Dan Alam is in the basement of Halifax's largest hospital, carefully cutting, at times sawing and hammering, as he tries to peel more and more skin away.
It's gruesome stuff. But the group of Nova Scotia surgeons in this chilly operating theatre, surrounding the superstar plastic surgeon from Ohio, are fascinated as they watch the doctor's hands at work.
He is pulling the face off a cadaver – it is that of an old man – and he is teaching these surgeons the technique and nuances of transplanting a human face. He is part of the first-ever head and neck transplant course in the world.
The facial plastic and reconstructive surgeon from the Cleveland Clinic successfully performed the first face transplant in the United States in 2008, and last year transplanted a new face on an American woman mauled by a chimpanzee.
Halifax's QE II Health Sciences Centre at Capital Health is making a play to become the centre in Canada for facial and laryngeal transplants, led by Mark Taylor, a 41-year-old head and neck surgeon.
Only 24 facial transplants have been performed in the world – none in Canada.
Dr. Taylor is hoping to change that, predicting his Halifax hospital will be able to transplant a face or larynx within six months or a year. He estimates the procedure will cost about $1-million.
In addition to Dr. Alam, Dr. Taylor invited Greg Farwell, director of head and neck oncology at California's UC Davis Health System, to demonstrate a laryngeal transplant.
In the Halifax operating theatre, the surgeons are in on what is still a very rare procedure, and there's excitement in the room. Other cadavers lie on stretchers; the Halifax surgeons will try out next what they have learned.
An outline is drawn in purple magic marker around the cadaver's face as a guide for cutting. Then Dr. Alam makes the first cut at the top of the forehead just below the hairline. He scrapes and peels down the skin, which is very thick, exposing white fatty tissue on the bony forehead.
It becomes trickier as he works around the cadaver's eyes. The surgeon pushes in the eyeballs to expose the sockets. "That's the kind of freaky part of it," he says about having to retract the eyeballs.
At one point a metal stake is hammered into the skull to remove the entire midsection of the face, including the nose, cheeks, lips and gums. The cadaver, it turns out, had dentures, which were removed, leaving just one tooth in his upper gums.
Removing the skin around the ears and jaw require skillful sawing. It's delicate work. Earlier in his lecture, he told the group that one of the "big problems" of all face transplants is that doctors haven't figured out the "nerves yet. That's the holy grail," he said.
After about an hour of scraping, cutting and sawing comes what they call the piece de resistance – the entire face was off the cadaver, complete with lips, nose, eyelids and eye sockets.
Face transplants are controversial, in part because they are not life-saving procedures like organ transplants.
Ian Alwayn, the director of the multi-organ transplant program at Capital Health, knows the expertise exists in Halifax to perform this procedure, but he poses an important question, "Is it something that we should do?"
Dr. Alam has struggled with that question as well. But while recognizing that transplanting a face does not save a life, he notes facial transplant patients would rather die as a result of the risky surgery than live with their disfigurement.
Both his transplant patients – Connie Culp, who was shot in the face by her husband, and Charla Nash, who was mauled by a chimpanzee – were blind.
"You don't get a face transplant to look in the mirror," Dr. Alam said. "You get a face transplant so the social mirror of other people can see you normally."
Charla Nash is able to smell and eat solid food; she has become a close friend of Dr. Alam and his family.
Connie Culp's transplant, which included bones and two teeth as well as muscle and blood vessels from her donor, was the first. It took place in December, 2008, and the team of surgeons spent about 23 hours.
Dr. Alam described putting the donor's face carefully into a small basin and walking with it from the operating room to Ms. Culp's room.
"I was thinking, 'Please God don't drop this,'" he recalled.
He remembers, too, wondering how such a lifeless piece of flesh that resembled a rubber Halloween mask could ever look like a human face.
But the "magical part" came after he attached the blood vessels with 37 sutures and "all of the things about it being alive, like the vibrancy and the glow, just came from the blood coming back … ," he said. "It's in a sense humbling."
After a career of doing facial reconstruction, he realized something at once practical and profound. "I didn't need to build it," he said, "I just needed to buy it off the shelf and hook up the power."