Face Transplant

Face Transplant Surgery | Comprehensive Transplant Center

Face Transplant | Johns Hopkins Medicine

A reconstructive transplant, also called a vascularized composite transplant or vascularized composite allograft, is an operation that can involve the transplantation of skin, muscles, nerves, blood vessels, and sometimes bone. This transplants facial features which may include areas from the scalp and skull down to the jaw and chin to help restore function that has been lost due to trauma or malformation.

Anatomy of the face

The face is a complex part of the human body. It is composed of many layers of skin, hair, and 44 muscles. These muscles control everything from eyebrow to nostril movements and lip control.

The face is also made of blood vessels, sensory and motor nerves, cartilage, bone, and other tissue.

In addition to basic functionality such as eating, smelling, and seeing, these facial components allow people to show essential non-verbal communication smiling or frowning.

Reasons for the procedure

Not everyone with facial malformations will be eligible for a facial transplant. For many, facial reconstruction may be possible using their own tissue. This type of reconstruction is managed through the Johns Hopkins Department of Plastic and Reconstructive Surgery.

Individuals with severe facial malformations may be interested in exploring facial transplants. The malformations could be the result of trauma, cancerous tumors, burns, or birth defects. For these individuals, traditional plastic and reconstructive surgery may not be an option, due to the extent of damaged facial structure, degree of malformation, lack of tissue available, etc.

Risks of the procedure

There are both short-term and long-term risks associated with this procedure, as well as risks associated with the immunosuppressant protocol that is used to prevent transplant rejection.

Short term risks

  • Long, complex operation
  • Blood vessels may become “clotted off,” stopping blood flow to the new tissue. This is one reason why patients are monitored so closely in the intensive care unit (SICU) after surgery so that if this complication occurs, we detect it early and have the best chance to correct it.
  • Infection
  • Wound healing problems
  • Pain
  • Bleeding
  • The development of other medical problems

Long term risks

  • Rejection of new face. This risk begins at the time of surgery and remains a possibility for the rest of a recipient’s life.
  • Possible problems with bone healing, which may require additional surgery.

Risks associated with immunosuppression

  • Infection
  • Development of cancers
  • Diabetes
  • Kidney damage
  • Heart disease

Before the procedure

  • Patients arriving for transplantation will undergo an examination by the transplant team to make sure they are healthy enough to tolerate surgery. Blood samples will be taken, IV’s will be placed and IV fluids and some “pre-treatment” medications will be given. Note: Significant medications or procedures will not occur until after the transplant team has confirmed that a donor face has been recovered and that it is suitable for transplantation.
  • An ultrasound machine may be used to mark out veins to be connected on the recipient’s skin.
  • Medications used to help tolerate immunosuppression are started.
  • The patient goes to the operating room before the start of the procedure so that any necessary lines or monitors they require can be placed.
  • Once the donor face is available, two teams of surgeons simultaneously operate: One team prepares the patient’s face to accept the transplant, and the other team prepares the donor’s face for transplantation.
  • Once the recipient and donated face have been prepared, the bones are connected with rigid plates and screws. Then, using a surgical microscope the arteries, veins, and nerves are connected.
  • Once blood is circulating throughout the transplanted face, any remaining muscles and nerves are connected and the skin and soft tissues are closed.
  • A dressing is applied as well as monitoring devices that help the surgeons see how well the blood is flowing into and the face.
  • The patient is then taken to the surgical intensive care unit (SICU) for close monitoring.

In the Hospital

  • Immediately following surgery, the patient will stay in the Surgical Intensive Care Unit (SICU). Here, the new face will be closely monitored and the patient will recover from surgery. During this time, the patient will be watched very closely by the nursing staff and checked every hour. The number of visitors will be limited.
  • Therapy begins almost immediately during the first few days after surgery. The goal of therapy is to help the patient gain as much function and independence as possible. Patients will meet a lead therapist and will start gentle range of motion exercises as appropriate. physical recovery and wound healing, rehabilitation exercises will progress to maximize functional recovery and patient outcomes.
  • After about a week, the patient will move to a regular (non-ICU) hospital room and begin to work with other types of therapy. The patient will be taught how to use a small, portable machine to help read nerve signals in the face while trying to do facial movements. The patient will continue to take medications and have blood tests to monitor the immune system. Over the next week or so the patient will have less monitoring and perform more therapy until they are ready to leave the intensive care unit.
  • The patient will be attached to several different types of monitors to check vital signs and blood flow to the new face. These will be checked very frequently at first and less often over time. The monitors will be removed before the patient leaves the hospital.
  • The patient will be cared for by many different members of the face transplant team. This will include intensive care nurses, hospital floor nurses, therapists, physical therapists, nutritionists, psychologists, and medication experts. Different kinds of physicians will also check on the patient including plastic surgeons, head and neck surgeons, infectious disease doctors, psychiatrists, and resident physicians.

