I’m Dr. Brian Gastman and I was one of the lead surgeons who performed a full face transplant for the youngest person in the U.S.—AMA

Amazing science! Do you expect that the swelling will continue to subside over time?

Yes we do. Swelling is controlled due in large part to what's called the lymphatic system in the body. This system controls how fluid shifts within tissues. Katie's lymphatic system in the head and neck are is deranged and it make take years for it to normalize.

Hello Dr. Brian! Excellent work, and congratulations!

My understanding is that with most transplants and skin grafts there's a risk of rejection. Was there anything particularly different about this that made the risk of rejection higher or more difficult?

The main issue with Katie that is somewhat unique is her age. The younger someone is, the stronger their immune system. Katie, in theory, was at great risk for rejection than someone who is older than her, which is more typical for the people who have received face transplants.

Were you there pretty much full 31 hours (with small breaks in between)? Or do you do a stretch of a couple hours, switch, take a break, and come back? What was the planning for it like? I am assuming you had to sleep at some point and eat/go to the bathroom etc!

During the surgery, I only took breaks to get caffeine and go to the bathroom, but that was it.

As for the planning, we had done 2 face transplants before, and we did multiple cadaveric studies related to face transplant research. Once Katie signed her consent, our team met more than once a week for planning, and every other week we did mock transplants with cadavers. Keep in mind, it was 14 months between the time of her consent and the transplant.

Where do you see procedures such as this going in the future e.g. will it get easier, will anything change and how can we expect this to impact the future?

That's an excellent question. There are many aspects related to this that will likely change. Number one.. we will eventually make discoveries in immunosuppression. Part of the issue with a non-live saving transplant, is that we are giving patients tissues that requires people to take life-long medications that have life-threatening side effects. With better therapies that are less toxic, more patients will be potential candidates for these types of therapies. In line with that, we as surgeons might consider smaller types of face transplants. For instance, we may choose to do only do a nose or lips, but currently we are not in that level of scientific advancement. There are other important head and neck structures we do not transplant, for example brain tissue, eyes, spinal tissue, and other structures that may become appropriate after more scientific advancement.

What would you most like to tell us that no one asks about?

To do what we do doesn't just include a great team, strong-willed patient, and excellent patient family support. It also includes a surgeon's family support, In many ways, siblings, spouses, significant others and surgeon's children are the unsung heroes in these events. So the question would be, how do your families prepare and deal with all the work a surgeon's lifestyle entails, let alone a major surgery like a face transplant.

Hey Dr.Gastman, I highly appreciate the time you're taking to do this AMA. I have several questions about the transplant you recently performed.

1. From a psychiatric/psychological perspective how does the facial transplant/new appearance affect the patient? Have those been studied before?

2. Will the transplant change the voice of the patient, considering the shape of the mouth is being altered?

3. What newer developments allowed for this procedure to happen now? To clarify, why didn't the patient undergo this procedure earlier?

4. What determines whether a face transplant succeeds or not? What things do you look for in a prospective donor to find a match?

5. Last question, I promise. Will the patient have full control over her facial expressions? Will her cranial nerves and muscles be intact/regrow, considering the possible atrophy from disuse over a span of 3 years since injury?

6. I lied. How did the anesthesiologists deal with intubation during surgery considering you were dealing with a maxillofacial surgery?

Thank you Dr. Gastman, and the entire team for the great work that you've done!

For question one, yes it has been studied. We have a psychiatrist who specializes in this, but it's not my area of expertise. Much of this is available through a google search.
For question two, there are major changes in the voice mainly due to scar tissue and nerve regeneration in and around the mouth.

For question three, any patient going through a face transplant has to go through an exhaustive physiological, physical, and psychological evaluation. In addition, Katie's trauma required a significant amount of rehabilitation to prepare her for such a significant surgery. On top of that, it took 14 months to get an appropriate donor.

For question four, in Katie's case, we needed a female who is Caucasian, who did not have a major craniofacial deformity. In addition, the donor had to have a certain level of health, and no major infections like HIV or Hepatitis.

For question five, she will get much of her function back but not all of it. We cannot completely predict how much she will.

For question six, there were able to do what's called a fiber optic intubation , which went smoothly.

Hi Dr. Brian! I'm from Manila, Philippines. I just wanna say that I have so much respect and admiration for you and your whole team (doctors, nurses and therapists) in Cleveland Clinic. You guys should seriously be awarded! Anyways, my question is... What was the most difficult thing you and/or your team encountered during the 31-hour surgery?

The most difficult thing, in my opinion, was when we had to figure out how much of the donor face we were going to give to Katie. It wasn't so much the amount of tissue we were using from the donor, it had more to do more with how much of Katie's tissue we would remove to make the donor's tissue fit.
The other issue was, this decision would greatly alter how Katie would look for the rest of her life. It was something we obviously couldn't ask her at the time, and we didn't feel comfortable making the decision ourselves, so we had to turn to her family for help and guidance.

Aside for the amazing transplant, can you share a story or two about another case that you are proud of or that stands out to you?

There are many. I operate and treat patients all over the body, not just in the head and neck area. I'm so proud of so many of my patients, for how they get through some of the most challenging situation most of us will every encounter.
Although it's hard to pinpoint a single case, one that comes to mind is an elderly woman who had lost a large portion of her skull due to infection and it resulted in a phenomenon that lead to her living as if she had a stroke. She could not walk, she could not talk, she could not take care of herself. Through advanced reconstruction techniques, we rebuilt her skull and her scalp tissues. She went from a woman who could not even speak intelligibly, to someone who could drive herself to and from appointments.

Hi Dr Gastman! I'm a medical student in the UK who hopes to become a surgeon in the future.

What was plan B if rejection did happen? I've questioned plastic surgeons who I've been on rotations with, but as none of them have ever been involved in a face transplant, they couldn't exactly answer!

There were contingency plans. First, we removed the tissues we put in Katie originally, slowly. We only removed them completely when we were absolutely sure we were moving forward with the transplant. Secondly, all of the same reconstructive options Katie had immediately after her trauma, were still available if her transplant failed.

Hello Dr. Gastman - does this field have significant research and innovations in particular areas? For instance, is there research focusing on nerve connection, immune response rejection, muscle sculpting, or other particular details in face transplants?

Yes to all of the above. There are groups focusing only on nerve transplant, other groups that focus on craniofacial transplant, others that focus on eye transplant. There is constant research to improve the drugs we give patients to reduce their side effects. Finally, there are many advancements in surgical planning, including virtual and augmented reality, 3D printing, and artificial intelligence.

Hello Dr. Brian,

What fueled your passion to become a surgeon?

When I was in middle school. A famous craniofacial surgeon left the Mayo Clinic and moved into my area in Michigan. He treated, pro bono, a child that was given up by his parents in South America. He performed dozens of surgeries on this child, making him functional and later he adopted the patient. That made me want to become not just a surgeon, not just a plastic surgeon, but someone who deals with advanced reconstructive surgery.

How many vascular anastamoses were created? Is this the longest part of the surgery? Obviously the bony structural reconstruction was immense, but is this essentially considered vascular microsurgery? Lastly, is there a plan to close her trach in the future?

Four were created. It was not the longest part of the surgery, it took about two hours.
It is considered vascular microsurgery.
Her trach is already closed.