Chad R. Gordon

First U.S. Near-Total Human Face Transplantation: A Paradigm Shift for Massive Complex Injuries

Background: Severe complex facial injuries are difficult to reconstruct and require multiple surgical procedures. The potential of performing complex craniofacial reconstruction in one surgical procedure is appealing, and composite face allograft transplantation may be considered an alternative option. The authors describe establishment of the Cleveland Clinic face transplantation program that led them to perform the first U.S. near-total face transplantation. Methods: In November of 2004, the authors received the worlds first institutional review board approval to perform a face transplant in humans. In December of 2008, after a 22-hour operation, the authors performed the first near-total face transplantation in the United States, replacing 80 percent of the patients traumatic facial deficit with a composite allograft from a brain-dead donor. This largest, and most complex, face allograft in the world included over 535 cm2 of facial skin; functional units of full nose with nasal lining and bony skeleton; lower eyelids and upper lip; underlying muscles and bones, including orbital floor, zygoma, maxilla, alveolus with teeth, hard palate, and parotid glands; and pertinent nerves, arteries, and veins. Immunosuppressive treatment consisted of thymoglobulin, tacrolimus, mycophenolate mofetil, and prednisone. Results: The patient tolerated the procedure and immunosuppression well. At day 47 after transplantation, routine biopsy showed rejection of the graft mucosa without clinical evidence of skin or graft rejection. The patients physical and psychological recovery went well. The functional outcome has been excellent, including optimal return of breathing through the nose, smelling, tasting, speaking, drinking from a cup, and eating solid foods. Conclusion: The functional outcome thus far at 8 months is rewarding and confirms the feasibility of performing complex reconstruction of severely disfigured patients in a single surgical procedure of facial allotransplantation.

The world's experience with facial transplantation: What have we learned thus far?

The objective of this review article is to summarize the published details and media citations for all seven face transplants performed to date to point out deficiencies in those reports so as to provide the basis for examining where the field of face transplantation stands, and to act as a stimulus to enhance the quality of future reports and functional outcomes. Overall long-term function of facial alloflaps has been reported satisfactorily in all seven cases. Sensory recovery ranges between 3 and 6 months, and acceptable motor recovery ranges between 9 and 12 months. The risks and benefits of facial composite tissue allotransplantation, which involves mandatory lifelong immunosuppression analogous to kidney transplants, should be deliberated by each institution’s multidisciplinary face transplant team. Face transplantation has been shown thus far to be a viable option in some patients suffering severe facial deficits which are not amenable to modern-day reconstructive technique.

The technical and anatomical aspects of the world's first near-total human face and maxilla transplant

OBJECTIVE To discuss the technical and anatomical analysis and design of an osteocutaneous allograft transplant incorporating the donor maxilla and the execution of the operative protocol during the transplant. METHODS The Cleveland Clinic reported the worlds first successful combined face and maxilla transplant in December 2008. Unlike the 3 prior face transplants, this surgical procedure was done as a salvage operation in a patient who had undergone 23 major reconstructive procedures. The additional complexity due to significant postoperative scarring and recipient vessel depletion presented a unique challenge in this case. The extensive 3-dimensional losses of facial structures in multiple tissue planes required a Le Fort III osteomyocutaneous allotransplant incorporating the donor maxilla. RESULTS We report the first successful transfer of a complete bony framework and soft-tissue envelope. The allograft has shown excellent integration and no long-term rejection. The traditional conception based on anatomical studies suggested that this transfer would require independent dissection of the internal maxillary vascular system. This was not required in our patient whose allograft was based solely on the facial arterial system and its arcades. CONCLUSIONS Successful near-total face and maxilla allograft transplant can be accomplished based on the facial arterial system and its arcades. This presents a novel method for reconstructing massive facial injuries with significant involvement of the facial skeleton.