At home

  • Every patient is different, and so discharge dates are not always the same. Transplanted patients should expect to be hospitalized for about four weeks. Some patients may need to stay in the hospital for longer depending on the type of facial injury, the patient’s health, how well the patient heals, consideration of any complications or unexpected problems while recovering, the amount of help available at home, and how far the patient lives from Johns Hopkins.
  • All patients will have very specific and detailed instructions given to them at discharge. It is imperative that patients follow these instructions exactly at all times. At any time, if a patient has a problem or concern, they should call the transplant team immediately so that we may help them find a remedy or have them return to see one of our team members. Patients should remember that their ultimate functional outcome is MOST DEPENDENT upon their ability to follow instructions regarding therapy and immunosuppression. The two most important instructions to follow regard performing therapy exercises to rehabilitate the transplant AND taking ALL medications every time and on time.
  • Every patient’s rehabilitation program and schedule will be personalized to their requirements. Most patients can expect to perform four to six hours or more of rehabilitation per day for the first six to 12 months. As your facial movement improves, fewer exercises will be needed.

Preventing Rejection

Rejection occurs when the recipient’s immune cells encounter the newly transplanted face as “foreign” and follow their natural response similar to the one against bacteria or viruses to attack/reject the graft.

This can result in a noticeable inflammatory reaction. Such acute rejection episodes can occur within days to months after transplant.

A scoring system for rejection was established similar to the Banff classification for solid organ transplants.

This process can be controlled/prevented using specific medications called immunosuppressants. After the transplant, patients need to take such medication for the rest of their lives. No patient taking his/her immunosuppression drugs on time and as advised has lost a face to rejection.

Signs of rejection

The skin component is the main target of rejection in face transplantation:

  • Clinical sign is usually a rash which can be spotty, patchy or blotchy, and is usually painless.
  • Un solid organ transplants such as a kidney or liver, the skin can be watched and monitored continuously by the patient.
  • This allows for early detection of rejections, diagnostic skin biopsies, timely intervention and treatment with certain skin creams.
  • All rejection episodes after face transplantation could be reversed with medication.

Source: https://www.hopkinsmedicine.org/transplant/programs/reconstructive_transplant/face_transplant_surgery.html

Facial Transplantation | Comprehensive Transplant Center

Face Transplant | Johns Hopkins Medicine

Johns Hopkins Medicine IRB #NA_00067257
Principal Investigator: Damon Cooney, M.D., Ph.D.

What is “VCA?”

“VCA” stands for “Vascularized Composite Allograft,” and has also been referred to as “composite tissue allograft” or CTA. It is the umbrella term used to refer to transplants composed of several kinds of tissues (i.e., skin, muscle, bone), the hand, arm or face.

Why is this research study being done?

Surgeons and researchers working on the research study at Johns Hopkins are proposing the use of an immunomodulatory / minimization protocol for immunosuppression after face transplant.

This protocol is different from most other immunosuppression protocols used to prevent rejection of face transplants in the United States.

For more information about this protocol, visit the Immunomodulatory / Minimization Protocol Website.

What immunosuppression treatment is currently used in face transplants around the world?

The standard treatment in human face transplants involve induction therapy with antibodies together with multi-drug maintenance therapy. While effective, such drug regimens have caused complications infection and drug toxicity, among others, jeopardizing the benefits gained from otherwise successful face transplants.

Who is on the Johns Hopkins Face Transplant Research Study Team?

Principal Investigator
Damon S. Cooney, M.D., Ph.D., Clinical Director of Face Transplantation

Co-Investigators
Gerald Brandacher, M.D., Scientific Director of the CTA Program
Patrick Byrne, M.D., Co-PI and Study Surgeon
Jordan Philip Steinberg, M.D., Ph.D., Study Surgeon

Why would I need a reconstructive face transplant?

