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Restoring Form and Function: Oncologic Reconstruction Oncologic reconstruction is the epitome of a team effort. Plastic surgeons collaborate with a multitude of other specialists, supporting the most appropriate oncologic treatment with cutting-edge reconstructive techniques. The goal is patient outcomes that maximize both form and function. As any surgeon knows, when resecting a tumor, it’s often impossible to avoid nerves, bone and muscle. In some cases, the tumor could not be removed unless surgical oncologists can count on reconstructive surgeons to rebuild what they must destroy. So with plastic surgeons at the table from the start, each procedure is planned and executed to ensure that patients with cancer leave not just free of the disease, but also at their highest possible level of physical functioning. Plastic surgery team members at Johns Hopkins attend regular tumor board and multidisciplinary clinic meetings to discuss cases with their interdepartmental colleagues. For example, when a patient presents with a sarcoma that’s invading the spinal cord, the physicians plan the resection that will best address removal of the tumor and simultaneously devise the reconstruction of the affected bone, muscle, tissue and blood vessels. The reconstructive team regularly collaborates with colleagues in urology, vascular surgery, surgical oncology, orthopaedic oncology, neurology, radiation oncology, gynecology, and physical medicine and rehabilitation, combining the highest level of cancer treatment with the most advanced surgical and microsurgical techniques. This approach treats the disease while preserving, or even enhancing, the patient’s wholeness, says oncological reconstruction director Justin Sacks. The department has made interdepartmental collaboration a centerpiece of its oncologic reconstruction efforts, and some faculty members consider it the essence of their work. “You’re getting the most sophisticated cancer surgery known to man,” Sacks says. Restoring Wholeness Through Reconstructive Surgery ONCOLOGIC RECONSTRUCTION “You’re getting the most sophisticated cancer surgery known to man.” Plastic and Reconstructive Surgery | 5 6 I n a span of just five years, the department has protocols approved and in place for hand, face and penile transplants—an indication of just how quickly its transplant portfolio has grown, and how the entire field has evolved. “Transplant is now accepted as a bona fide tool to restore both form and function in patients with devastating damage and tissue loss,” says Gerald Brandacher, scientific director of the reconstructive transplantation program. Hand Transplant Two patients in particular illustrate the dramatic effect reconstructive transplantation can have. Brendan Marrocco, severely injured in a 2009 roadside bomb attack in Iraq, was the first American soldier to survive losing all four limbs on the battlefield. In 2012, department surgeons led one of the nation’s most extensive and complicated bilateral arm transplants to give Marrocco two new arms. Today, he drives a truck, performs all activities of daily living and is preparing to move into his own home. “That represents independence, freedom and quality of life,” says Jaimie Shores, clinical director of the arm/hand transplant program. “He’s given us great hope for what people are capable of accomplishing after these transplants.” Marrocco’s progress laid the foundation for the department to complete another above-elbow transplant in June 2015.four limbs on the battlefield. In 2012, department surgeons led one of the nation’s most extensive and complicated bilateral arm transplants to give Marrocco two new arms. Today, he drives a truck, performs all activities of daily living and is preparing to move into his own home. “That represents independence, freedom and quality of life,” says Jaimie Shores, clinical director of the arm/hand transplant program. “He’s given us great hope for what people are capable of accomplishing after these transplants.” Marrocco’s progress laid the foundation for the department to complete another above-elbow transplant in June 2015. The patient was a man who’d fallen from a hotel balcony; during the fall, his arm tore off near the shoulder. The team expects substantial return of elbow strength and motion and meaningful return of hand function, Shores says. Along with the painstaking skills and techniques required to prepare tissue, bone, muscle, blood vessels and nerves to support a transplant, what has allowed the program to move forward so dramatically is the minimal immunosuppression protocol its faculty members have been developing over the last two decades. Shifting between Brandacher’s lab and the clinic for innovations and adjustments, the protocol uses donor bone marrow to shrink the typical three-medication immunosuppressive protocol down to just one drug. Ongoing preclinical large animal models suggest it may be possible to remove the remaining medication after one month of treatment, eliminating the need for a lifelong regimen altogether. “We’ve been pioneers in the field in regard to decreasing the burden of immunosuppression in patients getting transplants. We’re making excellent progress with the protocol,” Shores says. Besides representing a significant leap for the field, the protocol also has the potential to increase the pool of candidates for hand transplantation. And there is no reason, once fully proven, that it can’t translate to solid organ transplant, opening up brand-new possibilities for kidney, heart and liver patients. Exploring the Vanguard of Transplantation: Hand, Face and Urogenital RECONSTRUCTIVE TRANSPLANT “Transplant is now accepted as a bona fide tool to restore both form and function in patients with devastating damage.” 6 | Plastic and Reconstructive Surgery Face Transplant Since the world’s first face transplant in 2005, only nine have been completed in the U.S. and 35 worldwide. Given the complexity of the procedure, facial transplantation has been limited to patients with severe facial deformities. Following the success of the arm/hand transplant program, a multidisciplinary team at Johns Hopkins, including plastic and reconstructive surgeons, ENT surgeons, oculoplastic surgeons, and critical care and anesthesiologists, has been preparing for face transplants. “A critical aspect of our facial transplant program is the collaborative effort of these different specialties coming together, providing their expertise, and forming the very best that Johns Hopkins Medicine offers for our potential recipients,” says Amir Dorafshar, clinical co-director of the Face Transplant Program. The multidisciplinary team has identified a potential recipient and recently trained surgeons from various backgrounds to work cohesively in a synchronized fashion to perform one of the largest transplants to date, Dorafshar says. Working in close collaboration with the Johns Hopkins Applied Physics Laboratory and Walter Reed National Military Medical Center, the team will use the latest technology—customized cutting templates with threedimensional tracking, along with real-time cephalometry—to guide surgeons as they cut and attach face-jaw-teeth segments to ensure optimal positioning and functionality of the transplant, says Chad Gordon, clinical co-director of the Face Transplant Program and Multidisciplinary Adult Cranioplasty Center. This patent-pending technology is designed to minimize the follow-up revision surgeries common in the past, when surgeons had no way of knowing which microscopic bone cuts, measurements and angles would maximize functionality until the surgery was complete. “It’s like GPS for face transplant,” Gordon says. “If you get into a traffic jam based on unexpected findings and need a detour to get someplace better, quicker and safer, you simply hit adjust. That’s what we have now. You just click to see if you’re doing the right job, or if you need to adjust the plan on the fly.” The team is looking forward to putting its preparation into action. “Our teams are trained and ready,” Dorafshar says. “We have put into place the necessary infrastructure and team-oriented framework for many other face transplants to come. Using the unique immune modulation protocol with minimal immunosuppression, the team is ready to broaden the pool of candidates who could benefit not only from face transplant, but also eyelid, nose or lip transplants.” “It’s like GPS for face transplant.” Volume 136, Number 2 • Hybrid Occlusion and Cephalometry experiment, which did not show any deviations greater than 3 mm or 2 degrees from target measurements (Table 5). The plastic model experiment represents an idealized procedure with highly accurate patient-to-model registration error (0.727 mm and 0.306 mm for the plastic skull model
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