Novel Strategies for Facial Reconstruction After Cancer Extirpation

Podcast Transcript

Dale Shepard, MD, PhD: Cancer Advances, a Cleveland clinic podcast for medical professionals. Exploring the latest innovative research and clinical advances in the field of oncology. Thank you for joining us for another episode of Cancer Advances. I'm your host, Dr. Dale Shepard, a medical oncologist here at Cleveland Clinic overseeing our Taussig Phase I and Sarcoma Programs. Today, I'm happy to be joined by Dr. Patrick Byrne, Chair of the Head and Neck Institute at Cleveland clinic. Dr. Byrne is here today to discuss novel strategies for facial reconstruction after cancer extirpation, so welcome.

Patrick Byrne, MD, MBA: Thank you so much.

Dale Shepard, MD, PhD: So maybe to start, you can tell us a little bit about your role here at Cleveland Clinic. You've recently joined us and tell us a little bit about what you're doing here.

Patrick Byrne, MD, MBA: Yeah, thanks so much. So my specialty is facial plastic and reconstructive surgery. I perform a microsurgical facial reconstruction for a variety of conditions as well as aesthetic surgery. And I came from Johns Hopkins after 18 years to help with the head and neck Institute, which includes a huge part of our program is head and neck cancer and our head and neck cancer surgeons.

Dale Shepard, MD, PhD: All right. So maybe to start, we have a wide range of physicians that may be listening. Tell us a little bit about facial reconstruction techniques that you use after cancer extirpation.

Patrick Byrne, MD, MBA: Yeah. So cancer, as it relates to the head and neck, really falls into two main categories. There are aerodigestive tract cancers, so these are tumors that require the removal, or at least some form of treatment of the tongue, the palate, the jaw, the throat, the voice box. And then the other large category are cutaneous malignancies, so these are cancers of the skin, which tend to be more common on the face and head a neck than they are the rest of the body. So what binds these two major categories is most of the treatments do involve surgical extirpations, so our cancer surgeons have to remove varying degrees of skin, muscle, mucosa, and bone. And therefore the reconstructive needs are to as best as possible restore those structures.

Dale Shepard, MD, PhD: So what are some of the primary ways that that happens? What kind of techniques do you use?

Patrick Byrne, MD, MBA: By and large, we use autologous tissue, so that means we're going to change skin, muscle, fat, bone, whatever's missing, and we're going to try to recreate the missing anatomy as best as we can using the patient's own tissue. The biggest monumental change in the past in our lifetime certainly is we moved from regionally transformed tissues, so this means you take tissue that's fairly close to the defect and you rotate and move it and try to it to the local environment. The big change, which really started in earnest in the 1990s, is microvascular free tissue transfer. So this is basically a transplant of oneself, we're able to completely disconnect skin, muscle, bone, a combination thereof, from remote areas of the body, reconfigure it, and then replace the missing tissue and allow it to survive by connecting to blood vessels in the face or neck.

So that's been the biggest change in our lifetime. What has really been exciting in the past decade is most of the progress really has been around enhancing those techniques, so what was often a interminably long set of techniques with a high failure rate and outcomes both functioning, aesthetically that left much to be desired. By and large, especially in the past decade, we've learned how to do these techniques much more quickly with a lower complication rates and our functional aesthetic outcomes have actually gotten quite a bit better over time.

Dale Shepard, MD, PhD: So certainly as people in the lay press and physicians in general, we see the face transplants and the big splashy surgeries. And how have the developments that led to face transplants helped our cancer patients with the surgeries that they are getting?

Patrick Byrne, MD, MBA: Yeah, it's such a great question. I was one of the co-directors of the face transplant team at Johns Hopkins, and coming into that world after a decade or so of performing a high volume of cancer microvascular reconstructions, it's very, very complimentary. So one of the things that might be a surprise to some of the audiences, in many ways, a face transplant in terms of the technical demands are really quite a bit simpler than most of the cases that are done for major headache cancer. And the way to think about that makes it intuitive is if we're going to replace an entire upper jaw in a cancer patients, it's a relatively common thing for us to do here.