Patients may need a face transplant, or a vascularized composite allograft (VCA) of the face, if they have had a severe injury and disfigurement from a traumatic injury, burns, or acquired malformations.

The reconstructive transplant team coordinates with the Burn Center at Johns Hopkins Bayview Medical Center to provide care and healing for burn victims. Patients here benefit from having access to top plastic surgeons and a multidisciplinary team of experts trained in treating burn wounds.

The Johns Hopkins Face Transplant team is proud to work closely with Walter Reed National Military Medical Center in supporting our wounded warriors for their best medical options. This collaboration will allow our experts and veterans to explore the possibility of facial transplantation at The Johns Hopkins Hospital.

Am I eligible for a face transplant?

To be eligible for a face transplant, patients must meet the following criteria. This information is a general list; full eligibility will be determined after meeting with the reconstructive transplant team.

  • 18 – 60 years of age
  • Facial trauma or disfigurement
  • No history of HIV or hepatitis C
  • Able to take immunosuppressive drugs
  • No history of cancer for at least five years
  • Willingness to forgo pregnancy for one year

How many face transplants have been performed worldwide?

Since 2005, more than 20 patients have received full or partial face transplants at institutions around the world.

What is face transplant surgery ?

Patients waiting for a face donation can be called into the hospital for surgery at any time. Facial transplant surgery typically takes 12-36 hours, depending on how much and which parts of the face need to be restored.

After surgery, you will be placed in a surgical intensive care unit (SICU) for about one week.

Once the surgical team feels comfortable with you being moved the SICU, you will move to a transplant unit, where you will receive care specially designed for all types of transplant patients. You can expect to be in the hospital for about 3-4 weeks.

The amount of time spent in the hospital depends on several things, including the amount of support and assistance you have at home, the distance from your home to the hospital for follow-up care, and any delays that might occur in recovery.

How do you find facial transplant donors? Is that included in the organ donation box on my driver’s license?

Face donation is not included in the commonly used driver’s license organ donation registry. Facial donation requires a special and sensitive consent process with donor families.

For Johns Hopkins patients, this process is done through specially trained and experienced coordinators from the Living Legacy Foundation of Maryland, the organ procurement organization for the state of Maryland (with the exception of Charles, Montgomery and Prince Georges counties, which are covered by the Washington Regional Transplant Community).

In addition to matching a donor to a recipient tissue and blood tests, selecting a donor for a facial transplant must also involve careful emphasis on matching skin color, skin tone, gender, ethnicity/race, and the size of the face.

How long will I have to wait for a transplant?

Once you are approved for a face transplant, you will have to wait for a matching donor to become available. This can range from a few weeks to several months. The donor must have matching blood and tissue types as well as matching skin color, skin tone, gender, ethnicity, race and size of the face/head.

What is rehabilitation ?

Face transplant patients should be prepared for extensive rehabilitation, which can last from four to six months. Some parts of rehabilitation may be required for life.

The goal for rehabilitation is for the patient to regain function and movement so that he or she can participate confidently in daily activities.

The functional duties of the face include speech, communication, smiling, eating and drinking, blinking, and emotional expression. Medical providers involved with rehabilitation may include the following:

Therapy exercises may include muscle relaxation or stimulation, mirror exercises, facial expression training, speech and swallowing training, re-educating the olfactory system, and more.

What is rejection after face transplant?

Rejection refers to the body’s immune response towards the newly transplanted limb. Believing the tissues to be “foreign,” the body’s natural response is to attack and can occur within days to months after transplant. A special scoring system to monitor VCA rejection was established in 2008 (Cendales et al).

What does rejection look in face transplants?

Rejection can appear as a rash that could be spotty, patchy or blotchy. It could appear anywhere on the transplant and is usually painless.

As rejection almost always appears first in the skin, patients and their caregivers are encouraged to carefully watch for the signs and report to the physician for timely biopsy and treatment.

Un internal organ transplants, it is easy to detect and monitor signs of rejection in the face. This allows for early medical intervention.

How many faces have been lost to rejection?

No patient taking his/her immunosuppression drugs on time and as advised has lost a transplanted face.

Where can I get more information about this research study?

