Three Patients with Full Facial Transplantation

Pomahac, Bohdan; Pribaz, Julian J.; Eriksson, Elof; Bueno, Ericka M.; Diaz-Siso, J. Rodrigo; Rybicki, Frank J.; Annino, Donald J.; Orgill, Dennis P.; Caterson, Edward J.; Caterson, Stephanie A.; Carty, Matthew J.; Chun, Yoon S.; Sampson, Christian E.; Janis, Jeffrey E.; Alam, Daniel S.; Saavedra, Arturo; Molnár, Joséph; Edrich, Thomas; Marty, Francisco M.; Tullius, Stefan G.

doi:10.1056/nejmoa1111432

Cited by 222 publications

(213 citation statements)

References 19 publications

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“…Nasal receptors trigger spontaneous ventilation, so that chronic changes in nasal airflow provoke apneic episodes and hypoxia (7,8). Anatomical deficits in the upper airway result in decreased airway volume, increased airway resistance and ultimately dependency on a tracheostomy tube for respiration (4). In one of our recent studies we investigated effects of FT on airway recovery (Fischer et al, Boston, MA, USA, submitted April 2014).…”

Section: Discussionmentioning

confidence: 99%

“…The search terms were ''facial graft,'' ''facial transplantation,'' and ''facial allotransplant''; the time frame was between January 2000 and March 2014. Articles were in English language and contained at least one case report of FT. We identified 28 articles fulfilling these criteria (1,4,5,.…”

Section: Peer-reviewed Literaturementioning

confidence: 99%

“…FT cannot restore lost sight, but it can restore normalcy to the sense of smell by means of reconstruction of the nasal passage (4). Facial expression and speech are mandatory for communication.…”

Section: Introductionmentioning

confidence: 99%

“…Patients with severe facial injuries suffer from leakages of the oral cavity, trismus and absence of masseter muscles and thus are often unable to adequately ingest solid foods, liquids or even their medications (4). This ultimately leads to insertion of feeding tubes or gastrostomy, provoking significant discomfort, potential for malnutrition, infection, bleeding and possibly death (6)(7)(8)(9)(10).…”

Section: Introductionmentioning

confidence: 99%

“…We use simple descriptions and clearly visible changes to define common denominators of functional outcomes and thus generate an adequate basis for comparison. (4,19). Perioperative information for the five patients is given in Table 1.…”

Section: Introductionmentioning

confidence: 99%

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Functional Outcomes of Face Transplantation

Fischer

Kueckelhaus

Pauzenberger

et al. 2015

American Journal of Transplantation

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In this study we provide a compilation of functional impairments before and improvements after face transplantation (FT) of five FT recipients of our institution and all FTs reported in current literature. Functional outcome included the ability to smell, breath, eat, speak, grimace and facial sensation. Before FT, all our patients revealed compromised ability to breath, eat, speak, grimace and experience facial sensation. The ability to smell was compromised in two of our five patients. Two patients were dependent on tracheostomy and one on gastrostomy tubes. After FT, all abilities were significantly improved and all patients were independent from artificial air airways and feeding tubes. Including data given in current literature about the other 24 FT recipients in the world, the abilities to smell, eat and feel were enhanced in 100% of cases, while the abilities of breathing, speaking and facial expressions were ameliorated in 93%, 71% and 76% of cases, respectively. All patients that required gastrostomy and 91% of patients depending on tracheostomy were decannulated after FT. Unfortunately, outcomes remain unreported in all other cases and therefore we are unable to comment on improvements.

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Section: Discussionmentioning

confidence: 99%

Section: Peer-reviewed Literaturementioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Functional Outcomes of Face Transplantation

Fischer

Kueckelhaus

Pauzenberger

et al. 2015

American Journal of Transplantation

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The Evolving Clinical Presentation of Acute Rejection in Facial Transplantation

