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ANDREA TOOLEY: Welcome to the Mayo Clinic Ophthalmology Podcast brought to you by Mayo Clinic. I'm your host Dr. Andrea Tooley.
ERICK BOTHUN: And I'm Dr. Eric Bothun. We're here to bring you the latest and greatest in ophthalmology medicine and more.
ANDREA TOOLEY: In today's episode, we sit down with oculofacial plastic surgeon, Dr. Elizabeth Bradley, a member of the Mayo Clinic face transplant team. Dr. Bradley takes us through her involvement with the first face transplant at Mayo and everything a face transplant entails from the ophthalmologist's perspective.
ERICK BOTHUN: Dr. Elizabeth Bradley is an Associate Professor of Ophthalmology at the Mayo Clinic in Rochester, Minnesota, where she serves as program director for ASOPRS-sponsored Oculoplastic Surgery Fellowship. In addition to her clinical interests in ophthalmic aspects of facial nerve disorders, Dr. Bradley is a member of the Mayo Clinic's face transplant team.
She was the oculoplastic surgeon for Mayo Clinic's first face transplant performed in 2016. Dr. Bradley also works in multidisciplinary teams through Mayo Clinic's Facial Reanimation Clinic and the Thyroid Eye Disease Clinic. Welcome, Dr. Bradley.
ELIZABETH BRADLEY: Thank you. Happy to be here.
ERICK BOTHUN: We're excited to have you. I-- certainly, this is one of these topics that falls just beyond our comfort zone in facial transplants. And it seems like a foreign concept potentially to pediatric ophthalmologists like me, maybe a little bit better for you as an oculoplastics person.
ANDREA TOOLEY: No, even oculoplastic surgeon. Face transplant is out of this world unbelievable. So we're super excited to talk about it.
ERICK BOTHUN: Yeah. How-- tell us-- back us up to even before the actual preparing to do that technique, share with us just a little bit about the early days in considering performing a transplant. What went into even the concept, the background, our understanding? And what might need to be in place for that to happen?
ELIZABETH BRADLEY: Yeah. So really it started with a relationship with Samir Mardini, who leads our face transplant team at Mayo Clinic. And Samir first approached me more than a decade ago, so five or eight years before we did the face transplant saying, say, I have these cases where we need an oculoplastic surgeon. And some of them were very routine-- Medicare, blepharoplasty where they needed a ptosis repair, could you-- want to do these together.
So we started working together. And we found out that we worked very well together in the operating room. And then he started-- he had this goal to bring face transplantation to Mayo and for Mayo to have a clinical face transplant program, meaning outside the realm of research.
This is a surgery that's at that very tip of the pyramid. If this is what a patient needs that we have to be able to offer this service and this care to patients. And so that was his goal. And he set about assembling a team. And I was just one of the very, very lucky people who was able to be on that team.
ERICK BOTHUN: I think it's exciting to consider how cross-pollinating in different specialties not only complements what we do in our patients, but also brings in opportunities to do more and different things. And eventually, this led to facial transplants. Share with us a little bit about that journey.
You said you realized you worked together with-- how did that feel? How was that orchestrated on a patient-to-patient basis? I mean, did you do cases together? Or was it dialoguing and clinical care. And were there aspects of that working directly with a plastic surgeon that changed your practice outside of that care in your oculoplastics practice?
ELIZABETH BRADLEY: So yes to all of that. So, yeah. So we started working together really, like I said, on these very prosaic cases-- blepharoplasties, ptosis. And we said, OK. Well, gosh, we see these other patients that also could benefit from our services and especially in the realm of facial reanimation, which we'll talk about separately. But we were both seeing patients who had facial nerve palsies.
Our first effort together was to form our facial reanimation team. And so that was a multidisciplinary team that we grew just from our mutual patients. And then we recruited a neurologist. We identified Dr. Beth Robertson, one of our neurologists, and she became our neurologist. And then she became the neurologist for the face transplant team. And so that was certainly one of the core groups for the face transplant team.
But yes, we started doing more and more complex cases together, trauma cases, reconstructive cases. Our surgical schedules aligned. As you know, at Mayo, we have these blue and orange days. And so he and I had similar days in the operating room, and we started blocking one or two days a month.
I know, Dr. Tooley, you do something similar. And so that's really a core part of how we schedule so patients can arrive, see us, and be in the operating room potentially even later that week with the same team.
ERICK BOTHUN: I know early in my practice, some of my colleagues had went into comprehensive ophthalmology practices. I know a group or two that would dedicate a certain schedule, like once every three months, where they operated together, even on straightforward cataracts. Or it might be a strabismus case that they hadn't done in a while, and they didn't do those routinely.
