Trigger warning: This article includes discussion of suicide and graphic content
Derek Pfaff remembers being under a lot of stress throughout college. He remembers coming home from school during spring break in March 2014. But he does not remember the night that forever changed his life.
“I don’t remember anything,” said Pfaff, from Harbor Beach, Michigan. “I don’t remember getting the gun, going outside, shooting myself or the weeks afterwards.”
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It was shortly after 1.30am when his father, Jerry Pfaff, noticed that the family’s gun cabinet was open. He searched the area around the house and found his son lying in a snowbank next to the garage.
Derek Pfaff was rushed to the hospital. When he eventually regained consciousness and found himself in a hospital bed, he thought he had been in a car accident.
The gunshot wound from his suicide attempt had left his face severely damaged. He lost his nose, his lips, his teeth and parts of his forehead, which affected his ability to breathe, chew, swallow, smile or blink.
In the years that followed, Pfaff had 58 facial reconstructive surgeries. They were helpful, but he was still missing a nose, his upper and lower jaw, teeth, his eyelids and part of his forehead bone. He was unable to chew or speak easily.
“There was still a lot of work that needed to be done, and there was really nothing more that that hospital or facility could do for him,” said his mother, Lisa Pfaff.
At the time, she said, a doctor told her: “The only option for Derek is a face transplant.”
Pfaff, 30, is now one of just several dozen people in the world who have successfully received a life-changing face transplant. Among them are Aaron James, who received the world’s first whole-eye and partial face transplant, and Katie Stubblefield, who was the youngest person to receive a face transplant in the United States.
Mayo Clinic, where Pfaff’s surgery was completed, performed its first face transplant in 2016.
“There’ve been several patients in the United States that have had face transplants and over 50 around the world, and every single one of those patients is different. There’s no injury that’s the same,” said Dr Samir Mardini, chair of plastic surgery at Mayo Clinic, who serves as a facial reconstructive and facial reanimation surgeon and surgical director of Mayo Clinic’s Reconstructive Transplant Program. Mardini led Pfaff’s surgery.
When “you’re looking at a defect — the structure that you’re missing, the function that you’re missing — they’re never the same,” he said.
“So every face transplant that’s happening currently is innovative and it has something unique to it.”
‘It’s a life-giving procedure’
Pfaff’s 50-plus-hour transplant surgery was performed in February at Mayo Clinic in Rochester, Minnesota, involving a team of at least 80 healthcare professionals.
The team surgically removed the face of a donor and then surgically implanted the donor tissue onto Pfaff to restore his face structure and functions. About 85 per cent of his face was reconstructed and replaced with donor tissue, Mardini said.
Pfaff’s operation included replacing and reconstructing the majority of the facial structures, including part of the forehead, the nose, the cheekbones, the upper and lower jaws with teeth, the upper and lower eyelids, the mouth and all the muscles of the face that produce facial expressions, along with the skin overlying the entire face and neck.
The medical team also used a new microsurgery technique to transplant the donor’s tear drainage system, allowing Pfaff’s tears to drain normally into his new nose.
“With facial transplantation, it’s not a lifesaving procedure, but it’s a life-giving procedure,” Mardini said.
“It’s a life-enhancing procedure, and that’s something that’s really critical when we’re planning the surgery,” he said. “Unique to facial transplantation is the restorative nature of the procedure. You are not reconstructing parts of the face. You are restoring, bringing in fully formed facial parts.”
To ensure that the surgery was precise and accurate, Mardini and his colleagues created a virtual surgical plan that involved taking CT scans of both the donor’s and Pfaff’s faces. The team then did a “digital” surgery on a computer, with the help of biomedical engineers, before performing the real procedure.
“We decide together where the cuts are going to be on the bone, what angles the cuts should be at,” Mardini said. “And we do that the same on the donor and recipient so that when we go to surgery, we have printed models of the skull along with cutting guides of both the donor and the recipient, which allows us to execute the bony part of the operation exactly how we planned it in the virtual session.”