Haug

Kollar

Obed

et al. 2019

JAMA Facial Plast Surg

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IMPORTANCE Acute rejection is one of the most frequent complications in facial transplantation, with potentially severe consequences for the recipient if overlooked. Clinical signs, such as erythema or edema, are helpful to diagnose acute rejection in the early follow-up stage; however, it is not well known whether these clinical signs remain reliable markers of acute rejection beyond the second posttransplant year. OBJECTIVE To determine the diagnostic value of clinical signs of acute rejection after facial transplantation over time. DESIGN, SETTING, AND PARTICIPANTS A retrospective, single-center cohort study was conducted of patients who underwent facial transplantation at Brigham and Women's Hospital between April 2009 and October 2014, with up to an 8-year follow-up. Medical records were reviewed until September 30, 2017. The medical records from 104 encounters with 7 patients who underwent partial or full facial transplantation were analyzed for symptoms of rejection, immunosuppressive therapy, and histopathologic findings. MAIN OUTCOMES AND MEASURES The occurrence of 5 clinical signs of acute rejection were evaluated: erythema, edema, exanthema, suture line erythema, and mucosal lesions. Odds ratios (ORs) were calculated to determine the statistically significant association of these signs with the histopathologic diagnosis of rejection. In addition, tacrolimus blood levels, as a surrogate marker of immunosuppressive therapy, were evaluated. RESULTS Of the 7 patients included in the study, 5 were men. The mean follow-up was 66 months (range, 35-101). Of 104 clinical encounters, 46 encounters (44.2%) represented rejection episodes and 58 encounters (55.8%) represented no-rejection episodes. Beyond 2 years posttransplantation, only erythema (OR, 6.53; 95% CI, 1.84-20.11; P = .004) and exanthema (OR, ϱ; 95% CI, 2.2-ϱ; P = .004) were demonstrated to be reliable clinical signs of acute rejection in facial transplantation. There was also a statistically significant association of subtherapeutic tacrolimus levels with late rejection episodes (OR, 3.79; 95% CI, 1.25-12.88; P = .03). In addition, the occurrence of subclinical rejection was more frequent during later follow-up times (7 [24.1%] late rejections vs 1 [5.9%] early rejection). Five of 8 subclinical rejections (62.5%) were associated with subtherapeutic tacrolimus levels. CONCLUSIONS AND RELEVANCE Clinical signs of acute rejection in facial transplantation appear to be of limited diagnostic value, particularly after the second postoperative year. Until alternative biomarkers for rejection are identified, protocol skin biopsies will remain necessary for guiding assessments of allograft rejection. LEVEL OF EVIDENCE 3.

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Recognizing Emotional Expression as an Outcome Measure After Face Transplant

et al. 2020

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IMPORTANCE Limited quantitative data exist on the restoration of nonverbal communication via facial emotional expression after face transplant. Objective and noninvasive methods for measuring outcomes and tracking rehabilitation after face transplant are lacking. OBJECTIVE To measure emotional expression as an indicator of functional outcomes and rehabilitation after face transplant via objective, noninvasive, and nonobtrusive software-based video analysis. DESIGN, SETTING, AND PARTICIPANTS This single-center case-control study analyzed videos with commercially available video analysis software capable of detecting emotional expression. The study participants were 6 patients who underwent face transplant at Brigham and Women's Hospital between April 2009 and March 2014. They were matched by age, race/ethnicity, culture, and sex to 6 healthy controls with no prior facial surgical procedures. Participants were asked to perform either emotional expressions (direct evaluation) or standardized facial movements (indirect evaluation). Videos were obtained in a clinical setting, except for direct evaluation videos of 3 patients that were recorded at the patients' residences. Data analysis was performed from June 2018 to November 2018. MAIN OUTCOMES AND MEASURES The possibility of detecting the emotional expressions of happiness, sadness, anger, fear, surprise, and disgust was evaluated using intensity score values between 0 and 1, representing expressions that are absent or fully present, respectively. RESULTS Six patients underwent face transplant (4 men; mean [SD] age, 42 [14] years). Four underwent full face transplants, and 2 underwent partial face transplants of the middle and lower two-thirds of the face. In healthy controls, happiness was the only emotion reliably recognized in both indirect (mean [SD] intensity score, 0.92 [0.05]) and direct (mean [SD] intensity score, 0.91 [0.04]) evaluation. Indirect evaluation showed that expression of happiness significantly improved 1 year after transplant (0.04 point per year; 95% CI, 0.02 to 0.06 point per year; P = .002). Expression of happiness was restored to a mean of 43% (range, 14% to 75%) of that of healthy controls after face transplant. The expression of sadness showed a significant change only during the first year after transplant (−0.53 point per year; 95% CI, −0.82 to −0.24 point per year; P = .005). All other emotions were detectable with no significant change after transplant. Nearly all emotions were detectable in long-term direct evaluation of 3 patients, with expression of happiness restored to a mean of 26% (range, 5% to 59%) of that of healthy controls. CONCLUSIONS AND RELEVANCE Partial restoration of facial emotional expression is possible after face transplant. Video analysis software may provide useful clinical information and aid rehabilitation after face transplant.

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Three Patients with Full Facial Transplantation

Cited by 222 publications

References 19 publications

Functional Outcomes of Face Transplantation

Functional Outcomes of Face Transplantation

The Evolving Clinical Presentation of Acute Rejection in Facial Transplantation

Recognizing Emotional Expression as an Outcome Measure After Face Transplant

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