But this journey of just being intentional, to work together and collaborate and how that can complement practices, whether it's unique, comprehensive oculoplastic services like you guys provide, or even in a private practice setting with your partners to just be more intentional with talking through cases and doing them together. There's great reward.
ELIZABETH BRADLEY: Absolutely.
ANDREA TOOLEY: No. And that's one of the really fun parts about what we get to do is work together. I think cases that I have with colleagues and opportunities to work together, they're always the most fun cases, the most enjoyable and probably better for patient care with that collaboration.
So take us to the very, very early days of thinking about, OK, we've decided we're going to start offering face transplant. I mean, face transplant-- the whole concept of that surgery has not been around for very long. Not many places have done it. It's extremely challenging, much more than other solid organ transplants.
What goes into planning, conceptualizing, preparation for something like that? Because, I mean, you prepared for years and years. So take us through that, the very early days.
ELIZABETH BRADLEY: So certainly from an institutional standpoint, it requires a huge amount of groundwork, most of which was done by Samir Mardini getting this through the IRB so that they would approve this as clinical care, not research-based care.
And then there's a whole separate-- or there was a whole separate parallel system of approvals that had to go through the organ procurement organization. Because up here in the upper midwest, we have a fantastic organ procurement organization that helps work with families, donors for solid organ transplants. But they very much had to be on board and add this new protocol to their services of now approaching the family about potentially donating a face of a loved one.
When you sign your organ transplant-- when you sign your-- on your driver's license, when you sign your organ donor wishes, that applies to solid organs and corneas, but it does not apply to face transplant. That requires a special permission from the next of kin. So that all had to be worked out, that protocol.
Some of the other things that differ from solid organ transplant is that this happens in adjacent rooms. So the donor and the recipient need to be next to each other in the same room. And so that means that the donor potentially has to be transported to your hospital.
And, for example, if they die in another state, their body is actually in the jurisdiction of the local coroner, not even in their family's possession anymore. And so that coroner has to sign off to have the body transported across state lines. These are just examples of some of the thousands--
ANDREA TOOLEY: Logistics.
ELIZABETH BRADLEY: --and thousands of details that had to be ironed out.
So Samir Mardini worked on that, I think, for about five years before we even said, OK, we're actually ready to start screening patients. And then that was a whole system of finding patients. We see patients, of course. Every month we see patients who have horrible disfiguration from trauma, burns, congenital malformations, all types of things, and identifying in which patients we had exhausted traditional surgical techniques and they needed something else.
And then that patient has to, of course, go through a whole series of medical psychiatric evaluations to make sure that they would be committed to and a good patient for a face transplant. Again, this is really the ultimate quality of life surgery. It's not-- we're not adding years here. It's not like heart, liver, kidney. This is a commitment to take potentially life-altering, life-threatening medications to enhance your quality of life.
ANDREA TOOLEY: Right. Well, another thing I was thinking that I learned just by hearing you talk about face transplant is the skin is so highly immunogenic, or the immunogenicity of the skin is so high, and so the immunosuppressants that you have to take for a face transplant are in a complete new league compared to what you'd have to take for a kidney, for example. So it's a big deal in terms of the immunosuppression.
ELIZABETH BRADLEY: Absolutely. Yeah, lifelong immunosuppression. Yeah.
ANDREA TOOLEY: And hardcore.
ELIZABETH BRADLEY: Yes. And all these patients, every face transplant patient, has gotten some rejection. And so that needs to be, yes, closely monitored and treated.
ANDREA TOOLEY: Wow.
ERICK BOTHUN: Tell us-- and you talked about how important that selection is, both for the donor and the recipient. Can you share more about as you prepared for this step, what became the most important criteria that would make an ideal donor and/or recipient?
ELIZABETH BRADLEY: Well, so first and foremost, they had to have a defect that could not be in other ways managed by conventional surgery. And our particular patient-- and I'll mention his name, which is in the public record. So this is not HIPAA-protected information.
So Andy Sandness was a patient with whom we had a relationship. He had initially presented to Mayo clinic when he had his first trauma, which was in, I think, 2006, a full 10 years before he had the face transplant. And it's one of these things that gives you chills.
Samir Mardini was on call that night. Samir took care of Andy over the Christmas holidays when Andy first presented as the victim of a self-inflicted gunshot wound. And so he was a young man at that point. And then Samir had performed a multitude of reconstructive surgeries trying to reconstruct his jaw and had reached to the-- reached the point where really there wasn't a lot more that could be done that would give Andy the type of life-transforming result that he wanted.
