Elizabeth A. Bradley, M.D., is an ophthalmologist who specializes in oculoplastic and orbital surgery at Mayo Clinic in Minnesota. Dr. Bradley joins our podcast to share her experience as a surgeon on the team performing the first face transplant at Mayo Clinic.
For more information Mayo Clinic Ophthalmology Podcast
Welcome to the Mayo Clinic Ophthalmology podcast brought to you by Mayo Clinic. I'm your host, Doctor Andrea Tooley and I'm Doctor Eric Botham. We're here to bring you the latest and greatest in ophthalmology medicine and more. In today's episode, we sit down with ocular facial plastic surgeon. Doctor Elizabeth Bradley, a member of the Mayo Clinic, face transplant team. Doctor Bradley takes us through her involvement with the first face transplant at Mayo and everything a face transplant entails from the ophthalmologists perspective. Doctor Elizabeth Bradley is an associate professor of ophthalmology at the Mayo Clinic in Rochester, Minnesota where she serves as program director for Ace Oper sponsored Oculoplastic surgery Fellowship. In addition to her clinical interest in ophthalmic aspects of facial nerve disorders. Doctor 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. Doctor Bradley also works in multidisciplinary teams through Mayo Clinic's facial reanimation clinic and the thyroid eye disease clinic. Welcome, Doctor Bradley. Thank you. Happy to be here. We're excited to have you. I certainly, this is one of these topics that falls just beyond our comfort zone and facial transplants. And I, you know, it seems like a foreign concept potentially to pediatric ophthalmologist like me, maybe a little bit better for you as an oculoplastic oculoplastic surgeon, facial face transplant is out of this world. Unbelievable. So we're super excited to talk about it. 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 or understanding and what might need to be in place for that to happen. 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 IOP plastic surgeon and some of them were very routine, you know, Medicare blepharoplasties where they needed aosis repair. Could you wanna 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. You know, 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. 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 in different things. And eventually this led to facial transplants, share with us a little bit about that journey. You said you were realized, you worked together with, how did that, how, how did that feel? How was that orchestrated on a patient to patient basis? I mean, did you do cases together or was it, you know, 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? So, yes, to all of that. Um So yes. So we started working together really, like I said, on these very prosaic cases, blepharoplasty ptosis. And we said, OK, well, you know, 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 neurop palsies. Our first effort together was to form our uh 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 Doctor 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 Doctor 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. I know early in my practice with some of my colleagues that went into comprehensive ophthalmology practices. Um 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 straus case that they hadn't done in a while and they didn't do those routinely. But the this journey of just being intentional to work together and collaborate and how that can complement practices, whether it's unique compre comprehensive oculoplastic services like you guys provide or even in a, in a private practice setting with your partners to just be more intentional talking through cases and doing them together. There's great reward. 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 um and probably better for patient care with that collaboration. So when take us to the very, very early days of thinking about, OK, we 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 so take us through that the very early days. 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, which is that applies to solid organs and corneas, but it does not apply to face transplant that requires 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 and thousands of details that had to be ironed out. So Samir Marini 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, you know, every month we see patients who have horrible disfiguration from trauma burns, congenital malformation, all types of things and identifying in which patients we had exhausted traditional surgical techniques and they needed something else. Um 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, 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. Right? Well, another thing I was thinking that I learned just by hearing you talk about face transplant is the skin is so highly um immunogenic or the 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, absolutely, lifelong immunosuppression and hardcore. And all these, all these patients, every face transplant patient has gotten some rejection. And so that needs to be yes, closely monitored and treated. Wow, tell us and you talked about how important that selection is both for the donor and the recipient. Can you share more about as, as you prepared for this step? What became the most important criteria that would make an ideal donor and or recipient? Well, so first and foremost, they, they had to have a defect that could not be in other ways managed by conventional surgery. Um and our particular patient, and I'll mention his name, which is in the public record. So this is not h A um protected information. So Andy Sanni was a patient with whom we had a relationship. He had initially presented to Mayo Clinic when he had his first trauma, which uh 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 uh we evaluated Andy, we evaluate 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. Um and was really by all evaluations, felt to be a great candidate for this 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, how do you even do it? Right. So this is really, this is individualized surgery at, at its, you know, highest most challenging aspect because right, in, in Andy's case, we were transplanting really the lower two thirds 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 ac T 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, you know, 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 um 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 anaplastic 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 anoplasty who came and would make molds of the donor face and just an incredible lifelike mask. Wow, it's unbelievable. I mean, you, you are spending your weekends in the anatomy lab doing practice face transplants for a year 40 that is bananas about once a month and the whole team wouldn't have to be there. But different parts of the team and we'd go, we start at eight and end around three or four in the afternoon. It was a great time to get to know the team and we'd all break for lunch. The photographers, our, our photographers and videographers were just an essential part of our team. They were there photographing, videotaping the entire surgery. I remember seeing images of that team and it was you, 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 they were there. Um And so the, the multifaceted um operating filling team members, it was, it was like a, you know, college football team showing up in the operating room throughout that, that journey. So the leadership and communication parts obviously couldn't be underscored and how important they were. Yes, the team definitely grew from, you know, 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. Yeah, to the nth degree. Yeah. And then then finally decided we're ready, we're ready. And so at that point, that's when we listed Andy's case. And then how long did it take before a donor was available? 