The team 3D-printed a customised guide for the procedure that they used almost like art stencils to guide them on where to cut and execute all aspects of the surgery on the bones of the face.
And “critical to the success of the operation” was mapping out facial nerve branches on both the donor and the recipient, Mardini said.
“We match the nerves together based on function so that when Derek is thinking about smiling, it’s stimulating the nerve for smiling — his own native nerve that is connected to the donor nerve, that creates the smile,” Mardini said.
The next part is for the muscles in Derek’s face to then respond and form that smile.
“You should see a smile on his face,” Mardini said. “And that part of the surgery is what really creates success.”
‘A miracle for him to see himself’
Pfaff was told to wait about a month after the transplant before looking at his new face, and in that time, Mardini said, his patient met with a psychiatrist to prepare for the big reveal.
“He wasn’t allowed to have a camera, his phone, his iPad,” mom Lisa Pfaff said. “The mirror in the bathroom was covered so he couldn’t see himself.”
Exactly 10 years after that fateful night – March 5, 2024 – Pfaff was finally able to see his new face for the first time.
“We turned a really sad, hard day into a really joyful experience for Derek, and it was just a miracle — a miracle for him to see himself,” his mother said.
While at the hospital, Pfaff looked in a mirror. He said that he “looked like a person again” and that he had been given “a second chance”.
Pfaff can now express emotions on his face: joy, laughter, sadness and disappointment. He can speak much more clearly and easily.
He works out twice a week, trains with a speech therapist and takes immunosuppressive drugs to reduce the risk of transplant rejection, which happens when a transplant recipient’s immune system attacks the donor’s organ or tissue. He will continue to take these medications for the rest of his life.
Overall, Pfaff said, he is “doing well”. He is excited about his future and now wants to “help others” by raising suicide awareness.
“The sun will rise tomorrow,” Pfaff said. “You just have to stay positive, no matter what the situation is. Look past the down.”
Globally, more than 720,000 people die by suicide every year, and it’s the third leading cause of death among young people ages 15 to 29, according to the World Health Organisation.
In the United States, suicide was responsible for nearly 50,000 deaths in 2022. That represents about one death every 11 minutes, according to the most recent data from the US Centres for Disease Control and Prevention. The number of people who attempt suicide or have suicidal thoughts is even higher. And research suggests that most young people who die by suicide in the US do not have previous mental health diagnoses.
Suicide is a serious mental health issue, yet it can be preventable and can be addressed with strategies to mitigate risks on individual, familial and systemic levels, according to the CDC.
If you have a loved one who’s struggling, some tips include asking whether they are thinking about suicide, trying to listen without judgment, connecting them with resources such as the 988 crisis line (or free Australian service Lifeline) and keeping in touch with them.
In the days leading up to Pfaff’s suicide attempt, his parents said, everything felt normal. Pfaff had gone skiing with friends a couple of days before, and on the day of the shooting, the family discussed plans to attend an Ash Wednesday church service the next morning.
Pfaff had been popular in high school and was an all-state football player, Lisa said.
“He had everything going for him, and we didn’t see this coming,” she said.
She initially felt a lot of guilt for missing possible signs that her son was at risk of harming himself or ending his life.
But as Lisa reflects more about their family situation, “I don’t think we missed anything,” she said.
“It was just something that snapped and something that happened, and we just needed to take the strength and courage to work through it and to keep our family together.”
Pfaff is looking forward to spending the holidays with his parents, his four siblings and the extended family. They plan to enjoy Thanksgiving dinner at Lisa’s mother’s home and watch the Detroit Lions football game.
“We’re so proud of Derek and everything that he has overcame over the last 10 years with a fighting spirit and staying positive,” Lisa said. “We’re just hoping that now that Derek’s in a position, that doors will open for him, for us to all continue sharing our family’s journey and Derek’s recovery.”
If you need help in a crisis, call Lifeline on 13 11 14. For further information about depression contact beyondblue on 1300224636 or talk to your GP, local health professional or someone you trust.