On Labor Day, 1998, Dr. A. Jay Burns, a plastic surgeon affiliated with the Children's Medical Center of Dallas, got a call from a colleague at St. Francis Hospital in Tulsa, Oklahoma. "We've got a severe facial-trauma case to send you," Burns recalls his friend saying, "a dog mauling like you've never seen before. We've done what we can to stabilize the patient, a two-year-old boy who was bitten by the family dog."
Burns remembers telling his friend that it couldn't be that big a deal. At 42, he had seen a lot of horrific facial injuries in his time and performed many difficult facial reconstructions. And he knew that what might seem like an extraordinary case of trauma to a smaller hospital like St. Francis was likely a routine case at Children's, which has the busiest pediatric emergency room in the nation. "It was a dog bite," he remembers thinking. "How bad could it be?"
But when he first saw little Mycha Herbert in Children's Pediatric Intensive Care Unit three days after the incident, Burns says, "I was completely overwhelmed. I'd never seen anything like it before, and I knew I'd never see anything like it again."
From just below his eyes to just under his chin, the toddler's face had been filleted from the bone by the dog's powerful jaws. The tissues of his cheeks, nose, lips, mouth, and chin were simply gone, leaving only the glistening white bone of his skull and two very stunned eyes where once there had been an impish face. Though Mycha's tongue and teeth were intact, the damage was so total that the doctors at St. Francis had had to insert a tube through his throat so that he could breathe and a feeding tube directly into his stomach so that he could receive nourishment. Mycha's parents — Bobby, 24, and Veronika, 19 — weren't certain what had happened, but it appeared that their son had startled the family dog, a six-month-old Staffordshire terrier named Blue, and the dog had snapped at Mycha, locking his jaws on the lower two thirds of the boy's face with a single bite. Mycha must have then stumbled, causing the facial tissue to shear off the cranium more or less in a single piece.
"For the first time in my career, I truly didn't know what to do," says Burns, a rangy, baby-faced man with a receding hairline and a self-effacing manner. But he knew instinctively that whatever solution he devised for Mycha (pronounced Mi-cah), he was probably going to make history with it. Reconstructive facial surgery had come a long way in just the decade and a half that he'd been practicing it. Vascular microsurgery had made the transfer of so-called free flaps — patches of tissue that include skin, muscle, fat, blood vessels, and nerves — from one place on the body to another a fairly routine matter, without the need for awkward connecting tubes of tissue (called pedicles) to supply blood to the grafted site, and improved anti-rejection drugs were allowing even grafts from donors to "take." The occasional miracle was now possible. Still, as far as Burns knew, creating essentially a whole new face for a patient out of his own tissue had never been tried before.
So he began networking with colleagues for suggestions. Two serious options emerged. One, proposed by Dr. Steve Byrd, was a wholesale face transplant from a donor. This had never been done either, but the doctors learned from experts in the field that new techniques and medications made it at least feasible. However, they realized that a transplant would involve a lot of red tape — advertising for and finding a donor, for starters. "We just ran out of time," recalls the 53-year-old Byrd. "We had a kid on a respirator we needed to save."
The second option was even more daunting than a transplant. Though the most flap transfers any reconstructive surgeon had ever attempted in repairing a damaged face was three, Burns and Byrd could see how grafting as many as five flaps to intact tissue on different parts of the boy's exposed skull could give surgeons the flexibility necessary to fashion somewhat more-normal facial features, restore more muscle movement and strength, and better re-establish nerve conduction. But their timing had to be exquisite: Once harvested, a free flap of tissue must be completely hooked up to its new site within four to six hours or it will die. In fact, Burns was expecting at least two of the flaps to do just that. And even if attached in time, the grafts could fail for all sorts of reasons: clotting or spasms in the newly grafted blood vessels, for example, or failure of grafted nerve tissue to grow new nerves properly. Meanwhile, severe trauma would also be inflicted on the parts of Mycha's body where hunks of tissue would be harvested for grafting.
There were other questions as well. The Herberts were of limited means and uninsured, so the hospital would have to pick up the tab for Mycha's medical expenses, which would surely amount to several hundred thousand dollars. Moreover, the initial round of surgical procedures alone could tie up an operating room for days — something unheard of at a busy trauma hospital like Children's. Finally, Burns knew that he couldn't mince words with the boy's young parents, who were, to complicate matters further, expecting their second child soon. Mycha would have only a fifty-fifty chance of surviving the operation, he told them. And if he did survive it, there was no guarantee that his newly reconstructed face would work, or that it would ever look normal.
Bobby Herbert, who was an unemployed construction worker at the time, didn't flinch. "We'd been thinking Mycha wouldn't make it at all, so any chance to save him was fine by me," he recalls. The hospital, for its part, was just as resolute. "I was expecting all sorts of problems," says Burns, "but they said