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Perry BJ, Eshghi M, Stipancic KL, Richburg B, Ventresca H, Pomahac B, Green JR. Longitudinal Recovery of Speech Motor Function Following Facial Transplantation: A Prospective Observational Study. Laryngoscope 2022; 132:2359-2367. [PMID: 35218215 PMCID: PMC9402794 DOI: 10.1002/lary.30068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 01/10/2022] [Accepted: 02/11/2022] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Although facial transplantation is considered effective for restoring facial appearance, research on speech outcomes following surgery is limited. More research is critically needed to inform patients of expected rates and extent of recovery, and to develop interventions aimed at improving speech outcomes. METHODS Four patients in early recovery (3 weeks-24 months postsurgery) and three patients in late recovery (36-60 months postsurgery) were included. Clinical measures of speech recovery, including speech intelligibility measured using the Sentence Intelligibility Test, a lip strength testing device (Iowa Oral Performance Instrument), and kinematic measures of lip and jaw function measured using high-resolution 3D optical motion capture were used to describe the rate and extent of functional speech and lip recovery, describe and compare the rate of functional speech recovery and kinematic lip and jaw changes in early and late stages of recovery, and explore the association between kinematic measures and functional speech. RESULTS Speech intelligibility, speaking rate, and lip strength were below normative values in the first 2 years of postsurgery. Participants in the first 2 years of recovery demonstrated steeper slopes of improvement in clinical and kinematic measures than participants in the later stages of recovery (36-64 months). Gains in jaw range of movement and gains in lip speed and range of movement were significantly correlated with rates of sentence intelligibility improvement. Gains in lip strength were not associated with functional speech improvement. CONCLUSIONS These findings motivate ongoing work aimed at developing interventions for improving motor speech function in this population. LEVEL OF EVIDENCE 3 Laryngoscope, 132:2359-2367, 2022.
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Affiliation(s)
- Bridget J. Perry
- MGH Institute of Health ProfessionsDepartment of Communication Sciences and DisordersBostonMassachusettsU.S.A.,Brigham and Women's HospitalDepartment of Plastic and Reconstructive Surgery, BostonBostonMassachusettsU.S.A.
| | - Marziye Eshghi
- MGH Institute of Health ProfessionsDepartment of Communication Sciences and DisordersBostonMassachusettsU.S.A.,Massachusetts General HospitalAthinoula A. Martinos Center for Biomedical Imaging, MGHBostonMassachusettsU.S.A.
| | - Kaila L. Stipancic
- MGH Institute of Health ProfessionsDepartment of Communication Sciences and DisordersBostonMassachusettsU.S.A.,University at BuffaloDepartment of Communication Sciences and DisordersBuffaloNew YorkU.S.A.
| | - Brian Richburg
- MGH Institute of Health ProfessionsDepartment of Communication Sciences and DisordersBostonMassachusettsU.S.A.
| | - Hayden Ventresca
- MGH Institute of Health ProfessionsDepartment of Communication Sciences and DisordersBostonMassachusettsU.S.A.
| | - Bohdan Pomahac
- Brigham and Women's HospitalDepartment of Plastic and Reconstructive Surgery, BostonBostonMassachusettsU.S.A.
| | - Jordan R. Green
- MGH Institute of Health ProfessionsDepartment of Communication Sciences and DisordersBostonMassachusettsU.S.A.
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Skeletal and Dental Outcomes after Facial Allotransplantation: The Cleveland Clinic Experience and Systematic Review of the Literature. Plast Reconstr Surg 2022; 149:945-962. [DOI: 10.1097/prs.0000000000008949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Eshghi M, Perry BJ, Richburg B, Ventresca HM, Pomahac B, Green JR. Neuromotor Speech Recovery Across Different Behavioral Speech Modifications in Individuals Following Facial Transplantation. Front Neurol 2021; 11:593153. [PMID: 33488496 PMCID: PMC7815523 DOI: 10.3389/fneur.2020.593153] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Accepted: 12/04/2020] [Indexed: 11/13/2022] Open
Abstract
Despite signs of facial nerve recovery within a few months following face transplantation, speech deficits persist for years. Behavioral speech modifications (e.g., slower-than-normal speaking rate and increased loudness) have shown promising potential to enhance speech intelligibility in populations with dysarthric speech. However, such evidence-based practice approach is lacking in clinical management of speech in individuals with facial transplantation. Because facial transplantation involves complex craniofacial reconstruction and facial nerve coaptation, it is unknown to what extent individuals with face transplant are capable of adapting their motor system to task-specific articulatory demands. The purpose of this study was to identify the underlying articulatory mechanisms employed by individuals with face transplantation in response to speech modification cues at early and late stages of neuromotor recovery. In addition, we aimed to identify speech modifications that conferred improved speech clarity. Participants were seven individuals who underwent full or partial facial vascularized composite allografts that included lips and muscles of facial animation and were in early (~2 months) or late (~42 months) stages of recovery. Participants produced repetitions of the sentence “Buy Bobby a puppy” in normal, fast, loud, and slow speech modifications. Articulatory movement traces were recorded using a 3D optical motion capture system. Kinematic measures of average speed (mm/s) and range of movement (mm3) were extracted from the lower lip (± jaw) marker. Two speech language pathologists rated speech clarity for each speaker using a visual analog scale (VAS) approach. Results demonstrated that facial motor capacity increased from early to late stages of recovery. While individuals in the early group exhibited restricted capabilities to adjust their motor system based on the articulatory demands of each speech modification, individuals in the late group demonstrated faster speed and larger-than-normal range of movement for loud speech, and slower speed and larger-than-normal range of movement for slow speech. In addition, subjects in both groups showed overreliance on jaw rather than lip articulatory function across all speech modifications, perhaps as a compensatory strategy to optimize articulatory stability and maximize speech function. Finally, improved speech clarity was associated with loud speech in both stages of recovery.
