Face Value| February 12, 2019
Photos: Brian Kolin
Early Thursday morning of May 4, 2017, a select team of medical professionals crowded into an operating room at the Cleveland Clinic. Suppressed excitement electrified the room as the team prepared for the long-awaited surgery that would make the Cleveland Clinic the first US hospital to successfully perform a full-face transplant — and one of only six US institutions that have performed the procedure to date (the others have done partial face transplants). Face transplant program leaders Dr. Frank Papay, Dr. Brian Gastman, and Dr. Maria Siemionow were well aware of the risks and potential rewards they would face within the next many grueling and tension-filled hours — but only Dr. Gastman was hoping to make it home in time for Shabbos.
They were about to begin what would be a 31-hour trailblazing surgery that would give a new face — and the opportunity for a normal life — to a young woman with a traumatic facial injury. Leading the surgery was Dr. Gastman, the 49-year-old black-yarmulke-wearing medical and surgical director of the melanoma and high-risk skin cancer program at the prestigious Cleveland Clinic. His unique skills — he is also a double-boarded plastic surgeon and otolaryngologist specializing in soft-tissue malignancies and holds fellowships in head and neck surgery, microsurgery, and cancer research — put him at the helm of this team of highly specialized professionals who would change a girl’s life and establish the Cleveland Clinic Foundation at the frontier of transplant research, and would secure his place as a world-class transplantation surgeon.
In 2014, Dr. Gastman met Katie Stubblefield, an 18-year-old girl who had transferred from Tennessee to the Cleveland Clinic after sustaining massive facial injuries from a self-inflicted gunshot wound in a split-second of deep distress. For the next three years, Katie would be a major part of Dr. Gastman’s professional life as he, and a team of hundreds of medical professionals, attempted to treat her and grant her a sustainable quality of life.
“Katie was my patient from her arrival here — I’ve davened for her and for our success every day since,” says Dr. Gastman, whose impressive credentials have earned him a unique place in the groundbreaking transplant program of the clinic, an academic medical center in Cleveland, Ohio, owned by the Cleveland Clinic Foundation, which also runs ten regional hospitals, hospitals in Florida and Nevada, and 19 family health centers. To date, the Cleveland Clinic — ranked number two in the US and number one in many critical specialties, such as cardiac surgery and cardiology — has performed three of the fewer than three dozen face transplants conducted worldwide, with Dr. Gastman on the team for the last two.
In Memphis, Tennessee, where Katie underwent her first operation, doctors managed to save her life against the odds, but an attempted tissue graft hadn’t worked in covering the massive wound running right down the center of her face. When Dr. Gastman received Katie, he was more concerned about keeping her alive than about how to do the reconstructive work. Her brain was exposed, one of the many life-threatening aspects of her complex situation. In over 20 years of training and experience, it was one of the worst face traumas he’d ever encountered.
Beyond the wound to her face, the bullet caused traumatic brain injury, which not only limited her mobility but also caused damage to the optic nerve, leaving her essentially blind.
“We knew early on that she seemed to be a good candidate for eventual face transplantation, so we pursued a series of facial reconstruction operations to prepare for that and to get her functioning better,” Dr. Gastman told Mishpacha.
Pictures of Katie before her injury show a smiling, pretty all-American teenager, and her tragic circumstances captured the minds and hearts of the public. Katie’s parents agreed to allow National Geographic magazine to follow the family’s medical journey, and for three years they documented her progress as she fought for recovery against the odds. As her primary physician once she arrived in Cleveland, it was Dr. Gastman’s job to act as liaison to the press; he was often contacted multiple times a day for updates on her condition. But Katie’s parents had made a commitment to share their daughter’s story, and it was important for Dr. Gastman to get the word out about the wondrous advancements in the field. Dr. Gastman, with his trademark yarmulke never budging from his head, has been the force of the procedure since the story aired — and went viral. The National Geographic video has garnered more than 11 million views.
Staying the Course
Dr. Brian Gastman is unpretentious and friendly, and his professional credentials notwithstanding, he seems like the average guy you’d meet in shul or at an Avos U’Banim evening. He’s a native of Michigan where he attended medical school before continuing his education in Pittsburgh and St. Louis following a valuable stopover in Ohr Somayach, Jerusalem. It was in his hometown of Detroit that his passion for his uncommon specialty was ignited. A famous cranio-facial surgeon moved from the Mayo Clinic to Detroit where he treated a young boy whose face was eaten away by disease; he spent years on facial reconstruction, subsequently adopting the boy. The case made headlines and it inspired the young Brian Gastman, himself the son of a doctor, to pursue the field of cranio-facial surgery. “It’s been my passion now for more than three decades,” he says.
