Mayo Clinic's First Face Transplant

Abstract

In June 2016, we performed the first face transplant at Mayo Clinic. Mayo Clinic established a reconstructive transplant program as an extension of clinical practice in 2010. A 31-year-old Caucasian male had significant functional limitations and disfigurement despite multiple conventional reconstructive procedures following a self-inflicted gunshot to the face. These limited his social interactions and potential for career advancement. He was referred for transplant 7 years after his injury. He was listed for transplant after 2 1/2 years of evaluation, education, psychosocial assessment and follow-up. The surgical team rehearsed the planned surgery over 50 Saturdays in the cadaver lab. Guides developed by Medical Modeling using 3D CT reconstruction aided bone cuts. He received a blood group compatible, negative flow cross match, no DSA transplant. Donor and recipient were EBV negative. Donor was CMV positive and the recipient negative. The graft consisted of all facial tissues from below the eyelids including maxilla, mandible and teeth. Immunosuppression consisted of anti-thymocyte globulin (ATG) induction and a triple immunosuppressive regimen consisting of tacrolimus, mycophenolate mofetil, and corticosteroids. The patient recovered well from surgery. The aesthetic result was deemed excellent by the patient “better than I expected”. He regained his sense of smell, the ability to chew food (prior to the transplant he had only two molar teeth with significant microstomia. Gradually nerve regeneration progressed with the ability to smile and coapt his lips. Nasal breathing was also possible. One VCA Banff grade two rejection occurred on day 57-post transplant. This was successfully treated with a course of pulse corticosteroids. Seven months after transplant valganciclovir prophylaxis was discontinued due to leucopenia. Asymptomatic primary CMV infection was detected on surveillance. A combination of viral markers and virus specific immune monitoring was used to tailor therapy. A short course of valganciclovir controlled the infection and the patient developed humoral and cellular virus specific monitoring. One year after transplant two-point discrimination was 5 mm. Renal function was preserved and functional recovery continues.