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Affiliation(s)
- Marziye Eshghi
- Speech and Feeding Disorders Lab, MGH Institute of Health Profession, Boston, MA, United States
| | - Bridget J Perry
- Speech and Feeding Disorders Lab, MGH Institute of Health Profession, Boston, MA, United States
| | - Brian Richburg
- Speech and Feeding Disorders Lab, MGH Institute of Health Profession, Boston, MA, United States
| | - Hayden M Ventresca
- Speech and Feeding Disorders Lab, MGH Institute of Health Profession, Boston, MA, United States
| | - Bohdan Pomahac
- Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Jordan R Green
- Speech and Feeding Disorders Lab, MGH Institute of Health Profession, Boston, MA, United States
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Grigos MI, LeBlanc É, Hagedorn C, Diaz-Siso JR, Plana N, Rodriguez ED. Changes in Articulatory Control Pre- and Post-Facial Transplant: A Case Report. JOURNAL OF SPEECH, LANGUAGE, AND HEARING RESEARCH : JSLHR 2019; 62:297-306. [PMID: 30950699 DOI: 10.1044/2018_jslhr-s-18-0147] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Purpose Facial transplantation involves partial or total replacement of neuromuscular and skeletal structures of the face, head, and neck using donor tissues and is among the most extensive facial reconstructive procedures. This case report compares changes in speech production and articulator movement in a 44-year-old man from pretransplant to a 13-month posttransplant period. Method Speech production and articulator movement data were examined at 5 time points, once pretransplant and 4 times posttransplant (4, 7, 10, and 13 months), and compared to 4 healthy controls. A motion capture system was used to track jaw and vertical/horizontal lip movement during nonspeech and speech tasks. Speech intelligibility, jaw displacement, lip aperture, and movement variability were measured. Results Speech intelligibility varied across the study period and was restored to control status by 7 months posttransplant. Jaw displacement and lip aperture in the vertical plane significantly increased over time for nonspeech and speech tasks. Changes in horizontal lip movements over time were minimal. Jaw and lip movement variability fluctuated over time and was greater than the controls by 13 months posttransplant. Discussion Findings quantify changes in articulator movement and contributions to improved speech production following facial transplant. Changes reflect the adaptability of the speech motor system and are discussed in relation to pretransplant speech motor control patterns.
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Affiliation(s)
- Maria I Grigos
- Department of Communicative Sciences and Disorders, New York University
| | - Étoile LeBlanc
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health Center
| | - Christina Hagedorn
- Department of Communicative Sciences and Disorders, New York University
- Linguistics Program, College of Staten Island, NY
| | | | - Natalie Plana
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health Center
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Perry BJ, Richburg BD, Pomahac B, Bueno EM, Green JR. The Effects of Lip-Closure Exercise on Lip Strength and Function Following Full Facial Transplantation: A Case Report. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2017; 26:682-686. [PMID: 28654949 DOI: 10.1044/2017_ajslp-16-0101] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 11/23/2016] [Indexed: 06/07/2023]
Abstract
PURPOSE Facial transplantation is a relatively new option for individuals with severe facial disfigurements. Clinical case studies on existing patients indicate many instances of persistent facial motor impairment for facial expression, speech, and swallowing. These preliminary findings motivate additional research on the impact of lip-strengthening exercises following facial transplantation. METHOD In this study, we assessed the efficacy of an 8-week, biofeedback-driven, lip closure-strengthening exercise program in a single patient 1-year status post-full facial transplantation. Exercise was at 60% of peak strength. Outcome measures included instrumental measures of lip strength and mobility, clinical measures of speech, and patient-reported outcomes in feeding and facial expression. RESULTS Results revealed improvements in labial strength, speed of lip movement, and range of motion during speech. A 3-point improvement in sentence speech intelligibility was also observed following strength-training exercise. The patient reported improvements in her ability to drink from a straw and communicate via facial expression. CONCLUSION These preliminary findings motivate additional research on the efficacy of lip-strengthening exercises following facial transplantation.