In his personal life, Dr. Gastman knows about staying the course. His parents’ families were religious before the war but he grew up in a nonreligious “survivor” household. It was through a combination of seemingly random events that he eventually committed to Torah living. As a teenager he was involved in martial arts and weight lifting but he stopped after tearing ligaments in his shoulder. With extra time on his hands, he acquiesced when a relative pulled him into a small shul in Detroit to complete a minyan. There he met Rabbi Eli Mayer Jundef, a chaver of the Detroit Lakewood Kollel, who would become his lifelong mentor and posek. Later, in college, he befriended another student who was originally from a Modern Orthdox background but wound up going “black hat” after learning at Yeshivas Bais Yisroel.
Another pivotal experience was the opportunity to meet the Lubavitcher Rebbe. “I had never been in such an environment. There were 800 people davening together and it blew me away. I had never before witnessed such a level of respect as was directed at the Rebbe. It was an awesome experience,” he remembers. A detour to Ohr Somayach in Jerusalem before med school sealed the deal, and since then Dr. Gastman has had a steady roster of chavrusas and kollel connections. Today he’s a regular at Kollel Yad Mordechai.
Dr. Gastman and his family were settled in Baltimore where he had positions at Johns Hopkins School of Medicine and the University of Maryland, before being wooed by the Cleveland Clinic in 2010. “I came as a plastic surgeon, specifically to perform advanced cranio-facial surgery and to build a world-class melanoma program,” he says. “The Cleveland Clinic had done its one and only facial transplant in 2008, a first in the US, but the program was at a standstill and needed energy.” Today Dr. Gastman treats cancer patients “head to toe” as a cancer surgeon and performs high-risk reconstructive surgery of the head and neck to address malformations caused by birth defects, trauma, tumors, or infection. He regularly consults with major poskim regarding the complicated issues that come up in his field.
Five years ago, Dr. Gastman performed a near-total face transplant, his first at CCF, on a man with advanced facial trauma sustained in a car accident. Prepping and coordinating responsibilities kept him busy and sleepless in the days before the surgery. As part of a nine-member multidisciplinary team of surgeons and transplant specialists, Dr. Gastman spent twenty four and a half hours in the operating room performing the groundbreaking transplant. The surgery was originally scheduled for Rosh Hashanah, which left him in a halachic quandary, but in the end was pushed up a day — and Dr. Gastman wound up rushing home on Erev Rosh Hashanah only moments before candlelighting. “I didn’t know how I would get through Yom Tov,” he remembers. Armed by prior consultation with his Cleveland-based rav, Rabbi Yehuda Cahan, Dr. Gastman was well-schooled in what heteirim he could appropriately rely upon in observing the Yom Tov. “I didn’t end up relying on any of them — but after the whole experience, Rosh Hashanah hit me very emotionally that year. I just wanted to sit in shul and hear ‘HaMelech.’ ”
Dr. Gastman prefers to keep his personal and professional lives separate. “My work is intense and I do a lot of research, but I don’t have a tremendous interest in talking about it when I’m home.” What did his four kids think about his career during all the publicity surrounding Katie’s treatment? “I don’t think they knew too much. They just see me as a hardworking dad.” Because all the prep leading up to Katie’s transplant was so newsworthy and of such public interest, Dr. Gastman’s wife was cautioned not to talk about what she knew for fear of leaks to the press.
Stabilized for Surgery
Three years passed from the time Katie was admitted to CCF to when she was ready for transplant and an appropriate donor could be found. In those three years, the surgical team was assembled and a phalanx of professionals vigorously tested Katie and her parents to determine whether they medically met eligibility requirements for surgery, whether they were psychologically strong enough to endure the dangers of transplantation, and whether they could be relied upon to sustain the medical protocol necessary for long-term recovery. Katie underwent assessment and treatment by nutritionists, physical therapists, endocrinologists, infectious disease specialists, neurosurgeons, ophthalmologists, social workers, bioethicists, psychiatrists, anaesthesiologists, dentists, pharmacists, internal medicine specialists, vascular surgeons, and of course, plastic surgeons. Dr. Frank Papay, chairman of Cleveland Clinic’s Dermatology and Plastic Surgery Institute and overall director of the vascularized allotransplantation program (referring to face, hand, abdomen, and more), chose Dr. Gastman to lead the surgery. Transplant researcher Dr. Maria Siemionow, former director of Cleveland Clinic’s Department of Plastic Surgery Research and part of the team of surgeons who, in 2008, performed the first face transplant in the US, served as the co-director and was deeply involved in the planning.
