Psychiatric evaluation of the face transplant candidate.

PURPOSE OF REVIEW: There have now been a total of 32 face transplants done in the world since the first in Amien, France, in 2005. This procedure is moving from being considered experimental to being considered an accepted option for reconstruction in cases of severe facial disfigurement. RECENT FINDINGS: There have been three published reports of prospective quantitative assessments of facial transplant candidates related to psychological outcomes with face transplant recipients. Various instruments have been used in assessment, including the Beck Depression Inventory, Patient Health Questionnaire-9 (PHQ-9), and Center for Epidemiologic Studies Depression Scale for rating depressive symptoms. Quality-of-life instruments used have included the Short Form-12, the Short Form-36, the Euro-QOL-5D (EQ-5D), the WHO Quality of Life rating scale (WHO-BREF), and the Psychosocial Adjustment to Illness Scale-Self-Report. SUMMARY: There have been three deaths in the first 32 cases of facial transplantation (9.4%), two cases of post-transplant lymphoproliferative disorder in the first 20 face transplant recipients (10%). This rate of post-transplant lymphoproliferative disorder is about 10 times the rate seen in solid-organ transplant recipients. Collaborative assessment protocols are needed to determine whether the improvement in quality of life with facial transplantation is justified in the face of the risk of lifelong immunosuppression.

Ethics of facial transplantation revisited.

PURPOSE OF REVIEW: There have been 26 cases of facial transplantation reported, and three deaths, 11.5%. Mortality raises the issue of risk versus benefit for face transplantation, a procedure intended to improve quality of life, rather than saving life. Thus, one of the most innovative surgical procedures has opened the debate on the ethical, legal, and philosophical aspects of face transplantation. RECENT FINDINGS: Morbidity in face transplant recipients includes infections and metabolic consequences. No graft loss caused by technical failure, hyperacute, or chronic graft rejection or graft-versus-host disease has been reported. One case of posttransplant lymphoproliferative disorder, 3.45% and one case of lymphoma in an HIV-positive recipient were reported. Psychological issues in candidates can include chronic pain, mood disorders, preexisting psychotic disorders, post-traumatic stress disorder (PTSD), and substance abuse. SUMMARY: Early publications on ethical aspects of face transplantation focused mainly on informed consent. Many other ethical issues have been identified, including lack of coercion, donor family consent and confidentiality, respect for the integrity of the donor's body, and financial promotion of the recipient and transplant team, as well as the cost to society for such a highly technical procedure, requiring lifelong immunosuppression.

Face transplantation: psychological outcomes at three-year follow-up.

BACKGROUND: The advent of face transplantation has raised both ethical and psychological issues. Mortality of 18 existing face transplant recipients is 11.1% (2/18) through 2011. OBJECTIVE: Psychological outcomes are as important in face transplantation as is restoring the face physically. Little quantitative information has been published this area. METHODS: Data was systematically collected over 3 years with a face transplant recipient, including appearance self-rating, body image, mood changes, pain rating, perception of teasing, quality of life, self-esteem, and social reintegration. We identified a significant gap in rating instruments for use in the field, so we developed the Perception of Teasing-FACES, Facial Anxiety Scale-State, and the Cleveland Clinic FACES score, analogous to the model for end-stage liver disease (MELD) score for prioritizing patients for a face transplant registry. RESULTS: Appearance self-rating rose from 3/10 prior to transplantation to 7/10 now. Anxiety about body image and the Facial Anxiety score were halved by the end of the third year. Beck Depression Inventory fell from 16 (prior to transplant) to 8. Chronic daily pain was 6-7/10 prior to transplant and 0/10 by day 50. Perception of Teasing-FACES scores fell from 25 to 9 by the end of year 3. Quality of life improved on the Social Environment Domain of the psychological adjustment to illness scale-self-rated (PAIS-SR), where the score dropped from 15 to 1 by the end of year 3, indicating marked improvement in social reintegration. CONCLUSIONS: Standardized data collection may help quantify psychological outcomes with facial transplantation to determine whether the risks of immunosuppression over time are offset by improved quality of life for recipients.

Renal autotransplantation and modified pyelovesicostomy for intractable metabolic stone disease.

