Medicine

Replacing a face: costly, difficult, doable

 

Ronald Poppo will need extensive and long-term facial reconstruction surgeries after the MacArthur Causeway attack.

aburch@MiamiHerald.com

With little recognizable but an eye and chin, the man who lost most of his face in a vicious attack by a raving naked man on a Miami causeway is up against daunting medical challenges, including the possibility of infection delivered through human bites.

For now, Ronald Poppo, who has lived half his life on Miami’s streets, is without his most basic features.

“The loss of the face is one of the most devastating injuries because in so many ways it defines our identity,’’ said plastic surgeon Chad Perlyn, an assistant professor in the surgery department at Florida International University’s Herbert Wertheim College of Medicine. “He has a long road back, both physically and psychologically.’’

In a random encounter, Poppo, 65, was assaulted on the busy MacArthur Causeway over the Memorial Day weekend. As cars zoomed by, his attacker, Rudy Eugene, chewed off chunks of Poppo’s face in what police suspect was a drug-fueled rage. Detailed online photos of what is purported to be Poppo’s face show the left eye gouged out and the other features — eyelids, nose and lips — gone. Police have reported Poppo to be in critical condition. The Ryder Trauma Center at Jackson Memorial Hospital will not confirm his condition or release any personal information until they receive consent from a family member or surrogate.

But a police union representative for the officer who stopped the attack described the devastation to Poppo’s face. “He had his face eaten down to his goatee. The forehead was just bone,” Sgt. Armando Aguilar, president of the Miami Fraternal Order of Police, told the Associated Press. “No nose, no mouth.”

Poppo’s recovery will take months, possibly years, of medical and psychological treatment in a costly and ambitious effort to rebuild the features on his face or, possibly, replace it altogether in a transplant that has only been performed about two dozen times in the world. One of the most recent procedures, performed in March, was led by a Miami-born doctor, Eduardo Rodriguez.

“The human mouth has one of the highest counts of bacteria, and with bites where the skin is punctured, the teeth and saliva carry the bacteria into the wound,’’ said Perlyn, part of the Miami Children’s Hospital plastic surgery team. “The key to his injuries beyond the infections is determining how much tissue damage or loss there is. Damaged tissue can be repaired, but where there is loss, the feature must be reconstructed.”

Though few details are available about Poppo’s condition, several plastic surgeons and experts — none treating the patient but experienced in facial reconstruction — say that doctors treating a patient with such extensive injuries would confront steep challenges to construct a semblance of a normal face.

“Based on the extent of his injuries, he has a really tough road ahead. Facial reconstruction is difficult in the most simplistic case of trying to restore a feature back to the exact form and function,” says Dr. Reza Jarrahy, the co-surgical director of the University of California at Los Angeles Health Systems’ newly launched Face Transplantation program. “And prior to just a few years ago, the idea of a face transplant was far-fetched, a Hollywood type notion.’’

First, a team of Jackson doctors is focused on keeping Poppo stable, making sure his wounds are clean, hydrated and covered. They will work to build up his immune system to ward off infections through antibiotics and proper nutrition. They must take into account that Poppo has been homeless for more than 30 years, survived a gunshot and had been a chronic drinker.

They must also work to preserve his airways and the remaining eye, if possible. The eye is particularly vulnerable because the eyelid, which serves as a protector, was reportedly destroyed.

“The patient will probably have to have several trips to have the wounds washed out so that doctors can assess the viability of the tissue. They have to temporarily cover the exposed eye and cover any other open wounds, with a dressing,’’ said Rodriguez, chief of Plastic Surgery at R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center in Baltimore. “Then they have to start making decisions about the best way to reconstruct the patient’s face.’’

In March, Rodriguez led a team of 100 specialists and support personnel in the longest and most extensive face transplant to date. For 36 hours, Rodriguez and his team worked to replace a face, from hairline to neck, for Richard Lee Norris, 37, who had been shot in the face. Terribly disfigured, Norris had had been wearing a mask and living as a recluse for 15 years.

A face transplant can cost about $350,000 or more, depending on the complexity of the procedure, along with the cost of a lifelong regimen of immunosuppressive medication. For reconstructions, the cost can be comparable. Late last week, the Jackson Memorial Foundation established a fund for Poppo’s care and already people from across the nation have asked about donating.

While the cost to help Poppo may be high, at least one medical ethicist says medical need comes first.

“University of Miami and Jackson pride themselves on the fact that poor people get really good care. A wallet biopsy is not done before the person is treated,’’ said Kenneth Goodman, director of the Bioethics Program at the UM Miller School of Medicine, which provides physicians for Jackson. “If there is good clinical indication that the patient needs the procedures, then I think reasonable people would say let’s try to find a way.”

For Poppo, options could include taking skin and bone grafts to rebuild his features. Typically, the forehead can be used as a source of skin to help in reconstruction. If that is not possible, doctors can turn to another nearby region, such as the neck. Part of a broader reconstruction plan, the procedures would likely take place in phases and over a long period of time, said Dr. Seth R. Thaller, of the University of Miami.

“You have to take a global approach. You have to have an interdisciplinary team, which Jackson has, that can work prioritize and make appraisals along the way,’’ said Thaller, chief of the plastic surgery division at the UM Miller School of Medicine. “Ultimately, with a devastating injury, the goal is to get the patient to a point where they can function, where they can walk into a room with an acceptable appearance. It may not be what they looked like before, but at least it’s presentable.’’

In discussing Poppo’s case, experts cite a Connecticut woman’s injuries from a brutal attack by a 200-pound chimpanzee as a reasonable comparison to what may lie ahead for the Miami man.

Charla Nash was viciously mauled in 2009 by a friend’s pet, losing her nose, an eyelid, lips and both hands. Because of infection, doctors removed her eyes. Last year, she received a donated new face after 20 hours of surgery at Brigham and Women’s Hospital in Boston. She also received new hands, but after she contracted pneumonia they had to be removed.

“She had her face and hands ripped off,’’ said Nash family spokesman Ara E. Chekmayan. “There is the trauma of the actual attack, and then there is the trauma of her understanding what happened to her. She was fortunate in that she had a family and support system which is an important component of recovery.’’

Three years after the attack, Nash can speak and eat. She is in physical rehabilitation and will be on medication for the rest of her life.

“Her life was turned upside down,’’ he said.

“She lost what we take for granted: that you look in the mirror and see something familiar. She is a very positive person, but everyday is a struggle. She still has good days and bad days.’’

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