A gunshot took his face. Canada’s first face transplant gave him a new one.

In 2012 a Canadian man was severely disfigured by an accidental gunshot wound to his face. Over the following years he had five reconstructive operations, the conventional way of rebuilding a face: moving bone, skin and muscle from elsewhere on his own body.

They were not enough. He still lived with chronic pain. His speech was severely impaired. He could not chew, breathe or swallow normally, and he suffered the social stigma that comes with a visibly disfigured face. The photograph taken just before his transplant, Figure 1 in the original paper, shows how much of the lower half of his face had been lost.

For injuries like this, where a face has lost not just skin but the muscles and bones that make it move and work, a face transplant is the reconstruction of last resort. A donor’s face, with its skin, muscles, nerves, blood vessels and, when needed, bone, is transplanted as a single block of tissue and connected to the recipient’s own vessels and nerves. The first was performed in France in 2005, and by the time of this report more than 45 had been done worldwide. None had yet been done in Canada.

FIG 1the first yearoriginal diagram

He was first assessed for a transplant in 2015. Before the operation, the surgical team rehearsed it in three sessions of dissection on cadavers, and the operation was planned in advance on computer, with virtual surgical planning.

On 11 May 2018, at Maisonneuve-Rosemont Hospital in Montreal, a team of six plastic surgeons, two ear, nose and throat surgeons and one maxillofacial surgeon performed the first face transplant in Canada. He was 64. The surgeons did the operation as volunteers and did not bill the national health insurance for it.

One item in the costing is easy to overlook: 5,000 dollars for a donor mask. When a face is recovered from a donor, a lifelike mask of the donor’s face is made, so that the donor’s body can be returned to the family with dignity, and they can hold the kind of funeral they want.

After the operation he spent 13 days in intensive care and another 47 on the ward, without any major complication from the surgery itself. To stop his immune system from attacking the new face, he was given thymoglobulin, a powerful antibody treatment, for eight days. That drug alone accounted for more than 94% of the medication cost of his transplant stay. Like every transplant recipient, he would then need lifelong immunosuppressants: tacrolimus, mycophenolic acid and prednisone.

The skin of a transplanted face is checked for rejection with regular biopsies. On the 57th day, a weekly biopsy showed acute rejection. It was treated successfully with intravenous and then oral corticosteroids.

The drugs that protect a transplanted face also leave the body less able to fight infection and can damage other organs. In his first year he was readmitted to hospital four times.

Three months after the transplant, he developed a fungal infection of the skin of his thigh caused by Lichtheimia, a mould, which needed a short admission and more than five months of an expensive antifungal drug, posaconazole. In the seventh month, his tacrolimus level became toxic and caused a temporary acute kidney injury. In the eighth month came the longest admission, 49 days, for oesophageal disease that did not respond to treatment, combined with a cytomegalovirus infection that was found late. And in the tenth month he needed surgery for a perforated diverticulum of the bowel.

Over the whole first year, he spent 210 days out of hospital.

The purpose of the paper was to answer two questions that are asked about every face transplant: how much does it cost, and who pays? In Canada’s publicly funded health system, nobody had calculated it before.

The authors went through his records item by item, from the first assessment to a year after the transplant. The total came to 440,224 Canadian dollars, at 2018 prices. Six percent, 24,926 dollars, was spent before the operation, mostly on the cadaver rehearsals. Fifty-four percent, 237,427 dollars, was the 60-day transplant stay itself, driven by the operating room, the intensive care and ward days, and the thymoglobulin. The remaining 40% went on the year that followed: the four readmissions and the outpatient care, including the antifungal treatment and about 764 dollars a month of anti-rejection drugs.

A pharmaceutical company sponsored the cadaver training, the surgical materials and the virtual planning, and an external grant of 36,921 dollars offset part of the cost. And something the team had not planned for happened: in the year after the transplant, donations to the hospital’s foundation rose by 794%, to 1,787,148 dollars, far more than the transplant had cost.

For comparison, the authors cite the first face transplant in the United States, whose first year cost the equivalent of 595,408 Canadian dollars, with eight readmissions. Among solid organ transplants in Canada, a kidney cost about 62,000 dollars for the first year and a lung about 148,000; in the United States, a heart transplant cost the equivalent of about 497,000.

The paper’s second photograph, Figure 2, shows him two years after the transplant. The difference from the first is hard to overstate: a whole face, with a nose, closed lips, a jaw, teeth and a beard, looking straight at the camera.

The photographs are not reproduced here because of the paper’s licence, but they are free to see in the original paper linked below. The details of the operation itself were published separately by the same team.

A face transplant is not life-saving in the way a heart or a liver transplant is, and it commits a healthy-hearted person to lifelong immunosuppression, with its infections, kidney damage and higher cancer risk, as this man’s first year showed. That is why face transplants are reserved for people whose faces cannot be rebuilt any other way, and why they remain rare.

What they offer instead is function and a life in public: the ability to eat, breathe, speak, close the mouth and show expression, and to walk down a street without being stared at. Other studies have found that face transplants add substantial quality of life for the people who receive them. The authors’ argument is that, even in a public system with tight budgets, the cost can be carried through a mix of public funding, private sponsors and the goodwill a first-of-its-kind operation creates.

An accidental gunshot in 2012 left a Canadian man in chronic pain, unable to chew, swallow, breathe or speak normally, after five operations had done all they could. In May 2018, at 64, he received Canada’s first face transplant from a team of nine surgeons who worked as volunteers. He spent 60 days in hospital, survived a rejection episode on day 57, and was readmitted four times in his first year for a fungal infection, drug toxicity with kidney injury, oesophageal disease with cytomegalovirus, and a perforated bowel. The first year cost 440,224 Canadian dollars, and donations to the hospital rose almost eightfold the next year. Two years after the operation, he had a face again. A face transplant changes a life completely, but it is a year-long, lifelong commitment, not a single operation.