Dr. Gastman and his team performed more than a dozen surgeries to heal Katie’s functional and medical issues and to prepare her for a transplant. In several major reconstructive procedures they removed and repaired Katie’s shattered bones, made a rudimentary nose and upper lip from her thigh tissue and used a piece of her Achilles tendon to form her chin and lower lip. The team fashioned a new lower jawbone from titanium and a piece of her lower leg bone, using a 3D model made from a scan of her sister’s jaw as a guideline. It was challenging work and was intended to serve her temporarily, to stabilize her and lay the groundwork for future surgeries.
“However,” says Dr. Gastman, “we knew that if she wouldn’t go through the face transplant, this would be her final outcome.”
As Dr. Gastman describes the technicalities of the procedures required to rebuild Katie’s face, he reaches into a bookcase filled with his extra seforim (his personal overflow is stashed in his basement office). He pulls out a binder and shows the “before” and “after” pictures. His detailed explanation is fascinating: The “before” pictures — which were taken after the temporary reconstructive surgeries — are horrifying, making this entire accomplishment seem surreal. It’s hard to comprehend that current medical knowledge allows doctors to replicate and replace something as complex as an eyelid or a tongue. When I venture that a successful transplant, and certainly one of this magnitude, qualifies as a miracle, Dr. Gastman responds, “Well, every time we take a breath it’s a miracle.”
For the final 15 months before a donor was found and Katie was getting ready for surgery, Dr. Gastman was on call 24/7 and his mobility constrained. Going away for Shabbos or Yom Tov had to be carefully considered and visits to family in Israel limited. “We went to Israel for my son’s bar mitzvah but I was ready to fly home at a moment’s notice,” he says. The team used that interim time for extensive planning, with practice runs of mock surgeries in Cleveland Clinic’s cadaver lab and by using the Microsoft HoloLens augmented reality platform. The HoloLens allowed the surgeons to take Katie’s CT data set before the transplant and extrapolate a 3D representation of her skull for them to study and practice with.
Katie’s was a rare and compelling case. She was very young, barely 18. Her injury was a self-inflicted gunshot wound, which is unusual in a female. She had been a vivacious straight-A student who pushed herself to perfection, her act of self-violence an impulsive teenage reaction to an emotional crisis — the consequences of which she and her whole family will have to live with forever.
Katie’s parents are people of faith, which has given them the strength and conviction to be at her side come what may. Dr. Gastman comments on how their own faith-based commitment was a significant factor in their dangerous journey.
“We actually had a lot in common,” he says. “The process was so long and traumatic that many people would have been too emotionally fragile to go through what they went through, both psychologically and physically, in terms of basically putting their lives on hold for as long as it takes to make Katie better.”
When Dr. Gastman and the transplant team finally gathered in the operating room on the day set for Katie’s surgery, the adrenaline was pumping, but Dr. Gastman was focused and intent. For him, the procedure had begun days ago. He had already put in close to 100 hours arranging for the availability of two operating rooms, the appropriate microsurgical and nerve-dissection equipment, organizing a force of over a hundred professionals, residents and support staff, and managing security. During the surgery, at least 30 people were working at any given moment.
The operation was kept out of the media to avoid disturbances and to protect Katie’s family. Only the appointed National Geographic photographers were allowed into the operating room to document the surgery.
More Than Skin Deep
Before Katie was brought into surgery, the donor, attended by a separate team of surgeons, was prepped. She was a woman of Italian descent, a few years older than Katie, who died from a drug overdose. Until the last moment, the opportunity for transplant wavered, because there was a distinct possibility that the face would become disqualified for transplantation during the procedure — and Katie’s opportunity would be lost.