But what we have to do is take a straight bone from the leg, the fibula, we have to configure it by making cuts in the bone to convert this long rod shaped object into more three-dimensional object that mimics the upper jaw. We have to wrap skin from the lateral leg around it to replace the missing tissue of the pallet, so they can speak and hear. We have to perch on top of it a bent titanium plate to hold the eyeball in just the right position so they don't have double vision. We have to configure some fat around it, so it's a soft cheek so it looks natural, right? You get the picture. It's an unbelievably complex task.

We have people like Michael Fritz here, and our head and neck Institute who have taken this to a new art form. If you compare that to a face transplant, we just take off perfect part and just plug it in. So technically it's clearly simpler. But where face transplant has just kind of... I'm really excited about the field, because there are a couple of areas which have resisted effective solutions with traditional techniques. And mostly it's the sphincter function of the lips, and the sphincter function of the eyelids. We haven't yet. There is progress there's hope and work being done, but that's where traditional techniques really don't offer what we really want for our patients, which is to approach normalcy.

Dale Shepard, MD, PhD: And I guess another component that would be different with a face transplant compared to cancer is that radiation is a big component of head and neck cancers. And how does that play into what you're able to do from a reconstruction standpoint?

Patrick Byrne, MD, MBA: Yeah. Fantastic question. And you're absolutely right, the majority of our patients are... We had several cases like this yesterday, and thank God for our radiation oncologists and the fact that they're able to increase our cure rates. And so given that trade off we'll take having to deal with the ravages of radiation with someone who's been cancer free, because it can work. So we're happy to take that on, but enormous challenge. And the most advanced manifestation of that is probably osteoradionecrosis, where there's a percentage of head and neck cancer patients due to the course of their radiation component of their adjuvant therapy, they're going to develop very serious complications of their jaw. Usually the lower jaw, sometimes the upper jaw. And it does progress in times where it's unsalvageable.

Again, here's an area where there's been some major advances. Fritz and Ganther and others here have developed minimal access techniques to take vascularized tissue from the thigh and wrap bone that has a marginal blood supply. and in the past we would have just tried hyperbaric oxygen and probably ended up resecting the bone. We found that we can save a high percentage of those mandibles, and it's a short stay kind of experience for patients through, kind of a game changer. But to your point, absolutely. The challenges we have to anticipate in advance often with radiation. And so that means we err towards bringing in hypervascularized tissue to protect against these future effects, and then for many patients who just have to deal with it with these same techniques to provide more vascularized, healthy tissue. It's an ongoing, constant part of our lives.

Dale Shepard, MD, PhD: When you mentioned earlier about the difficulties getting things the right size and shape, and you think about using bones and, how much progress, how much change has there been using bone versus artificial things? Like you mentioned titanium, but are there other things that are coming to deploy in terms of use for these surgeries?

Patrick Byrne, MD, MBA: Yeah, it's a great question. Again, it's a really exciting area. We found that as long as the soft tissue coverage and blood supply is sufficient, there are many areas of the maxillofacial skeleton that we can actually substitute. So an example that's very common is our work with the neurosurgeons around cranioplasty. The skull under the scalp is not a weight-bearing bone. The demands on it in terms of functionality are relatively low in comparison to other areas, so we find a host of alloplastic materials, polyether ether ketone and titanium and porous polyethylene. There's a number of materials we can use to replace pretty large segments of the skull, actually. And that's been just really, really helpful. There's some interesting research being done about even having translucent cranioplasty materials that can transmit ultrasound waves through it, for example, to monitor intracranial conditions. So we're really excited about that.

And there are other areas and the load bearing requirements, the mechanical requirements of the jar have resisted that to date. So so far, and you read sometimes as reports of artificial jaws, but by and large, we are not really able to apply those meaningfully in a lot of clinical situations, because we demand so much in terms of a load bearing requirements on the jaw that we generally use and harvest tissue. But even there, tremendous research. Dr. Gastman here, for example, in plastic surgery is doing a trial looking at the use of adipose-derived stem cells to seed and grow new bone when bone is insufficient. My personal belief is that these hybrid strategies where we're using tissue engineering techniques, bioengineering and materials, and reconstructive surgery strategies in combination are really going to be the next wave. And so I think the future is bright, I think we'll see some major breakthroughs within the next five years in terms of the lower facial skeleton.