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. Um 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 that just gives me chills. It's really amazing. You hear stories of the personal impact of, 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 just, it obviously was transformative, but a very uh you know, a lot of heartbeats and fast paces coming together on that actual call. And once you renew 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? Right? So as I recall, I think Samir Mardini got the call um 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 uh organ donation card, but we need to talk to the family. And again, this is all in the public record. There was in the mail video, 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 um 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, 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 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 uh the the donor had been transported across state lines, Rudy. And uh he arrived at Saint Mary's. Andy was all checked in. Samir did his briefing just before midnight on Friday night and then we started the case or a little bit after three 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 eight o'clock just in time to get the room turned over for the next case. Unbelievable. Wow. And what, what was the energy like? What was the, 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 and 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 like this is the another level you can't even imagine a surgical feet like this. It's so cool to hear about. So, so tell us about the day. So, I mean, it 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 I've ever done and that I might ever do. But you're also there with all these people, your team. And so, you know, I'm literally standing there with one of the other surgeons and you felt more than anything. I think we felt ready and uh walked into the operating room with the donor and the organ procurement organization is there uh 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. Um And just what an amazing gift again, from the family, so appreciative of all the strength that they had. Um And uh with that, then the case gets underway. Um And again, we were, we were certainly very ready for every step of the case. Um 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 uh 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, 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 go and you'd get a few hours of sleep and then come back so Samir got certainly the less the least sleep. I'm not sure that he slept for the full 50 hours. Um But we all had breaks and so, yeah, you'd come back and be reengages and ready to go back at it. Wow, so powerful. And the story continued. I know Andy's story has become as you were as part of the public record, but one that we've celebrated share with us kind of postoperatively then as things, you know, 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. So, I mean, first of all, I would say that we think of it, you know, 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. Um you know, there's intubation for days, there's nutrition status, there's so many issues going on. And so, you know, this is these, these patients have to be healthy, going into the surgery for Andy was a young, healthy man. Um So that was the first thing that really struck me and um then we did prepare Andy, of course, he didn't see his face right away. Um And we have an amazing psychiatrist, Sheila Joy 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. Um And his family was there with him and he said it was better than he could have ever dreamt. Um Now, at that point, the face, his face was not animated. And um so mayo, you know, 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 un animated 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 7 February of 2017. I want to back up just a little bit. Tell us about some of the kind of ophthalmic considerations for face transplant because Andy was lower face but still had some some ophthalmic involvement. Um And then just for face transplant in general, what are the things considered from an eye perspective? Yes. So um 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. The probably the most um 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 take on taking off the entire floor with the lower face. And so that all had to be reconstructed. Um 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 in his seeing eye. That and then the other issues were nasal arial system. So, um there was an issue we had to announce most both laal sacks, um issue of chronic dacryocystitis and you know, the infection risk that that posed particularly with immunosuppression. And so we got that treated um other issues that come up are the anastomosis of the infraorbital nerves which happens within the orbit. Um 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, that's the challenge with that approach. Are you able to animate eyelids to blink? We did not have to do that because Andy kept his own upper eyelids that has not been done with 100% success. That would be a major challenge. Fascinating. I mean, I just, this, it's enjoyable to just think through this journey. You've been, it's like something coming back from a, you know, a AAA season away or a trip overseas or just, it's just such a different experience to imagine for a comprehensive ophthalmologist or, or most of us in regular practice. Now, as you've gone through that and you see facial patients needing reconstructive work in your ontop plastics, uh 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? Um I mean, it's, it, it's a tiny subset of patients who you would ever think about for face transplantation. Um 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 um 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 shows the power of practice, the power of teamwork, power of leadership, everybody collaborating together, 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 um I, I hope that everybody listening, really enjoyed hearing about it because I sure did. Thank you. I certainly appreciate your commenting over the appreciation that it was a gift to hear from about the, the the donor's family and that it was a honing experience for the team involved. I just stories like this to 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 and uh servicing our patients and it's a gift to work together on a team. So I 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. Thanks, Doctor Bradley. You're most welcome. You can find all episodes of the mayo clinic ophthalmology podcast on our website. Thank you for listening and we definitely look forward to sharing more.