Nearly four hours after they’d started on the donor, when they were sure she was stable and they wouldn’t have to abandon the surgery, they brought Katie into an adjoining operating room. Dr. Gastman and two other surgeons began removing most of the reconstructive work that had been done on her over the previous three years. The operating room was quiet and the atmosphere intense. Residents crowded around the surgical table, monitors beeped steadily and the room was busy with the flurry of nurses handling instruments and checking monitors.
Finally, Dr. Papay entered from the adjoining operating room with the donor’s face on a tray, looking quite healthy and at peace. This iconic and unbelievable picture was captured by National Geographic photographer Lynn Johnson who commented, “It was just a breathless moment. People were sort of stunned.” The operating room fell into temporary silence, awed by the sight of this face that lingered between two lives.
For Dr. Gastman, the pivotal moment came when the donor face was laid over Katie’s. “It looked so good — it was shocking. It changed everything. I realized what an incredible opportunity this girl was being offered,” he says. The surgeons began to connect the blood vessels, attaching the face from the neck up, reversing the steps they’d taken to remove it. First they connected the donor’s bones to Katie’s bones with plates and screws, and then specially trained microsurgeons — including Dr. Gastman — began connecting the motor nerves, stitching the ends together with sutures the size of a strand of hair.
When they finished one side and unclamped Katie’s vessels, her blood rushed in and the new face, coursing with life-giving blood, turned pink. “There was a very large internal sigh of relief by all of us surgeons,” Gastman recalls.
The doctors had planned to perform a partial transplant, keeping Katie’s own cheeks, eyebrows, and forehead. But as the operation progressed, they realized a full transplant might be a better option. The donor’s head was larger than Katie’s, and there wasn’t enough room for all of the donor’s muscles and vessels. Additionally, her skin tone was darker than Katie’s, which would make for more obvious scarring. These discrepancies forced them to make a critical decision. A partial transplant might have yielded better function but clearly would not have looked as good. A more complex transplant would enhance the risks of rejection. To explain the options to Katie’s parents, Drs. Gastman and Papay pulled out their cell phones, took photos with the new face in place, and left the operating room to confer with them. Dr. Gastman assured them that, “Every decision you’re going to make now is going to be right,” but he urged them to do what they thought Katie would want.
When the doctors left them alone, Katie’s parents imagined what she would say if she woke up to the partial transplant, with its more visible scarring and mismatched skin tone. “She’d say, ‘You mean I could have looked better than this, and you decided not to do it?’ ” her father said. Her mom thought about what Katie had said to her recently: “I want to go out and be a face in the crowd that no one looks at.”
Ultimately, her parents decided that she would want to take the risk and “would want the full, the full-on.” In the end, the surgery effectively replaced 100 percent of Katie’s facial tissue, including scalp, forehead, upper and lower eyelids, eye sockets, nose, upper cheeks, upper jaw and half of lower jaw, upper and lower teeth, partial facial nerves, and facial muscles and skin.
At 3 p.m. Friday afternoon, after 31 hours of surgery, the surgeons finished suturing Katie’s skin and attaching her new face, and doctors, nurses, residents, and staff broke into spontaneous applause. And Dr. Gastman? He got home for Shabbos. “I think I came into the house and collapsed. Then I went to shul. All Shabbos I couldn’t really sleep — just waiting for my phone to ring. The first 72 hours are crucial and we had to be vigilant for signs of rejection.”
Rejection is not the only major hurdle Katie and her family have to deal with. Our faces are an astonishing combination of major muscles that move the jaws and assist in swallowing and speech. They are made up of layers of blood vessels, sensory and motor nerves, cartilage, bone, and fat. Cranial nerves transmit sensory information to the brain, making us able to see, smell, taste, hear, and feel sensation on the skin. Other cranial nerves are responsible for facial, jaw, and tongue motion, among other activities.
But a face is also an identity. When we look in the mirror, we see who we are. How does it feel to wake up with someone else’s face? “In this regard,” Dr. Gastman explains, “there are limits to how long we can wait for an appropriate donor and how perfect that donor has to be before we move forward. Keep in mind, we had to find a donor who had no facial trauma and was in Katie’s age range. In the end, she doesn’t look like the donor because when you take the tissue and stretch it and fit it, it changes form — the face adapts to the facial structure. However, she doesn’t look like Katie either.”