Requirements for the development of a hand transplantation program

Since 1998, 42 hand transplants in 30 patients have been performed in countries such as France, United States, China, Austria, Malaysia, Italy, Belgium, Poland, Spain, and Germany. Now, with recent improvements in immunosuppression, the clinical applicability may expand and the ethical obstacles may soon be overcome, allowing multiple US institutions to perform hand allotransplantation. The main purpose of this article is to facilitate access to pertinent details in regards to hand transplantation, such as donor/recipient selection criteria, immunosuppressive therapies, and associated complications. It is a comprehensive literature review compiled from published reports from multiple hand transplant programs throughout the world. Due to its inherent complexity, hand transplantation should only be attempted at institutions within the US capable of orchestrating a specialized multidisciplinary team, and each institutions protocol should be extremely detailed and individualized.

Composite Tissue Allotransplantation: A Proposed Classification System Based on Relative Complexity

Numerous achievements have been made encompassing a wide array of composite tissue allograft (CTA) subtypes. We sought to develop a simple, reproducible CTA classification system for the purpose of comparing clinical investigation. Each CTA subtype differs in relative complexity and can therefore be theoretically classified based on its unique combination of multiple factors. Eight complexity factors (CFs) are hypothesized: anatomic detail, psychological obstacles, rejection risk, required rehabilitation, relative antigenicity, functionality/cosmesis, skin ratio, and salvageability. A distribution of total complexity scores, ranging from 8 to 24, is classified into 3 ordered categories representing varying degrees of complexity. In conclusion, we have created a new classification system so that ongoing research and future data may be compared in a type-specific fashion.

Skin Area Quantification in Preparation for Concomitant Upper Extremity and Face Transplantation: A Cadaver Study and Literature Review

Background. Numerous experiments in composite tissue allotransplantation (CTA) have identified skin as the most antigenic, with recent experimentation from our laboratory finding a direct correlation between large antigenic skin loads and chimerism. Therefore, in preparation for clinical application of concomitant upper extremity (UExt) and face transplantation, we aimed to identify the exact skin quantities accompanying various upper UExt and concomitant scenarios using a cadaver study. Methods. Five fresh cadavers were obtained and dissections were performed to simulate five different UExt transplant levels. Exact skin quantities (cm2) and total body surface area (TBSA) percentages were calculated using digital image analysis for both unilateral and bilateral hand transplant levels. UExt measurements were then cross-analyzed with our laboratorys facial/scalp alloflap data for similar evaluation of various concomitant CTA scenarios. Results. Skin quantities for unilateral hand transplants ranged from 335 (±58) to 787 (±82) cm2, and from 670 (±117) to 1575 (±163) cm2 for bilateral. Concomitant CTA quantities (from “unilateral wrist-level with face” to “bilateral elbow-level with face/scalp”) extended from 1010 (±81) to 2766 (±202) cm2, totaling a range of 5.6% to 15.4% TBSA. Conclusion. The findings presented here, for the first time, define exact skin quantities and TBSA percentages accompanying unilateral, bilateral, and concomitant hand/face transplant scenarios. Unilateral UExt transplants contain between 335 and 787 cm2 and bilateral between 670 and 1575 cm2. Concomitant face/scalp and UExt transplants contain between 1000 and 2800 cm2, equating 5% to 15% TBSA. Furthermore, there exists a tremendous void in research and some inconsistencies between animal investigation and clinical experience related to large skin-bearing CTAs. These concerns warrant further investigation by all teams pursuing concomitant CTA.

Hand surgery volume and the US economy: Is there a statistical correlation?

Background:To the best of our knowledge, there have been no previous studies evaluating the correlation of the US economy and hand surgery volume. Therefore, in light of the current recession, our objective was to study our institutions hand surgery volume over the last 17 years in relation to the nations economy. Methods:A retrospective analysis of our institutions hand surgery volume, as represented by our most common procedure (ie, carpal tunnel release), was performed between January 1992 and October 2008. Liposuction and breast augmentation volumes were chosen to serve as cosmetic plastic surgery comparison groups. Pearson correlation statistics were used to estimate the relationship between the surgical volume and the US economy, as represented by the 3 market indices (Dow Jones, NASDAQ, and S&P500). Results:A combined total of 7884 hand surgery carpal tunnel release (open or endoscopic) patients were identified. There were 1927 (24%) and 5957 (76%) patients within the departments of plastic and orthopedic surgery, respectively. In the plastic surgery department, there was a strong negative (ie, inverse relationship) correlation between hand surgery volume and the economy (P < 0.001). In converse, the orthopedic departments hand surgery volume demonstrated a positive (ie, parallel) correlation (P < 0.001). The volumes of liposuction and breast augmentation also showed a positive correlation (P < 0.001). Conclusion:To our knowledge, we have demonstrated for the first time an inverse (ie, negative) correlation between hand surgery volumes performed by plastic surgeons in relation to the US economy, as represented by the 3 major market indices. In contrast, orthopedic hand surgery volume and cosmetic surgery show a parallel (ie, positive) correlation. This data suggests that plastic surgeons are increasing their cosmetic surgery-to-reconstructive/hand surgery ratio during strong economic times and vice versa during times of economic slowdown.

