Dr Samir Mardini of the Mayo Clinic in Rochester, Minnesota, is a plastic surgeon and director of the face transplant department. He treats brachial plexus injuries, cleft lips, and cleft palates, and often facial reanimation.
His latest achievement, beyond the patient’s expections, was the face transplant of Andrew Sandness in a 56-hour surgery in June 2016 that gave him a donor’s nose, cheeks, mouth, lips, jaw, chin, and teeth.
Sandness, at 21 years of age, from Wyoming, suffered depression and wanted to end it all. He placed his rifle beneath his chin and pulled the trigger in December 2006. He survived, but was left with horrific facial injuries. He said he instantly knew he had made a terrible mistake.
Mardini, a newcomer at Mayo Clinic, was on duty when Sandess was transferred to the clinic soon after the accident. Despite their skills, the doctors couldn’t miraculously turn him back into the same guy. “I just need you to be strong and patient,” Mardini said to Sandness.
Sandness had no nose and no jaw. He’d shot out all but two teeth. His mouth was shattered, his lips almost non-existent. He’d lost some vision in his left eye. He needed breathing and feeding tubes at first.
Mardini and his team removed dead tissue and shattered bones, then connected facial bones with titanium plates and screws. They reconstructed his upper jaw with bone and muscle from the hip; they transferred bone and skin from a leg to make the lower jaw. They used wires and sutures to bring together his eyelids, which had been spread apart because of the powerful blast.
After eight surgeries over four months, Sandness returned home to Newcastle, Wyoming, with a population of 3,200, where friends and family embraced him. He worked at a lodge, in the oil fields, and as an electrician’s apprentice. But he avoided looking at people, especially children, because he was afraid of frightening them. People would ask him what happened, and he avoided answering the question.
His mouth was about an inch wide — too small for a spoon — so he tore food into bits, then sucked on them until he could swallow the pieces. He wore a prosthetic nose but it constantly fell off outdoors; he carried glue to reattach it. It discolored often, so he had to paint it to match his skin.
The prospect of 15 more surgeries that Mardini had planned for him scared Sandness. He didn’t want more skin grafts, more scars, or dental implants. Over the next five years, Sandness made yearly visits to Mayo. Then in the spring of 2012, he received a life-changing call.
Mardini told Sandness that the Mayo Clinic was going to launch a face transplant program. Mardini had already begun traveling to France, Boston, and Cleveland to meet doctors who had conducted face transplants. But only about two dozen transplants had been conducted around the world, and he wanted Sandness to understand the risks and the aftermath: a lifelong regimen of anti-rejection drugs. Sandness says he was concerned about the possibility of skin graft rejection and potential side effects of anti-rejection drugs, including skin cancer, infection, diabetes, and weakening of the bones.
Three more years passed and by then, the Mayo Clinic had completed a long internal review to get the face transplant program approved. Meanwhile Sandness had to undergo a rigorous psychiatric and social work evaluation to address, among other things, a key question: Should this surgery be performed on someone who’d attempted suicide?
Several factors were in his favor: his resilience and motivation, a strong support network of family and friends, a long-standing rapport with Mardini, and a gap of several years since the shooting. The doctors asked Sandness what he expected from the transplant, to make sure he had realistic goals. Sandness said he wanted a working nose, the ability to bite, swallow, chew, and to “get good stares as opposed to bad stares.”
Mardini and his team devoted more than 50 Saturdays over three and a half years to rehearse the surgery, using sets of cadaver heads to transplant the face of one to another. They used 3-D imaging and virtual surgery to plot out the bony cuts so the donor’s face would fit perfectly on Sandness. In January 2016, Sandness’s name was added to the waiting list of the United Network for Organ Sharing.
Mardini thought it would take up to five years to find the right donor: a man with matching blood and tissue types, roughly the same size as Sandness, within a 10-year age range and a close skin tone. But just five months later, Mardini got a call: there might be a donor.
