Bohdan Pomahač: Transplanted kidneys’ half-life is about 15 years – we can’t expect faces to last longer

Bohdan Pomahač, foto: Barbora Němcová

Bohdan Pomahač led the team that carried out the first ever full transplant of a human face in the United States. The Boston-based plastic surgeon recently received the Gratias Agit award from the Czech Ministry of Foreign Affairs’ for promoting the good name of the Czech Republic abroad. After the ceremony, I spoke to the famous physician about various aspects of facial transplantation – and much more.

Bohdan Pomahač | Photo: Barbora Němcová,  Radio Prague International
You were 18 in November 1989. Was that the ideal age to go through that experience?

“I would say absolutely.

“Even during the high school years we were realising that the Communist was kind of a joke – and that a lot of the Young Communist activities that we had to participate in mandatorily were pretty much laughable matters.

“So in 1989, when the change came, the hardest thing was to believe that this is real this time, that it’s not another 1968.

“But the more the Velvet Revolution continued, the more it was apparent that this time it will happen – just like East Germany, Hungary, we will set a sort of a path forward in a democratic way.

“So I think being young and being able to participate in it was very, very special.”

When you were studying medicine in Olomouc, you had a study stay in Boston. I guess that was a real turning point in your life?

“The way it happened was our associate dean, Professor Dušek, in Olomouc was interested in introducing problem-based learning, a system of education that only existed in McMaster University in Hamilton, Ontario and Harvard Medical School.

“I happened to spend the summer in the United States and Professor Dušek found that out.

“He asked me if I would be willing to participate for a week in a student experience, so that when I come back I could provide feedback, as a student, on the new problem-based pathway that he was preparing.

“So that was my first exposure to Boston and that’s the first time I was impressed by the number and size of the hospitals.

“And somewhat naively I felt that there would be room for one extra physician to get trained well.”

What led you to the area of plastic surgery?

“There is definitely, without a doubt, change in each patient that reflects in loss of a little bit of volume, a little bit of a change in the quality of skin.”

“That was really a coincidence. I went to medical school with the goal of becoming a surgeon.

“But I changed what kind of surgery based on my experience throughout the school.

“Ultimately, even when I departed to the United States I leaning towards transplant surgery or vascular surgery.

“But that’s when I met Professor Elof Eriksson from plastic surgery. I ended up working in his laboratory for two years and ended up really getting exposed to plastic reconstructive surgery.

“It was the reconstruction of the face that absolutely fascinated me and from then on I just knew that that’s the field I want to be in.”

You famously led the team that carried out the first full transplant of a human face in the US. What were the advances that had allowed this to happen, 10 years ago?

“There were quite a few.

“Evolution is sort of a spiral event and in the ‘70s Ian Taylor and his New Zealander-Australian team with Wayne Morrison came with the fundamental principles and proofs of being able to transfer tissues using microscope reconnecting vessels.

“So the development of the field of microsurgery was ultimately the first stepping stone.

“Then later on it was probably the right environment, where immunosuppressive medications were considered not as harmful and the benefits for patients with major facial deformities seemed to be reasonable.

“So it all happened at the right time when I was starting in my practice.

“I saw the opportunity and felt that we should be able to provide these types of reconstructions for the patients in the greatest need.”

It’s still a very unusual procedure. How do you select the patients who receive it?

Bohdan Pomahač with one of his patients,  photo: US Army,  Public Domain
“The selection process is rather long. We have overall had almost 100 patients that either called us or were referred to us by physicians.

“Only around 20 of them were seriously looked at.

“The other patients had either major medical issues, major socio-economic issues or just surgically there were other options than transplant.

“Out of the 20, we ended up selecting 10 or 11 who were actually listed for transplantation. And eight of those we were able to transplant.

“A couple of patients actually changed their minds in the process and decided against it, even though they were deemed suitable candidates.

“The process includes evaluation of the patients’ background, socio-economic situation, medical understanding, but also their overall medical wellbeing: comorbidities and ultimately their surgical suitability as well.

“So it’s a multi-disciplinary team that looks at these patients and comes to a conclusion.”

Given that the first one was 10 years ago, you’ve been able to observe the aging process. How do transplanted faces age?

“Yes, there is no question. We’ve had the oldest patient 10 years ago to the newest transplant one year ago and there is definitely, without a doubt, change in each one of those that reflects in loss of a little bit of volume, a little bit of a change in the quality of skin.

“There probably is some sort of a chronic rejection process that occurs.

“I’ve always said that kidney transplants’ half-life is about 15 years so we cannot expect that faces that were transplanted are going to last any longer.

