Virginia man receives face transplant at Maryland Shock Trauma

When Richard Lee Norris opened his eyes after a marathon 36-hour surgery to give him a new face, he immediately wanted a mirror.

A natural reaction for a man who had been practically living as a recluse since a 1997 gun accident took off his nose, chin, lips and teeth, said doctors from the University of Maryland who had just performed the world's most extensive face transplant on the 37-year-old from Hillsville, Va.

Norris is relearning to talk and couldn't convey his wonder in words — but his doctors could.

"'This is so cool'" one of the surgeons kept repeating, said Dr. Thomas M. Scalea, director of the University of Maryland School of Medicine trauma program and physician-in-chief of the Maryland Shock Trauma Center, where the transplant was performed last week.

Scalea oversees care of the state's most horrific injuries at the center but called these results "the most remarkable thing I've ever seen."

He counted up to 150 doctors, nurses and other professionals from the Maryland medical system who had a direct hand in caring for Norris. Just six days after his surgery, Norris was saying some words, shaving and brushing his teeth. He's also beginning to get some feeling back in his face.

Norris received donor skin from his scalp to his neck, as well as a new jaw, teeth, tongue and the underlying muscle and tissue. In addition to matching his blood type, doctors had to match his skin color and bone structure to a donor.

Unemployed and living with his parents before he came to Maryland in 2005, Norris had undergone a dozen surgeries, but none that could restore him to functioning membership in society, said Dr. Eduardo D. Rodriguez, associate professor of surgery at Maryland's school of medicine and chief of plastic, reconstructive and maxillofacial surgery at Maryland Shock Trauma Center.

Maryland had been working for the past decade on face transplant methods, improving the way tissue, muscle, skin and bone are woven onto a recipient and increasing the odds of acceptance by a recipient.

The Department of Defense's Office of Naval Research funded the work with eight grants totaling $13 million. It supports research that could aid returning service members injured by explosives. At some point, injured veterans could undergo transplants at Maryland.

"Our goal is to restore function as well as have aesthetically pleasing results," said Rodriguez, who led the surgery.

The hospital provided no details about the gun accident, but during Tuesday's news conference at Maryland, doctors and university officials recounted Norris' transformation through a series of photos.

Doctors showed before and after pictures that included a photo from Norris' high school prom; a post-injury photo where Norris appeared to have no chin and a mangled nose; and a post-surgery photo that made him appear close to normal, if swollen, after surgery.

Norris' facial features appear to be a blend of his own and those of his donor, whose family he has not met, Rodriguez said. The donor was not named by the Living Legacy Foundation of Maryland, which works in the state to supply recipients with needed organs. The same donor provided five life-saving organs to five other recipients, four of whom also had surgeries at Maryland.

Drivers who check "organ donor "on their licenses do not consent to face transplants. A family must give special permission, said Charlie Alexander, the foundation's president and CEO.

Around the world, 22 people have received face transplants since the first was performed in France seven years ago. While Maryland is a large transplant center, this was its first face transplant.

Doctors there have been working to perfect the protocol to prevent rejection of any transplant, said Dr. Stephen T. Bartlett, chair of the medical school surgery department and surgeon-in-chief at the University of Maryland Medical Center. Normally, patients are given a daily three-drug cocktail for the rest of their lives to keep them from rejecting their transplants.

Starting five years ago, the center's doctors began using two drugs for many kidney and pancreas transplant patients and they're trying them on Norris, the first time for a face-transplant patient, surgeons said. The drugs suppress the immune system and make a patient more vulnerable to infection, so a smaller amount can reduce that side effect. Eventually, doctors hope to reduce the dosage of the two drugs.

Doctors felt confident using the new drug regimen on Norris after years of lab work at Maryland, Bartlett said. The research supported the change as long as they also transplanted high amounts of "vascularized" bone marrow, which came inside the jaw transplanted into Norris' face. The bones and attached vessels give the marrow a ready place to live and steady supply of blood, and that seems to offer some continuous protection from rejection, Bartlett said, though researchers aren't entirely sure why.

Surgeons are now considering replacing some rib bone with other organ transplants, he said.

Translating research to surgery, or "bench to bedside," is something Maryland's leaders want to continue to promote, said Dr. E. Albert Reece, vice president of medical affairs at Maryland and dean of the medical school.

"This should affect the lives and well being of patients who before were without hope," he said of the face transplant.

The first few face transplants were limited to skin and some underlying tissue. In 2008, a team at the Cleveland Clinic transplanted a face and jawbone, according to Dr. Chad R. Gordon, who participated in the surgery while he was a fellow in Cleveland.

Gordon, who did not participate in the Maryland transplant, now works with a team at Johns Hopkins Hospital that expects to be ready to perform facial transplants within the year. This team also has been working to further advance the anti-rejection research.

The Hopkins protocol aims to reduce the daily drugs to one a day, also by employing the donor's bone marrow, said Gordon, assistant professor of plastic and reconstructive surgery at the Johns Hopkins University and clinical director of the hospital's craniomaxillofacial transplantation program.

That will leave the patients more ability to fend off bugs that can sicken or kill them. So far, two of the 22 face transplant recipients worldwide have died, one of infection, Gordon said.

All, however, have had episodes where their faces were nearly rejected. Typically, a patient will have two or three episodes in the first year and remains at risk of rejection forever. Someday, Gordon said, doctors hope to eliminate that risk.

"Imagine a seesaw," Gordon said. "On one side is a transplant patient who rejects everything including their new face. On the other side is a transplant patient who doesn't reject anything at all, including much simpler things such as the common cold or flu. Therefore, we need to get in the middle of the seesaw."

Norris has shown no signs of rejection yet, but doctors will be watching him closely. They expect him to leave the hospital in a few weeks but remain in Baltimore for about three months.

The surgeons expect Norris to only need "nips and tucks" via outpatient surgery in the future. Bartlett said he soon will be "downright handsome."

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