And so we evaluated Andy. We evaluated other patients as well. But we evaluated Andy. And he was just-- he had come a long way emotionally, physically, and in every other way from when he had first had his trauma. And his life wasn't what he wanted it to be. And he was really fully committed. He had a supportive family, supportive network, and was really, by all evaluations, felt to be a great candidate for this.
ANDREA TOOLEY: When you're thinking about the surgical planning-- so you've identified a potential patient. We're talking about not just transplanting the skin, but vasculature, nerves, bone, cartilage. How do you plan what gets transplanted, and how do you even do it?
ELIZABETH BRADLEY: Right. So this is really-- this is individualized surgery at its highest, most challenging aspect. Because right, in Andy's case, we were transplanting really the lower 2/3 of the face-- every layer. So muscle-- bone, muscle, skin, nerve, artery, vein. And so that requires meticulous planning. And that's where we headed to the anatomy lab. And over the course of three years had about 40 anatomy lab sessions.
And so with that, you have a donor head, and you have a recipient head. And then the recipient cadaver head, you recreate the defect that, in this case, Andy, our patient, had. And then in the donor head, you create what you think you need to do to bring the two together.
And the resources were incredible in our anatomy lab. Both heads, both donor heads, would get scanned. And so we would have a CT imaging of both heads. And then we would have cutting guides that were specific for both heads. And so that would tell us on the donor cut here, on the recipient cut here. And that was for the bone.
For the soft tissue, that's how we figured out how to do it. Well, what if we make them come together here? What if we make an incision here versus there? And so we worked through all those details over many, many sessions a couple of years.
And then we finally got to the point where we were very pleased just making minor modifications because then we would have the reconstructed head and then that would actually go through CT imaging again. And we would see where our cutting guides were off by a millimeter or two.
Medical Modeling, the company that we use, they would fly their representatives in from Colorado with the cutting guides to refine things. We had an anaplastologist who was there working on making a death mask. Because a big part of face transplantation is donor restoration. You want to be able for the family of the donor to potentially be able to have a viewing in a casket. And so we had anaplastologist who came and would make molds of the donor face and just an incredible lifelike mask.
ANDREA TOOLEY: Wow. It's unbelievable. I mean, you were spending your weekends in the anatomy lab doing practice face transplants for years-- 40. That is bananas.
ELIZABETH BRADLEY: Yeah, about once a month. And the whole team wouldn't have to be there, but different parts of the team. And we'd start at 8:00 and end around 3:00 or 4:00 in the afternoon. It was a great time to get to know the team and we'd all break for lunch. The photographers are-- our photographers and videographers were just an essential part of our team. They were there photographing, videotaping the entire surgery.
ERICK BOTHUN: I remember seeing images of that team, and it was-- you speak about the time involved. But as you've already communicated, there are pieces or staff members that you wouldn't even dream that needed to be there that were there. And so the multifaceted operating filling team members, it was like a college football team showing up in the operating room throughout that journey.
ELIZABETH BRADLEY: Yes. At-- right--
ERICK BOTHUN: So the leadership and communication parts obviously couldn't be underscored and how important they were.
ELIZABETH BRADLEY: Yes. The team definitely grew from our fairly small team in the early days to by the end, we were doing an entire run-through with surgical scrub techs, real instruments. We really-- we practiced this to the n-th degree. And then finally decided we're ready. We're ready. And so at that point, that's when we listed Andy's case.
ERICK BOTHUN: And then how long did it take before a donor was available?
ELIZABETH BRADLEY: Not long. So there were some special circumstances. I think we listed Andy-- I believe it was in January of 2016. And again, the transplant happened in June. And we were fully ready, but we were also prepared to wait. We thought that we would need to wait for about four years due to, a, the donor, that not everybody is going to consent to having their loved one be a face transplant donor.
And then Andy had some special medical issues, too. Again, this is in the public record. He was EBV negative-- Epstein-Barr virus. And 85% of the population is EBV positive. And so that right there would have eliminated potentially 85% of our donors. And so we expected a long wait. And we were shocked then when we got a call in June that there was a potential donor.
ANDREA TOOLEY: That just gives me chills. It's really amazing.
ERICK BOTHUN: You hear stories of the personal impact of donor recipients getting that call that we have something for you now. And I can't imagine from Andy's aspect too how long he waited and was at a different position in his life that to have a new face coming would have been-- it obviously was transformative, but a very-- a lot of heartbeats and fast paces coming together on that actual call.
And once you knew a donor was coming, how quickly did it take? Take us through, then, we have one. It's going to happen. How long did it take to get everything in an operating room? And take us through what that journey was in the OR when it's happening?
