press kit - CHU Amiens

PRESS KIT
December 2009, 9th
Press contacts :
University Hospital of Amiens
Cathy Josse
03 22 66 87 83
[email protected]
University Hospital of Lyon
Céline Chaux-Bardyn
04 72 40 70 88
[email protected]
Facial allograft (lips – chin - mandible)
As the haunting memory of WWI’s broken faces remains, we are confronted with
contemporary disfigurements, following a domestic accident or a traumatism, like a
burn or a gun shot. Unfortunately, the immense technical progress in reconstructive
microsurgery has not yet permitted, in spite of more or less elaborated
autotransplants, to give these patients back a humanly visage.
The huge step taken with the first facial allograft conducted on November 27th 2005
at the University Hospital of Amiens by Professors DEVAUCHELLE and
TESTELIN, DUBERNARD (University Hospital of Lyon), has opened the way to
new techniques in reconstructive facial surgery. Since then, 9 other facial grafts
have been performed in France and in the rest of the world, including the most
recent one, performed on November 2009, 27th at the University Hospital of
Amiens, exactly four years after the first world allograft.
The patient
He is a 26-year-old man, severely disfigured by a firework explosion in May 2008.
This explosion caused very severe orbital and upper face fractures, firstly operated
by Dr P. JAMMET and YACHOUH at the University Hospital of Montpellier
(south of France). The explosion also caused a substantial loss of tissue, since all of
the lower part of the face, including lips, chin, mandible and maxillar bone were
destroyed. Since the accident, the patient was not able to speak, to eat or to
participate in any kind of social life. He always wore a mask and be was fed at
night with a tube.
Considering these facts and the very good result of the first facial allograft
performed in the Amiens Hospital, in collaboration with the Lyon Hospital team, it
became obvious that the best solution for the reconstruction of his face was to offer
him a facial transplant of lips, chin and mandible.
This man, very motivated and determined, was completely informed of this
solution, the treatment, the follow up, the immunosuppressive treatment. He totally
understood the risks of the surgery and immunosuppressive treatment required by
the transplant. He accepted to be treated and followed up by both teams in Amiens
and Lyon, on the medical and the psychological point of view.
Surgical procedure
Dossier de presse
Harvesting of the transplant
Under general anaesthesia, stem cells were firstly taken from the hips of the donor
by the haematologists of the Lyon team, in order to be prepared for possible future
infusions of stem cells.
The transplant was surgically dissected in order to harvest the exact among of skin
from the lips, chin, neck, mandible the attached muscles, salivary glands, vessels
and nerves, the latter in order to restore sensibility and motricity. In particular, the
facial vessels, orbital and mandible, and the sensitive nerve branches and facial
nerve branches were dissected.
To respect the face of the donor, the restoration of his face was realised by
maxillofacial prosthetic technicians, thanks to the initial print of the face taken prior
to harvesting. Shape, colour and texture of the tissues were respected thanks to the
use of coloured and sophisticated silicones. These first harvesting steps did not
jeopardize in any way the harvesting for other transplantations of several vital
organs in this multi-organ donor.
Surgery of the recipient
The treatment was performed under general anaesthesia on Friday November 27th,
during 19 consecutive hours. In a first stage, the surgery consisted in preparing the
edge of the defect, completing the dissection of the different layers constituted by
muscle, facial nerves, and bone fragments of the mandible with the sensitive nerves
branches isolation of the vessels and all that before the arrival of the transplant.
At that time, firstly we performed the bone synthesis just before the vascular
anastomasis on the facial vessels under microscope on the left than right side. After
two hours of ischemia the facial transplant was well revascularized. After the final
bone fixation, muscles, nerves were carefully sutured with the corresponding
anatomical element on the patient. Finally the mucosal plan was sutured in the way
to restore the intra-oral watertightness. At the end, the skin was closed from the
neck to the nose to obtain the best aesthetic result.
All that surgery was made by maxillofacial team of Amiens with the help of Pr
LENGELE of Brussels and YACHOUH from Montpellier.
Post operative period
Immunosuppression and follow up
The immunosuppressive regimen associated first by an induction by
Thymoglobuline*, Tacrolimus*, Mycophenolate mofetil* and Prednisone*.
That is a strong immunosuppressive treatment because of the immunogenecity of
composite tissue allograft. An infusion of stems cells has completed this treatment.
Association of stem cells to prevent the rejection
More than the surgical challenge, the most difficult thing for allograft of organ or
composite tissue is to prevent the transplant from the rejection episode. Those could
be occurred at anytime after surgery and long life time.
The purpose is to induce a tolerance phenomenon in which the transplant could be
accepted by the recipient immunologic system.
That way it will be possible to inject some cells of the donor (cells stems) to the
patient, even if the H.L.A. system are not the same. The cohabitation of those two
different population of cells is named Chimerism.
This medullar chimerism could be induced by infusion of stems cells of the donor
harvested before the facial transplant.
Protocol
Stems cells of the donor had been infused to the patient at Day 4 as it was done for
the first facial grafted patient. As that time a transitory chimerism occurred at Day
60. This cohabitation even for a short time could be allowed a better tolerance of
the transplant.
For that second case, teams agreed in a stronger protocol to induce the better
chimerism.
Those infusions are obviously associated with strong immunosuppression regimen
for 10 days.
The patient is treated and followed in the University Hospital in Lyon until a good
balance of the medical treatment with less risk of acute rejection episode.
Physiotherapy
The patient had benefit preoperatively of an evaluation of motricity and sensibility
of the face but also intensive physiotherapy to prevent muscular atrophy and scar
retraction.
