Frank A. Papay

Near-total human face transplantation for a severely disfigured patient in the USA

BACKGROUND Multiple reconstructive procedures are common for the reconstruction of complex facial deformities of skin, soft tissues, bony structures, and functional subunits, such as the nose, lips, and eyelids. However, the results have been unsatisfactory. An innovative approach entailing a single surgical procedure of face allograft transplantation is a viable alternative and gives improved results. METHODS On Dec 9, 2008, a 45-year-old woman with a history of severe midface trauma underwent near-total face transplantation in which 80% of her face was replaced with a tailored composite tissue allograft. We addressed issues of immunosuppressive therapy, psychological and ethical outcomes, and re-integration of the patient into society. FINDINGS After the operation, the patient did well physically and psychologically, and tolerated immunosuppression without any major complication. Routine biopsy on day 47 after transplantation showed rejection of graft mucosa; however, a single bolus of corticosteroids reversed rejection. During the first 3 weeks after transplantation, the patient accepted her new face; 6 months after surgery, the functional outcome has been excellent. In contrast to her status before transplantation, the patient can now breathe through her nose, smell, taste, speak intelligibly, eat solid foods, and drink from a cup. INTERPRETATION We show the feasibility of reconstruction of severely disfigured patients in a single surgical procedure using composite face allotransplantation. Therefore, this should be taken in consideration as an early option for severely disfigured patients. FUNDING None.

Complications of postmastectomy breast reconstructions in smokers, ex-smokers, and nonsmokers

Smoking results in impaired wound healing and poor surgical results. In this retrospective study, we compared outcomes in 155 smokers, 76 ex‐smokers, and 517 nonsmokers who received postmastectomy breast reconstructions during a 10‐year period. Ex‐smokers were defined as those who had quit smoking at least 3 weeks before surgery. Transverse rectus abdominis musculocutaneous (TRAM) flap surgery was performed significantly less often in smokers (24.5 percent) than in ex‐smokers (30.3 percent) or nonsmokers (39.1 percent) (p < 0.001). Tissue expansion followed by implant was performed in 112 smokers (72.3 percent), 50 (65.8 percent) ex‐smokers, and 304 nonsmokers (58.8 percent) (p = 0.002). The overall complication rate in smokers was 39.4 percent, compared with 25 percent in ex‐smokers and 25.9 percent in nonsmokers, which is statistically significant (p = 0.002). Mastectomy flap necrosis developed in 12 smokers (7.7 percent), 2 ex‐smokers (2.6 percent), and 8 nonsmokers (1.5 percent) (p < 0.001). Among patients receiving TRAM flaps, fat necrosis developed in 10 smokers (26.3 percent), 2 ex‐smokers (8.7 percent), and 17 nonsmokers (8.4 percent). Abdominal wall necrosis was more common in smokers (7.9 percent) than in ex‐smokers (4.3 percent) or nonsmokers (1.0 percent). In this large series, tissue expansion was performed more often in smokers than was autogenous reconstruction. Complications were significantly more frequent in smokers. Mastectomy flap necrosis was significantly more frequent in smokers, regardless of the type of reconstruction. Breast reconstruction should be done with caution in smokers. Ex‐smokers had complication rates similar to those of nonsmokers. Smokers undergoing reconstruction should be strongly urged to stop smoking at least 3 weeks before their surgery. (Plast. Reconstr. Surg. 107: 342, 2001.)

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.

Use of calcium-based bone cements in the repair of large, full-thickness cranial defects: a caution.