The donor was Calen “Rudy” Ross, also 21. He was similar to Andy Sandness – they both loved the outdoors and going hunting and shooting. In early June 2016, Ross shot himself in the head. His devastated widow, Lilly, was eight months pregnant. Despite her grief she was committed to carrying out her husband’s wishes: on his driver’s license, Ross, who lived in Fulda, Minnesota, had designated that he wanted to be an organ donor. Lilly met with a coordinator from LifeSource, a nonprofit group that works with families in the upper Midwest to facilitate organ and tissue donation.
Since Ross had been healthy and just 21, his heart, lungs, liver, and kidneys could be transplanted. But additional screening determined he could do even more: he was a good match for a man awaiting a face transplant at Mayo Clinic. Lilly was skeptical at first. She said, “I didn’t want to walk around and all of a sudden see Calen.” She was reassured that Sandness had his own eyes and forehead and would not be recognizable as her husband. She thought of her baby son when she agreed to it. “The reason that I decided to … go through with it was so that I can later down the road show Leonard what his dad had done to help somebody,” she said in a video produced by LifeSource.
Mardini said when the doctors studied Ross’s photo, “we got chills when we actually saw how close they were in hair color, skin — just the overall look. It could be his cousin.”
Dr Samir Mardini and his team took 24 hours to procure Ross’s face, which involved taking bone, muscle, skin, and nerves. “It’s just a miracle that we were able to offer this gift to Andrew,” Mardini said.
On 16 June, Sandness was wheeled into surgery. In adjoining operating rooms, about 60 surgeons, nurses, anesthesiologists, and others had gathered for what would be a 56-hour marathon.
The medical team rotated, many taking four-hour breaks through the weekend. One of the most intricate parts of the surgery was identifying facial nerve branches on both men and stimulating them with an electric current to determine their function. That allowed doctors to make the correct transfers, so when Sandness thinks about smiling or closing his eyes, for example, those movements actually happen. After the surgery ended, Mardini proclaimed it “a miracle.”
Sandness, who was sedated for several days, wasn’t allowed to see himself immediately. His room mirror and cell phone were removed. His father, Reed, served as his eyes. “I said, ‘Andy, I’ve never lied to you. I’m telling you you’re going to be happy with what you see,” his father recalls.
Three weeks later, Sandness finally did see his face. He was overwhelmed. His father and his brother, joined by several doctors and nurses at Mayo Clinic, watched as Andy studied his swollen features. He was just starting to heal from one of the rarest surgeries in the world — a face transplant, the first at the medical center.
Sandness looked at his new face for a long time. “Far exceeded my expectations,” he wrote, handing the note to Dr. Samir Mardini, who read the message to the group. “You don’t know how happy that makes us feel,” Mardini said, as his voice cracked with emotion. The journey for all of them had been ten years.
“Once you lose something that you’ve had forever, you know what it’s like not to have it,” Sandness said. “And once you get a second chance to have it back, you never forget it. Just having a nose and mouth are blessings. The looks are a bonus.”
Andy Sandness can pinpoint the day he looked normal. About three months after the transplant, he was in an elevator when a little boy glanced at him, then turned to his mother without appearing scared or saying anything. “I knew then,” Sandness said, “that the surgery was a success.”
In December 2016, he had follow-up surgery to tighten skin on his face and neck and build up bone around his eyes so they’re not so recessed. His facial muscles are growing stronger. He has received speech therapy to learn to use his tongue in a new mouth and jaw, and enunciate clearly.
He can smell again, breathe normally, and eat foods that were off-limits for a decade: apples, steak, and pizza that he shared with his doctors.
Sandness, now 31, plans to return to Wyoming, work as an electrician and, he hopes, marry and have a family someday. Recently, he attended a Minnesota Wild game. He bought some popcorn. He watched some hockey. He didn’t see anyone staring at him, and he didn’t hear any whispers. He was, as he says, “just another face in the crowd.”