Brigham Otolaryngologist Takes His Expertise to Haiti

Source: Brigham and Women's - On a Mission
Date: 02/13/2019
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The expertise of the physicians and surgeons at Brigham and Women’s Hospital benefits patients well beyond New England. Through Partners in Health, the Boston-based nonprofit health care organization, specialists from the Brigham travel to hospitals in developing countries around the globe, offering patient care as well as training for local doctors.

Over the past decade, Brigham otolaryngologist Anthony A. Prince, MD, has made a number of trips with his colleague, Robert Boucher, MD, MPH, to Hôpital Universitaire de Mirebalais (HUM), in Mirebalais, Haiti. At HUM, he works with local otolaryngologists and general surgeons in providing a range of surgical services to treat head and neck disorders. On their most recent trip in November 2018, Dr. Prince and Dr. Boucher treated children, adolescents and adults for problems including sinonasal masses, thyroid goiters and malignant salivary tumors.

HUM is a modern, 300-bed facility that delivers primary care services to about 185,000 people and sees as many as 700 patients every day in the outpatient setting. As a university hospital, it also provides training and education for the next generation of Haitian nurses, medical students and resident physicians. Many other members of the Brigham community spend time at HUM, offering training and patient-care services in internal medicine, general surgery, pediatrics, and obstetrics and gynecology.

“Haiti has a population about the size of New York City—more than 10 million people—but there are only about 20 fully trained otolaryngologists in the whole country,” Dr. Prince said. “Access to otolaryngology services is quite limited for a variety of reasons, including lack of providers, cost and geographic distance to clinics and hospitals. Due to these constraints, many patients end up presenting with advanced disease. This can make treatment challenging and surgeries complex.”

At HUM, Dr. Prince and his U.S.-based colleagues support and supplement the care provided by the university’s sole otolaryngologist, who is available at HUM only on a part-time basis. Their support of HUM’s otolaryngology services includes donating surgical equipment and supplies that allow the team to safely perform a broad spectrum of head and neck surgical procedures, some of which were not possible in this part of Haiti a few years ago.

“It’s very busy, but it’s rewarding at the same time, especially seeing patients after surgery and knowing that we’ve made a difference in their lives,” Dr. Prince said. “Many of these patients have waited a long time to have these surgeries.”

Due to the lack of otolaryngology specialists in Haiti, transfer of surgical skills is an additional and important goal of Dr. Prince’s visits. During each visit, he teaches, advises and assists general-surgery resident physicians as well as the local otolaryngologist in contemporary head and neck surgical techniques.

“There are cases where they feel uncomfortable doing these procedures, but I think it’s helpful that I’m able to provide that level of expertise for them, as well as to help with their surgical volumes,” Dr. Prince said. “As the number of general-surgery training programs in Haiti far outnumber the sole otolaryngology training program, it is important that we take opportunities to transfer current head and neck surgery techniques to the general surgery trainees.”

Dr. Prince and his colleagues hope to eventually work with trainees in the country’s sole otolaryngology residency and training program in Port-au-Prince, which is about a 90- minute trip via winding, mountainous roads. For now, however, they’re focused on working with the local otolaryngologist and general surgeons to develop surgical plans for the more complicated cases. Eventually, Dr. Prince would like to bring some of Haiti’s otolaryngologists to Boston so that they can receive further training at the Brigham.

Maximizing Function in Full Face Transplant Recipients

Source: Brigham and Women's Hospital - On a Mission
Date: 12/12/2019
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In 2011, Brigham and Women’s Hospital made headlines as the site of the nation’s first full face transplant. In July 2019, the Brigham set another milestone with the world’s first full face transplant procedure on a black patient and the oldest recipient ever. It was the ninth face transplant at the Brigham and the 15th nationwide.

Robert Chelsea, a 68-year-old man from California, came to the Brigham with disfiguring facial injuries resulting from a traumatic, fiery car crash six years earlier. After the accident, Chelsea went through over 30 surgeries, yet his face remained severely scarred. His lips, part of his nose and part of his left ear couldn’t be reconstructed, limiting his ability to eat, drink, smile and speak normally.