PURPOSE: Some patients with intractable metabolic stone disease experience narcotic dependence, which cannot be managed with standard treatments. We offered these patients renal autotransplantation with a modified pyelovesicostomy as an alternative solution. MATERIALS AND METHODS: Renal autotransplantation with pyelovesicostomy was performed for 15 kidneys in 12 patients (3 bilateral, 2 solitary), 9 female and 3 male, with a mean age of 33.8 years (range 16 to 55). The etiology of metabolic stone disease was calcium oxalate (40%), cystinuria (33%), type 1 renal tubular acidosis (14%), calcium oxalate/urate (7%) and medullary sponge kidney (7%). Patients reported that lifetime stone events ranged from 10 to more than 70, that underwent an average of 3 to 4 surgical interventions per year in the previous 2 years and that they were dependent on daily oral narcotics for stone related pain. RESULTS: All 15 kidneys were successfully autotransplanted with a mean followup of 41.8 months (range 3 to 74). We used a modified pyelovesicostomy with ureteral strip in 13 and standard Boari tube in 2 cases. All patients continued to pass small stone debris per urethra with minimal symptoms. Of 12 patients 11 (92%) were weaned off daily narcotics. There have been 17 stone episodes in 4 patients (3 cystinuria) for which medical intervention and pain medication was required. The number of urological procedures/patients before (155/12 [12.9]) and after (8/12 [0.66]) autotransplantation was dramatically reduced (paired t test p = 0.0001). The preoperative mean estimated glomerular filtration rate was 77.2 cc/minute, and 73.5, 71.9, 79.2 cc/minute at 12, 36 and 60 months, respectively. CONCLUSIONS: Renal autotransplantation and pyelovesicostomy offer patients with intractable metabolic stone disease the opportunity to improve quality of life and to decrease daily narcotic use.

Ethical considerations in the first American face transplant.

BACKGROUND: Before performing the first face transplant in the United States, the authors addressed several ethical considerations: subject selection, adequacy of informed consent, and risk-to-benefit analysis. METHODS: Destruction of the patient's midface, including its bony architecture, had impaired the ability of the authors' patient to speak, eat, smell, and socialize. These functional impairments and the inability of conventional reconstruction to reconstruct this deformity justified considering this patient for face transplantation. The patient's resilience in adapting to her injury, her conscientious self-care following her initial injury, and her ability to understand the risks and uncertainties of the proposed procedure were important factors in selecting her as a candidate for this innovation. To enhance our patient's understanding of this largely untried procedure, the informed consent process occurred over multiple encounters involving both information disclosure and assessment of comprehension of what the procedure involved, including its potential benefits and risks. The patient demonstrated not only understanding of the procedure, including its innovative nature and concomitant uncertainties, but also that its goals were consistent with her values. RESULTS: Research risk-to-benefit analysis involved balancing societal and subject benefits against subject risks. The potential benefit to society and increased knowledge of the role of face transplantation in facial reconstruction were substantial. The subject's benefits had been maximized and harms minimized through subject selection, team expertise, and preparation. This produced a risk-to-benefit profile in which we considered that the benefits sufficiently outweighed the risks to proceed with transplantation in this patient. CONCLUSION: Ethical considerations were important determinants in the decision to proceed with facial transplantation in this woman.

Psychological outcomes with face transplantation: overview and case report.

PURPOSE OF REVIEW: The purpose of this review is to provide guidance in a burgeoning new field of facial composite tissue transplantation. This review will contrast face transplant with solid organ transplantation, provide information to guide selection of face transplant candidates, and share information on psychological outcomes. RECENT FINDINGS: Previously published face transplant reports have not investigated body image, mood changes, perception of teasing, quality of life, self-esteem, or social reintegration quantitatively. Face transplantation appears to decrease depression and verbal abuse, and improve quality of life and social reintegration, though may not alter anxiety or self-esteem. The Psychosocial Adjustment for Illness Scale-Self-Report scale may have advantages over the SF-36 and World Health Organization Quality of Life (WHOQOL)-BREF rating scales for measuring psychological distress and social reintegration. SUMMARY: Face transplantation is currently a technique of last resort after traditional reconstructive techniques have failed, not for cosmesis alone. Mortality among eight existing face transplant patients is 25%, two of eight. Some consider blindness as an absolute contraindication; however, those who are legally blind but retain some vision may be appropriate candidates. Physical goals of transplantation include regaining movement of underlying structures and restoring the appearance of a normal face. However, psychological outcomes and quality of life are also important to the success of face transplantation and ultimately will determine the value of the procedure.

The Cleveland Clinic FACES Score: a preliminary assessment tool for identifying the optimal face transplant candidate.

In lieu of limited resources, our multidisciplinary face transplant team requires a preliminary, supplemental objective grading scheme for identifying the optimal face transplant candidate. Therefore, our objective was to develop an effective method for evaluating "facial deficit," which could also be used in the future for the allocation of limited facial organs, analogous to liver transplantation.Each candidate is screened using our institutional review board-approved protocol's current inclusion/exclusion criteria. Five categories were conceptualized to be of significance in evaluating patients in pursuit of facial allotransplantation as per our recent experience, as determined by the face transplant team. All patients with unfavorable characteristics such as evidence of poor medical compliance, an unsatisfactory psychosocial evaluation by our team's transplant psychiatrist, and/or end-stage organ disease suggestive of significant comorbidity were excluded.This study resulted in a reproducible scoring system allowing our team the unprecedented ability to stratify facial deficit in a standardized fashion. The FACES scores ranged from 10 (minimum) to 60 (maximum). Besides being used as a supplemental prescreening and/or postscreening tool, the FACES score has also provided an unprecedented framework for establishing a face transplant candidate registry within our institution, with the optimal recipients receiving the highest of scores.This FACES score objectively stratifies face transplant candidates for their facial deficit during multiple steps throughout the screening process and affords our institution the means of creating a registry. If substantiated, this supplemental score may ultimately predict successful outcomes, determine optimal utility, and provide insight toward prognosis with respect to facial composite tissue allotransplantation.

