Katie Stubblefield\u2019s wit shows through when she describes her face transplant surgery.\n\n\n\n

Those unfamiliar with Katie\u2019s still-developing speech pattern may not easily make out those words, but her parents are usually there to interpret. Robb and Alesia Stubblefield have been by her side \u2013 helping her \u201ctake four steps forward, two steps back,\u201d as Robb describes it \u2013 since Katie, then 18, endured severe facial trauma and significant complications from a self-inflicted gunshot wound on March 25, 2014.
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It would take a team of 11 Cleveland Clinic surgeons and multiple specialists to perform the hospital\u2019s third face transplant \u2013 and its first total face transplant \u2013 on Katie. At 21, Katie was the youngest person in the United States to receive a face transplant.\n\n\n\n

And, indeed, it was extensive: The surgery included transplantation of the scalp, the forehead, upper and lower eyelids, eye sockets, nose, upper cheeks, upper jaw and half of lower jaw, upper teeth, lower teeth, partial facial nerves, facial muscles, and skin \u2013 with 100 percent of her facial tissue effectively replaced.\n\n\n\n

$\"Katie$
Katie Stubblefield before her face transplant in March 2015 and after in August 2018. (Courtesy: Cleveland Clinic)\n\n\n\n

Despite the success of the transplant, Katie\u2019s journey is far from over. She currently remains unable to see; so, Katie is learning Braille. She\u2019s also undergone additional surgeries to improve function in her tongue and jaw.\n\n\n\n

But the path forward \u2013 to college (she would like to be a counselor, or a teacher), to independence, and to walking down the street \u201cand blending in,\u201d as Katie describes it \u2013 seems reachable at last.\n\n\n\n

As Katie herself told the Cleveland Clinic Ethics Committee, during a meeting to ensure she was ready for her face transplant surgery: \u201cI can\u2019t go backward. I have to go forward.\u201d\n\n\n\n

Katie had suffered life-threatening, severely traumatic injuries from her gunshot wound. However, when paramedics arrived a few minutes later, one called out: \u201cShe\u2019s alive. We got a pulse.\u201d\n\n\n\n

While the single bullet pierced through her mouth and nasal cavity, exiting her skull between her eyebrows, it miraculously only grazed her brain tissue.\n\n\n\n

$\"$
Katie Stubblefield before her face transplant in March 2015 and after in August 2018. (Courtesy: Cleveland Clinic)\n\n\n\n

Sped by ambulance to a hospital in Oxford, Miss., Katie was quickly intubated with an endotracheal tube and placed on a ventilator. When her condition stabilized, she was flown the 22 minutes by helicopter to a Memphis hospital with a Level I trauma center.\n\n\n\n

By the time Robb and Alesia arrived, by car, a half-hour or so later, Katie was already in surgery; it would be the first of more than a dozen operations she would receive in the ensuing years.\n\n\n\n

\u201cThe surgeons were very matter-of-fact with us. No gloom and doom, but no peaches and cream, either. One of them \u2013 an elderly gentleman \u2013 said it was the worst case he\u2019d ever seen,\u201d said Robb.\n\n\n\n

And then the physician used a phrase Robb had never heard before, in all his life.\n\n\n\n

\u201cHe said, \u2018Outside of a face transplant, I just don\u2019t know.\u2019\u201d\n\n\n\n

\u201cAnd I\u2019m thinking, \u2018Face transplant? What is that?\u2019\u201d\n\n\n\n

Five weeks later, in early May 2014, Katie was flown to Cleveland, Ohio, and admitted to Cleveland Clinic.\n\n\n\n

Robb and Alesia also accompanied her to Cleveland, and they haven\u2019t left since.\n\n\n\n

Soon after Katie\u2019s time in Memphis, the opportunity for her to be transferred to Cleveland Clinic \u2013 ultimately, for a possible face transplant \u2013 emerged. On a Sunday morning, the family met Brian Gastman, MD, who would become Katie\u2019s primary plastic surgeon and a member of the face transplant team. Robb described him as a ball of energy, who came to their meeting armed with a 3D image of Katie\u2019s head.\n\n\n\n

\u201cI\u2019m seeing inside of my child\u2019s head. Everything. The wound area, her bone structure. It was fascinating.\u201d\n\n\n\n