Dale Shepard, MD, PhD: I know it's become popular in some areas of medicine and reconstruction. How about 3D printing?

Patrick Byrne, MD, MBA: Yeah, we do use it some. And again, there's a lot of reports you'll read about... And it goes back years about 3D printing jobs and what have you. Again, the load bearing requirements particularly on are radiated patients makes that a bit of a probably premature conversation in terms of immediate clinical applicability. But 3D printing is still very helpful, so it's useful, for example, again on maxillofacial reconstruction for creating templates.

For example, we will often, for very complicated cases, we can do some pre-surgical planning. And this is an amazing workflow that is really seamless now. A recent case I was involved in, for example, is a woman with fibrous dysplasia, massive bony overgrowth in her upper and lower jaw. And it was a very complicated case, because we wanted to replace her jaw, upper and lower, with bone from the leg. But we really wanted to make sure that that dentition aligned as perfectly as possible so she could chew and have a normal life.

So the oral maxillofacial surgeon, the plastic surgeon, myself, as the microvascular surgeon, and some of our technologists who work with private industry, we're able to create 3D printed versions of her facial skeleton. We can perform therefore practice runs, not only on the computer, but on us real three-dimensional object to design our surgery, and then even create cutting guides. What this means is we can have in the fibula bone and leg during a non-surgical day, a device that tells us precisely where to place the blades. And so the cuts are pre-made, and it ensures optimal accuracy. Not every case needs that, but when both the upper and lower jaw are being reconstructed, you want the team to lineup. That's an incredibly complicated thing. 3D printing and pre-surgical planning have been phenomenal for this.

Dale Shepard, MD, PhD: And that takes more work upfront, but you had mentioned previously that a lot of the new techniques decrease operating time and things like that.

Patrick Byrne, MD, MBA: Yeah. We think operating time, number of revision surgeries. So we believe there's a credible healthcare value argument to be made with a lot of these technology-based pre-surgical efforts. And I think you're spot on. Shorter stays, lower complications, and better functional outcomes also reducing revision surgeries.

Dale Shepard, MD, PhD: So which patients benefit most from coming to see us here at Cleveland Clinic and take advantage of what we have to offer?

Patrick Byrne, MD, MBA: Well, the reason I came, there's a lot of reasons I chose to come here to become chairman of the Head and Neck Institute. I'm thrilled that I'm here. Clearly the quality of our head and neck cancer care, it's truly remarkable. People know how great the head and neck cancer care team is here, but probably not to the degree that is deserved. We see a very high volume, it's complex care so we tend to see tertiary cases, coronary cases, and the outcomes are phenomenal.

What's unique here, I think, in my experience, if you look across the landscape of the top tier locations where head and neck cancer care is, I think the emphasis on clinical outcomes excellence here is certainly unsurpassed. And so really any patient with head and neck cancer is I don't believe there's a better place on planet earth where you could be treated. And a big part is this topic, the integration of the head and neck cancer surgeons with the reconstructive surgeons is seamless. They work together every single day. Yesterday was three different rooms running with three double sets of teams. The rooms were all out the door by five, 6:00 PM. Probably three free flaps and a bunch of other cases. There really is a clinical machine here that produces quite excellent outcomes. It's a special place.

Dale Shepard, MD, PhD: What sort of multidisciplinary team is in place?

Patrick Byrne, MD, MBA: Well, the head and neck cancer patients are treated with really an amazing and multidisciplinary team. So that includes the medical oncologist, the radiation oncologist, the head and neck cancer surgeons. They have a weekly tumor board, so all patients are discussed and treatment plans agreed upon. They actually patients together in clinics, so that's been a great innovation that I credit Dr. Bolwell at Cancer Institute is sort of spearheading over many years now. And so there is truly integrated care, and the benefits are proven really the outcomes.

Dale Shepard, MD, PhD: And then things like social work. And what sort of support do you guys provide? Because certainly there's a huge component when you have facial reconstructions and things like that.