Background: Calcium-based bone cements have increased in popularity for the correction of craniofacial contour defects. The authors’ experience with them in more than 120 patients has resulted in the establishment of strict criteria for their use. Although the authors’ overall complication rate with these cements has been low, certain patient groups have an unacceptably high complication rate. The authors describe their experience with the repair of large, full-thickness cranial defects using calcium-based bone cements. Methods: The study group comprised 16 patients who underwent correction of large, full-thickness (>25 cm2) skull defects. The surgical technique included reconstruction of the floor of the defect with rigid fixation to the surrounding native bone, interposition of the cement to ideal contour, and closure of the defect. Results: The mean patient age was 35 years (range, 1 to 69 years). The mean defect area was 66.4 cm2 (range, 30 to 150 cm2). Cases were equally divided between BoneSource and Norian CRS. The mean amount of bone cement used was 80 g. Follow-up varied between 1 and 6 years (mean, 3 years). Major complications occurred in eight of 16 patients, with one occurring as late as 6 years postoperatively. Complications occurred throughout the course of review, indicating that they were not caused by a learning curve. Conclusion: Because of the unacceptably high complication rate with the use of calcium-based bone cements in large skull defects, the authors believe that their use is contraindicated and have returned to using autogenous split skull cranial bone reconstruction for these patients.

Relationship of obesity and specimen weight to complications in reduction mammaplasty

Obesity and specimen weight have both been associated with a higher incidence of complications for patients undergoing reduction mammaplasty. However, obesity has been arbitrarily and inconsistently defined, and the degree of obesity has not been considered in these previous studies. Because insurance companies are increasingly demanding weight loss before authorizing surgery, the relationship of obesity and breast size to complications is of great importance. Upon critical review of the literature, a number of fundamental questions remain unanswered. If complications are more frequent in the obese patient, are these complications directly proportional to the degree of obesity? Also, if the patient is required to lose weight before surgery, is weight loss effective in reducing complication rates? In an attempt to clarify these issues, 395 patients who underwent reduction mammaplasty over a 10-year period were reviewed retrospectively. Patients were arbitrarily divided into five groups in which, depending on their degree of relative obesity, they were classified as less than 5 percent, 5 to 10 percent, 10 to 15 percent, 15 to 20 percent, or greater than 20 percent above average body weight. To evaluate the relationship of specimen weight to complications, patients were also arbitrarily divided into five groups according to weight of the breast reduction specimen, which was classified as less than 300 g, 300 to 600 g, 600 to 900 g, 900 to 1200 g, and greater than 1200 g reduction per breast. Complications were then divided into local and systemic and major and minor. When bilateral reductions alone were analyzed (n = 267), there was a statistically significant increase in complication rate in the obese (p = 0.01). However, when the obese population was further subdivided according to their degree of obesity (less than 5 percent, 5 to 10 percent, 10 to 15 percent, 15 to 20 percent, and greater than 20 percent above average body weight), no further correlation was found. However, the relationship between specimen weight per breast and complications was much stronger with a direct correlation existing between increasing specimen weight and the incidence of complications. Although this study has shown that patients who are average body weight have fewer complications than obese patients after breast reduction surgery, it has not shown an increasing incidence of complication with increasing degrees of obesity. The implications of these findings and their relationship for denying patients surgery on the basis of weight alone are discussed in detail.

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.

Lip augmentation with AlloDerm acellular allogenic dermal graft and fat autograft: A comparison with autologous fat injection alone

Abstract. Many surgical options exist for lip augmentation, none of which consistently provide safe, lasting, and predictable volume gains. We describe and evaluate the use of AlloDerm acellular allogenic dermal graft in combination with fat autograft and compare the postoperative results with those of autologous fat injection alone. Analysis of the preoperative and 1- and 3-month postoperative photographs was done using digital imaging software. Outcome measures included vermilion show and horizontal lip projection from the soft tissue pogonion–subnasale plane. A 61% mean increase in vermilion show was observed in lips augmented with AlloDerm/fat injection, in comparison to a mean increase of 13% in lips augmented with fat injection alone. Lip projection demonstrated a mean increase of 1 mm in AlloDerm/fat lips at 3 months. Postoperatively, no evidence of resorption was seen in lips augmented with AlloDerm/fat between the 1- and the 3-month follow-ups, however, a 9% decrease in vermilion show occurred in lips augmented with fat injection over the same period. No complications occurred in either group. We conclude that AlloDerm in conjunction with autologous fat injection constitutes a safe, reliable, and lasting method of lip augmentation providing increased vermilion show compared to that with autologous fat injection alone.