For more information about the Johns Hopkins face transplant research study, contact the study’s Reconstructive Transplant Coordinator at (410) 955-6875. If you get an automated message, please leave a voice mail with a telephone number and a good time to contact you.

Source: https://www.hopkinsmedicine.org/transplant/programs/reconstructive_transplant/face_transplant.html

Facial Plastic and Reconstructive Surgery

Face Transplant | Johns Hopkins Medicine

Meet Our Team Shaun Desai, M.D., is board certified in both otolaryngology-head and neck surgery and facial plastic and reconstructive surgery. His practice encompasses both cosmetic and reconstructive surgery.

Some of the procedures he performs include rhinoplasty; facelift; browlift; eyelid surgery; facial augmentation and wrinkle treatments; facial trauma reconstruction; microvascular (free-flap) reconstruction of major head and neck defects after cancer or trauma; skin cancer reconstruction after Moh’s surgery and management of skin cancer, such as malignant melanoma.

In addition to his practice at Johns Hopkins, Dr. Desai travels with the Healing the Children Organization to perform cleft lip and palate repairs in Peru and India. More About Dr. Desai Meet Our Team

Meet Our Team Lisa Ishii M.D., is board certified in both otolaryngology-head and neck surgery and facial plastic and reconstructive surgery. Dr.

Ishii is the first facial plastic surgeon to have received a prestigious National Institutes of Health K12 Award to pursue research in facial plastic surgery received a Master of Health Sciences degree at The Johns Hopkins University Bloomberg School of Public Health.

The research skills she acquired propels her clinical practice to identify the best techniques in facial plastic surgery. Dr.

Ishii is an expert in hair transplantation for women and men, rhinoplasty, facial rejuvenation surgery of the aging face, facial reconstructive surgery and minimally invasive facial augmentation, such as injections or fillers. More About Dr. Ishii Meet Our Team

Meet Our Team Kofi Derek Owusu Boahene, M.D., is board certified in both otolaryngology-head and neck surgery and facial plastic and reconstructive surgery. As a facial plastic surgeon, Dr. Boahene specializes solely in plastic surgery of the face, head and neck.

As such, his patients are provided a focused expertise.

He treats both children and adults, and his practice encompasses the entire spectrum of facial plastic and reconstructive surgery, including rhinoplasty, nose reshaping, eyelid surgery, facial rejuvenation surgery, fat transfers, facial augmentation, wrinkle treatment, corrective surgery for congenital facial defects, cleft lip and palate repair, ear reshaping, craniofacial surgery, minimally invasive and endoscopic skull base surgery, microsurgery, reconstruction of cancer patients and extensive post-traumatic deformities. More About Dr. Boahene Meet Our Team

Meet Our Team Patrick Byrne, M.B.A., M.D., is a Professor and the Director of the Johns Hopkins Division of Facial Plastic and Reconstructive Surgery. He is also the Director of the Facial Plastic Surgery Fellowship program at The Johns Hopkins University School of Medicine. Dr.

Byrne focuses exclusively on plastic surgery of the face, head and neck. His robust clinical practice has a specific focus on aesthetic surgery, with a vast experience in rhinoplasty, revision rhinoplasty, and face lifting. Dr.

Byrne is one of the world’s leading experts in facial reanimation, the surgical field that deals with the treatment of facial paralysis. Patients with facial paralysis routinely travel across the country, and from around the world, to seek his help.

Byrne's research interests dovetail his clinical practice, and include the best techniques and effects of cosmetic surgery, the treatment of facial paralysis and the reconstruction of deformities due to cancer. More About Dr. Byrne Meet Our Team

Source: https://www.hopkinsmedicine.org/otolaryngology/specialty_areas/facial-plastic-reconstructive/

Face Transplant

Face Transplant | Johns Hopkins Medicine

Linkedin Pinterest What You Need to Know

  • A face transplant can be life changing for individuals who have been disfigured after a severe injury, were born with differences (or birth defects) or suffered from burns
  • A face transplant is a complex procedure and involves: a rigorous screening process, detailed surgical preparation,16 hours or more of surgery, nerve regeneration, physical therapy and immunosuppressive medications taken for the rest of the patient’s life.
  • Since 2005, more than 35 patients have received full or partial face transplants at institutions around the world.