Patrick Byrne, MD, MBA: Yep. There's a real emphasis on social work, and even beyond some of the specific rehabilitation measures. So one of our gems here is a uniquely experienced and frankly compassionate and committed speech language pathology group. So for patients, for example, we have a number of these procedures, but probably the most obvious is a laryngectomy where the voice box is removed. And they're reconstructing the tissue often from the thigh to create a new throat to swallow through, and they're rehabilitated in terms of their speech with a number of techniques. We have a team of speech language pathologists that works with those patients before surgery, and then for months after surgery. And they see them in the hospital and then they see them in the outpatient center, and their clinics are adjacent to our head and neck cancer service.

So it's a wonderful model where we assign the specialist who can best help specific needs to work intently and a long duration with patients to make sure we get them to their functional outcomes as best as possible. What you can do is sort of abandon these patients, just like you intimated with the question. You can't go through this massive cancer surgery, reconstructive surgery and then tell patients, "Okay, good luck," and send them home. It's overwhelming to patients, so we really focus the family and they're support and the rehab.

Dale Shepard, MD, PhD: What are the biggest limitations?

Patrick Byrne, MD, MBA: I think one we touched on, which is some of the dynamic aspects of reconstruction. We've made huge strides, so my major focus academically and clinically has been topical facial reanimation. So that's not just restoring the static structures of maxillofacial reconstruction, but also the dynamism. And so we are dramatically better now than we were 10 or 20 years ago in taking muscle from other areas of the body, connecting it to targeted motor nerves in the face and neck, and coaxing function out of it. So for example, helping people smile again after radical cancer surgery that removes their facial. We actually got quite good at that.

And we're now moving into blink restoration, and so we have a number of patients who we've been able to restore a functional blink too. That's one of the trickiest things in all of reconstructive surgery, but we're adapting and innovating some of the existing techniques for dynamic smile restoration, which starting to apply that to the eyelid. And then the sphincter function the mouth, which I mentioned, that's a tricky one. We've had a number of patients who've been able to get good outcomes though, again, adapting some of the smile restoration techniques to our functional sphincter effect. So I think that's the next big wave where we want to evolve our techniques on how to restore movement, both from the functional and the social aspects.

Dale Shepard, MD, PhD: So from an aspect of how you can best help patients, are patients generally getting to you at the right time? You mentioned with the radiation, for instance, trying to think ahead in terms of what might be required. Is there an educational effort to have someone maybe see you at the very beginning to plan out the map of what's going to happen?

Patrick Byrne, MD, MBA: I believe you're right. I believe there is lost opportunity. We see more patients than I wish, one who had cancer surgery and I would say, could have been managing the reconstructive needs a little better, and we can help those people for sure. But your best chance is at the first surgery, usually. So a simple example would be the parotid glands, so that's the largest salivary gland, it sits in front of our ear. And people can get tumors in the salivary gland that are sometimes cancer.

We see a pretty high number of patients every year who have had a cancer surgery, remove the gland, the facial nerve was damaged and they're left with complete facial paralysis as well as an unsightly divot in their face where there's a depression that they're self-conscious about. That is largely preventable, actually, and our team has a strategy where they use a variety of techniques to restore the volume and the function and the support at the time of the cancer surgery. So before they get their radiation, they've got all the components in place with a healthy influx of vascularized tissue, which helps them manage the radiation as well. So I don't think it happened too soon, I think with the cancer diagnosis, ideally you would be plugged into a multidisciplinary team.

Dale Shepard, MD, PhD: That's great. So you've provided some great insight today, I really appreciate you joining us. Thanks for being with us.

Patrick Byrne, MD, MBA: Thanks, Dale, so much and appreciate all you're doing in this space.

Dale Shepard, MD, PhD: This concludes this episode of Cancer Advances. You will find additional podcast episodes on our website, clevelandclinic.org/canceradvancespodcast. Subscribe to the podcast on iTunes, Google Play, Spotify, SoundCloud, or wherever you listen to podcasts. And don't forget, you can access real-time updates from Cleveland Clinic's Cancer Center experts on our Consult QD website at consultqd.clevelandclinic.org/cancer. Thank you for listening, please join us again soon.