Risal Djohan

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.

Nipple-sparing mastectomy update: one hundred forty-nine procedures and clinical outcomes.

OBJECTIVES To describe our experience with patients who underwent the nipple-sparing mastectomy procedure developed and standardized at our institution and to report clinical outcomes for those patients with a breast cancer diagnosis. DESIGN Prospective study for consecutive nipple-sparing mastectomy procedures. SETTING Multidisciplinary breast center at a large tertiary care facility. PATIENTS One hundred ten consecutive patients underwent nipple-sparing mastectomy between July 2001 and June 2007. INTERVENTION Nipple-sparing mastectomy was offered to carefully screened patients; the nipple-areola tissue was cored and sent for histologic frozen-section analysis intraoperatively. MAIN OUTCOME MEASURES Assessment of nipple-areola cored tissue for neoplastic involvement; postoperative stability of retained nipple-areola complex; and clinical outcomes. RESULTS Data were available for 149 nipple-sparing mastectomies performed on 110 patients. No procedure performed for prevention had neoplastic involvement of the cored nipple-areola tissue, while 9 procedures performed for breast cancer treatment were found to have neoplastic involvement. Postoperatively, 2 patients had partial loss of the nipple-areola complex due to sloughing and a third patient developed an infection that required surgical removal of the nipple-areola complex. Among patients with breast cancer, none with ductal carcinoma in situ has developed a recurrence, while 4 patients with infiltrating breast cancer have, including 2 patients with distant metastases only, a third with a chest wall recurrence, and a fourth with an axillary recurrence. CONCLUSION A low incidence of neoplastic involvement of the nipple-areola cored tissue leads to successful completion of nipple-sparing mastectomy for most patients.

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.

A Prospective Analysis of Free Flap Monitoring Techniques: Physical Examination, External Doppler, Implantable Doppler, and Tissue Oximetry

No universally accepted method of flap monitoring exists, and several techniques are in use. Repeated physical examination is most popular and is often supplemented with a handheld, external Doppler, and/or implantable Doppler probes; near-infrared spectroscopy is less commonly used. We investigated the nursing and resident house staffs experience and confidence with physical exam for flap monitoring. Also, a consecutive series of 38 patients with free flaps were monitored using physical examination, external Doppler, implantable arterial and venous Doppler probes, and near-infrared spectroscopy. Five patients developed signs of microvascular complications within 3 days of surgery; all were explored and salvaged. Neither the residents nor the nursing staff were universally trained or experienced in flap monitoring by physical exam. In all patients, changes in the appearance of the flap suggestive of a microvascular complication lagged 30 to 60 minutes after the adjunctive monitoring methods indicated that a problem had occurred. Near-infrared spectroscopy was the first warning sign in four of the five patients. Two patients were explored before thrombosis of the anastomoses occurred. Near-infrared spectroscopy may identify early microvascular complications more reliably than physical examination, external Doppler, or implantable Doppler.

Assessment of Donor-site Morbidity Using Balance and Gait Tests After Bilateral Fibula Osteoseptocutaneous Free Flap Transfer

The donor-site morbidity from harvesting unilateral free fibular osteoseptocutaneous flaps has been previously evaluated and is considered minimal. The purpose of this study was to investigate functional deficits after bilateral fibular osteoseptocutaneous flap harvest. Between 1990 and 2004, 7 consecutive patients undergoing mandible reconstruction utilizing bilateral autogenous free fibular osteoseptocutaneous flaps were included in the study. They were evaluated for the following subjective symptoms on the donor leg: pain, paresthesia, walking ability, restriction in activity, gait alteration, and aesthetic result. In addition, balance test and gait analysis were used to quantitatively assess functional outcomes. The results of this objective assessment were compared with those of 8 age-matched control subjects. Most patients had few subjective symptoms. The most common complaints were pain after prolonged walking (14%), slight difficulty in squatting (28%), and minimal paresthesia on 1 of the donor legs (14%). There were no significant differences in reaction time and movement velocity on either the balance test or gait analysis between the study and control groups (P > 0.05). However, there were significant differences with regard to right backward directional control, maximum stability with eye closing, sway referenced support, and ankle strategy (P < 0.05). Long-term follow-up revealed minimal donor-site morbidity after bilateral fibular osteoseptocutaneous free flap harvests. The functional deficits could only be found under the most unfavorable sensory feedback conditions.