Ophthalmologic findings in patients with nonsyndromic plagiocephaly.

The purpose of this article was to study the prevalence of strabismus and astigmatism in children with nonsyndromic plagiocephaly. Children with deformational plagiocephaly do not have an increased prevalence of strabismus compared with the general population but do have an increased prevalence of astigmatism, whereas children with nonsyndromic craniosynostotic plagiocephaly have an increased prevalence of strabismus and astigmatism. This observational cohort study retrospectively reviewed patients in a multidisciplinary craniofacial clinic between 1993 and 2001. Patients were referred for evaluation and management of plagiocephaly or craniosynostosis. One hundred eleven patients had deformational plagiocephaly, and 45 had synostotic plagiocephaly. Patients with lambdoid craniosynostosis, hemifacial microsomia, any syndromic form of craniosynostosis, or without a formal diagnosis were excluded. All patients underwent detailed ophthalmologic, ocular motility, and craniofacial examinations. Diagnosis was based on clinical and radiographic findings. Patients were evaluated between birth and age 14 years (mean = 13 months; SD = 22 months). Only 1 of 111 (<1%) patients with deformational plagiocephaly had an esodeviation, and none had an exodeviation. Three of 45 patients (7%) with synostotic plagiocephaly had an exodeviation, and none had an esodeviation. Eight of 93 patients (9%) with deformational plagiocephaly had unilateral astigmatism, and 14 (15%) had bilateral astigmatism (mean = 1.82 diopters). Three of 43 patients (7%) with synostotic plagiocephaly had unilateral astigmatism, and 9 (21%) had bilateral astigmatism (mean = 1.83 diopters). Patients with deformational plagiocephaly do not appear to have a higher prevalence of horizontal strabismus than the normal population. Exotropia is more common in patients with nonsyndromic craniosynostotic plagiocephaly than in the general population. The prevalence of astigmatism in patients with nonsyndromic craniosynostotic plagiocephaly appears to be greater than in the general population, but this higher prevalence requires further study.

The Use of Botulinum A Toxin to Ameliorate Facial Kinetic Frown Lines

PURPOSE External photography and subjective response were used to evaluate the use of botulinum A toxin to diminish glabellar kinetic folds. METHODS Eleven patients with glabellar folds and midline forehead wrinkling received one to four injections of 0.1 ml of 100 U/1 ml botulinum A toxin. The injections were given into the procerus or corrugator muscles or both. The number of injections corresponded to the wrinkle lines in each patient. The patients were examined and photographed just before the injections and at 7 to 10 days after the injections. Treatment efficacy was judged by photographic evaluation and by the patients subjective evaluation of the effect of the treatment. RESULTS Photographic evaluation showed objective improvement in the glabellar wrinkling in 6 of 11 patients in relaxed facial position and in all 11 patients during contraction of the periocular mulscles. Ten of the 11 patients reported satisfaction with their cosmetic results and indicated that they would choose to have the procedure done again. CONCLUSIONS The results of this study suggest that botulinum A toxin is a safe and effective treatment for glabellar folds.

Nasopharyngeal Presentation of Second Branchial Cleft Cyst

From the Section of Pediatric Plastic Surgery (Dr. Papay), the Department of Otolaryngology and Communicative Disorders (Drs. Kalucis and Tucker), and the Section of Laryngotracheal Reconstruction (Dr. Eliachar), Cleveland Clinic Foundation. Received for publication Dec. 11,1992; revision received Aug. 23, 1993; accepted Sept. 13, 1993. Reprint requests: Frank A. Papay, MD, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, OH 44195. OTOLARYNGOL HEAD NECK SURG 1994;110232-4. Copyright