The Acid Behind The Scarred Face

A life as full of agonizing pain and gratuitous cruelty as that of Pakistani acid-burn victim Fakhra Younas must be honored and brought to bear upon the souls of nations in many ways. Karachi filmmaker Sharmeen Obaid-Chinoy had begun to do just that, winning Pakistan’s first Academy Award for “Saving Face”, a documentary that followed harrowing acid-attack stories like Ms Younas'. So does Declan Walsh, in a recent New York Times story announcing her suicide, on March 17, 2012.

Here, I want to make a space to understand just that facial disfigurement is a uniquely devastating wound. Not just an irretrievable loss of a multiple-function system, facial disfigurement is profoundly jarring to a fundamental sense of self—which may explain why acid attack is a weapon of choice for some vindictive South Asian men.

Born of a heroin addicted mother into a brutally difficult life, Fakhra Younas had become a dancing girl as a teenager. A photograph of Ms. Younas taken before the crime displays a tough cookie, ebulliently self-aware, self-reliant, even ambitious. After the crime, frighteningly disfigured, she fled her home and her husband, taking her young son with her to Italy, where she was protected under political asylum. She learned to speak Italian, and submitted herself thirty-eight times to facial surgery, paid for by a Milan cosmetics company, just to be able to open one eye and close her lips. Plastic surgeon Dr. Valerio Cervelli found her “so headstrong, so independent.” She knew how to leverage the notoriety of her plight, and spared no energy doing it. She wrote a memoir, “Il Volto Cancellato (The Erased Face)”, published in Italian, French and German, which sold well enough to support herself and her son, now a high school student in Rome. “She ventured outside fearlessly,” writes Walsh, “armed only with a bawdy sense of humor ingrained on the streets of Karachi,” sometimes, for example, brandishing her false ear at the soccer stadium as crowd control. Then the faces of acid-attack victims like herself appeared on the silver screen, winning accolades and a sense of Pakistani national pride, despite the documentary's damning subject matter, for the homeland to which she could never return.

And in the astringent limelight have awakened the stirrings of a national conscience, of political movement, however timorous, toward justice for women. And once-unimaginable miracles of craniofacial innovation have begun to make daily headlines around the world...

But Ms Younas herself, say her son and her closest friends, had never overcome her sense of isolation, and a deep-rooted depression, and an unassuageable sorrow for her lost self. Finally, last month, perhaps in search of that self, Fakhra Younas stepped off a sixth-floor balcony in Rome, and died.

More Miraculous Face Transplants. STAT.

Richard Norris, before and after

Thirty-seven-year-old Richard Lee Norris had lived fifteen years as a recluse, a masked man to all but his closest relatives. His face was a gnarled mass of scarred flesh and useless features, after a close range shooting accident in 1997. Luckily—or not—Norris was not blinded in the accident that blew his face off. He has been able to see clearly the life that was passing him by—and the expressions of horror in the faces of others. And then, one day last month, Norris was able to look in a mirror and see a handsome man looking back.

In a 36-hour operation at the University of Maryland Medical Center in Baltimore, Norris received the “most extensive face transplant ever carried out”, including not only a continuous facial tissue from scalp to clavicle, but also a tongue, both upper and lower jaws, and all their perfectly matched teeth. Faculty surgeon Eduardo Rodriguez, M.D., D.D.S.,

 Dr. Eduardo Rodriguez with transplant team at UMMC

led a team of more than 100 physicians, nurses and professional staff, whose expertise included not only dental and facial reconstruction, but also shock and trauma, for the first time in a face transplant. UMMC houses the R. Adams Cowley Shock Trauma Center, where the critical care concept of the golden hour was coined, and which has long experience in treating just such “high-velocity ballistic facial injuries”. And UMMC’s renowned Division of Transplantation has focused on the anatomic and immunologic challenges to craniofacial transplantation. Research there has found that high amounts of vascularized bone marrow (VBM) may significantly reduce the risk of tissue rejection, reducing the amount of dangerous immunosuppression required over the lifetime of the recipient. The mandible that Norris received is rich in VBM, and expectations, though guarded, are high.