The world's experience with facial transplantation: what have we learned thus far?

The objective of this review article is to summarize the published details and media citations for all seven face transplants performed to date to point out deficiencies in those reports so as to provide the basis for examining where the field of face transplantation stands, and to act as a stimulus to enhance the quality of future reports and functional outcomes. Overall long-term function of facial alloflaps has been reported satisfactorily in all seven cases. Sensory recovery ranges between 3 and 6 months, and acceptable motor recovery ranges between 9 and 12 months. The risks and benefits of facial composite tissue allotransplantation, which involves mandatory lifelong immunosuppression analogous to kidney transplants, should be deliberated by each institution's multidisciplinary face transplant team. Face transplantation has been shown thus far to be a viable option in some patients suffering severe facial deficits which are not amenable to modern-day reconstructive technique.

Near-total human face transplantation for a severely disfigured patient in the USA.

BACKGROUND: Multiple reconstructive procedures are common for the reconstruction of complex facial deformities of skin, soft tissues, bony structures, and functional subunits, such as the nose, lips, and eyelids. However, the results have been unsatisfactory. An innovative approach entailing a single surgical procedure of face allograft transplantation is a viable alternative and gives improved results. METHODS: On Dec 9, 2008, a 45-year-old woman with a history of severe midface trauma underwent near-total face transplantation in which 80% of her face was replaced with a tailored composite tissue allograft. We addressed issues of immunosuppressive therapy, psychological and ethical outcomes, and re-integration of the patient into society. FINDINGS: After the operation, the patient did well physically and psychologically, and tolerated immunosuppression without any major complication. Routine biopsy on day 47 after transplantation showed rejection of graft mucosa; however, a single bolus of corticosteroids reversed rejection. During the first 3 weeks after transplantation, the patient accepted her new face; 6 months after surgery, the functional outcome has been excellent. In contrast to her status before transplantation, the patient can now breathe through her nose, smell, taste, speak intelligibly, eat solid foods, and drink from a cup. INTERPRETATION: We show the feasibility of reconstruction of severely disfigured patients in a single surgical procedure using composite face allotransplantation. Therefore, this should be taken in consideration as an early option for severely disfigured patients. FUNDING: None.

Loin pain hematuria syndrome: a psychiatric and surgical conundrum.

PURPOSE OF REVIEW: The loin pain hematuria syndrome presents a dilemma with regards to the etiology, as well as the treatment of this rarely seen entity. In view of the increasing frequency of diagnosis, and the question of whether this disorder constitutes a somatoform disorder or a physical disorder remedied through renal autotransplantation we should familiarize ourselves with this condition, so as to clarify its nature. RECENT FINDINGS: There may be a subset of loin pain hematuria syndrome patients that have a somatoform disorder. Patients appear to have better outcomes with autotransplantation, than with intraureteric capsaicin treatment or renal denervation. SUMMARY: This paper attempts to provide an overview of the topic and propose further investigation to better determine whether a subset of these patients have a somatoform disorder.

The debate about marijuana usage in transplant candidates: recent medical evidence on marijuana health effects.

PURPOSE OF REVIEW: Cannabis is currently the most widely used illicit substance in the world. The issue of how to handle transplant candidates with active use of cannabis is a commonly encountered one for transplant-selection committees. RECENT FINDINGS: Correlates of marijuana use include increased risk of use of other illicit substances, increased risk of affective disorders and psychosis, as well as impaired cognition and motor skills. Risk of fungal infections and possible effects on cellular immunity that may increase cancer risk have also been reported. Reliability of laboratory testing for cannabis is discussed. False-negatives may occur with stealth peroxidases and false-positives with efavirenz (Sustiva). Photometric immunoassay (EMITS) has a 3% false-positive rate. Using a cutoff point of 20 ng/ml with confirmation via GC/MS will give a 'virtually 100% reliable accuracy' in detecting cannabis abuse. SUMMARY: Guidelines on management of the problem should be based on objective medical evidence on the health effects of marijuana, as well as on the implications in the transplant setting where medical urgency can drive medical decision-making. A recent survey of 16 academic transplant centers showed little consensus on guidelines for length of abstinence prior to listing candidates for transplantation.

Psychiatric issues in pulmonary disease.

This article has attempted to provide an overview of the clinical literature regarding the psychological issues facing patients with pulmonary disease, depending on when the illness begins in the life span, because different developmental tasks are disrupted. Patients must contend with side effects of medication that may mimic or exacerbate psychiatric disorders. The main drug interactions for psychiatrists to be aware of in this patient population occur between rifampin, or theophylline and psychotropic medications. In lung transplant recipients on cyclosporine therapy, the antidepressant drug nefazadone may cause increased cyclosporine levels. Psychiatrists must be aware of the risks, benefits, and survival statistics; educate patients; and ascertain whether the patient is competent to make medical decisions regarding treatment procedures.