The protocol will be continued in the same way after the graft according the
evolution in the way to recover functions of mastication, phonation and aesthetic as
soon as possible.
RMM evaluation
In few months objective evaluation of the functions will be done by MRI compared
to the preoperative one according to protocol established by Pr Angela SIRIGU
(Institute of cognitive sciences CNRS Lyon).
Psychological follow up
Despite the very important traumatism of this facial disfigurement, the patient had
been very courageous and serene.
Dossier de presse
He also waited very patiently for transplant. He always would like to maintain his
social life event if it was very difficult because of this mask and the behaviour of
other people.
Since now10 days, his acceptation of his new face is obvious.
The team
The team which realised this transplantation of lips, chin and mandible gathered
around 50 people with surgeons, anaesthesiologists, nurses and prosthetic
technician, all under the responsibility of Professor DEVAUCHELLE head chief of
the department of maxillofacial surgery in Amiens.
During the post operative period, the patient was transferred to the department of
transplantology in Lyon (head chief Professor Xavier MARTIN and Jean Michel
DUBERNARD) for the immunosuppressive treatment and follow up in
collaboration with Professor MICHALLET (heamatologist) and her team, as well
as all the other specialists involved : psychiatrists, phoniatrists, haematologists and
researchers….
AMIENS
Bernard DEVAUCHELLE
Coordination
Ghassan BITAR, surgeon
Pierrick BOUTE, surgeon
Sophie CARTON , surgeon
Kamel CHEBOUBI, anaesthesiologist
Sophie CREMADES, psychistrist
Stéphanie DAKPE, surgeon
Corentin DENGLEHEM, surgeon
Evgeny DIMOV, anaesthesiologist
Olivier DUNAUD, surgeon
Benjamin GUICHARD, surgeon
Sebastien LAVAQUERIE, surgeon
Audrey LEMAIRE, surgeon
Anthony MARTON , prosthetic
technician
Cecilia NEIVA, surgeon
Johann ORYE, surgeon
Farid TAHA, surgeon
Sylvie TESTELIN, surgeon
Jean TCHAOUSSOFF, coordination
anaesthesiologist – intensive care
Elie ZOGHEIB, anaesthesiologist
UCL BRUXELLES
Benoit LENGELE, surgeon
CHU MONTPELLIER
Jacques YACHOUH, surgeon
LYON
JM DUBERNARD
Coordination
Lionel BADET, transplantology
Jean –Luc BEZIAT, maxillo-facial surgeon
Maria BRUNET, transplantology
Assia EL JAAFARI, immunology
Olivier HEQUET, cellular therapy
Jean KANITAKIS, dermatology
Pascale LABUSSIERE ,hematologist
Xavier MARTIN, transplantology
Mauricette MICHALLET, hematologist
Emmanuel MORELON, transplantology
Emmanuelle NICOLAS, hematologist
Olivier DUBOSC de PESQUIDOUX,
coordination
Palmina PETRUZZO, transplantology
Christophe SEULIN , psychiatrist
Angela SIRIGU, neuroscience
Medical, ethical and psychological aspects
As in the case of the first facial graft, (nose-lips-chin) in 2005, the Agency of
Biomedecine requested that all medical, ethical and psychological expertise be
properly conducted, in a way that all respects are paid to the donor family and to
the patient.
Dossier de presse
The facial allograft (lips-chin-mandible) is possible after several expertises.
The Amiens and Lyon teams submitted a specific request to the Agency of
Biomedicine, concerning the facial composite graft for a 26-year-old patient, whose
face was severely wounded by an explosion. More than an important esthetical
prejudice, this lesion led to a complete oral incompetence, without any possibility
to eat or speak.
Like organ transplants, composite grafts are under the responsibility of the Agency
of Biomedecine, which manages this type of harvesting and distribution of graft.
This facial transplant was requested through the national protocol of research
(P.H.R.C.) attributed to the Amiens team in 2006 and confirmed by the AFSSAPS.
The Agency of Biomedecine verified that the harvestement of the facial
transplant did not impair the multi organharvestement.
The surgical teams were very cautious to prepare a protocol which included the
possibility to harvest all other organs. In fact, great care was taken not to lose any
organ, which is very precious. Nowadays, even if there is a real improvement of
organ donation in France, donors are scarce. All medical teams are always
concerned with this request of organ.
The Agency of Biomedecine controlled that satisfying means were available to
reconstitute the donor’s face.
The Agency of Biomedecine paid special attention to the fact that the donor’s face
reconstruction was faithful to its state before the harvesting. The expertise of the
maxillo facial department, in terms of prothesists, allowed the best solution for this
restoration in terms of shape, volume, colour, thanks to a first print of the face,
taken prior to surgery.
The donor’s body was fully respected.
The Agency of Biomedecine controlled that there will be a psychological follow
up of the patient and the relatives of the donor.
All things were managed in the way that the patient could be clearly .and totally
informed of the surgical procedure, the risks and constraints associated to the long
life immunosuppressive treatment.
The patient agreed and signed the information-and-consent form for this protocol.
Following a similar purpose, the Agency controlled that there will be a
psychological follow up of the relatives of the donor, if needed.
Dossier de presse
The donor’s family could be informed and followed by a coordinating doctor and
nurses.
All the medical teams have carefully explained the situation to the family. All
procedures depend on the expertise and competency of the hospital coordination.
The teams are specifically prepared and trained to help the family in this difficult
decision.
Annex
(Dr Taha Amiens)
Figure 1 :
Figure 2 :
Figure 3 :