Supplementary Appendix

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Supplementary Appendix

This appendix has been provided by the authors to give readers additional information about their work.

Supplement to: Kauke M, Panayi A, Tchiloemba B, et al. Face transplantation in a black patient — racial consid-erations and early outcomes. N Engl J Med 2021;384:1075-6. DOI: 10.1056/NEJMc2033961

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Supplementary Appendix

Methods and Outcomes

Study Approval

The herein presented study was approved by the Human Research Committee at our institution (Protocol 2019P002841). The patient provided written informed consent for publication of identifying clinical photographs.

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Study design and outcomes

In 2017, a 67-year-old black male presented for consideration of face transplantation. In August 2013, the patient was involved in a motor vehicle accident, resulting in a 50% total body surface area burn and complete loss of critical facial structures (lips, lower lateral nasal cartilages) with depigmentation (Figure 1). He also developed as complications: ischemic colitis resulting short gut syndrome, acute kidney injury necessitating transient hemodialysis with near total resolution (pre-transplant creatinine baseline 1.3-1.4), bilateral toe amputations and left hand 4th_{and 5}th_digit amputations. Full thickness skin grafting was performed on the extremities, head, neck and trunk for reconstruction.

Given significant burns involving the forearms, the only option for conventional lip reconstruction was free tissue transfer from the anterior lateral thigh (ALT). This reconstructive option was deemed suboptimal as an ALT flap would be immobile, excessively thick, provide poor oral competence, and slurred speech. Moreover, both sides of his anterior thigh had previously been utilized as skin graft donor sites and depigmentation was present. Hence, conventional reconstruction was not expected to provide a satisfactory outcome and facial allotransplantation was recommended. Medical history included hemoglobin CC disease, monoclonal gammopathy of undetermined significance (MGUS), hemosiderosis and mild chronic kidney disease.

After the patient was listed for transplantation, donor offers were made to the lead surgeon who received pictures from potential donors without identifiable parts of the donor’s face. Skin tone was compared to the scale shown in Figure S1 and communicated to the recipient. The recipient declined two donor offers based on skin tone preference alone. The first offer was rejected at approximately 9 months after listing and the second one three months later, before he underwent

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Diagnosis of Rejection and immunological complications and considerations

For diagnosis of acute T-cell mediated rejection 4-mm punch biopsies of the facial skin (typically of the neck) and of the interior aspect of the lip mucosa were obtained per monitoring schedule (scheduled biopsies of mucosa and skin weekly for the first month, then at post-operative month (POM) 3 and 6, thereafter biannually). Biopsies were also taken at the time of suspected rejection (indication biopsy). Donor-specific antibody (DSA) testing is performed at similar time-points. Detection of DSA triggers a careful evaluation of the graft biopsy for suspected rejection, the performance of a detailed characterization of the antibodies (crossmatch tests and dilution assays) and trend over time of DSA levels. Biopsied tissues were formalin-fixed, paraffin-embedded, and stained with hematoxylin & eosin. Grading of cell-mediated rejection episodes was performed according to the Banff-classification of skin-containing VCA by two independent dermatopathologists. Diagnosis of antibody-mediated rejection (AMR) required evidence of DSAs, positive tissue C4d stain and presence of clinical signs of rejection (e.g., erythema). Prior to listing for transplantation, the patient underwent a tacrolimus load trial to confirm that therapeutic levels required for long-term immunosuppression could be attained despite his short gut. At the time of transplantation, the patient received induction with four doses of Thymoglobulin. Maintenance immunosuppression consisted of Mycophenolate Mofetil (MMF), Tacrolimus (goal of 8-10ng/ml) and Prednisone. On post-operative day (POD) 3, the patient did not demonstrate development of DSAs (Table S1). On repeat testing, at POM 1, de novo class II DSAs were noted (DQ2, DR53, DR7). Routine histology on POD31 revealed grade II skin and grade III mucosal allograft rejection (no clinical evidence of rejection) and the patient was treated with steroid pulse and an increase in maintenance Tacrolimus. On repeat testing, at POM 3 post-transplant, all the DSAs, except for against DR53, disappeared. CDC T- and B-cell crossmatch

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remained negative. Due to the persistent DSAs, the patient subsequently received two doses of Rituximab at POM 3 and POM 4. DR53 persisted beyond the first post-operative year without any additional signs of rejection.

Infectious complications and considerations

Vancomycin, cefepime, metronidazole and micafungin were given for perioperative prophylaxis. Post-operatively, the patient initially received trimethoprim-sulfamethoxazole (TMP-SMX) and letermovir (favored due to hemoglobinopathy, MGUS and renal dysfunction) for prophylaxis against Pneumocystis Jirovecii and CMV infection, respectively. Owing to financial considerations, the Letermovir was switched to Valganciclovir two weeks post-operatively. On POD 12, the patient developed an organizing subgaleal hematoma and edema at the base of the neck accompanied by leukocytosis and a rise in beta-glucan levels. On CT-imaging, fluid collections (peri-parotid, submental, frontal subgaleal) were noted and drained. The subgaleal hematoma was washed out and operatively debrided on POD 22 (Table S2). Cultures from the left scalp wound grew Aspergillus flavus, and micrococcus was isolated from a submental collection. The patient initially received micafungin, which was switched to isavuconazole and ultimately posaconazole, which was continued for one year, with resolution of the lesions. Over the entire post-operative course, the patient was hospitalized twice for urinary tract infections with sepsis requiring ICU care without long-term sequalae.