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Affiliation(s)
- Bridget J Perry
- Department of Communication Sciences and Disorders, MGH Institute of Health Professions, Boston, MA
| | - Brian D Richburg
- Department of Communication Sciences and Disorders, MGH Institute of Health Professions, Boston, MA
| | - Bohdan Pomahac
- Center for Reconstructive and Restorative Surgery, Brigham and Women's Hospital, Boston, MA
| | - Ericka M Bueno
- Center for Reconstructive and Restorative Surgery, Brigham and Women's Hospital, Boston, MA
| | - Jordan R Green
- Department of Communication Sciences and Disorders, MGH Institute of Health Professions, Boston, MA
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De Letter M, Vanhoutte S, Aerts A, Santens P, Vermeersch H, Roche N, Stillaert F, Blondeel P, Van Lierde K. Facial nerve regeneration after facial allotransplantation: A longitudinal clinical and electromyographic follow-up of lip movements during speech. J Plast Reconstr Aesthet Surg 2017; 70:729-733. [PMID: 28351610 DOI: 10.1016/j.bjps.2017.02.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 12/07/2016] [Accepted: 02/27/2017] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Facial allotransplantation constitutes a reconstructive option after extensive damage to facial structures. Functional recovery has been reported but remains an issue. CASE REPORT - METHODS A patient underwent facial allotransplantation after a ballistic injury with extensive facial tissue damage. Speech motor function was sequentially assessed clinically, along with repeated electromyography of lip movements during a follow-up of 3 years. RESULTS Facial nerve recovery could be demonstrated within the first month, followed by a gradual increase in electromyographic amplitude and decrease in reaction times. These were accompanied by gradual improvement of clinical assessments. CONCLUSIONS Axonal recovery starts early after transplantation. Electromyographic testing is sensitive in demonstrating this early recovery, which ultimately results in clinical improvements.
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Affiliation(s)
- Miet De Letter
- Department of Speech, Language and Hearing Sciences, Ghent University, Belgium; Department of Neurology, Ghent University Hospital, Belgium.
| | | | - Annelies Aerts
- Department of Neurology, Ghent University Hospital, Belgium
| | | | - Hubert Vermeersch
- Department of Head and Neck Surgery, Ghent University Hospital, Belgium
| | - Nathalie Roche
- Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Belgium
| | - Filip Stillaert
- Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Belgium
| | - Philip Blondeel
- Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Belgium
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Abstract
PURPOSE OF REVIEW Acute rejection is the most common complication after vascularized composite allotransplantation (VCA). This review provides a state-of-the-art analysis of prevention, diagnosis and treatment of acute rejection episodes and highlights recent findings with the potential to improve patient care and enhance understanding of the underlying biologic processes. RECENT FINDINGS Recent reports suggest that maintenance immunosuppression dose reduction and steroid withdrawal are realistic goals in VCA, despite the known high immunogenicity of the skin component. It appears that utilization of sentinel flaps, in-depth histological analyses and application of novel biomarkers have facilitated early diagnosis and characterization of acute rejection episodes, leading to timely institution of appropriate therapy. The successful management of the first highly sensitized face transplant recipient suggests the possibility of carefully considering these high-risk VCA candidates for transplantation. SUMMARY Acute rejection is higher in VCA than in any other organ in the field of transplantation, although most episodes are controlled by high-dose steroids and optimization of maintenance immunosuppression. Because of limitations in patient number and the duration of follow-up, the long-term safety and effectiveness of VCA remain unclear. Moreover, the tests currently used to diagnose acute rejection are of limited value. Better diagnostic tools and a better understanding of the immunologic events during acute rejection are therefore needed to improve diagnosis, treatment and outcomes of this life-changing restorative surgery.
