Frank Rybicki lecture at the 2015 Annual Meeting of the Radiological Society of North America (RSNA). This lecture was invited by the American Society of Radiologic Technologists (ASRT) and features amazing technologists from my past position in Boston Massachusetts, at Brigham and Women's Hospital. Many of these slides were generous provided by Bo Pomahac, MD, brilliant surgeon, caring physician, and wonderful friend. I have removed the images of Bo's patients. We have permission to publish them, but I wanted to play it safe to avoid any possible complaints

1. ASRT@RSNA 2015
Face Transplantation and Surgical Planning
Frank J. Rybicki, MD, PhD
Professor and Chair, Department of Radiology
The University of Ottawa Faculty of Medicine

2. Disclosures
I have no financial disclosures.
Wonderful, passionate, and dedicated technologists
acquired all of the CT and MR scans in this
presentation. The patients are and will be forever
grateful to them.

3. People that everyone may recognize but
no one may know

6. The whole volume in one moment (RSNA 2007)

7. 3.2cm16 cm
The whole volume translated to CT (RSNA 2008)
4x0.5 Detector Elements16x0.5 Detector Elements64x0.5 Detector Elements320x0.5mm Detector Elements

8. This is Kurt Schultz, RT

9. Charmaine Ashton, RT
Jeff Hall, RT

11. TRANSPLANTATION
RESTORE
rather than reconstruct
form and function
Dr. Bohdan Pomahac

13. Recipient
#3
Allograft

14. Recipient
#4
Allograft

16. 200 year anniversary
New England Journal
of Medicine
Surgical breakthroughs

17. Transplantation restores, rather than reconstructs,
form and function
•Blood supply to “tissue blocks”
•Immunosuppression
•Function: motor and sensory nerves
•Esthetics
•Integration

18. Concept #1: Angiosomes are the tissue blocks
Composite anatomic vascular territory
of skin and underlying muscles,
tendons, nerves, and bones, based on
segmental or distributing arteries
Interconnected by “choke vessels”
Neighboring angiosomes deprived of
their own blood supply can survive by
opening the choke vessels

19. Dermatomes Angiosomes
Pomahac B, Bueno EM, Sisk GC et al. Plastic and Reconstructive Surgery. May 2013. 131(5):1069-1076

20. Pre-op vascular preparation
Anatomy from CTA & MRA
Operation design from vessels/angiosomes

22. Concept #2: Radiology in Surgical Planning
The Soga Protocol
Soga S, Ersoy H, Mitsouras D, et al. JCAT 2010; 34:766-9
Scan Type kVp mA Rot. Time Start Sample
Time
Acquisition
Interval
Total Acquisition
Time
One Shot
(Mask)
80kVp 310 mA 0.75 sec 7 sec ---- 1 sec
Dynamic 80 kVp 150 mA 0.75 sec 11 -17 sec 2 sec 8 sec
Dynamic 80 kVp 300 mA 0.75 sec 19 -27 sec 2 sec 6 sec
Dynamic 80 kVp 150 mA 0.75 sec 30 -36 sec 2 sec 6 sec
Dynamic 8 kVp 150 mA 0.75 sec 40 - 60 sec 5 sec 20 sec

23. Standard FBP reconstruction
(9 mSv for entire dynamic
volumes)
Standard FBP reconstruction
with 50% simulated dose
reduction
Simulated 50% dose reduction
plus iterative reconstruction
(AIDR 3D)
Soga S, Wake N, Bueno EM, et al. ePlasty 2011; 11:519-529
Surgical Planning
• Simulated Dose Reduction

24. Surgical Planning
• Realized Radiation Dose Reduction
Schultz K, George E, Mullen KM, et al. PLoS One 2013, Apr 26;8(4):e63079
FBPAIDR3D

25. Soga S, Pomahac B, Mitsouras D, et al. Plastic and Reconstructive Surgery 2011; 128(4):883-91

26. Kanako Kumamaru, MD, PhD

27. Full face transplantation planning
• Arterial Anatomy
Right Left
Lingual
Lingual
Facial
Facial
Sup. thyroid
Sup. thyroid
Occipital
Occipital
Post. auricular Post. auricular
Right Left
• Venous Anatomy
Common facial
Ext.
jugular
Ext.
jugular
IJ

28. Patient with insufficient vessels for anastomosis
• Arterial Anatomy
Lingual
Facial
Sup. thyroid
Occipital
OccipitalPost. auricular
• Venous Anatomy, no EJ bilaterally
Common
facial Common
facial
Right Left Right Left