Like the only other full-face transplant in the US, performed by Dr. Bohdan Pomahac and his team at Brigham and Women's Hospital in Boston, Norris’ FFT was paid for by grant funding from the Office of Naval Research (ONR) in the United States Department of Defense. The ONR funds medical research to support military operational medicine and clinical care of returning veterans. In addition to conducting research, the University of Maryland Medical Center trains military medical staff prior to deployment and performs organ transplant surgeries for patients at Walter Reed/Bethesda National Naval Medical Center. At this moment the Department of Defense estimates that as many as 200 wounded soldiers are eligible for an operation like Norris’.

Two hundred. Ready right now. Since 2005, when the first partial face transplant stunned the world, this once unimaginable miracle has already been repeated twenty-three times.

Only twenty three.

"Saving Face" takes Oscar® for Best Documentary Short

Saving Face tells the stories of two acid-attack survivors: Zakia, a 39-year old whose husband threw acid on her after she filed for divorce, and Rukhsana, a 25-year-old whose husband and in-laws threw acid and gasoline on her, then set her on fire.

Plastic surgeon Dr. Mohammad Jawad, put his London practice on hold to return to his home country to help Zakia, Rukhsana and other victims. Proving that attack by sulphuric acid is neither isolated nor unique to Pakistan and south Asia, Dr. Jawad made news for restoring the face of British model Katie Piper, victim of an acid-throwing in London in 2008. But key to a crucial disparity in cultures is that Ms Piper's attackers are serving life in prison, and she has found her way back, however excruciatingly, to a fruitful life.

Nicholas Kristoff has been trying to bring attention to this barbarity for some years, writing in the New York Times that in spite of intermittent and wan efforts at increased controls, it is still “easy in Asia to walk into a shop and buy sulfuric or hydrochloric acid suitable for destroying a human face.” Says Kristoff, “The first step is simply for the world to take note, to give voice to these women.”


Directed by Oscar® and Emmy®-nominated filmmaker Daniel Junge and Emmy®-winning Pakistani director Sharmeen Obaid-Chinoy, Saving Face is a powerful look inside Pakistani society, and the ongoing legal and political efforts to allow desperately needed change. “We want to dedicate this award to all the heroes on the ground working in Pakistan,” said Ms. Obaid-Chinoy.

Saving Face  airs in the United States and Canada on HBO, Thursday, March 8, at 8:30 pm.

Face Transplant as Hero's Journey

Dallas Wiens

Images of 25 year-old Dallas Wiens are all over the Internet, especially in unguarded contexts that invite repellent invective in stupid comments. But Raffi Khatchadourian, writing in The New Yorker recently, recounts Wiens’ riveting story as a hero’s journey—how he went from handsome wrong-headed teen to philosophical Melon Head, to heroic recipient of the first full face transplant in the U.S. How the arc of a young man’s journey became a crucible for intrepid scientists and human possibility. His grace in survival, his willingness to hang on against all odds became an inspiration, and the impetus behind medical miracles that came together around him.

Scholar and noted mythologist Joseph Campbell taught that all peoples in all times idealize human potential in a “Hero’s Journey":

“A hero ventures forth from the world of common day into a region of supernatural wonder: fabulous forces are there encountered and a decisive victory is won: the hero comes back from this mysterious adventure with the power to bestow boons on his fellow man.”

Dr. Bohdan Pomahac, a plastic surgeon at Brigham and Women's Hospital in Boston, has led the surgical team that has performed all of the full face transplants in the United States. Pomahac explains, “Full face transplantation include the forehead, eyelids, nose, lips, chin, and cheeks, with or without underlying    bone… [and] has been considered nearly impossible, because of the complexity of the blood supply—as well as ethical, psychological, and social implications."

In 1997—the year, incidentally, that doctors had to excavate my own face to get at a fast-growing bone cancer in the sinus space behind my right cheekbone—the hot action thriller was a fabulist brain teaser called Face-Off: Bad-guy Nicholas Cage switches faces with good-guy John Travolta, effectively becoming each other for the balletic chase and spectacular explosion of those climactic cigarette boats. In the end, the bad guy dies and the good guy gets Travolta’s face back. It was diverting and preposterous.