Donald J. Annino, MD, DMD, from the Division of Otolaryngology-Head and Neck Surgery, was among those responsible for attaching the donor face to Chelsea and making sure he regained optimum function after the procedure. His surgical expertise related to the microvascular and facial nervous systems made him a key part of the surgical team.

“Otolaryngology expertise is crucial to helping face transplant recipients resume breathing, swallowing and speaking function,” Dr. Annino explained. “We focus on how and what the patient is eating, how they are breathing, how their tongue functions and how well they can communicate both before and after the procedure. We also closely evaluate the facial nerves to determine the specific nerve branches that need to be harvested from the donor face in order to achieve that optimum function.”

Dr. Annino worked closely with the surgical lead, Bohdan Pomahac, MD, the Roberta and Stephen R. Weiner Distinguished Chair in Surgery and director of plastic surgery transplantation.

“Our experience has demonstrated that face transplantation is a viable option for patients with severe disfigurement and limited function who have no alternatives,” Dr. Pomahac said. “We recently published a follow-up study of the first patients to receive a face transplant at the Brigham, which showed they had a robust return of facial motor and sensory functions, allowing them to socially reintegrate in a way that would not have been possible pre-transplant.”

Face transplantation is not a first-line treatment and is never considered for strictly aesthetic reasons. To be a candidate, a patient must have severe functional limitations, sometimes following many rounds of conventional reconstruction procedures. Patients must be willing to go through extensive psychological counseling both pre- and post-procedure. In addition, because transplantation requires the patient’s immune system to be suppressed for the rest of their life to keep their bodies from rejecting the donor organ, patients must demonstrate a history of good compliance with medication protocols and other therapies.

Chelsea met the requirements. After an evaluation by the surgical team and an extensive screening process, he began the wait for a donor, a process that took longer than for previous Brigham face transplants due to his skin tone.

“Face transplantation has significant obstacles that don’t exist with transplanting other organs such as livers, lungs and kidneys,” said Dr. Annino. “The donor and the recipient need to be a good match in terms of gender, age and skin tone. Complexion shade can be especially hard to match, even between two African Americans, because the range of skin tones is much larger than with whites.”

Due to the intricacies of blending skin of different shades of the donor’s face with Chelsea’s native one, the decision was made to pursue full face transplant. Once a donor of the same gender, a similar age and a nearly identical skin color became available, the Brigham sprang into action. More than 45 physicians, nurses, anesthesiologists, residents and research fellows assisted during the 16-hour transplantation procedure.

After the surgery, Chelsea began the recovery process. For nearly a month, he remained in the hospital, monitored closely by Brigham transplant medicine and infectious disease physicians for signs of rejection. Under the direction of Dr. Annino, occupational therapists helped him regain the ability to swallow after his tracheotomy and feeding tubes were removed.

“One of our goals was to make sure he was able to ingest proper nutrition while also protecting his airway,” said Dr. Annino.

Upon leaving the hospital, Chelsea convalesced nearby, continuing therapy and starting a lifelong immune-suppression medication protocol crucial to preventing infection.

“Our social workers found a temporary apartment in Boston, and a couple of his family members came to help with his follow-up care,” Dr. Annino said. “His recovery went very well, and he was able to return home to California two-and-a-half months after surgery.”

According to Dr. Annino, Chelsea is not the first face transplant patient to come to the Brigham from outside of Massachusetts. Eight of the Brigham’s nine face transplant recipients have hailed from other regions of the country.

“The foundation of the Brigham’s leadership reputation in face transplants is strong,” he concluded. “We have a well-established transplant center with an extensive history of transplants in general, along with the institutional knowledge, specialized surgeons and multidisciplinary teams needed to achieve good results. When people have a choice, they choose Brigham and Women’s Hospital.”