Face Transplant: Yale Surgeon Finds His Work ‘Profound’

It’s difficult to even imagine experiencing an injury so devastating that it destroys a person’s face—but in truth, it’s not just appearance that is ruined but, often, also the ability to speak, eat, smell, breathe, blink, and show emotion. As the science of face transplantation evolves, the procedure can now restore all those basic functions (including movement of the mouth and eyelids), along with sensation, and a person’s sense of identity.

Yale Medicine’s Bohdan Pomahac, MD, who has performed 10 of the 18 face transplants done in the United States—more than any other surgeon in the world—says he is deeply moved each time he performs the dramatic procedure, even after 15 years of doing it. “It is probably the most profound experience that a surgeon can wish to have in their lifetime,” he says. As chief of plastic and reconstructive surgery at Yale School of Medicine, Dr. Pomahac specializes in restoring vital functions, such as eating, breathing, and emotional expression, to individuals with severe facial disfigurements.

Depending on the level of disfigurement, a face transplant can be partial, meaning only parts of the face, or full, meaning the entire face. This entails transplantation of the skin, underlying bones, ligaments, tendons, cartilage, muscles, nerves, and blood vessels.

For this type of complex, intricate transplantation work, surgeons use microsurgery, a technique that requires instruments with very fine tips and grasping ends (like miniaturized forceps) and specialized microscopes to disconnect tissue from one part of the body and reconnect it somewhere else.

Before coming to Yale in 2021 to start the Yale Face Transplant Program, Dr. Pomahac directed the Plastic Surgery Transplantation Program at Brigham and Women’s Hospital in Boston, where his team performed the first three full-face transplant procedures in the United States. This included a full-face transplant in 2011 for Charla Nash, a victim of a chimpanzee attack in Stamford, Conn., in 2009.

In 2019, he performed the first face transplant on a Black male—the oldest person yet to receive one: Robert Chelsea, 68, who suffered face-disfiguring burns after being hit by a drunk driver in 2013.

Dr. Pomahac is a pioneer in vascularized composite allotransplantation (VCA), which is the transplantation of multiple tissue types (including bone, muscle, nerves, and skin) as a functional unit (such as a hand or face) from a deceased donor to someone who has experienced a severe injury. Dr. Pomahac also established and led the team that performed three bilateral (or double) hand transplants.

We spoke with Dr. Pomahac about his work and what the future of VCA looks like.

This interview has been edited for space and clarity.

My fascination with plastic surgery started with facial reconstruction—where all the intricacies of different aspects of plastic surgery come together. For example, hand surgery is all about function. The patient may have three digits, missing fingers, or deformed joints, but as long as they can grasp and function, surgery is considered a success.

Another example is breast reconstruction, which is all about shape. As long as the breast looks natural and symmetrical, it's considered a win. With the face, however, it is a marriage of both function and shape, contour, and a natural appearance. And that's the hardest thing to do in reconstructive surgery. As I was starting my practice, I was dealing with patients with trauma and burns and some cancer patients that, no matter how hard I tried, the results were suboptimal; it really resembled more of a wound closure.

Then, in 2005, the first face transplant in the world was performed in France. I thought, “Oh my God, if I could operate 100 times on that same patient, I would never get close to what they did with one transplant." That was the primary reason why I developed the program at Brigham and Women’s.

The biggest problem is figuring out who will pay for these surgeries. As one of the first centers performing them, Brigham and Women’s was able to attract significant interest from the U.S. Department of Defense [DoD]. That was primarily because, at that time, many soldiers were returning from wars in Iraq and Afghanistan with major facial deformities. And unlike prosthetics, which can work reasonably well for lower and upper extremities, there is nothing that works for the face. Because of that, we were able to attract quite a bit of funding from the DoD, but we were one of only a few programs, so that's why it never spread or grew massively.

Then, the DoD put a hold on funding clinical trials. Instead, they put out a proposal to develop guidelines for who the right patient is, how we treat them, the primary outcomes, and how much it should cost. The goal would be to run a multi-institutional clinical trial based on those standards, so we get absolutely clear—and the same—outcomes from all the different institutions that may be performing them.

And there is now a clinical trial based on these standards. Yale is the primary site for the trial, and I’m the principal investigator of the study. So, we're technically in charge of that next phase in face and hand transplantation. Based on what insurance companies have told us, if we come to them with a consensus in the field and show them the outcomes, they're willing to pay for the proper patient for the surgery.

Right now, commercial insurance companies, Medicare, and Medicaid won’t pay for such surgeries because they are considered experimental.

The last one was done in 2023 at NYU Langone [in New York City], where they transplanted not only a partial face, but also the eyeball. They are one of the few sites with independent funding for these surgeries.

Here at Yale, we are now UNOS-approved for face transplantation.

[UNOS (United Network for Organ Sharing) is a private, nonprofit organization that manages the nation’s organ transplant system under contract with the federal government.]

We’ve published research showing that most patients get a revision surgery [an additional surgery to correct or improve results from an earlier surgery], and that's primarily because at the time of transplant, tissues are swollen. As swelling comes down over time and gravity takes effect, the face tends to droop a little.

Most of the revisions are cosmetic enhancements so that the face looks more natural and is properly positioned on the skeletal structure. Occasionally, we try to adjust occlusion—in this context, how teeth come together—or other more functional problems.

Typically, a revision surgery can take place as early as six months and maybe a year or a year and a half after the transplant.

I’m most excited about starting the process to help steer the field into consensus via standardized clinical trials. We are heading somewhere where everybody understands that we need to work together. Otherwise, the field will not survive. In the past, there was a lot of competition and a lot of surgeons’ egos—a lot of barriers that we seem to have overcome.

And I'm just excited that we'll eventually do a transplant here at Yale.

The fascinating aspect of it is when you see the patients who go on the operating room table deformed, with no face or missing parts of the face, and then they wake up with a complete face. It's something so unique that it leaves a lasting impact, but at the same time, I don't want it to be about the surgeon's experience.

It’s an incredible change for the patient. Seeing it is still mind-blowing to me after 15 years of doing it.

For face transplants, we have a four-hour window between detaching the face from the donor and re-establishing blood flow in the recipient. This is a very short period of time. You have to take the donor part with you, package it, and bring it by airplane or whatever means of transportation you are using, and then get into the operating room and connect it under a microscope to re-establish blood flow. So, it’s pretty stressful.

In a broader sense, it’s the same situation if you have an amputation that happens in an industrial accident or on a battlefield. My interest is in figuring out a way to extend the viability of these tissues so that the window to re-establish blood flow is not only possible within this urgent, four-hour window. I have to give credit to the organ transplant field because there are many viable technologies emerging for this same purpose. We essentially said, “Let’s do research in this area for limbs.”

We have been able to show that on an extracorporeal, or artificial, perfusion system, you can extend the window from four hours to 24 hours. You get more time and can maintain the viability of the tissues. You have the same, or even better, results. But it’s still not current practice for face or limb transplants, and it will take some time.

It's an interesting question. Does chess naturally align with my mindset, or does it help develop a certain way of thinking? Either way, engaging in chess exercises the brain in valuable ways. In surgery, as with chess, I always try to think ahead and keep the big picture in mind.

And that is what I believe sets me apart—my ability to anticipate the next steps and envision the overall trajectory of a procedure. It allows me to orchestrate an operation, anticipate future actions, and effectively coordinate with my team for optimal outcomes.