From business school to the pinnacle of CMF surgery
01 November 2018
Just five months after performing Canada’s first full face transplant, acclaimed plastic surgeon and AO CMF faculty member Dr Daniel Borsuk discusses his work, the AO CMF mentors who inspired him and how technology is evolving to improve patients’ lives.
It’s a a chilly Thanksgiving Day morning in Montreal, Canada, and a rare day off for Borsuk. But his passion for his patients, who represent some of the world’s most complex cases, takes no holidays. At 40, the native Montrealer could easily be seen as at the top of his game: He has played key roles in three high-profile, successful facial reconstructions. The most recent was a full face transplant on a 65-year-old Canadian roofer whose face was severely disfigured in a 2011 hunting accident. Borsuk led the team that, in May 2018, performed a 30-hour surgery on Canada’s first—and the world’s oldest—face transplant patient. In the wake of that successful surgery, Borsuk’s head has not been turned by acclaim.
“People are still in need and are suffering. My job is to figure out how to help them,” he says matter of factly.
"We look at people’s faces to judge personality, intelligence, warmth, kindness. If you can’t read someone’s face or they can’t read yours, there’s a disconnect."
Listening to patients
At the root of his affinity for the human face is a reservoir of compassion. Borsuk believes that listening to patients’ needs and desires and treating them with compassion “is the No. 1 thing.” “Not everyone is going to have the same desires. What we do is not about our own goals. It’s about what the patient wants,” he says. “I try to understand what they feel and I try to deliver on those feelings and needs.”
The prominent cases he has assisted and led generate headlines, but for each of those cases, there are many less-prominent ones that inform his skills, experience and understanding of the complexity of craniomaxillofacial surgery. “A person with a bump on his or her nose can experience the very same stress as a patient with a severe deformity, for example. Whether it’s a minor or a severe deformity, we want to see what we can do to help,” Borsuk says. “People recognize that appearance is important. You can get hung up on the cause or pathology but if we are helping people, that is the important thing.”
A life-changing realizationBorsuk took a circuitous route to where he is today: He was a Master of Business Administration candidate at McGill University in 2001 when eminent plastic surgeon Dr Chen Lee, then chairman of plastic surgery and associate professor at McGill, reached out to the business school to find volunteers to help identify bottlenecks to rapid care for patients needing reattachment of amputated body parts. Borsuk volunteered.
“It was taking six to 10 hours for patients with accidentally amputated body parts to get to the operating room (OR),” says Borsuk, emphasizing that prolonged insufficient blood supply to amputated body parts has a significant impact on successful reattachment. Lee—former AO North American Craniomaxillofacial (CMF) Chair—one day called Borsuk to the OR, where a 14-year-old patient lay awaiting reattachment surgery, his arm on an adjacent table. Borsuk’s career path changed in an instant. “I realized, ‘This is what I want to do for the rest of my life. I don’t belong in business,’” he recalls.
"Dr Rodriguez is still my mentor and my friend. He taught me everything, from how to build a team and get others involved with your projects to inspiring people to flourish. I learned so much just from the way he talks to people and manages his patients.”
A solid foundation
For the year that he was finishing his MBA program at night, Borsuk was going to medical school during the day. His collaboration with Lee introduced him to the AO Foundation and, intent on learning from the masters of craniofacial care, he sought out CMF luminary and AO Foundation Past President Paul Manson, MD.
“Where do you go when you want to do craniofacial? Paul Manson,” he says. During his one-year fellowship at Johns Hopkins Medicine in Baltimore, Maryland (US), Borsuk was mentored by Manson and his protégé, renowned CMF surgeon and AO CMF faculty member Eduardo Rodriguez, MD, DDS. In Rodriguez, Borsuk gained another AO CMF mentor—and the opportunity to be part of Rodriguez’s team performing a highly complex 2012 reconstruction on a young man whose face had been destroyed by gunshot. One of the most extensive face transplants in history, the procedure gave the patient a tongue, jaw, teeth and skin, and it set in motion Borsuk’s own trajectory as a CMF pioneer.
“Dr Rodriguez is still my mentor and my friend. He taught me everything, from how to build a team and get others involved with your projects to inspiring people to flourish,” he says. “I learned so much just from the way he talks to people and manages his patients.”
This solid foundation prepared Borsuk to take on a complex 2015 case involving a 23-year-old patient whose face had been ravaged in an altercation. Despite earlier reconstruction attempts, the patient was still disfigured and suffering chronic pain. Borsuk’s approach broke new ground: To avoid the infection risk posed by conventional methods like implants or bone grafts, he used state-of-the-art 3D scanning and printing technology to model the patient’s skull. With these 3D-printed models as his guide during the eight-hour surgery, Borsuk carved a piece of bone from the patient’s hip to produce a flawless reproduction of the cheekbone. The result: a scar-free, deformity-free reconstruction.
“I had learned all about virtual surgical planning in Baltimore: computer-aided design in manufacturing, printing cutting guides and doing the microsurgical approaches developed by Dr Rodriguez,” he explains. As technology continues to evolve, Borsuk sees opportunities to restore patients’ quality of life. “3D printing, for example, has allowed us to minimize risks and improve outcomes as well as being an important educational tool for residents,” he said. “The software is becoming better at soft tissue simulation and printing better profiles, and obviously the potential for printing biointegratable and osteoconductive materials is very interesting. It’s an exciting time to be on the wave of it all.”
Evolving technology is just one of the issues with which CMF surgeons must grapple; another is the risk associated with existing treatments. For example, existing data indicates that immunosuppressants can cause cancer in face transplant patients 10 years subsequent to surgery. “That’s a very significant consideration. With the evolution of immunosuppressant drugs, as they become less toxic, grafts will last longer and have fewer side effects,” Borsuk says. Until then, he continues to give patients the information essential to them being able to provide informed consent. “Most of these patients are suffering so terribly that, even understanding the risks to their lives, they say, ‘Do you really think I have a life right now?’”
Dr Daniel Borsuk completed his undergraduate, business and medical degrees at McGill University in Montreal, Canada. After earning his medical doctorate, he went on to specialize in plastic, reconstructive and aesthetic surgery at the Université de Montréal training program. Upon completing his residency, Borsuk earned the Dr. A. Ross Tilley Scholarship bestowed upon one graduating resident of plastic surgery in Canada. Following his plastic surgery training, Borsuk pursued further specialization in pediatric and adult craniomaxillofacial surgery, microsurgery, and aesthetic surgery at the world-renowned Johns Hopkins Hospital and the R Adams Cowley Shock Trauma Center, in Baltimore, Maryland (US).
Today, an assistant professor of surgery in both pediatric and adult craniomaxillofacial (CMF) surgery and plastic surgery at the Université de Montréal teaching hospitals Sainte Justine and Maisonneuve Rosemont, Borsuk is a lecturer on advanced CMF and aesthetic surgery and is actively involved in plastic surgery research and education.
His special interest in the human face lies in the power of the face itself. “It’s the organ of emotion. We look at people’s faces to judge personality, intelligence, warmth, kindness. If you can’t read someone’s face or they can’t read yours, there’s a disconnect,” says Borsuk, an AO CMF faculty member. “If you’re not able to interact with people in the ways they expect, that can lead to isolation and unhappiness. We want people to be happy. People are social beings.”