$\"Katie\u2019s$
Katie\u2019s clinical team used 3D modeling to rebuild her jaw. (Courtesy: Cleveland Clinic)\n\n\n\n

They also learned face transplantation was the ultimate goal, but it would be \u201cway down the road somewhere,\u201d said Robb. To get there would require many preparatory procedures including a jaw reconstruction surgery, using bone from Katie\u2019s leg and a metal prosthesis.\n\n\n\n

Over time, as Katie endured many other operations, dozens of other physicians and specialists from other disciplines entered her life. Robb and Alesia have kept a running list: Nutritionists. Physical therapists. Endocrinologists. Infectious disease specialists. Neurosurgeons. Ophthalmologists. Social workers. Bioethicists. Psychiatrists. Anesthesiologists. Dentists. Pharmacists. Internal medicine specialists. Vascular surgeons. Dozens and dozens of nurses. And of course, plastic surgeons.\n\n\n\n

Throughout this process, Cleveland Clinic psychiatrist Kathy Coffman, MD, was a key specialist.\n\n\n\n

Dr. Coffman has counseled all three of Cleveland Clinic\u2019s face transplant patients, typically starting a year before the surgery and extending a full year or more afterwards. As she has written, \u201cFacial transplantation combined with the right psychological care can enable (patients) to reclaim their identity, reestablish their social contacts and ultimately get their life back.\u201d\n\n\n\n

As Katie inched closer and closer to the possibility of a full facial transplant, Dr. Coffman would gently prod her with questions, to ensure this is what Katie really wanted.\n\n\n\n

Alesia vividly remembers one of those conversations: \u201cDr. Coffman was speaking about all the risks involved. Katie let her finish, and then she says, \u2018I still want to do this, Dr. Coffman.\u2019\n\n\n\n

\u2018I want to be able to go out in the world. And not be looked at like this.\u2019\u201d\n\n\n\n

Katie signed the consent forms for facial transplant surgery in November 2015. It would be another 18 months before she would be physically and mentally prepared \u2013 and the search could then begin for a suitable donor.\n\n\n\n

It would prove to be a difficult process. Because of Katie\u2019s small stature, and relatively young age, the potential donor pool was smaller. And even smaller because the majority of available donors are male. Additionally, the donor\u2019s other organs would possibly be used for other patients with more life-threatening conditions, meaning they could take precedence over a face transplant.\n\n\n\n

\u201cMy biggest concern is getting her the right donor, one that is really appropriate for her,\u201d Dr. Gastman said in an interview, months before the transplant.\n\n\n\n

In those long months before her surgery, Katie\u2019s team assembled. Frank Papay, MD, chairman of Cleveland Clinic\u2019s Dermatology & Plastic Surgery Institute, would co-direct the surgical team with Maria Siemionow, MD, PhD, former director of Cleveland Clinic\u2019s Department of Plastic Surgery Research.\n\n\n\n

$\"Katie\u2019s$
Katie\u2019s face transplant included Cleveland Clinic experts in 15 specialties. (Courtesy: Cleveland Clinic)\n\n\n\n

As her primary team readied her for surgery, the face transplant team conducted numerous practice surgeries \u2013 some using an innovative technology called HoloLens, a self-contained mixed-reality computer headset that allowed the user to see holograms of 3D images of Katie\u2019s head. The technology allows surgeons to virtually practice aspects of the surgery, prior to entering the operating room.\n\n\n\n

$\"Kihyun$
Kihyun Cho, MD, a member of Cleveland Clinic\u2019s face transplant surgical team, uses HoloLens for preoperative face transplant surgery planning, for Katie Stubblefield\u2019s surgery. (Courtesy: Cleveland Clinic)\n\n\n\n

\u201cWe deliberate and discuss and respectfully argue, about what we should or should not do for Katie. It\u2019s very complex, and every face transplant is unique,\u201d said Dr. Gastman. \u201cIf something is going to increase the risk to the patient, we have to decide, is it really worth it?\u201d\n\n\n\n

From the moment of Katie\u2019s arrival, the team had the end goal of face transplantation in mind \u2013 as facial reconstruction alone would not correct her facial disfigurement or improve her quality of life. Thus, during her preparatory reconstruction surgeries, the surgeons were able to safeguard any potential blood vessels that could be used for the transplant.\n\n\n\n

