Mark Hendrickson

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.

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 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.

Experimental model of pyridoxine (B6) deficiency-induced neuropathy

A pyridoxine (B6) dietary deficiency was studied in female adult Sprague–Dawley rats by hind-limb walking-track analysis. Serum levels of pyridoxine and three metabolites were quantified by high-pressure liquid chromatography with fluorescence measurement. Morphometric analysis of the sciatic and posterior tibial nerves (from within the tarsal tunnel) was performed after 1 year on a diet deficient in vitamin B6. The B6-deficient rats developed abnormal walking-track patterns by 8 months, and these track parameters were different from age- and sex-matched normal diet control rats at the p < 0.05 level. Adding B6 at 10 parts per million to the diet then partially corrected these parameters, whereas the addition of 30 parts per million B6 corrected the abnormal pattern completely. Serum pyridoxal concentration correlated with the functional parameters, dropping from a mean of 115 mg per liter to 39.5 mg per liter (p < 0.05), and correcting with the B6 additive. Morphometric analysis demonstrated that the B6-deficient nerve from the tarsal tunnel had a decreased nerve fiber density (p < 0.001), with a normal total myelinated nerve fiber number, and an increased axon-to-myelin ratio (p < 0.003). It is concluded that a diet totally deficient in vitamin B6 results in a peripheral neuropathy.

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.

Long-term outcomes of total knee arthroplasty following soft-tissue defect reconstruction with muscle and fasciocutaneous flaps

Background: Insufficient soft-tissue coverage following total knee arthroplasty jeopardizes prosthesis retention and may lead to significant complications. The aim of this study was to evaluate the natural history of total knee arthroplasty following flap reconstruction of soft-tissue defects. Methods: A retrospective review of patients treated with flaps after failed total knee arthroplasty between 1998 and 2013 was conducted. Patients with preexisting soft-tissue defects who required reactive flap reconstruction were included in group 1. Patients with no preexisting soft-tissue defects, but with extensive débridement during revision total knee arthroplasty requiring immediate proactive flap coverage, were included in group 2. Results: Fifty-eight patients in group 1 were treated with 86 flaps, and 15 patients in group 2 were treated with 17 flaps. Mean length of follow-up was 67.0 and 54.7 months, respectively (p = 0.21). Flap-related complications and number of subsequent flap revisions were comparable in both groups. Patients in group 1 had a higher rate of implant reinfection (58 percent versus 27 percent; p < 0.05), amputations (25 percent versus 0 percent; p < 0.05), and subsequent prosthesis revisions (2.2 versus 0.9; p < 0.05). Functional joint was preserved in 54 percent and 80 percent of cases, respectively. Mean gain in range of motion and quality of life were significantly better in group 2 (p < 0.05). Conclusions: Early proactive soft-tissue coverage of total-knee arthroplasty is critical to long-term success. In cases where reactive treatment is required, significantly worse outcomes and a high rate of complications should be expected. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Establishing the Feasibility of Face Transplantation in Granulomatosis With Polyangiitis.

Granulomatosis with polyangiitis (GPA; formerly Wegeners granulomatosis) is a rare vasculitis that commonly starts in the craniofacial region. We report a case that was masked by prior facial trauma and associated with pyoderma gangrenosum (PG). Disease progression and aggressive debridements led to severe facial tissue loss. The decision to perform a face transplant was controversial because of the risk of disease relapse on the facial allograft. We reviewed renal transplant outcomes in GPA for possible relevance. A PubMed search retrieved 29 studies. Patient and graft survival, relapse, morbidity, mortality, rejection and immunosuppression were assessed. Ten‐year patient survival and graft survival were 84.4% and 72.6%, respectively. GPA relapse occurred in 31.5%, and upper airway/ocular relapse occurred in 17.8% (resolved in 76.9%). Mortality was 12.3%. Acute and chronic rejection rates were 14.9% and 6.8%, respectively. Traditional posttransplant immunosuppression was effective. Our review suggests that GPA renal transplant outcomes are comparable to general renal transplant cohorts. Furthermore, transplanted GPA patients exhibit lower disease relapse secondary to lifelong immunosuppression. This supported our decision to perform a face transplant in this patient, which has been successful up to the present time (1‐year posttransplantation). Untreated GPA and PG are potential causes of worse surgical outcomes in the craniofacial region.

Single-stage versus two-stage arteriovenous loop microsurgical reconstruction: A meta-analysis of the literature

Arteriovenous (AV) loops can be utilized in a single‐ or two‐stage approach in free flap reconstruction when proper vessels are not available. However, there exists no consensus on which method leads to superior microsurgical and patient outcomes. The purpose of this article was to review single‐ versus two‐stage AV loops utilized in free flap reconstruction with a focus on complications and overall outcomes.

Variations in the origins and absence of the common digital arteries of the hand: a cadaveric study:

We studied anomalies of the common digital arteries by dissecting 33 fresh cadaver hands under magnification. In the majority of the dissected hands (25 hands), common digital arteries took off from the superficial palmar arch and ran superficial and parallel to the flexor tendons. Variations were found in eight out of 33 hands. In four hands the common digital artery to the second web space was replaced by an atypical vessel, originating from the deep palmar arch, that crossed posterior to the index flexor tendons proximal to the A1 pulley. In eight hands, the common digital artery to the fourth web space was replaced by an atypical deeper vessel, originating from the superficial palmar arch and crossing posterior to the little finger flexors. No nerve anomalies were identified. Unrecognized, these atypical arteries to the second and/or fourth web spaces could lead to vascular complications during surgery, especially pollicization.

Abstract 58. Single-Stage versus Two-Stage Arteriovenous Loop Microsurgical Reconstruction: An Evidence Based Review of the Literature and Analysis of Institutional Experience

RESULTS: The decision tree shows the associated QALYs, costs and probabilities used to calculate the ICUR of