“As a matter of fact, one would expect a shorter half-life, due to the high immunogenicity that the skin elicits in the body.

“So we’re studying the processes, we’re trying to learn from it, we’re trying to figure out how to slow it down, stop it, reverse it.

“I can see bad plastic surgery. But good plastic surgery should really not be that visible.”

“And it’s a fascinating scientific endeavour.”

But if somebody needed a second operation would you amend the face that they have received, or would you somehow give them a second new face?

“A patient may lose a face probably in two different ways.

“One would be acute rejection that we cannot control. This could lead to catastrophe, with the face literally dying off.

“That’s a more difficult scenario, because we would have to probably use conventional techniques but potentially down the line retransplant the patient.

“The other option is chronic slow rejection where the quality of the tissues will be gradually changing. Probably the face would lose a lot of functionality and even the appearance may not be as nice and natural.

“But it would give us the time to work with the patient and decide – do we leave it as it is, or do we potentially consider retransplantation?”

What have your patients told you about how this surgery has changed their lives?

“That’s quite amazing.

“Our first patient was able to come to the graduation of his daughter from college.

“Later on she got married so he went to her wedding and led her down the aisle.

“He is the grandfather of two children. And I don’t think that would be easy without a face, with the horrendous deformity that he suffered.

“So I think he really had the best 10 years of his life after the transplantation.

“And it goes on and on – the second patient got married after the transplantation.

“So I think this social integration, the ability to interact, find romantic relationships and be active in society have been the major benefits of the surgery.”

You also perform regular plastic surgery. Does this work with face transplantation feel more important to you than, I don’t know, a normal facelift or something like that?

“I wouldn’t say so.

Bohdan Pomahač,  photo: YouTube
“For me, the range of reconstruction of the face starts from the most extreme, like transplants, and goes through major reconstructive efforts all the way to maybe cosmetic corrections of minor deformities.

“And it’s all in my mind one sort of continuum of surgical techniques.

“So it’s actually complementing what I’m doing on a usual and regular basis.

“My practice is still mostly reconstructive but now about 30 percent of my practice is now aesthetic, and I think it definitely helps.”

More generally, given your job, can you recognise people who’ve had plastic surgery? Are you on the tram going, She’s had her eyes done and, He’s got a new nose, or whatever?

“I can see bad plastic surgery [laughs].

“But good plastic surgery should really not be that visible.

“Although if you know the patient or person well then of course you would pick it up.”

Do Czech doctors in the States have a reputation for any particular trait or characteristic?

“I think in general Czechs in the United States are viewed as intelligent, hard-working people.

“Because most of the people who actually ended up in the United States and stayed there were those kind of people: hard-working, intelligent and so forth.

“I think it’s, in general, a very good name that the Czechs have in the United States.”

Do you get a lot of offers to come here to the Czech Republic to do surgery?

“There have been a few. It’s logistically incredibly complicated.

“I have a busy practice of my own, booked in many months in advance, so it’s sort of not very practical.

“But at the same time I think that there are very skilled surgeons here that can do pretty much everything that I can.

“So I would be happy to help with advice, but it may not be necessary that I would be flying all over just to do a case.”

Is there anything that the Czech Republic could learn from the US health care system?

“I think in general Czechs in the US are viewed as intelligent, hard-working people. Because most of those who actually ended up in the United States and stayed there were those kind of people.”

“I think the system of postgraduate training is the best in the United States among all the countries that I’ve visited and seen in the world.

“So I think what we could learn is really how to give responsibilities to the physicians – how to develop training system and how to gradually increase the responsibilities and the difficulty of tasks and cases that young physicians would do, so that they graduate comfortable and confident that they can do the whole range of their specialty.”

Your wife is also Czech. How often do you come home? And what’s your children’s relationship to the Czech Republic?

“I met my wife just before medical school. She’s a physician as well, although she stayed at home with the children when we moved to the United States.

“I personally have the opportunity to come twice a year and they, including the children, generally come once a year.

“Our daughter keeps telling us that one day she will live in the Czech Republic, so she has a very, very warm and nice relationship.

“She feels that she belongs to two countries, rather than one.

“And our son, I think in a similar fashion, can both speak the language as well as recognising the differences in culture.

“But he also enjoys being sort of a citizen of two nations.”

I guess in the US not many people recognise you. Here in the Czech Republic many people do. Is that something that’s strange – when you get off the plane and suddenly you’re a celebrity?

“People are very nice and it’s actually, if anything, only pleasant that somebody wants to shake your hand or thank you for giving the Czech Republic a good name abroad.

“So it’s very pleasant and I’m very honoured and humbled that people perhaps recognise my name or face.”