Now, a total of 18 patients have full facial transplants. 
And it is always a hero’s journey. 
Thanks to Mr. Khatchadourian and The New Yorker for giving Dallas Wiens, Dr. Pohamac, and all the others, the epic context they deserve.

DISGUSTED

In her new book “That’s Disgusting; Unraveling the Mysteries of Repulsion”, psychologist Rachel Herz writes that DISGUST is one of “the six basic human emotions”. In fact, DISGUST itself has become a hot topic among neuroscientists and behaviorologists alike. James Gorman, in a recent Science Times article, gives a handy overview of the "disgustologists", psychologists, neurologists and anthropologists who are finding implications moral, evolutional, and emotional in the phenomenon of DISGUST per se.

Apparently it affects us at levels both amygdalar and cerebral, hormonal and aesthetic, from our diet to our choice of mate and/or political affiliation. Author Hertz writes that DISGUST is a “cognitive emotion”— i.e., though universally experienced, it is not innate but learned, and culturally conditioned. That is, we’re not all disgusted by the same things. Still, we know DISGUST when we see it.

It is the signature expression of Roman water spouts and Medieval gargoyles; in 1870 Charles Darwin explored the expression of DISGUST—why it is so universally recognized, what that may mean to us and say about us—in “The Expression of the Emotions in Man and Animals.”  

Drawing upon his observations of his own children, and citing the documentary photographs of Guillaume-Benjamin Duchenne he described the face of DISGUST as like that when “one expels some horrible-tasting substance from the mouth.” Furthermore, "...the protrusion of the tongue in letting a nasty object fall out of the mouth, may explain how it is that lolling out the tongue universally serves as a sign of contempt and hatred [pg. 274]." 

The Facial Action Coding System [FACS] describes the “essential actions of one kind of DISGUST” more succinctly. Disgust consists of, in the upper face, AU9 [a wrinkled nose]… AU 4 [eyebrows pulled down]… AU 7 [lower eyelid is tensed]… AU 6+AU7 [eye opening narrowed]… AU 41 [upper eyelids relaxed]… AND, in the lower face, AU 26 [mouth open]… AU10+15 [upper lip drawn up, lip corners depressed]… A turn of the head is consistent with avoiding something distasteful.

Thirty-five years ago, psychologist and facial micro-expression expert, Dr. Paul Ekman was a pioneer in the study of facial expression. Identifying about three thousand facial muscle movements, individually and in combination, Ekman compiled 500 pages of notes into a catalog of human emotion, now widely used by neuropsychologists, police forensic departments and cgi animators. 

 
Dr. Ekman himself has entered popular culture as the model for Dr. Cal Lightman (played by actor Tim Roth) of the Fox TV series “Lie to Me”. Says Ekman: "DISGUST expressions are often displayed as a commentary on many other events and people that generate adverse reactions, but have nothing to do with the primal origin of DISGUST as a rejection of possible foodstuffs..."

How do YOU read these facial expressions?

Candidate Newt Gingrich, Rep. Debbie Wasserman Schultz, Candidates Mitt Romney, Ron Paul, and Rick Santorum,  pictured here with Random Voter

Let's look for them this election year. 

Plastic Surgery and the Great War

World War I seems like only yesterday this year:

Steven Spielberg's "War Horse", based on a novel by Michael Morpurgo, sweeps into the cineplex this month. The stage phenomenon of the same name, brilliantly realized by Handspring Puppet Company, continues on Broadway.

Susan Orleans tells the true life and legend of Rin Tin Tin, Dog Star of stage and screen, born on a World War I battlefield, delivered from it by a doughboy. Orleans writes that animals were deployed to the front in staggering numbers — some sixteen million horses, dogs, oxen, camels, donkeys, mules and pigeons went to the front—including “8 million horses that were killed… or sold to French butchers at the end.” 
War has come to the public television hit Downton Abbey in its second season. And HBO's Boardwalk Empire is haunted by characters like Richard Harrow, decimated by the unexpected savagery of that conflict.