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facial mobility using manual muscle testing,2_{labial competence, and labial strength; functional} speech outcomes included speech intelligibility;3_{and sensory outcomes included skin sensitivity} to touch and temperature.4_{Motor recovery was adequate, with the score rising from 1.2 at POM 4} to 1.9 at POM 13, using a 0-3 scoring system, where 0 is no motor function and 3 is normal motor function. Synkinesis was judged observationally using the Sunnybrook Facial Grading System (0-3 with 0 indicating no synkinesis). No evidence of synkinesis was present at either POM 4 or POM 13. Labial closure was incomplete at POM 4, but complete at POM 13, at which time lip strength was found to be 1.66 kPa (normal range is 14.5±3.9 kPa for older men). Speech intelligibility improved from 86% at POM 4, to 95% at POM 13. Deficits in speech intelligibility at POM 4 were attributed to mild pharyngeal cul-de-sac resonance due to decreased air flow through the oral and nasal cavity and articulatory imprecision, particularly with labial sounds. At POM 13, resonance remained mildly impaired. Articulation had improved, however, remained mildly imprecise, particularly with labial sounds. No deficits in voice were noted at either timepoint.

Sensory recovery was assessed using two-point discrimination, hot/cold discrimination and pressure monofilament (Weinstein Enhanced Sensory Testing (WEST)) testing in a standardized manner. For all tests, 17 pre-determined locations over the whole full-facial allograft were tested. From POM 4 to POM 13, facial sensation also improved. Heat/cold differentiation improved from 50% to 71% (range 0 (worst) to 100%), while two-point discrimination improved dramatically, from 2 % to 33 % (range 0 (worst) to 100%).1_{Cumulative Weinstein Enhanced Sensory Test} (WEST, testing of pressure sensation) scores for the full face increased from 0 at POM 4 to 33 at POM 13. For this test, at each of 17 locations, 0 indicated the inability to feel the testing monofilaments, and 1-5 indicated that the patient was able to feel at least 200g, 4g, 2g, 0.2g and

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0.07g of force, respectively. Previously, a cumulative score of 85 has been shown to demonstrate 100% sensory recovery for full face transplant recipients.1

Satisfaction and quality of life

The patient has expressed satisfaction with the appearance and function of his transplant. A major factor negatively impacting his quality of life prior to the transplant was complete oral incompetence. Complete loss of his upper and lower lips made it very difficult for him to eat and drink; he required a syringe for drinking and compensated by extending his neck during eating in order to prevent food from falling from his mouth. Post-transplant, his oral and labial competence have been restored. He is now able to close his mouth while showering so that no water gets in, something he was not able to do prior to the transplant. His overall quality of life has improved, particularly in terms of social integration with the patient stating that his physical appearance no longer interferes with social activities like visiting friends.

Acknowledgments

The authors would like to thank all members of the multidisciplinary face-transplantation team and the administration at Brigham and Women’s Hospital. More specifically we thank Dr. Dennis Orgill, Dr. Christian E. Sampson, Dr. George F. Murphy, Dr. Christine G. Lian, Dr. Simon G. Talbot, and Dr. Ali-Farid Safi for participating in the research and clinical care activities of the patient. We also want to thank the nursing staff, surgical anesthesia team as well as the Infectious Disease Department at BWH under the leadership of Dr. Francisco Marty for their excellent

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Kauke and Valentin Haug received financial support from the German Research Foundation (DFG).

Figures

Figure S1. Skin complexion scale. On this scale, the patient expressed preference for complexions 8-16.

Tables

Table S1. Donor-Specific-Antibodies (DSA) during the first four months post-transplant. POD, Post-operative Day.

POD Class I Class II

3 None None 32 None DR53, DQ2 41 None DR53 55 None DR53 83 None DR53 119 None DR53

Table S2. Relevant surgical history after facial transplantation. POD, Post-operative Day.

POD Procedure

0 Tracheostomy

22 Washout debridement

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References

1. Tasigiorgos, S. et al. Five-Year Follow-up after Face Transplantation. New England Journal of Medicine (2019) doi:10.1056/nejmc1810468.

2. Hislop, H. J. & Montgomery, J. Daniels and Worthingham’s Muscle testing. Techniques of manual examination (2014).

3. Yorkston, K., Beukelman, D. & Tice, R. Sentence intelligibility test [Measurement instrument]. (1996).

4. Roseén, B. & Lundborg, G. A model instrument for the documentation of outcome after nerve repair. Journal of Hand Surgery (2000) doi:10.1053/jhsu.2000.6458.

Supplementary Appendix