Risk Factors for Complications of Radiation Therapy on Tissue Expander Breast Reconstructions

Abstract:  Radiation therapy has been shown to increase complication rates of tissue expander/implant breast reconstructions. The purpose of this study was to evaluate patient characteristics to assess their impact on complications. A retrospective review of patients who underwent mastectomy plus tissue expander/implant reconstruction from January 2000 to December 2006 was performed. The main outcome of interest was the development of postoperative complications. Analyses were performed to detect risk factors for complications. A total of 560 patients were included in the study. A total of 385 patients underwent unilateral and 174 underwent bilateral tissue expander/implant reconstructions, for a total of 733 reconstructions. A total complication rate of 31.8% and a major complication rate of 24.4% were calculated. The risk factors associated with a significantly increased incidence of complications were age greater than 50 years, body mass index (BMI) greater than 30, and radiation. Women younger than 50 years had a complication rate of 28.4%, whereas women older than 50 years had a complication rate of 37.0%. Women with a BMI less than 30 had a complication rate of 27.5%, whereas women with a BMI greater than 30 had a complication rate of 49%. The major complication rate in nonradiated and radiated patients was 21.2% and 45.4%, respectively. Despite higher complication rates, tissue expander/implant reconstructions were successful in 70.1% of radiated patients. Based on this study, the ideal radiated patient would have a BMI less than 30 and be younger than 50 years of age to maximize the likelihood of a successful tissue expander/implant reconstruction.

Operating room fires: optimizing safety.

Background: This prospective study was undertaken to determine the safest means of supplemental oxygen delivery for patients undergoing facial cosmetic surgery under conscious sedation. Two common methods of oxygen delivery were used in 20 patients: (1) a nasal cannula and (2) a red rubber nasopharyngeal tube through which the cut ends of the nasal cannula were passed into the posterior pharynx. Methods: The project was carried out in two parts. In part one, each subject was placed supine and oxygen supplementation at 3 liters/minute was applied through the nasal cannula. The oxygen concentration at 24 different set locations around the patient’s face was analyzed using the random access mass spectrometer unit, starting at the right and left alar rim and then at 2-cm intervals laterally, superiorly, and inferiorly. The procedure in part one was repeated with oxygen being delivered by passing the cut cannula end through a red rubber nasopharyngeal tube into the posterior pharynx. Results: Statistical analysis has showed that in all sites at or above the nasal area, the difference between the nasal cannula and red rubber nasopharyngeal tube is significantly greater than 0, indicating that higher concentrations are observed with the nasal cannula than with the red rubber nasopharyngeal tube (p = 0.004). Conclusion: The authors’ study demonstrates a significant reduction in oxygen concentration, to levels consistent with ambient air, even at points extremely close to the oxygen source, when the nasopharyngeal tube system was used.

A Comparison of Dermabond Tissue Adhesive and Sutures in the Primary Repair of the Congenital Cleft Lip

Objective:To compare the long-term cosmesis of Dermabond (octyl-2-cyanoacrylate) and traditional skin sutures among patients undergoing primary cleft lip ± palate repair. Materials and Methods:Eleven patients underwent photographic analysis following primary cleft lip ± palate repair, including the use of Dermabond. Eleven age-matched controls who underwent cleft lip ± palate repair with traditional suture closure served as controls. Cosmesis was assessed by 3 blinded plastic surgeons using a visual analogue scale (VAS) and the Hollander Wound Evaluation Scale (HWES). Results:The overall mean VAS score for the patients treated with and without Dermabond was 70.0 (SD, 9.5) and 68.3 (SD, 13.4), respectively (P = 0.46). The overall mean HWES score for the patients treated with and without Dermabond was 1.7 (SD 1.7) (P = 0.92). Conclusions:Dermabond tissue adhesive offers equivalent mature wound cosmesis as traditional suture closure in the repair of the congenital cleft lip ± palate.

Cost analysis of conventional facial reconstruction procedures followed by face transplantation.

For the first time, this study analyzes the cost of multiple conventional reconstructions and face transplantation in a single patient. This patient is a 46‐year‐old female victim of a shotgun blast resulting in loss of multiple functional and aesthetic subunits. For over 5 years, she underwent multiple conventional reconstructions with suboptimal results. In December 2008, she became the recipient of the first U.S. face transplant. This has provided the unique opportunity to present the cost of 23 separate conventional reconstructive procedures and the first face transplant in the United States. The combined cost of conventional reconstructive procedures and the first U.S. face transplant was calculated to be