"Go to 35," Halls said, and then, "Go to 40."
As a child, Ana had undergone a series of operations at Loma Linda University Medical Center that had brought no lasting improvement. Treating neurofibromatosis is like trying to stop time. As long as the affected cells continue to divide, the tumors continue their uncontrolled growth.
Batra and Halls, however, believed that they might have better luck than the previous surgeons, especially if the cells were dividing at a slower rate than when Ana was younger. Unlike other physicians who have treated comparable cases with one marathon surgical session, they wanted to proceed slowly and sequentially.
They planned up to five surgeries, each with the intent of restoring the landmarks of her face, and today, April 1, 2006, they intended to reposition the brow, the cheek and the jaw by eliminating as much tumor as possible and by reattaching the underlying soft tissue to the bone.
Batra recognized how radical and transformative each operation would be, and he believed that if he mapped out small, incremental steps, Ana would be more tolerant of the pain and more encouraged by the progress. He wanted to make sure they reached the final destination together.
The journey he proposed reminded him of "Life of Pi," a novel by the Canadian writer Yann Martel, in which an Indian boy is stranded in a lifeboat in the middle of the Pacific Ocean for 227 days with a 450-pound Bengal tiger.
Each cut was an encounter with forces more volatile than anything he could prepare for, and he knew that if everything worked out, he and Ana would be in this boat together for a long time.
With a 2-inch flap of skin removed from her forehead and the skull exposed, Batra drilled into the bone and set a number of small metal anchors, to which the surgeons sutured the soft tissue of Ana's left eyebrow, elevating it nearly two inches.
Their hands were a symphony of motion. They thought of themselves as Michelangelo shaping his marble and as furniture upholsterers, draping and cutting and stitching. By 11 a.m., three hours after starting, Batra had begun to talk about sushi for lunch. Weezer kicked in on the Rodarte mix.
At 12:10 p.m., an inventory of equipment was taken to make sure that nothing had been left behind, and the anesthetic was discontinued. The increase of carbon dioxide in Ana's lungs triggered her breathing reflex, and she was ready for post-op.
In the empty space of the waiting room, Ana's parents, Ismael and Margarita, sat with her Aunt Teresa and Fran Vigil, the family friend who had contacted Batra seven months earlier to see if he could help. On a table between them were the husks from an empty bag of sunflower seeds.
The doctors briefed the family and invited them back to recovery. Margarita kissed her daughter's bandaged face. When Ana awoke, she asked for an ice chip. Ismael wiped a tear from his eye.
Ana liked Batra. She thought he was cute.
Like her, he had come to America from somewhere else. In his case, it was a small village in northern India where electricity and running water were scarce. Baboons played on the roof of his home, and reinforced basements served as bomb shelters whenever Pakistani jets flew overhead.
His father, who earned $200 a month as a chemist in New Delhi, came to this country in 1970 and found work in a smelting and refining factory in Cleveland. Two years later he sent for his wife, their oldest son, their daughter and Munish. Their home was in a tough part of the city. At 14, Munish had the Sanskrit syllable om tattooed on his left arm.
As a sophomore in high school, Batra worked in a steel mill. After graduation, his father conspired with the foreman to have him laid off, spurring him to follow his brother to Ohio State University. He studied English, favoring Longfellow and Vonnegut, and dreamed of becoming a writer.
Eventually he decided that medicine would be more practical and enrolled at Case Western Reserve School of Medicine in Cleveland. In 1996, he moved to Southern California and brought his parents and his younger sister with him. He was 30.