About reconstructive face transplants
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 like 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 Plastic and Reconstructive Surgery Department.
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.
- Wound healing problems
- 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
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 out of the face.
- The patient is then taken to the surgical intensive care unit (SICU) for close monitoring.
After the procedure
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. Based on 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.
- 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.
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.
- Unlike 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.