Facing the Unknown An SLP treated a patient before and after his facial transplant surgery. Here’s what she learned. In the Limelight
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In the Limelight  |   November 01, 2017
Facing the Unknown
Author Notes
  • Shelley D. Hutchins is content editor/producer for The ASHA Leader. shutchins@asha.org
    Shelley D. Hutchins is content editor/producer for The ASHA Leader. shutchins@asha.org×
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Swallowing, Dysphagia & Feeding Disorders / In the Limelight
In the Limelight   |   November 01, 2017
Facing the Unknown
The ASHA Leader, November 2017, Vol. 22, 26-27. doi:10.1044/leader.LML.22112017.26
The ASHA Leader, November 2017, Vol. 22, 26-27. doi:10.1044/leader.LML.22112017.26
Name: Matina Balou, PhD, CCC-SLP, BCS-S
Title: Assistant professor, Department of Otolaryngology–Head and Neck Surgery and Department of Rehabilitation Medicine, New York University School of Medicine
Hometown: New York City
Ever since she was 12, Matina Balou knew she wanted to specialize in swallowing disorders. Watching a family member struggle with dysphagia following surgery for head and neck cancer made her determined to help people with similar issues. “He was in remission, but had a feeding tube and he died from recurring pneumonia because of aspiration,” the speech-language pathologist says.
Balou not only accomplished her mission—she was also part of the medical team that performed the first face transplant at New York University (NYU) in August 2015.
After changing countries (her native Greece did not yet recognize speech-language pathology as a profession when she initially decided on it) and completing several degrees, Balou joined Rusk Rehabilitation in the NYU Langone Medical Center (now NYU Langone Health) in 2012.
She works primarily with facial reconstruction patients, so preparing for the transplant wasn’t completely new. What was new was the breadth of swallowing issues she worked on with the patient. She also provided interventions for facial expressions and speech.

Comprehensive facial transplant patients often can’t swallow, breathe on their own, speak, nod or even blink for the first 48 hours after surgery.

Selecting and preparing the patient
NYU’s medical center launched a comprehensive facial transplant program three years ago. Balou served with the team from day one. Their first task involved identifying a qualified candidate, but Balou was surprised at the characteristics the team psychologist sought in an ideal patient. “I thought we’d look for someone with the worst difficulties, but this is an elective surgery and a dangerous one,” she explains.
Instead of looking for the person with the worst physical impairments, the team psychologists identified someone who had lost so much quality of life that he could no longer participate in daily activities. Patrick from Sanatobia, Mississippi, met the criteria.
Although he could eat and talk, Patrick’s poor vision, inability to blink and severe disfigurement from extensive burns prevented him from working, driving and enjoying even simple activities like playing with his kids. Nearly two months of testing revealed he was also a good candidate physically.
Once Patrick qualified, Balou started working with him as they waited for a donor—for more than a year. Comprehensive facial transplant patients often can’t swallow, breathe on their own, speak, nod or even blink for the first 48 hours after surgery. So prepping Patrick for these crucial two days involved a lot of education.
Balou worked with him on what to expect from post-operative swallowing issues. She also discussed probable resulting treatments and started him on swallowing exercises to build those muscles. There’s no way to predict what specific issues a patient might experience after the surgery, but Balou knows those exercises at least corrected his existing—albeit mild—swallowing problems.
In addition, the SLP fitted him with an alternative and augmentative communication system. Patrick might experience intense pain in addition to lack of facial mobility, so Balou set up a system based on a simple grid of 3D boxes attached to an iPad, then pre-populated them with messages about basic needs—pain management, suction, communication with a doctor and more. Patrick memorized which boxes contained which messages and practiced finding and pressing them without looking.

“Rehabilitation for a facial transplant patient involves thinking really outside the box as an SLP.”

Rehabilitation
Balou reached out for insights from other SLPs who had treated facial transplant patients, as well as from an occupational therapist doing innovative work with facial animation. However, the surgery isn’t standardized yet, so the healing and rehabilitation needs vary depending on which medical team performs the procedure.
“Rehabilitation for a facial transplant patient involves thinking really outside the box as an SLP,” Balou says of planning her post-operative strategies. “As a swallowing specialist, I usually treat patients with one problem. This was very different, because I had to completely rehab him quickly for every aspect of swallowing, airway, facial animation and speech.”
Patrick lives in Mississippi, so Balou not only needed to help him regain the ability to eat, drink and speak, she had a deadline within which to do so—before Patrick left for home in three months.
The intense sessions lasted around four hours every day. Of course, he also received daily treatment from occupational and physical therapists and counselors. The surgery took place on Aug. 15 and Patrick was discharged on Nov. 15. Balou used those three months to help Patrick regain nearly all of his swallowing and verbal communication abilities.
The most frustrating—and slowest—part of Patrick’s recovery was learning to swallow again. Balou helped him transition from a feeding tube to a modified diet and then reintroduced foods, with thin liquids being the last goal. The pre-op swallowing exercises probably allowed Patrick to build his abilities faster, but Balou says he worked hard to re-learn each movement—no matter how minute. She also credits Patrick for being more highly motivated than any other patient she’s treated.
“Only Patrick can say how he’s doing, but from our team’s perspective he was a success from week one, because he had no rejections,” Balou says. “He can drive and he’s not disfigured, so he can now enjoy things like taking the kids to school, or meeting with friends and not getting constant stares.”
The facial transplant team has already started the search for the next candidate and Balou knows they will deal with completely different issues from those she helped Patrick overcome. But she relishes these types of challenges. Seeing a patient return to a life they never thought possible is more than enough reward.
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November 2017
Volume 22, Issue 11