29. Concept #3: Teamwork in Radiology
Dick Prior, R.T. Walter Surette, R.T.

30. Concept #3: Teamwork in Radiology
Dick Prior, R.T.
Sara Powers, R.T.
Abe Haboub, R.T.

31. Concept #4: 3D Visualization & 3D Printing

32. 3D Visualization
ePlasty VOLUME 11
Figure 2. (a) Candidate 2 during initial evaluation for face transplantation. (b) 3-dimensional
volume rendering from the computed tomographic acquisition with windowing to show the bony

33. DICOM files contain pixel information and study
information for each image in a set.
3D Printers, however, need a digital 3D model and
cannot use DICOM files directly.

34. RSNA 2014 Press Conference
Application of 3D Printing in Face Transplantation
3D Printing is increasingly applied in
research, education, and clinical
medicine

35. 3D Printers enable materialization of digital models,
usually by fusing sequential 2D layers.
This process requires three steps:
A. Appropriate Image Acquisition
B. Printable Model Creation
C. 3D Printing
Chepelev L et al. 3D Printing in Radiology (ePoster) RSNA 2015, IN-121-ED-TUA6
Matsumoto J, Morris JM, Foley TA et al. Radiographics; 35: 1989-2006

36. Image Acquisition for 3D Printing
• Any imaging modality with sufficient quality for
relevant anatomy is acceptable.
• CT imaging most often used
• Reconstructions with <1.25mm isotropic voxels
are preferred
• DICOM Images are generated

37. 3D Printable Model Creation
• Imaging converted to 3D models using
segmentation, similar to 3D visualization.
• Appropriate segmentation is achieved using
thresholding (A), region growing (B), direct
feature editing, and numerous tools and
algorithms.
• These images need further refinement and
conversion to the correct format to 3D print.
A
B
Volume-
Rendering
Calculated 3D
Model

38. 3D Printable Model Creation
The desired output is an STL (Standard Tesselation Language)
model.
3D shape is a set of connected triangles.
Specialized postprocessing with Computer Aided Design
(CAD) needed before 3D Printing. This is a new skill set for
radiology and will be done by dedicated, skilled
technologists.

39. DICOM to Standard Tessellation Language (STL)
Mitsouras D, Liacouras P, Imanzadeh A, et al. RadioGraphics 2015; 35:1965-1988
Software & new breed of expertise

40. Craniofacial model includes arteries and
veins and is now an essential component
for the planning of complex interventions
Craniofacial Surgery
Mitsouras D, Liacouras P, Imanzadeh A, et al. RadioGraphics 2015; 35:1965-1988

41. 3D Models (left) and
printed models (right) of
a patient scheduled for
face transplantation
Vat Photopolymerization
with SLA 7000 (3D
systems)
3D Printing in Face Transplantation (RSNA 2014)

42. Results
3D Printing

43. Tissues in red represent Carmen’s new face. RSNA hands-on
education participants are actively learning the tools to make
these types of images from standard CT scans.

44. Pomahac B, Pribaz J, Eriksson E, et al.
NEJM 2012; 366(8):715-22
Concept #5: Post-operative Imaging and Follow-up

45. Perfusion Imaging
Sisk GC, Kumamaru KK, Schultz K, et al. ePlasty 2012; 12:e57
postpre

46. Vascular Communications between Donor and Recipient Tissues 1
Year after Successful Full Face Transplantation
RSNA 2013 Press Conference
No vascular-related
symptoms or
complications

47. New vessels developed post-surgery
Flow to the native tongue
Kumamaru KK, Sisk GC, Mitsouras D, et al. Am J Transplant. 2014;14(3):711-9

48. New vessels maintained blood flow around the
ears and back of the neck
Kumamaru KK, Sisk GC, Mitsouras D, et al. Am J Transplant. 2014;14(3):711-9

49. Summary
We learned about CT flow and how CT gives new information
We learned about angiosomes and tissue blocks
We did ands on surgical planning / Hands on patient care
We learned about 3D Printing and got to teach the world
We learned about vascular reorganization after transplantation

51. BWH Video

53. SAM Questions (Rybicki, ASRT@RSNA2015)

54. SAM No 1
Which of the following imaging modality is most widely
accepted for surgical planning for reconstruction surgery?
A. Ultrasound
B. MRI
C. Conventional (catheter-based) angiography
D. CT