Face transplant candidates must:

  • Be 18 – 60 years of age
  • Have experienced facial trauma or disfigurement
  • Have no history of HIV or Hepatitis C
  • Be able to take immunosuppressive drugs
  • Have no history of cancer for at least five years
  • Be willing to forgo pregnancy for one year

Consult with your transplant surgeon for more information about eligibility.

Screening for Face Transplant

Face transplant candidates undergo rigorous physical and psychological screening. Your facial transplant team will determine the health of your muscle and nerves to ensure they can support nerve regeneration.

Regrowth of the nerves after transplantation is essential for adequate motor function.
Candidates and their families may also be interviewed to evaluate whether they’ll be able to adhere to requirements for recovery, including taking anti-rejection medications and attending physical therapy.

They will also be evaluated for their ability to overcome any short-term setbacks.

Learn more about new technology aimed at improving chewing functions for patients.

Face donation is not included in the commonly used driver’s license organ donation registry. Face donation involves a special and sensitive consent process with donor families.

In addition to matching blood type and immunological parameters in solid organ transplantation, face donation involves careful emphasis on matching skin color, skin tone, gender, ethnicity, race and the size of the face and head.

Once you are approved for a face transplant, you may have to wait anywhere from a few weeks to many months for a donor match.

Face Transplant Surgery

Patients waiting for a face donation can be called into the hospital for surgery at any time. When the patient arrives to the hospital, they are evaluated to ensure they are healthy enough to undergo surgery. An ultrasound machine may be used to help mark out veins to be connected on your face. At that point, you may receive medications to help them tolerate immunosuppression.

Once the donor’s face is available, two teams of surgeons start operating simultaneously. One team would prepare your face to accept the transplant while the other prepares the donor for transplantation. Once you and the donor are surgically prepared, the surgeons will connect the bones with plates and screws.

Surgeons will use a surgical microscope to connect the arteries, nerves and veins. Once blood is flowing through the transplanted face, any remaining muscles and nerves are connected, and the skin and soft tissues are closed.

Facial transplant surgery typically takes 16 hours or more depending on how much and which parts of the face need to be restored.

After surgery, you will be placed in a surgical intensive care unit (SICU) for about one week. Once the surgical team feels comfortable with you being moved the SICU, you will move to a transplant unit, where you will receive care specially designed for all types of transplant patients.

You can expect to be in the hospital for about three to four weeks. The amount of time spent in the hospital depends on several things, including the amount of support and assistance you have at home, the distance from your home to the hospital for follow-up care, and any delays that might occur in recovery.

Surgeons and researchers at Johns Hopkins are leading research aimed at warding against rejection and reducing the number of medications patients have to take for the rest of their lives.

As with any organ transplant, the greatest risk is that your body will regard your new limb as a foreign object and your immune system will fight against it. With face transplants, rejection can appear as a rash that could be spotty, patchy or blotchy. It could appear anywhere on the face and is usually painless.

As rejection almost always appears first in the skin, patients and their caregivers are encouraged to carefully watch for the signs and report to the physician for timely biopsy and treatment.

Un internal organ transplants, it is easy to detect and monitor signs of rejection in the face. This allows for early medical intervention.

However, as long as the patient follows the prescribed immunosuppressant regimen, there has been no evidence that the transplant will fail.

In a span of just five years, Johns Hopkins Medicine has protocols approved and in place for hand, face and penile transplants—an indication of just how quickly its transplant portfolio has grown, and how the entire field has evolved.

Face transplant patients should be prepared for extensive rehabilitation, which can last from four to six months. Some parts of rehabilitation may be required for life. The goal for rehabilitation is for the patient to regain function and movement so that he or she can participate confidently in daily activities.

The functions performed by the face include speech, communication, smiling, eating and drinking, blinking and emotional expression. Therapy exercises may include muscle relaxation or stimulation, mirror exercises, facial expression training, speech and swallowing training, re-educating the olfactory system and more.

Source: https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/face-transplant

New Computer-Based Technology May Lead to Improvements in Facial Transplantation – 07/29/2015

Face Transplant | Johns Hopkins Medicine

Following several years of research and collaboration, physicians and engineers at Johns Hopkins and Walter Reed National Military Medical Center say they have developed a computer platform that provides rapid, real-time feedback before and during facial transplant surgery, which may someday improve face-jaw-teeth alignment between donor and recipient.