The Great War was a wanton slaughter of innocence and innocents, none more so than the boys who fought from a 6-foot ditch scarred into scorched earth. It was, writes William Boyd in a recent editorial, “a conflict between 19th-century armies equipped with 20th-century weapons...in which millions of soldiers on both sides slogged through...a 500-mile line of trenches...to meet their deaths in withering blasts of machine-gun fire and artillery...."

Eager boy soldiers faced “a battlefield dominated by tanks, machine guns, howitzers, aircraft and poisonous gas...," exposed from the neck up.

In fact, the signature wound of the war was facial disfigurement. Unimaginable, mutilating wounds, once mercifully unsurvivable. And in the vestigial Victorian aesthetic of the times, unspeakably hideous. In her article, “The Rhetoric of Disfigurement,” social historian Suzannah Biernoff writes that an estimated 60,500 British soldiers suffered head or eye injuries... at the specialist hospital for facial injuries...over 11,000 operations were performed on some 5,000 servicemen between 1917 and 1925. "Many soldiers were shot in the face simply because they had no experience of trench warfare." One contemporary surgeon wrote, "They seemed to think they could pop their heads up over a trench and move quickly enough to dodge the hail of machine-gun bullets....”

One who had seen the carnage first hand was Harold Gillies, a battlefield medic who returned to Britain in 1916 to devote his life to finding a way to restore to these patients the “perceived loss of humanity.” Gillies would become known as the “father of modern plastic surgery". But in that first year—after the Battle of the Somme, when he expected 200 casualties and got 2,000—even the physician felt "fear, disgust and shame surrounding facial disfigurement, both for the men who suffered these injuries, and for those...who came into contact with them....”

Subsequent blogs will explore how Dr. Gillies, and the post-war world with him, came to terms with the bodily and spiritual carnage in the wake of The Great War, what it has meant to the science of facial reconstruction, and how it has shaped 21st century concepts of beauty and worth.

Martin Luther King: Stone Faced

This week’s observance of Martin Luther King Day is the first to be overseen by the man himself. That is to say, by a “Stone of Hope,” the nation’s official memorial to the great man, towering 30-foot over the Tidal Basin on the National Mall.

George Tames/The New York Times

Named for a line in King’s famous “I Have a Dream” speech of 1963, the 46-ton granite face of the statue was carved by Chinese master sculptor Lei Yixin, and for all its power to stir both memory and emotion, it has stirred controversy from the very beginning. Critics have found the face too steely, squinty, Chinese; the expression too stern, or lacking the “soft eyes” and “open face that conveys the blessed assurance of a man who walks by faith.” Charles Krauthammer wrote that this “flat, rigid, socialist realist King does not do justice to the supremely nuanced, creative, humane soul of its subject.”

Sculptor Lei at work on Stone of Hope

Bob Fitch/Courtesy Ed Jackson

Over years of research, 53-year-old sculptor Lei covered the walls of his studio with pictures of Martin Luther King, and researched hundreds of hours of King’s speeches and letters. Finally choosing as the model for his sculpture a famous 1966 photograph of King standing at his desk with arms folded, Lei's interpretation was to be of Martin Luther King, Jr., "a great man who was also an ordinary man". Still, he acquiesced repeatedly to requests to soften the facial expression in his likeness of Dr. King. In the end, King's children all chose this, the final of four different facial expressions that Lei produced, as looking most like their father. And a majority of viewers will likely find with Krauthammer that withal, “you cannot but be deeply moved.... There is no denying the power of this memorial.”

Bettman/GettyArchive

Ultimately, of course, any quest for a single facial expression to  capture the whole of the human presence is doomed from the outset, and is the bane of the monumenaltist’s mission (think Mt. Rushmore). For the face, any face, is recognized most profoundly, and identified best by the way it moves—and it is always in motion.

In What the Face Reveals, for example, Paul Ekman, et al, identify literally hundreds of specific facial expressions and “microexpressions” that occur in direct relation to muscular contractions. Using the renowned technical classification system known as the Facial Action Coding System (FACS) Ekman categorizes facial behaviors based on the muscles that produce them. More on this in a future post.

For now though, this is my bid to cut a little slack to sculptor Lei Yixin, whose monumental King was never intended to supplant the magnificent face of the man, in all of its ordinary and splendid expressiveness.