ELIZABETH BRADLEY: Right. So as I recall, I think Samir Mardini got the call when he was at the airport ready to leave for a flight that we have a potential donor. We don't know the EBV status. And he's signed his organ donation card, but we need to talk to the family.
And again, this is all in the public record. There was-- it was in the Mayo video, and it was in People magazine, that the donor was a young man who himself had committed suicide. So again, another just striking parallel with Andy. And he had a young wife who had the strength to say that she would donate his face for Andy.
And so that process was going through. He came back EBV negative. The entire surgical team actually was here in town on a summer weekend. Because Mayo had said that they would fly the surgeons back, and yet we were all here.
Samir left the gate, came back to Rochester. And then by Friday afternoon, we knew for certain that it was a go. Actually, Friday morning we knew it was for certain. And then Friday afternoon we all convened.
Andy had been flown in from Wyoming, where he lived at the time. And the donor had been transported across state lines-- Rudy. And he arrived at Saint Marys. Andy was all checked in. Samir did his briefing just before midnight on Friday night. And then we started the case a little bit after 3:00 on the wee hours of Saturday morning.
Again, the timing was amazing that we had these two OR suites all weekend long. And so we ran all day Saturday, all day Sunday, and then finished up Monday morning around 8:00, just in time to get the room turned over--
ERICK BOTHUN: For the new room.
ELIZABETH BRADLEY: --for the next case.
ERICK BOTHUN: Wow.
ANDREA TOOLEY: That is unbelievable.
ELIZABETH BRADLEY: Yeah.
ANDREA TOOLEY: Wow. And what was the energy like? What were the days like operating for 48 hours in shifts? And we've seen pictures. We could probably put a link in the description of this podcast to show some of the photos of the cots and people sleeping between shifts in the OR. And you brought in food. And it's just-- it's remarkable.
And we're all surgeons. And I'm sure there's a lot of surgeons listening to this podcast. But this is the Olympic-- not even Olympics. This is another level. You can't even imagine a surgical feat like this. It's so cool to hear about. So tell us about the day.
ELIZABETH BRADLEY: So, I mean, certainly you're standing there at the scrub sink thinking, this is so incredibly routine. I'm scrubbing my hands for this biggest case that I'll probably-- certainly that I've ever done and that I might ever do.
But you're also there with all these people-- your team. And so I'm literally standing there with one of the other surgeons. And you felt-- more than anything, I think we felt ready and walked into the operating room with the donor.
And the organ procurement organization is there at the beginning of the case. And something that has changed, at least since I did my transplant rotation as a medical student, is that they read a brief statement written by the family about the donor. And that is definitely a centering experience for everybody and just what an amazing gift, again, from the family. So appreciative of all the strength that they had.
And with that, then the case gets underway. And again, we were certainly very ready for every step of the case. And you just keep marching through.
One thing that Samir had done to prepare for the entire experience was he had visited, I think, every face transplant center in the entire world and had talked to the lead surgeon. They were all friends and colleagues of his.
And one piece of advice that he was given was you have to manage your team so that they don't all crash at the same time. Everybody has huge adrenaline, but you can't all crash at hour 24 or 30. So you have to have forced breaks.
And so Samir managed that. He would just tell us, say, it's time for you to go home. And so we would. We did have a MASH type unit. Although, Rochester being a small town, we were all pretty much able to go home, sleep in our own beds. You'd go and you'd get a few hours of sleep and then come back.
So Samir got certainly the least sleep. I'm not sure that he slept for the full 50 hours, but we all had breaks. And so you'd come back and be re-engaged and ready to go back at it.
ANDREA TOOLEY: Wow. So powerful.
ERICK BOTHUN: And the story continued. I know Andy's story has become, as you-- part of the public record, but one that we've celebrated. Share with us kind of post-operatively then as things-- the result became apparent that this was a success. Share with us some of the lessons and things you've thought about, both from the human story, but also from an ophthalmic plastic perspective as a specialist caring for his eyes.
ELIZABETH BRADLEY: Yes. So first of all, I would say that we think of it as a face transplant. But it's really-- it's a systemic procedure when you see the fortitude that's necessary physically and emotionally. But especially physically, I was struck early on.
There's intubation for days. There's nutrition status. There's so many issues going on. And so these patients have to be healthy going into the surgery. And fortunately, Andy was a young, healthy man. So that was the first thing that really struck me.
And then we did prepare Andy. Of course, he didn't see his face right away. And we have an amazing psychiatrist, Sheila Jowsey, who had worked with Andy for years beforehand. And she was there, and she walked him through the process before he got to see his face.
