a mystery to me how we’ll manage to get our helicopter safely to its destination.
“Don’t worry,” says the pilot, as if reading my mind. “Everything gets easier once you start moving forward.”