Pain, gratitude and a long fight back

Marilyn buoyed his spirits with her steadiness. She had taken a leave of absence from the high school where she taught, and she adapted to life at Harborview. When Johan craved something fresh to eat, she walked to Pike Place Market and bought blueberries and blackberries. She held his hand the day that Nicholas Vedder, chief of plastic surgery, introduced himself and explained how he planned to reconstruct his scalp.

"We need to remove the latissimus muscle," Vedder said, "and transplant it to cover your skull."

Johan knew this meant the latissimus dorsi, a long muscle on the back that extends from the armpit to the hip. The transplanted muscle would provide its own active blood circulation.

"And our success rate is around 95%," Vedder said. He also mentioned the risks: excessive blood loss, complications from the anesthesia and, of course, clotting that could lead to the loss of the transplant.

Johan reached for Vedder's hand and squeezed it. He was grateful to be alive and to know that his daughter was all right.

"Good luck," he said. "I trust you."

Vedder checked his schedule. He had an opening in the morning.

VEDDER began by making a 3-inch incision just in front of Johan's right ear, where he found a small artery and vein network known as the superficial temporal. For three hours he worked, separating the vessels from the dense and fibrous tissue that surrounded them.

Meanwhile, the surgical team prepared Johan's skull, which for five days had gone unprotected and exposed. Grinding it with a burr until it began to bleed, they brought it back to life.

Now Vedder cut along Johan's back. Slowly separating the latissimus dorsi from connective tissue that held it to his rib cage, the team lifted this flank steak-like muscle from Johan. Vedder dissected the connecting subscapular artery and vein.

The clock was running. The team had two hours to reinfuse the muscle with blood or it would die. They flushed it with blood thinner, bathed it in an icy saline slush and stretched it like taffy over Johan's scalp. The contour wasn't perfect, but Vedder knew that as it atrophied from disuse, the muscle would conform to the bony surface of the skull.

An 8-foot-tall surgical microscope was wheeled in. Looking through a lens that makes a human hair look like rope, Vedder connected the subscapular vessels to the superficial temporal vessels. Each is no wider in diameter than a cocktail straw. Each took 20 stitches. As Vedder pulled them together, the blood vessels bunched up as if they'd been hemmed with a gathering stitch. The bunching would act as a seal.