And I had the tremendous honor of being there when he saw his face, and it was amazing. And his family was there with him. And he said it was better than he could have ever dreamt.
Now, at that point, the face-- his face was not animated. And so Mayo-- we all knew that the transplant had happened, but we thought that Andy would be best served by waiting for things to be announced until he had some animation. Because other than that, the face is really just hanging there in an unanimated state.
And so then by about month six, Andy was having really excellent animation back. And so that's about when the announcement was made. Yeah. So this transplant was in June. I think it was actually around month seven-- February of 2017.
ANDREA TOOLEY: I want to back up just a little bit. Tell us about some of the ophthalmic considerations for face transplant. Because Andy was lower face, but still had some ophthalmic involvement. And then just for face transplant in general, what are the things considered from an eye perspective?
ELIZABETH BRADLEY: Yes. So, as you say-- so Andy was is blind in one eye with a central scotoma, as are many face transplant recipients and face transplant candidates. So as we've reviewed the literature, at least half of patients who have undergone face transplantation are blind in one or both eyes. So I really looked at-- my number one goal was to protect his other eye and make sure that nothing untoward happened to it during the surgery.
Probably the most invasive part of Andy's procedure was the reconstruction of the orbital floor. So we were making our incisions up by the glabella and then at the lateral rim and taking off the entire floor with the lower face. And so that all had to be reconstructed. And so just making sure that the orbital contents were manipulated in such a way that there was no threat at all to the vision and his seeing eye.
That, and then the other issues were nasolacrimal system. So there was an issue. We had to anastomose both lacrimal sacs, issue of chronic dacryocystitis and the infection risk that that posed, particularly with immunosuppression. And so we got that treated.
Other issues that come up are the anastomosis of the infraorbital nerves, which happens within the orbit. So those were the major issues that we faced with our case. With other face transplant cases where it's soft tissue but involving the eyelids, then you really have to worry about the blink, especially in a monocular patient. So that's the challenge with that approach.
ANDREA TOOLEY: Are you able to animate eyelids to blink? That seems super challenging.
ELIZABETH BRADLEY: We did not have to do that because Andy kept his own upper eyelids. That has not been done with 100% success.
ANDREA TOOLEY: Yeah. That would be a major challenge.
ERICK BOTHUN: Fascinating. I mean, I just-- it's enjoyable to just think through this journey you've been. It's like something coming back from a season away or a trip overseas. Or just-- it's just such a different experience to imagine for a comprehensive ophthalmologist to-- or most of us in regular practice.
Now, as you've gone through that, and you see facial patients needing reconstructive work in your oculoplastics practice, much less of a scale of even the facial transplant journey, how has it changed you as a provider or being involved in this team? How has it changed how you approach complex patients or patients that need team care?
ELIZABETH BRADLEY: I mean, it's a tiny subset of patients who would ever think about for face transplantation. I mean, I'd say-- I have-- first of all, I have just 100% confidence that we can handle anything that we see, that we have internal medicine colleagues, immunologists, neurologists who learn new things and take on new challenges.
And I mean, I think that Andy had-- of all the face transplants I've seen, he's had the most amazing result. And I think it's that dedication. Every single person did their job so incredibly well that it's a tremendous source of pride and also of confidence moving forward for the care that we can provide to these most complex patients.
ANDREA TOOLEY: It shows the power of practice, the power of teamwork, the power of leadership, everybody collaborating together. It really kind of-- every piece came together the way that it should. And the story is remarkable how everything was in line right when you were ready. Then it happened against all odds. It's such an amazing story. Thank you for sharing it with us.
Even if you've heard-- I've heard this story a couple of times, and I still get chills hearing it every time. So thank you so much for sharing it with us. Congratulations on your success. And I hope that everybody listening really enjoyed hearing about it because I sure did.
ELIZABETH BRADLEY: Thank you.
ERICK BOTHUN: I certainly appreciate your commenting over the appreciation that it was a gift to hear about the donor's family, and that it was a honing experience for the team involved. I just-- stories like this help all of us appreciate and be honed in on what a gift it is to be in a care team, to help and put the patient first as we strive to do that here in servicing our patients. And it's a gift to work together on a team. So just thank you for being here and sharing your time with us as a gift. And we hope it was a blessing for our listeners.
ANDREA TOOLEY: Thanks, Dr. Bradley.
ELIZABETH BRADLEY: You're most welcome.
ANDREA TOOLEY: You can find all episodes of the Mayo Clinic Ophthalmology Podcast on our website.
ERICK BOTHUN: Thank you for listening, and we definitely look forward to sharing more.
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