55. SAM No 1 Answer
Which of the following imaging modality is most widely accepted for surgical planning for reconstruction surgery?
A. Ultrasound
B. MRI
C. Conventional (catheter-based) angiography
D. CT
Answer: D. CT
Successful reconstructive surgery depends on minimizing ischemia time, and surgical planning depends on vascular
maps that minimize this time. Ultrasound is beneficial to determine patency of superficial vessels but is otherwise
limited. MRI can be used, but the artifacts induced by susceptibility can limit the evaluation. Conventional (catheter-
based) angiography has been used for reconstruction of the extremities but in general is considered to be more
invasive and not better the CT. CT provides vascular roadmaps and enables 3D reconstruction of important vascular
and nonvascular structures.
Reference:
Soga S, Pomahac B, Mitsouras D, Kumamaru K, Powers SL, Prior RF, Signorelli J, Bueno EM, Steigner ML, Rybicki
FJ. Preoperative Vascular Mapping for Facial Allotransplantation: Four- Dimensional Computer Tomographic
Angiography Versus Magnetic Resonance Angiography. Plastic and Reconstructive Surgery. 2011 Oct;128(4):883-91.

56. SAM No 2
Resortative surgery such as full-face transplantation enabled
by vascular mapping differs from conventional surgery
because:
A. Rejection is less common, leading to better outcomes
B. The vascular maps in restorative surgery are lower in
complexity than that for conventional surgery
C. Restorative surgery restores form and function and this
offers superior outcomes over conventional methods
D. Conventional surgical methods have not matured, despite
extensive experience.

57. SAM No 2 Answer
Resortative surgery such as full-face transplantation enabled by vascular mapping differs from conventional surgery
because:
A. Rejection is less common, leading to better outcomes
B. The complexity of the vascular maps in restorative surgery is lower than that for conventional surgery
C. Restorative surgery restores form and function and thus offers superior outcomes over conventional methods
D. Conventional surgical methods have not matured, despite extensive experience.
Answer: C.
Conventional surgical methods such as free flaps are a mature set of surgical intervention with complex injuries with
large volumes of exposed tissue. These methods are available to individuals who suffer catastrophic injuries, but
outcomes have been limited because of contractures. Restorative methods such as full face transplantation are now
widely accepted as the only method to restore form and function. When an allograft is used, the recipient is vulnerable
to rejection, and the surgical approach does not modulate this risk. The complexity of vascular mapping depends on
the injury and the body region, not the surgical approach.
Reference:
Pomahac B, Pribaz J, Eriksson E, Bueno EM, Diaz-Siso JR, Rybicki FJ, Annino DJ, Orgill D, Caterson EJ, Caterson
SA, Carty MJ, Chun YS, Sampson CE, Janis JE, Alam DS, Saavedra A, Molnar JA, Edrich T, Marty FM, Tullius SG.
Three Patients with Full Facial Transplantation. New England Journal of Medicine. 2012; 366(8):715-22

58. SAM No 3
After full face transplantation, which of the following best
characterizes the vascular and tissue response.
A. Vascular reorganization with neo-vascularization increases
the overall perfusion of the allograft
B. Donor and recipient vessels remain compartmentalized
and perfusion is dependent only on the anastomoses
C. Tissue hypo-perfusion requires life-long vasodilation
D. Mapping of the vessels is not possible because of
limitations in technology

59. SAM No 3 Answer
After full face transplantation, which of the following best characterizes the vascular and tissue response.
A. Vascular reorganization with neo-vascularization increases the overall perfusion of the allograft
B. Donor and recipient vessels remain compartmentalized and perfusion is dependent only on the anastomoses
C. Tissue hypo-perfusion requires life-long vasodilation
D. Mapping of the vessels is not possible because of limitations in technology
Answer: A
Vascular reorganization with neo-vascularization increases the overall perfusion of the allograft.
This principle has also been demonstrated in other transplantation organ beds such as the liver, but the findings
after full face transplantation is striking with neo-vessels crossing traditional angiosome planes. The vessels do
not remain compartmentalized, in fact there can be increased perfusion, not hypo-perfusion, from this
neovascularization. This has been demonstrated by perfusion CT maps and CT angiograms that are enabled by
modern CT angiography technology and protocols.
Reference:
Kumamaru KK, Sisk GC, Mitsouras D, Schultz K, Steigner ML, George E, Enterline D, Bueno EM, Pomahac B,
Rybicki FJ. Vascular Communications between Donor and Recipient Tissues after Successful Full Face
Transplantation. American Journal of Transplantation. 2014 Mar; 14(3):711-9.