Steven Bernard

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.

Breast reconstruction with abdominal-based free flaps in high body mass index population: postoperative complications and impact of weight loss.

AbstractObesity, which is becoming endemic in the United States, causes a significant challenge for reconstructive surgeons. This study evaluates postoperative complications and impact of weight loss in the high body mass index (BMI) population undergoing breast reconstruction with abdominal free flaps. A retrospective review of 182 consecutive patients was performed. Patients were divided into groups according to their BMI at the time of surgery (preoperative BMI) and presence of weight loss, and data were compared among groups. Multivariate analysis of effect of preoperative BMI on complications revealed that overall flap (P = 0.008) and donor (P = 0.016) complication rates were significantly higher in the obese group. Analysis of preoperative weight loss did not yield a statistically significant reduction in flap (P = 0.5161) or donor (P = 0.8034) complication rates. Univariate analysis showed that higher preoperative BMI is associated with higher risk of systemic complications (P = 0.027). It is important to inform patients preoperatively that weight loss, although beneficial for ease of procedure and quality of life, does not diminish their increased risk of complications. Body mass index during surgery is the most important predictor of complications.

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.

Achieving patient satisfaction in abdominally based free flap breast reconstruction: correlation with body mass index subgroups and weight loss.

Background: The goal of this study was to evaluate the relationship between body mass index, preoperative weight loss, and patient satisfaction in breast reconstruction with abdominally based free flaps. Methods: A custom survey with overall, breast, and abdomen questions was sent to patients who underwent abdominally based free flap breast reconstruction over the past 4 years. Clinical data were collected for patients who returned surveys. Data analysis was performed based on body mass index and percentage weight loss before surgery. Results: One hundred seventy-nine surveys were sent. Ninety-two patients (51.4 percent) responded. Normal weight patients versus overweight patients did not have statistically significant differences in any satisfaction scores. Overweight patients had higher overall satisfaction (p = 0.01), breast-specific satisfaction (p = 0.01), and abdomen-specific satisfaction (p = 0.02) compared with obese patients. Normal weight patients had higher breast-specific satisfaction (p = 0.05) and abdomen-specific satisfaction (p = 0.03) scores compared with obese patients. Patients with significant preoperative weight loss were more satisfied with feeling of breasts in clothes (p = 0.01), social appearance (p = 0.05), and current abdominal appearance (p = 0.01) compared with patients with moderate preoperative weight loss. Overall, breast- and abdomen-specific satisfaction scores decreased with increase in pannus thickness. Conclusions: Patient satisfaction with abdominally based free flap breast reconstruction was highest in patients with normal body mass index and lowest in obese patients. Overweight or obese patients should be encouraged to participate in healthy weight loss programs to achieve improved postoperative satisfaction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Clinical application of the FACES score for face transplantation.

ObjectiveThis study aimed to systematically evaluate all reported outcomes of facial allotransplantation (FT) using the previously described FACES scoring instrument. MethodsThis was a retrospective study of all consecutive face transplants to date (January 2012). Candidates were identified using medical and general internet database searches. Medical literature and media reports were reviewed for details regarding demographic, operative, anatomic, and psychosocial data, which were then used to formulate FACES scores. Pre-transplant and post-transplant scores for “functional status”, “aesthetic deformity”, “co-morbidities”, “exposed tissue”, and “surgical history” were calculated. Scores were statistically compared using paired-samples analyses. ResultsTwenty consecutive patients were identified, with 18 surviving recipients. The sample was composed of 3 females and 17 males, with a mean age of 35.0 ± 11.0 years (range: 19–57 years). Overall, data reporting for functional parameters was poor. Six subjects had complete pre-transplant and post-transplant data available for all 5 FACES domains. The mean pre-transplant FACES score was 33.5 ± 8.8 (range: 23–44); the mean post-transplant score was 21.5 ± 5.9 (range: 14–32) and was statistically significantly lower than the pre-transplant score (P = 0.02). Among the individual domains, FT conferred a statistically significant improvement in aesthetic defect scores and exposed tissue scores (P ⩽ 0.01) while, at the same time, it displayed no significant increases in co-morbidity (P = 0.17). ConclusionThere is a significant deficiency in functional outcome reports thus far. Moreover, FT resulted in improved overall FACES score, with the most dramatic improvements noted in aesthetic defect and exposed tissue scores.

Applying to Integrated Plastic Surgery Residency Programs: Trends in the Past 5 Years of the Match.

Background: The average integrated plastic surgery applicant spends over

Establishing the Feasibility of Face Transplantation in Granulomatosis With Polyangiitis.

6000 for interviews. The average program director reviews over 200 applications per cycle. It is important to make the application process efficient and cost effective for both applicants and programs. The authors analyzed recent trends and the literature in an attempt to increase the likelihood that applicants match, suggest means of reducing applicants’ costs, and improve the process. Methods: A cross-sectional study of the National Residency Matching Program Charting Outcomes and results and data for the years 2009 to 2014 was performed. Applicant profile elements were examined for differences between matched/unmatched U.S. senior medical students. In addition, a literature review was performed. Results: The number of integrated plastic surgery positions rose from 69 in 2010 to 130 in 2014. Both matched and unmatched U.S. senior medical students have higher Step 2 scores, research and volunteer experiences, than 5 years ago. The likelihood of matching into an integrated plastic surgery residency has increased (2009, 52 percent; 2011, 44 percent; and 2014, 71 percent). Successful match rates were associated with Alpha Omega Alpha status and graduating from a top-40 ranked medical school (p < 0.05). Applicants with a lower number of ranked programs had increased match rates in 2014 than in previous years. Literature review revealed that program directors also value strong recommendation letters, publications, persistent work ethic (“grit”), away rotations, and an accurate curriculum vitae. Conclusions: Within the setting of increased applicant competitiveness, the authors recommend maximizing subjective qualities in order to differentiate themselves from a highly eligible applicant pool. In addition, applicants should diversify the types of programs at which they interview to maximize their chances of matching.

Hand Anatomy and Examination

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.