Her family refers to it as her “third face.” The first she was born with, the second was her reconstructed face that Dr. Gastman and his team worked on to make her functional, and the third is the transplanted version. When Katie came out of surgery it took a little while for her parents to absorb the change. Her mother worried if “her Katie was still in there.” But Katie’s hope was to become “another face in the crowd” and Dr. Gastman and his qualified team brought her much closer to that goal. She now has a chance to live a normal life.
It’s Happening Now
Appearances matter to Dr. Gastman as they apply to his work, but not as much in reference to himself. In pictures and videos of him representing the hospital and interacting with patients, he’s always there wearing his big black yarmulke. He says that while it’s not an asset professionally, being visibly religious is a chizuk to himself and other Jews in the profession. He notes that there has been a noticeable change in the makeup of medical professionals at the hospital. Whereas it was never uncommon to see religious Jews in the medical field, they were most often the product of broader or secular educational systems. “Today I’m seeing sheitels and yarmulkes walking around in white coats. Guys with right-wing yeshivah backgrounds, who went to the Mir and then to med school.” Dr. Gastman notes that today, the frum doctors at CCF have an assigned room for davening — something that never would have been allowed to exist at the hospital’s inception. While the medical profession poses many challenges for an Orthodox Jew and he wouldn’t necessarily recommend it to everyone, “If it is something you’re interested in doing, you can succeed and be a good Jew and a successful medical practitioner. There are no limits for a frum Jew in the medical field except for the limits you place on yourself.”
Katie’s surgery and the previous face transplants performed at CCF were not covered by insurance companies, Medicare or Medicaid, because they are still considered experimental. Instead, they were fully funded by the US Department of Defense’s Armed Forces Institute of Regenerative Medicine (AFIRM). The military’s goal in funding the research was to support the development of therapies that could ultimately be used for wounded military personnel. Katie, with both youth and extensive gunshot injuries, was a pretty close model of a wounded soldier. To date, about 4,000 servicemen from wars in Iraq and Afghanistan have sustained facial injuries, about 50 of which were considered catastrophic. But so far, although candidates have been interviewed, no service members have consented to the procedure; many of these tough, patriotic soldiers injured in the line of duty consider their wounds a badge of honor. Furthermore, a transplant requires a regimen of lifelong immunosuppression, so those hoping to be redeployed would be ineligible to rejoin the forces.
What does the future hold for Dr. Gastman, now that Katie’s transplant has made history? Currently, the US Defense funding has come to an end and until the hospital develops new resources and finds other eligible candidates for facial transplants, Dr. Gastman continues to serve patients as a reconstructive surgeon and is focusing his energies on cancer research. “Even though you’re supposed to be ‘samei’ach b’chelko,’ in this field you can’t be satisfied with your level of learning or your previous accomplishments. You have to expand and do more and not stay stagnant. There is a lot of cancer research going on and new discoveries and surgeries are maturing every day.”
Dr. Gastman notes that we are living in an incredible era and cancer research is progressing at an amazing rate. He quotes a 2011 study that reports that the doubling time of medical knowledge in 1950 was 50 years; in 1980, seven years; and in 2010, three and a half years. In 2020 it is projected to be a fraction of a year — just 73 days. That means that students who graduate in 2020 will experience four doublings in knowledge over the course of their education. What was learned in the first three years of medical school will be just 6 percent of what is known at the end of the decade from 2010 to 2020. “People will always be worried about any severe diagnosis, medically and psychologically. But these successes should give people hope. Things are only getting better.”
Dr. Gastman is excited about the medical world’s advances and the breakthroughs both in transplantation and in cancer care, and as a frum Jew he takes note of its incredible timing. “Hashem has made it all happen now — not in years past or in coming years — but at this specific time. He is opening our eyes to new discoveries and new advances daily. We don’t know why we need it today or why today is the right time — but it’s something we have to notice and think about.”
Does Dr. Gastman find G-dliness in his work on a regular basis? “I’ll tell you what I find G-dly,” he explains. “When I suture tissues and they seal a gap, and those tissues reform and regenerate — that’s G-dly. That’s Yad Hashem.” For a transplant like Katie’s, where the doctors had to depress an immune system and transplant intricate tissue, bone, veins, and arteries, thousands of things could have gone wrong. And to succeed, thousands of things had to go right, all at the same time. “There is no other explanation but Hashem. You can’t get so lucky in so many ways. Hashem gives us tools and infinite nissim. We just simplify it for ourselves by calling it science.”
(Originally featured in Mishpacha, Issue 748)
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