Risal Djohan, M.D.
Plastic Surgeon, Cleveland Clinic
Wednesday, May 6, 2009 2:30 PM
Five years ago, a shotgun blast left a ghastly hole where the middle of her face had been. Five months ago, she received a new face from a dead woman. Connie Culp stepped forward Tuesday to show off the results of the nation's first face transplant, and her new look was a far cry from the puckered, noseless sight that made children run away in horror.
Risal Djohan, M.D., staff surgeon in the Departments of General Surgery and Transplantation at Cleveland Clinic and member of the team that performed the transplant, was online Wednesday, May 6, at 2:30 p.m. ET to discuss the operations and the recovery.
Risal Djohan: Hi, this is Dr. Risal Djohan of Cleveland Clinic. I am part of the face transplant team here and look forward to taking your questions.
Southern Maryland: I think she looks beautiful.
I see a person who has survived a murder attempt and then had to live with unimaginable challenges. On top of it all, she had the courage to participate in the surgery and all that surgery and recovery entails. When I see her, I see a woman of great courage and determination. I see a beautiful woman who is a role model for many people. I doubt she ever knew how strong she was until adversity came to her. For those who look at her and see only the physical, they are truly missing out on the beautiful soul that radiates within her.
Risal Djohan: You're right. She's a beautiful person with a strong will and high spirit. She has approached everything in such a positive manner and we couldn't have done this without her wonderful attitude.
Fairfax, Va.: How many operations did it take to get to this point, and how many more are needed?
Risal Djohan: There have been six major reconstructions with a total of 30 operations prior to the face transplant. We expect two to three additional operations for improvements, including the removal of excess skin/tissues. That skin and tissue was deliberately placed to allow for the healing process.
Baltimore, Md.: She looks much better than before the transplant, but she also looks very different from the picture of her before the shooting. Will she wind up looking more like the donor than her previous self?
Risal Djohan: She won't look like the donor, nor will she look like herself before the shooting. The transplant involves combining components of the donor with components of Connie's face.
Washington, D.C.: I read that you said, initially upon being introduced to her case, that you weren't sure you could help but that you'd try. Was this plastic surgery an extremely difficult one? Why?
Risal Djohan: Her problem was severe and our traditional reconstructive tools are limited -- there was no satisfactory way to reconstruct all of her problems through conventional plastic surgery. There was a limited amount of tissue available to work with; the extensive nature of the blast injury resulted in a substantial amount of scarring.
After trying to use standard techniques, Connie wasn't satisfied and we weren't satisfied. The next option was to attempt a face transplant.
The face transplant presented plenty of challenges because we had never done it before and it also entailed significant risks.
Reston, Va.: What type of person do you look for in a groundbreaking surgery like this, i.e. what is the psychological make up of such a person? Failure of the transplant would be psychologically devastating.
Risal Djohan: We had to have a patient who was optimistic and resilient -- and one who also had reasonable expectations.
What was involved in the transplant?: Skin, obviously, and muscles and tendons and nerves, but bone too?
Risal Djohan: Skin, bone, pallate, teeth, lip, lower eyelid, nerve, muscle, blood vessels, parotid gland -- basically component of the mid-face.
Chantilly, Va.: How much of a demand in this country is the need for extreme plastic surgery? And how does this particular type of plastic surgery differ from that of the more popular type that people often get?
Risal Djohan: It's difficult to know how many patients are in this situation, but it's not a small number. Most candidates for this type of procedure would be trauma victims. There are a significant number of facial injuries as a result of war all over the world.
Annapolis, Md.: What organs needed reconstruction and does/will she have normal sight, smell and taste restored?
Risal Djohan: (By the way Dr. Rob Lohman, another member of the transplant team, has joined the chat.)
From the original injury, she lost sight completely in her right eye and has limited sight in her left eye. She has an improved sense of smell and taste.
Not to inject any negativity but: What happens to her if her body rejects the face? I am really not familiar with what happens to the patients whose bodies reject donor organs.
Risal Djohan: If she has an episode of rejection, we expect to be able to diagnose it early. With prompt treatment, it should resolve without injury to the face. She has had one mild episode of rejection to date, which was successfully treated with drugs.
Washington, D.C.: Will there always be a risk of tissue rejection? Or does the body get used to the new tissue?
Risal Djohan: We expect she will always be potentially at risk for rejection, however her highest risk is in the first several years. Currently, she is on one drug treatment to prevent rejection.
Arlington, Va.: Obviously Ms. Culp was willing to take the risk. Is she satisfied with the work now? Is there anything she would like changed?
Risal Djohan: She is very pleased with the result, especially with her nose, and she is much more socially confident.
Northwest D.C.: How could she have survived the initial shotgun injuries -- wasn't there a tremendous loss of blood? Was there any brain injury, since the brain is directly behind those facial bones?
Our thoughts and prayers are with her and the reconstruction team -- you are all heroes.
Risal Djohan: She is lucky to have survived. She did not have a brain injury.
Austin, Tex.: What are the likely issues she will face in the longer term (say 20 or 30 years)?
Risal Djohan: She will be on immunosupressant drugs for life. That's the primary issue. Since she is basically healthy, we think she has a potentially normal life expectancy.
Philadelphia, Pa.: Will the Cleveland Clinic be doing other similar face implant operations? Do you think this type of operation will be done more widely now that you've done it in Cleveland?
Risal Djohan: More face transplants will occur. There are lot of roadblocks, such as cost, donors and ethics. Planning the operation and preparing the candidate is very complicated. I don't think it will ever be a common operation.
Downtown D.C.: I don't understand, in this or any case, why a transplant should work better or differently than conventional plastic surgery, with silicon implants and all the rest of it. Can you give an explanation?
Risal Djohan: This is living tissue that she can move and use for facial expressions -- there's no way you can create that with implants. There's no way you could rebuild her lips and mouth and palate with implants. Implants always have a tendency to look very artificial when you for reconstruction. They also tend to be associated with a high rate of complications.
McLean, Va.: I read that one surgeon said that there was "really an entire mid-face missing and there was no way to reconstruct with conventional means." Can you explain further and also how you did reconstruct?
Risal Djohan: In Connie's case, it was more of a replacement of her mid-face which was destroyed by the gun shot. There really was nothing left to reconstruct. All of her other operations really amounted to covering up the injuries, but they really didn't provide any function.
Washington, D.C.: Obviously, the reconstruction of Ms. Culp's face could not have been inexpensive. Could you please tell whether the Cleveland Clinic and/or the physicians involved waived their fees or whether Ms. Culp had private insurance to cover the costs? I'm not asking to be intrusive, I'm just genuinely curious how such rare and expensive surgery would be funded.
Risal Djohan: We really haven't calculated the cost, and it's ongoing. It was not covered by insurance. Cleveland Clinic essentially donated her care.
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