Cosmetic Surgery Volume and Its Correlation With the Major US Stock Market Indices

BACKGROUND As a consumer-driven industry, cosmetic plastic surgery is subject to ebbs and flows as the economy changes. There have been many predictions about the short, intermediate, and long-term impact on cosmetic plastic surgery as a result of difficulties in the current economic climate, but no studies published in the literature have quantified a direct correlation. OBJECTIVES The authors investigate a possible correlation between cosmetic surgery volume and the economic trends of the three major US stock market indices. METHODS A volume analysis for the time period from January 1992 to October 2008 was performed (n = 7360 patients, n = 8205 procedures). Four cosmetic procedures-forehead lift (FL), rhytidectomy (Rh), breast augmentation (BA), and liposuction (Li)-were chosen; breast reduction (BRd), breast reconstruction (BRc), and carpal tunnel release (CTR) were selected for comparison. Case volumes for each procedure and fiscal quarter were compared to the trends of the S&P 500, Dow Jones (DOW), and NASDAQ (NASD) indices. Pearson correlation statistics were used to evaluate a relationship between the market index trends and surgical volume. P values <.05 were considered statistically significant. RESULTS Three of the four cosmetic surgery procedures investigated (Rh, n = 1540; Li, n = 1291; BA, n = 1959) demonstrated a direct (ie, positive) statistical correlation to all three major market indices. FL (n =312) only correlated to the NASD (P = .021) and did not reach significance with the S&P 500 (P = .077) or DOW (P = .14). BRd and BRc demonstrated a direct correlation to two of the three stock market indices, whereas CTR showed an inverse (ie, negative) correlation to two of the three indices. CONCLUSIONS This study, to our knowledge, is the first to suggest a direct correlation of four cosmetic and two reconstructive plastic surgery procedures to the three major US stock market indices and further emphasizes the importance of a broad-based plastic surgery practice in times of economic recession.

Clinical Experience with Hand Transplantation

Since 1998, 40 hand transplants (HTs) in 29 patients have been performed in countries such as France, United States (US), China, Austria, Malaysia, Italy, Belgium, Poland, and Spain. Now, with recent improvements in immunosuppression, the clinical applicability may expand, and the ethical obstacles may soon be overcome, allowing multiple US institutions to perform hand allotransplantation. Therefore, the objective of this chapter is to provide a comprehensive review of hand transplantation and to assist multidisci-plinary teams in creating an Institutional Review Board (IRB) protocol for their hospital. Using a variety a published reports, a comprehensive literature review of hand transplantation was performed in May 2008. Due to its inherent complexity, hand transplantation should be attempted only at institutions capable of orchestrating a specialized multidisciplinary team, and the IRB protocol used should be extremely detailed and individualized. Without question, further research is warranted, and surgeons and scientists alike have yet to identify the clinical role of hand transplantation.

178B: A NOVEL CADAVER STUDY QUANTIFYING THE POTENTIAL ANTIGENIC SKIN COMPONENT ACCOMPANYING CONCOMITANT FACE AND UPPER EXTREMITY TRANSPLANTATION

Background: The clinical success of composite tissue allotransplantation (CTA) is restricted primarily because of the lifelong immunosuppressive requirements dictated by the skin component. Therefore, in light of the unexpected death of the first face/bilateral upper extremity (UExt) transplant recipient, we aimed to scientifically quantify the size of the antigenic skin component accompanying this type of CTA.