Surgeons performed the first successful transplant of facial features, including the jaw and teeth, in 2008, mainly relying on visual judgment.

Since then, approximately 30 facial transplants have been done worldwide, costing an estimated $250,000 to $500,000. These transplants have led to the improvement of patient survival and enhancement of physical appearances.

However, current surgical methods often leave patients with some undesired residual deformities and abnormalities in function.  

The new computer-assisted development should make it less ly to misalign the new set of bones, jaw and teeth, and prevent other reconstructive abnormalities for patients with severe craniofacial trauma, the researchers report.

Use of the new platform in mock surgeries performed on plastic and cadaveric human donor/recipient pairs is described in the journal Plastic and Reconstructive Surgery, published in August.

Called the computer-assisted planning and execution (CAPE) system, the platform is first used to help plan surgery once a donor has been identified for transplantation.

Using information from CT scans, the donor’s anatomy is matched to the recipient’s anatomy in an effort to optimize form, or appearance, and function, such as chewing and breathing, according senior author Chad Gordon, D.O.

, an assistant professor of plastic and reconstructive surgery at the Johns Hopkins University School of Medicine and co-director of the Multidisciplinary Adult Cranioplasty Center at Johns Hopkins.

The execution portion of the system’s name refers to the technology used during surgery, which includes a novel feature known as real-time cephalometry (RTC), says Gordon. RTC provides the surgeon with objective measurements and angles related to ideal jaw-teeth positions, with instantaneous visual feedback in the operating room un ever before.

“Every time the donor’s jaw-teeth segment moves during facial transplant inset, the computer recalculates its movements in comparison to the face transplant recipient, meaning the surgical team can have unprecedented visual data in achieving ideal alignment of the face, jaw and teeth,” explains Gordon. His collaborators included faculty members and scientists at the Johns Hopkins University Whiting School of Engineering and Applied Physics Laboratory.

The preciseness of the technology will ly reduce the need for patients to undergo revision surgery and will help to improve outcomes in various areas, says Gordon.

Gordon and his colleagues have jointly filed for eight patents related to the system, which has various applications within the field of craniomaxillofacial surgery.

For the study, the team performed donor-to-recipient, Le Fort-based face-jaw-teeth transplantation on two plastic models and two human cadavers using the CAPE system.

Gordon says the current prototype system can assist face-jaw-teeth transplantation, known as Le Fort-based jaw surgery, and can help surgeons in all forms and types of craniofacial surgery, in both adults and children.

“CAPE and RTC can be adapted for use in other surgical disciplines, such as oral-maxillofacial surgery, head and neck surgery, and neurosurgery,” adds co-author Mehran Armand, Ph.D.

, director of Biomechanical- and Image-Guided Surgical Systems, a collaborative laboratory between the Applied Physics Laboratory and Whiting School of Engineering.

“In fact, they share principles with our biomechanical guidance system, which was previously developed for orthopaedic surgery through a grant funded by the National Institute of Biomedical Imaging and Bioengineering.”

The team members at Walter Reed National Military Medical Center may find the system especially useful for treating victims of improvised explosive device blasts who have survived but are severely deformed and need reconstruction, according to Gerald Grant, service chief of the 3D Medical Applications Center at Walter Reed. “RTC will provide our team with a much-needed advantage when it comes to reconstructing wounded warriors with devastating maxillofacial or mandibular injuries, both for transplant surgery and for routine reconstruction,” he says.

The research and development of the system was supported in part by numerous grants, including an American Society of Maxillofacial Surgeons’ research award, an American Association of Plastic Surgeons’ Academic Scholar Award, the Johns Hopkins’ Institute for Clinical and Translational Research ATIP Award, internal research funds from the Applied Physics Laboratory and the Maryland Innovation Initiative award provided by TEDCO. The technology published here also received notable distinction from the Abell Foundation and won a Technology Innovation Award from TechConnect. The team says it hopes to obtain larger-scale research funding from the National Institutes of Health to help guide further development of the CAPE system, with the goal of launching a clinical trial within the next three to five years.

Source: https://www.hopkinsmedicine.org/news/media/releases/new_computer_based_technology_may_lead_to_improvements_in_facial_transplantation