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Saving Face

Waner learned that little new thinking had been done on the subject of hemangiomas since 1929, when an article in a medical journal reported that the tumors, which appear in the first month after birth, typically wither on their own by the time the child approaches adolescence. This natural regression made it convenient for insurers to classify treatment of hemangiomas as elective, and to deny coverage. Not only did the prospect of unreimbursed work sap surgeons of the inclination to treat the tumors, but hemangiomas, with their unruly clusters of blood vessels, were apt to summon up a surgeon’s nightmare: babies dying on the table of blood loss during a procedure that could be derided as “cosmetic.”

“You show this picture to most surgeons,” Waner told me, “and most of them would run a mile in the opposite direction.”

We were sitting in his office, and Waner was thumbing through a binder containing photos of hundreds of patients on whom he had operated. The snapshot in question featured an infant whose right eyelid had all but disappeared under what looked like a rotten plum. Waner explained that the hemangioma was blocking visual stimuli and causing the child to go blind. Another photo showed a child with an inflamed, fist-size protuberance dangling from her nose. “That child reflexively put her hand in front of her face when anyone looked at her,” Waner said. “You can’t for one moment call these surgeries cosmetic.”

Waner knew that operating on such children, against the advice of the medical establishment, was risky. “I was going out of line,” he says. “But clearly the way we were approaching these children was wrong, and something had to be done.” He had discovered that, contrary to orthodox belief, severe hemangiomas rarely healed completely without intervention. Rather, they often left behind damaged skin that had to be surgically repaired, and organs whose functions had been impaired by pressure from the tumor. In extreme cases, like Aslynn’s, the tumors could be life-threatening. Waner was also keenly aware of the psychological trauma suffered by disfigured children. “The world is a cruel place for these children,” he says.

As Waner found, “There was no manual to show you how to do these surgeries. It was completely uncharted territory. I had to improvise as I went.” Waner brought a unique blend of assets to the task. He had cut his surgical teeth on cancerous tumors, but unlike most tumor specialists, he also had extensive experience with the techniques of plastic surgery. While other surgeons would typically try simply to cut a hemangioma off the skin, producing large areas of skin loss and requiring extensive reconstructive surgery, Waner had developed a method for folding back the skin, working the tumor out from underneath, and tailoring the remaining skin so that scarring was barely noticeable. He also found ways to stanch the severe blood loss. His primary tools were cauterizing devices that plugged blood vessels as he cut. He also enlisted radiologists to plug blood vessels in order to harden the tumors before excision.

Waner thrived on intellectual adventure, and was eager to tackle problems that others avoided. Not least of all, he found himself consumed with sympathy for the plight of his patients and their families—a situation he relates to his childhood in South Africa. “I saw the most terrible injustices being inflicted on blacks,” he says. “And I felt powerless to intervene.”

Waner also felt marked by having been a Jew in a society he described as rampant with anti-Semitism. “I had teachers who referred to me as ‘Jew-boy’ or ‘dirty Jew’ in front of the class. I remember being beaten up in the second grade by boys who accused Jews of killing Christ. I never felt like I belonged in South Africa,” he says. “I felt like a pariah. So naturally I find it emotionally gratifying to be able to help the children who are my patients.”

After two years in Australia, Waner took a job at Arkansas Children’s Hospital, in Little Rock, which supported his forays into the treatment of vascular tumors. He took on cases in which the child’s condition was so severe—heart failure, organ damage, blindness—that surgery could be justified as a last-ditch measure. His results were spectacular. When Linda Shannon, a highway-safety analyst from Albany, sent Waner a photo of her 19-month-old daughter, who had a golf-ball-size hemangioma on her lip, Waner called four days later and said, “I can have your daughter looking normal in two hours.” Shannon flew to Little Rock, and after the surgery she walked past her daughter, unable to recognize her at first. Shannon, who has since founded the Vascular Birthmarks Foundation, and who has referred thousands of desperate parents to Waner, speaks of the doctor in beatific terms: “His hands were anointed by God to help children.”

As Waner’s reputation grew (he published dozens of articles describing his research, and appeared at medical conferences around the world), Alejandro Berenstein, director of Beth Israel’s elite Hyman-Newman Institute for Neurology and Neurosurgery, learned of Waner’s work and felt a kinship. Berenstein had invented methods for treating endovascular ailments like aneurysms by snaking catheters into regions of the brain made visible by high-tech imaging. “Waner and I had the same philosophy,” Berenstein says, “which was to intervene early from the inside, so kids can develop in a more normal fashion. But we were yin and yang. I was doing it with radiology, and he was doing it with surgery. It became obvious to me that the two of us could put together a fantastic program that could do a lot of good for children with facial deformities. We could actually advance the field.”

For Beth Israel, luring Waner to New York to join Berenstein was akin to bringing A-Rod to the Yankees to pair with Jeter. The hospital promised Waner it would create a program around him—the Vascular and Birthmarks Institute of New York—and place significant research tools at his disposal. Waner couldn’t resist the chance to work with Berenstein and his colleagues. He served notice to Arkansas that he would wind down his practice and head to New York in the spring. A few days before Christmas last year, he received an e-mail containing photos of Aslynn Brown.

Waner opened the perimeter of Aslynn’s tumor with exacting slowness. He made a nick of an incision. Blood poured from the opening. He asked for an electrocautery device—a pencil-like instrument that transmits electricity from its nib—and touched it to the end of a blood vessel to stanch the bleeding. Waner repeated this pattern—cut and cauterize, cut and cauterize—dozens of times, until the skin lay across the tumor like a snug flap. A burning smell rose from the incision, along with wisps of smoke. Waner lifted an edge of skin and moved beneath. He was following the precise technique he had developed for removing hemangiomas that others dared not treat: Attack the tumor from beneath the skin, leaving the skin itself intact, all the while plugging the sites of the relentless bleeding. He began looking for a “plane”—a gap between the skin and the tumor that would allow him room to begin cutting off the tumor’s blood vessels. He inched deeper. Rather than a clear plane, though, he found only the equivalent of a murky path through thick brambles. The hemangioma adhered to the underside of the skin. Clumps of blood vessels blocked his way. “When you’re in the wrong plane, it bleeds like there’s no tomorrow,” he says. “You can’t see any separation between normal tissue and the hemangioma. It’s frightening.” Again and again, Waner paused to measure the thickness of the skin flap, to ensure that he remained in the barely discernible opening between skin and tumor. Eventually he reached the top of the hemangioma.