Dr Alam was in search of a radical solution. He believed Charla would be an ideal candidate to undergo a pioneering and risky new procedure. A full facial transplant. The Cleveland clinic had performed the very first face transplant in America in December 2008. Dr Alam, a key member of the transplant team, pushed Charla to be next in line bringing hope to the family at the prospect.
First Face Transplant
Steve Nash "The preparation was to do the transplant, everything revolved around the preparation with Dr Alam. He was making all the plans necessary to do the transplant."
But because of Charla's unique need for both her face and hand transplants to be performed simultaneously, a procedure never before attempted in the US, the evaluation process hit a wall at the Cleveland clinic.
Dr Alam "As a collective decision of the transplant team, it was clear that she did not fit the protocols that the Cleveland clinic had for face and hand transplantations. It was very, very difficult to go to Charla and go through the process and explain that we couldn't do the transplant there."
Dr Bohdan Pomahac
Steve Nash "It was quite devastating, at that point again, like the attitude on everything, where do we go from here."
For Charla Nash and her family the news that the Cleveland clinic would not be able to perform a face and hand transplant was a brutal blow. Her lead surgeon Dr Daniel Alam was also disappointed. He vowed not to give up her case. To move the process forward, he brought another expert on board, Dr Bohdan Pomahac of Brigham and Women's Hospital in Boston. Pomahac was a pioneer in research in facial transplants.
Dr Pomahac "We evaluated Charla. It turned out that not only myself and my psychiatrist but also our cranial investigators felt that she would, indeed, be a very good candidate for a face transplant. We arranged for her transfer here to Brigham."
In May 2010, after 15 months at the Cleveland clinic, Charla said goodbye to her care-givers. Even though there was no guarantee that this surgery would happen once she arrived at Boston, Charla knew she had to go.
Once in Boston, Charla took up residence in a nursing home where she continued to build the strength, skills and confidence she needed to survive a double hand and face transplant.
By now, she had a nose, built from cartilage from her rib. But, it was purely cosmetic to improve her appearance, until she was approved for the transplant. As part of the evaluation process, she spent much time at Brigham and Women's Hospital receiving scans and meeting with surgeon's and psychiatrists. To live with someone else's face and hands, a patient has to be deemed strong enough, physically and mentally.
Mitch Hunter Disfigured
In December 2011, seven months after arriving in Boston, and nearly 2 years after her attack, Charla Nash was approved for the experimental procedure. Her name was now added to a donor waiting list. But, there was no telling how long it would take to find a family willing to make such a personal donation.
Back at the nursing home, there wasn't much for Charla to do but wait. As she adjusted to life as a blind person one thing became clear, the key to any future independence was a new pair of hands.
If you don't have your eyes, your hands are what you use to touch the world, to explore the world.
Only a handful of people in the world could understand what Charla was going through. Mitch Hunter was one of them. His face was severely disfigured in a car crash in 2001. In May 2011, he came to see Charla. 10 years after his accident, Mitch had a facial transplant at the same hospital which was treating Charla. He was just six weeks into his recovery when he came to visit. As they compared notes, they were able to bond over their common experience.
Within a week of meeting Mitch, the long awaited phone call finally came. There was a donor, it had been nearly 2 1/2 years since Charla's attack. When the news arrived, Dr Daniel Alam her surgeon from Cleveland was in of all places, the mountains of Peru fixing cleft palettes.
Dr Alam "I ended up taking three planes, two trains and a bus to make it back to Boston."
May 2011, the evening of Charla's transplant. At the same time that the face and hands are being harvested from the anonymous donor in one operating room, Charla is being prepped to receive them in another. Transplants at a race against the clock, once body parts are removed, the blood supply must be re-established within four hours.
Dr Pomahac "After that, it becomes strictly that, muscle can be damaged, the recovery of facial muscle or the muscles of the hands or forearms may not fully occur."
Charla has already undergone several reconstructive surgeries, including a procedure to insert cosmetic, non-functioning eye implants, now someone else's face is going to be moulded and sewn over all of that work. This will be the fifth full facial transplant performed in the world and only the second attempt at a face and double hand transplant ever.
The first patient to go through one in France in 2009, died shortly afterwards. So, the stakes couldn't be higher.
The plan is to start with the hands and then move onto the face. This is work that requires the utmost precision. The surgical team, using microscopes, deconstruct and rebuild the intricate maze of nerves, blood vessels and tendons so that Charla's blood can start pumping to her new body parts making them her own. Once the underlying elements are fully attached, the face itself goes on last. An army of medical personnel must work together in perfect synchronisation, there is no margin for error.
Charla Nash, New Face
Dr Pomahac "Everybody knows their role, everybody knows what is expected from them and that makes it, in the big picture, a lot easier, because all units almost work simultaneously but also independently in this big complex one operation"
After 20 hours, the surgery is finally over. The doctors are exhausted, but jubilant.
Dr Pomahac "The operation went, I thought, terrific, in the end, everybody was very happy that the hands looked great, the face looked great."
It's a full day after Charla Nash's groundbreaking face and double hand transplant. The initial 24 hours of recovery are crucial. At first, it appears, that Charla's body is fully accepting the transplants, but then she takes a sudden turn for the worse.
Charla's body temperature rose and we found out that she had bad pneumonia causing the patient to be really, really sick.
With her health rapidly declining Charla's new hands of not getting the blood flow the need to thrive. The surgeon overseeing her hands realises they can't be saved, despite all their efforts.
Dr Matthew Carty
Dr Matthew Carty "We never wanted to get into a situation where we were having to choose limb over life, in the end it was an easy decision. In the end, it was an easy decision, because we knew it was the safest thing for her to remove the hands when we did."
The devastating loss of the hands is tempered with the incredible success of the face. After 2 1/2 years of crippling disfigurement, Charla's new face is an astonishing transformation.
Mike Nash "She had lips and a nose. It's amazing, the miracles of science"
Still in the intensive care unit, Charla regains consciousness slowly and learns the sad fate of her new hands. After three weeks, Charla moves from Brigham and Women's Hospital to a rehabilitation centre to recover.
It is here that Charla begins another intensive stretch of therapy. Charla's facial nerves and muscles are expected to activate over a period of years, before she has optimal control. She must also remain on a regimen anti-rejection drugs for the rest of her life.
Until Charla is fully recovered, travel outside the facility is limited, but Briana arranges a special outing to see her favourite horses.