Ronald Poppo, the homeless man who lost half of his face last month in a bizarre attack by a man who chewed off chunks of his flesh, is aware of what happened to him.
What is unclear is how much Poppo is aware of the road that lies ahead.
Aged 65 and living on the streets for up to three decades, Poppo also suffered a brain injury and a broken rib in the attack. Doctors also found a puncture wound, suggesting he may have been shot by the police officer who fired at Poppo's attacker.
"This brings to light 100 different social issues at once, not including the bizarre nature of the attack," said one prominent facial reconstruction plastic surgeon. The surgeon, who has himself performed high-profile face transplant procedures, declined to be identified for this article because he is not affiliated with the Poppo case.
"He's probably a poster child for everything good and bad in healthcare," the surgeon said.
Poppo does not have health insurance, though his doctors have said he could qualify for Medicare. The costs of his care could range from several hundred thousand dollars to more than a million.
Miami taxpayers will pick up the tab, and the hospital has set up a fund that now contains more than $15,000. In some respects, the surgeon said, the fact that his attack is the subject of such widespread media curiosity could end up helping him raise money. Other trauma victims lacking significant means are even less fortunate.
This is a fact lamented by the most prominent bioethicists.
"It's not simply rude, it's not just discourteous – it's immoral to have a health system that doesn't supply a level of care for everyone," said Kenneth Goodman, co-director of the University of Miami's Ethics Programs.
"We do not ask children why their parents didn't make better investments. We do not ask veterans: 'Why did you squander your health?' We do not ask indigent people for a deposit and a credit card before we save your life. We have a moral responsibility to take care of people, independently of their ability to pay for it."
Floridians tend to agree. Several counties have voted to pass a half-penny sales tax specifically designed to fund healthcare to those who can't afford it. Voters in Dade County also approved of the Children's Trust, which allocates taxpayer money to children who need it.
Poppo has already had at least one operation, in which flaps of skin were sewn over his eyes. His nose is a mass of cartilage and flesh. Doctors at Jackson Memorial Hospital said in a press conference on Tuesday that they have briefed him on reconstruction options.
The facial reconstruction surgeon who spoke with the Guardian said that Poppo will need "a bare minimum" of two to five reconstructive surgeries. "If you really want to make things look better and better, that can get up to 10, 15, 20 procedures."
Facial reconstruction, which is different from a facial transplant, involves taking bone and flesh from other parts of the patient's body and grafting them onto the damaged area.
The fibula, which isn't required for walking, can be removed to rebuild a jaw bone, for example. Cartilage from the ribs can be used to rebuild a nose. Flesh can be taken from the patient's arm and back to sculpt new features.
From there doctors can carve a more human-looking face onto the patient's head. Looking "normal" again, however, is unlikely.
"I don't think that's a realistic endpoint given the extent of the injuries," said the surgeon. "Normal life is something he lost the day he had that injury."
In Poppo's case, Wrood Kassira, one of the plastic surgeons attending to him, said in the news conference that he could end up with a prosthetic nose if what is left is beyond repair.
The upside to a prosthesis is that it requires a less involved surgical procedure, said the surgeon who spoke with the Guardian. The drawback, however, is that it's essentially just a mask, and is functionally less ideal.
The types of injuries Poppo suffered does raise the spectre of a face transplant, but there are many factors that must be considered, said the surgeon.
The center of the human face is not just a structural object like the jaw. The nose, mouth and lip musculature are connected directly to the brain. You can't rebuild eyelids, for example, without hooking the nerve of the transplanted lid to the nerve of the face.
The patient would then need to be on immunosuppressive drugs for the rest of his life, which if not taken properly could be life-threatening.
"A patient who has been homeless who is likely not to be the most compliant with medical care and maybe not able to take the drugs reliably is probably a no-go as a candidate," said the surgeon.
"But where he was in his past life should not be a sentence for him for the rest of his life."
What is unclear is how much Poppo is aware of the road that lies ahead.
Aged 65 and living on the streets for up to three decades, Poppo also suffered a brain injury and a broken rib in the attack. Doctors also found a puncture wound, suggesting he may have been shot by the police officer who fired at Poppo's attacker.
"This brings to light 100 different social issues at once, not including the bizarre nature of the attack," said one prominent facial reconstruction plastic surgeon. The surgeon, who has himself performed high-profile face transplant procedures, declined to be identified for this article because he is not affiliated with the Poppo case.
"He's probably a poster child for everything good and bad in healthcare," the surgeon said.
Poppo does not have health insurance, though his doctors have said he could qualify for Medicare. The costs of his care could range from several hundred thousand dollars to more than a million.
Miami taxpayers will pick up the tab, and the hospital has set up a fund that now contains more than $15,000. In some respects, the surgeon said, the fact that his attack is the subject of such widespread media curiosity could end up helping him raise money. Other trauma victims lacking significant means are even less fortunate.
This is a fact lamented by the most prominent bioethicists.
"It's not simply rude, it's not just discourteous – it's immoral to have a health system that doesn't supply a level of care for everyone," said Kenneth Goodman, co-director of the University of Miami's Ethics Programs.
"We do not ask children why their parents didn't make better investments. We do not ask veterans: 'Why did you squander your health?' We do not ask indigent people for a deposit and a credit card before we save your life. We have a moral responsibility to take care of people, independently of their ability to pay for it."
Floridians tend to agree. Several counties have voted to pass a half-penny sales tax specifically designed to fund healthcare to those who can't afford it. Voters in Dade County also approved of the Children's Trust, which allocates taxpayer money to children who need it.
Poppo has already had at least one operation, in which flaps of skin were sewn over his eyes. His nose is a mass of cartilage and flesh. Doctors at Jackson Memorial Hospital said in a press conference on Tuesday that they have briefed him on reconstruction options.
The facial reconstruction surgeon who spoke with the Guardian said that Poppo will need "a bare minimum" of two to five reconstructive surgeries. "If you really want to make things look better and better, that can get up to 10, 15, 20 procedures."
Facial reconstruction, which is different from a facial transplant, involves taking bone and flesh from other parts of the patient's body and grafting them onto the damaged area.
The fibula, which isn't required for walking, can be removed to rebuild a jaw bone, for example. Cartilage from the ribs can be used to rebuild a nose. Flesh can be taken from the patient's arm and back to sculpt new features.
From there doctors can carve a more human-looking face onto the patient's head. Looking "normal" again, however, is unlikely.
"I don't think that's a realistic endpoint given the extent of the injuries," said the surgeon. "Normal life is something he lost the day he had that injury."
In Poppo's case, Wrood Kassira, one of the plastic surgeons attending to him, said in the news conference that he could end up with a prosthetic nose if what is left is beyond repair.
The upside to a prosthesis is that it requires a less involved surgical procedure, said the surgeon who spoke with the Guardian. The drawback, however, is that it's essentially just a mask, and is functionally less ideal.
The types of injuries Poppo suffered does raise the spectre of a face transplant, but there are many factors that must be considered, said the surgeon.
The center of the human face is not just a structural object like the jaw. The nose, mouth and lip musculature are connected directly to the brain. You can't rebuild eyelids, for example, without hooking the nerve of the transplanted lid to the nerve of the face.
The patient would then need to be on immunosuppressive drugs for the rest of his life, which if not taken properly could be life-threatening.
"A patient who has been homeless who is likely not to be the most compliant with medical care and maybe not able to take the drugs reliably is probably a no-go as a candidate," said the surgeon.
"But where he was in his past life should not be a sentence for him for the rest of his life."
(culled from the guardian)
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