$\"Katie$
Katie endured more than 17 surgeries at Cleveland Clinic. (Courtesy: Cleveland Clinic)\n\n\n\n

\u201cPlastic surgery is about restoring form and function,\u201d said Dr. Papay. \u201cFunction comes before form, and prior to the face transplant, Katie had extremely poor function and form.\u201d\n\n\n\n

It would be three years to the day Katie arrived in Cleveland that Cleveland Clinic doctors would receive a call for a potential donor. That donor would ultimately be Katie\u2019s. When the day for surgery arrived, Katie was ready. And her \u201clongest nap ever\u201d began.\n\n\n\n

At various points during the 31-hour procedure, Drs. Papay and Gastman would leave the surgical suite armed with photos taken during the surgery to discuss next steps and options with Robb and Alesia.\n\n\n\n

As Dr. Papay explained, \u201cWe were well prepared. But we knew our game plan could change in the middle of surgery. And that\u2019s what happened. We ended up using more of the donor\u2019s face than we originally planned and went to option B about halfway through the surgery,\u201d which would increase the risk but improve both the form and function of her face.\n\n\n\n

$\"Dr.$
Dr. Frank Papay reviews Katie\u2019s preoperative photos in the operating room at Cleveland Clinic. (Courtesy: Cleveland Clinic)\n\n\n\n

Alesia remembered at first she was shocked the medical experts would ask her opinion. But she ultimately appreciated she and Robb had a role in weighing options and making some of the decisions, as the choices would have aesthetic implications that would also increase the surgical risks.\n\n\n\n

\u201cI kept thinking, \u2018What do we think Katie would have wanted to do?\u2019\u201d said Alesia. Rob added, \u201cAt some point, someone said, \u2018Katie would want us to go all the way.\u2019 And it clicked in. We knew what we had to do.\u201d\n\n\n\n

Ultimately, with option B, doctors effectively replaced 100 percent of Katie\u2019s facial tissue with the donor\u2019s, from mid-scalp all the way down to her jaw and neckline. Further, her upper jaw and the area beneath her orbital floors, as well as two-thirds of her lower jaw, are bone from the donor. One of the trickiest parts of the surgery involved her vascularity, ensuring blood vessels remained functional and sufficiently carried blood throughout her body.\n\n\n\n

Including her face transplant, Katie has endured more than 17 surgeries at Cleveland Clinic. Collectively, those procedures have given her the capability to breathe, chew, and swallow more effectively. She\u2019s also able to use her face to better express emotions. In addition to significantly improved physical function, Katie is on the way to having enhanced physiological, psychological, and social function.\n\n\n\n

On reflection, a year later, Dr. Papay calls Katie\u2019s transplant a success. She has not suffered any signs of rejection, or side effects from being on immunosuppressant drugs, and a series of subsequent operations to fine-tune certain areas (including her tongue to improve speech) have gone as planned.\n\n\n\n

Beyond the medical triumphs, he is certain Katie would not be on the verge of a new life if not for the constant support of her parents, siblings and extended family. \u201cIn addition to the physical trauma that Katie went through is the emotional trauma they all suffered,\u201d Dr. Papay stated. \u201cThey are about as resilient as you can be, and I am proud of them as much as I\u2019m proud of Katie.\u201d\n\n\n\n

$\"Robb$
Robb Stubblefield, Katie Stubblefield, and Alesia Stubblefield at Ronald McDonald House in Cleveland, Ohio, where they\u2019ve lived for four years. (Courtesy: Cleveland Clinic)\n\n\n\n

When speaking of face transplants doctors aren\u2019t sure what the future holds for these types of surgeries, including the possibility of hand transplants and uterine transplants. To date, most U.S. face transplants have been paid for by the U.S. Department of Defense\u2019s Armed Forces Institute of Regenerative Medicine I (AFIRM I) grant program, which is designed to help improve the treatment of U.S. service members wounded on the battlefield.\n\n\n\n

\u201cWill third party government and private payers support these patients that are in desperate need of a transplant?\u201d Dr. Papay asked. \u201cThe key for (the future) is the source of financial support in these cases.\u201d\n","protected":false},"excerpt":{"rendered":"