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Roche NA, Vermeersch HF, Stillaert FB, Peters KT, De Cubber J, Van Lierde K, Rogiers X, Colenbie L, Peeters PC, Lemmens GM, Blondeel PN. Complex facial reconstruction by vascularized composite allotransplantation: The first Belgian case. J Plast Reconstr Aesthet Surg 2015; 68:362-71. [DOI: 10.1016/j.bjps.2014.11.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2014] [Revised: 10/14/2014] [Accepted: 11/08/2014] [Indexed: 10/24/2022]
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Wall A, Bueno E, Pomahac B, Treister N. Intraoral features and considerations in face transplantation. Oral Dis 2015; 22:93-103. [DOI: 10.1111/odi.12301] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Revised: 11/07/2014] [Accepted: 11/07/2014] [Indexed: 11/27/2022]
Affiliation(s)
- A Wall
- Department of Oral Medicine and Dentistry; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - E Bueno
- Division of Plastic Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - B Pomahac
- Division of Plastic Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - N Treister
- Department of Oral Medicine and Dentistry; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
- Department of Oral Medicine, Infection and Immunity; Harvard School of Dental Medicine; Boston MA USA
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Fischer S, Kueckelhaus M, Pauzenberger R, Bueno EM, Pomahac B. Functional outcomes of face transplantation. Am J Transplant 2015; 15:220-33. [PMID: 25359281 DOI: 10.1111/ajt.12956] [Citation(s) in RCA: 79] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2014] [Revised: 07/29/2014] [Accepted: 07/30/2014] [Indexed: 01/25/2023]
Abstract
In this study we provide a compilation of functional impairments before and improvements after face transplantation (FT) of five FT recipients of our institution and all FTs reported in current literature. Functional outcome included the ability to smell, breath, eat, speak, grimace and facial sensation. Before FT, all our patients revealed compromised ability to breath, eat, speak, grimace and experience facial sensation. The ability to smell was compromised in two of our five patients. Two patients were dependent on tracheostomy and one on gastrostomy tubes. After FT, all abilities were significantly improved and all patients were independent from artificial air airways and feeding tubes. Including data given in current literature about the other 24 FT recipients in the world, the abilities to smell, eat and feel were enhanced in 100% of cases, while the abilities of breathing, speaking and facial expressions were ameliorated in 93%, 71% and 76% of cases, respectively. All patients that required gastrostomy and 91% of patients depending on tracheostomy were decannulated after FT. Unfortunately, outcomes remain unreported in all other cases and therefore we are unable to comment on improvements.
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Affiliation(s)
- S Fischer
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Hand-, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
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Lemmens GMD, Poppe C, Hendrickx H, Roche NA, Peeters PC, Vermeersch HF, Rogiers X, Lierde KV, Blondeel PN. Facial transplantation in a blind patient: psychologic, marital, and family outcomes at 15 months follow-up. PSYCHOSOMATICS 2014; 56:362-70. [PMID: 26096323 DOI: 10.1016/j.psym.2014.05.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 05/07/2014] [Accepted: 05/07/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Quality of life has frequently been reported to improve after vascularized composite allotransplantation of the face. However, psychosocial functioning of the partner or of particular patient groups such as blind patients are until now less well investigated. OBJECTIVE The aim of this study is to investigate psychologic, marital, and family functioning of a blind 54-year-old patient, Mr. A, and his partner after facial transplantation. METHODS Depressive and anxiety symptoms, hopelessness, personality, coping, resilience, illness cognitions, marital support, dyadic adjustment, family functioning, and quality of life of Mr. A and his partner were assessed before and after facial transplantation and at 15 months follow-up. Reliable change index (RCI) was further calculated to evaluate the magnitude of change. RESULTS Most psychologic, marital, and family scores of both Mr. A and his partner were within a normative and healthy range before and after transplant and at 15 months follow-up. Resilience (RCI: 3.6), affective responsiveness (RCI: -3.6), and disease benefits (RCI: 2.6) of Mr. A further improved at 15 months follow-up whereas the physical quality of life (RCI: -14.8) strongly decreased. Only marital support (RCI: -2.1) and depth (RCI: -2.0) of the partner decreased at 15 months. CONCLUSIONS The results of this study point to positive psychosocial outcomes in a blind patient after facial transplantation. Further, they may underscore the importance of good psychosocial functioning before transplantation of both partners and of their involvement in psychologic and psychiatric treatment. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, V.
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Affiliation(s)
| | - Carine Poppe
- Department of General and Hepato-Biliary Surgery and Transplantation, Transplantation Centre, Ghent University Hospital, Ghent, Belgium (CP, XR)
| | | | - Nathalie A Roche
- Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium (NAR, PNB)
| | - Patrick C Peeters
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium (PCP)
| | - Hubert F Vermeersch
- Department of Head and Neck Surgery, Ghent University Hospital, Ghent, Belgium (HFV)
| | - Xavier Rogiers
- Department of Speech, Language and Hearing Sciences, University of Ghent, Ghent, Belgium (KVL)
| | - Kristiane Van Lierde
- Department of Speech, Language and Hearing Sciences, University of Ghent, Ghent, Belgium (KVL)
| | - Phillip N Blondeel
- Department of Plastic and Reconstructive Surgery, Ghent University Hospital, Ghent, Belgium (NAR, PNB)
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