Question and Answer with Dr. Daniel Alam

A Q &A with Daniel Alam, MD, AAO-HNS member and section head, Aesthetic & Reconstructive Surgery at the Head and Neck Institute of the Cleveland Clinic, about the first U.S. face transplant surgery. Dr. Alam was a member of the multidisciplinary team that performed the operation.

Q. Can you briefly describe what a face transplant is?

A. A face transplant is an extremely new and groundbreaking medical procedure that has only been successfully completed on four patients in the world. The surgery requires a multidisciplinary team of surgeons, including otolaryngologist – head and neck surgeons, working together to complete the complex and intricate process. The procedure involves the full or partial removal of skin tissue, muscles, nerves, bones, and blood vessels from a clinically brain dead donor face. Depending on the extent of injury or disfigurement in the recipient's face and neck, a team of surgeons will then begin rebuilding the damaged or deformed areas with the transplanted tissue. Each individual component has to be reconnected to its recipient counterpart to restore function and viability to the transplanted face (donor artery to recipient artery, nerve to nerve, muscle to muscle, etc). The recipient will need to be placed on a lifetime regimen of immunosuppressive medications to ensure the transplanted tissues aren't rejected, but the goal of the surgery is restore a patient's ability to function in society and significantly enhance their quality of life.

Q. What role does an otolaryngologist-head and neck surgeon play in such a major procedure?

A. As an otolaryngologist - facial plastic surgeon, I performed the dissection of the critical structures in both the donor patient face harvest and in the inset and reperfusion of the flap in the recipient. After transferring the critical vessel, nerve, muscle and bony components of the face, I performed the microvascular anastomosis which reestablished the blood flow to the new face. Performing the many complex steps of such an extensive surgery requires a thorough understanding of the anatomy of the superficial and deep structures of the face and neck. That kind of understanding is unique to otolaryngologist - head and neck surgeons.

Q. What's the difference between facial transplant, reconstructive facial surgery, and cosmetic surgery?

A.  Facial transplantation is not cosmetic surgery. It is done to restore function and form to patients with severe facial injury and disfigurement, where conventional techniques would be inadequate. Due to the need for immunosuppression, it is also not a procedure that is appropriate for patients with cancer-related deficits. Transplantation can be viewed as a form of reconstructive facial surgery, but unlike traditional approaches where tissue is taken from one area of the patient, reshaped, and moved to another, transplantation involves transfer of like tissue from a donor. In simple terms, instead of using various microvascular flaps to attempt to form the critical structures in the face, the face itself with all of its intricate structural elements is transferred from the donor, creating a much better functional and aesthetic outcome.

Q. How important was the multi-specialty approach to this procedure?

A. The care of a transplant patient is a complex interplay of surgeons, transplant physicians, and a number of other medical specialties. The care of our transplant patient has required the involvement of 12 medical specialties that have all played an important role to ensure a good outcome.

Q. Among other things, you were trying to reestablish the patient's smell, which is such an important sense. What challenges did this present?

A. The sense of smell comes from olfactory receptors at the roof of the nose. Unfortunately, our patient had significant scar tissue in the regions around this from her prior injury and surgeries. The new transplanted nose was transferred with a nasal turbinate and the septum to ensure normal airflow through the nose, which will hopefully allow odorant particles to reach the patient's olfactory receptors. She has reported smelling peppermint since the surgery.

Q. You helped map out this procedure (a 26-page surgical protocol). How difficult was it to plot a course for such a new surgical innovation?

A. The development of the operative plan for this type of complex procedure requires weeks of planning and extensive study of the recipient patient’s clinical exam, radiological studies, and prior operative history. The first step is a thorough analysis of the deficits in the recipient, both in terms of missing tissue and function. This is followed by mapping out the tissue that would need to be transferred to recreate a normal and functional face. Finally, a vascular map is created to ensure the vessels that are used will be sufficient and appropriate to support all of the transplanted tissue. After this initial plan is created, the next step was to organize the steps in an efficient way to allow a team of surgeons to work simultaneously. I divided the group of surgeons in the protocol into a craniofacial team that focused on the bony framework, and a microvascular/soft tissue team that worked on the nerves, vessels, and skin. This allowed a fluid and simultaneous flow of the procedure in both the donor and recipient operating rooms. I was primarily involved in leading the microvascular and soft tissue team.