As a child, Francis Papay was a “tinkerer” who enjoyed building, fixing, and inventing things. Inspired by his father, who was also a fixer and builder—and once rebuilt a World War II Jeep from the ground up—Papay’s mother and a sister were very artistic, exposing the young man to the arts, to newness, and the process of how one creates something out of nothing.

Papay’s fifth-grade biology teacher inspired him to pursue the study of living things. In high school, Papay was a drummer in the drum line that played in Ohio when he met astronaut Neil Armstrong, who had just returned from the historic walk on the moon.

After receiving an undergraduate degree in zoology, Papay moved to biomedical engineering, after which he worked for a brief time at NASA, becoming involved in biomaterials and surface morphologies. He worked on earthbound applications for an ion thruster that was used in space flight. “It was a tinkerer’s dream to be working at NASA,” he says, “trying to figure out how to do earth applications for NASA’s technical failures.”

Two events had a powerful influence on shaping Papay’s life. An early tragedy was the drowning death of his brother at age 13. “It taught me the fragility of life, how life can be snuffed out in a moment. It goes so quickly, and since one never knows how when life may end, you must be willing to take risks,” he says. The second influence has been his mother, who is 80 but, sadly, has been suffering from Alzheimer’s for the past several years. After med school, Papay considered neurosurgery before venturing into the ears, nose, and throat (ENT) field. It was a short walk from there to first plastic surgery and then craniofacial and maxillofacial surgery, with fellowships in Europe and in Salt Lake City. After this, he came to Cleveland Clinic, where he remains to this day.

Papay has been a staff member the Cleveland Clinic since 1992 and was recently appointed that organization’s chairman of the Dermatology and Plastic Surgery Institute. He also serves as vice chairman of the Department of Plastic Surgery, Section Head of Craniofacial/Pediatric Plastic and Reconstructive Surgery. He has published more than 100 scientific papers, abstracts, and book chapters; and he holds five medical device patents, one of which is an implantable device for the treatment/prevention of migraine headaches.

His current clinical research interests include the utilization of bone substitutes in craniofacial reconstruction; nasal valve function in rhinoplasty; facial plastic surgery; and pediatric craniofacial anomalies, of which there are many. Among the most common craniofacial abnormalities are the cleft lip and cleft palate. Others, such as congenital facial paralysis, are much less common but can now be successfully treated.

Papay claims the combination of plastic surgery and biomedical engineering is the ultimate playground for someone with his background. As part of the Cleveland Clinic’s Department of Innovations, Papay has been involved in some extraordinary surgery cases—he is perhaps best known for being on the team that performed the first near total face transplant in 2009. Connie Culp, who had survived a shotgun blast to the face that shattered her nose, cheeks, and upper lip, had a band of scar tissue extending across her face. The face transplant was successful, and physicians expect Culp will be able to have full facial function within a year.

Papay has worked successfully in other areas as well, such as the treatment of chronic wound infections caused by resistant bacteria and the ongoing development of the implantable device to minimize or eliminate migraine headaches. He continues to tinker, to create, and now he holds patents on some of his medical device inventions.

One of Papay’s specialties, pediatric plastic surgery, is primarily reconstructive in nature and has long been performed on infants and children in order to repair either congenital abnormalities or traumatic injuries. One rapidly growing area that Papay gets excited about is pediatric plastic surgery that is almost purely cosmetic.

Connie Culp (left) survived a shotgun blast to the face that shattered her nose, cheeks, and upper lip. The face transplant was successful, and Papay expects Culp will have full facial function within a year.

PSP: Please share some of your impressions of working on the face transplant.

Papay: We got permission to perform three transplants here at the clinic, and Connie is our first patient. We have had great success with her. It was a 22-hour surgery; there were eight surgeons. I was the lead craniofacial surgeon. I saw her 2 weeks ago. She’s doing well and not rejecting her face. We did about a 70% to 80% facial reconstruction from the lower eyelids on down. The nose, upper and lower jaw, and the sinuses are all from a donor patient.

The key to that was not just the technical feat but how can we allow the patient to accept the donor tissues without the antirejection meds. However, she was an amazing technical feat, and we are going to evaluate a second patient.

PSP: How has the field of pediatric surgery changed in recent years?

Papay: With cleft lip and cleft palate, things have been more toward the preventive end. As far as the surgical end, there have been recent advancements in what we call premacular orthopedics, which is molding of the palate before and after surgery. Also, molding of the nose in relation to the surgery so you get a better result for the cleft lip nasal deformity has been increasing in popularity over the past 5 to 6 years. It is more a multidisciplinary approach, with major contributions from the prosthetic and orthodontic fields. This has changed how we approach the cleft lip and cleft palate reconstructions surgically.

PSP: What are some of the most effective treatments currently in use?

Papay was recently appointed the chairman of the Dermatology and Plastic Surgery Institute at the Cleveland Clinic.

Papay: In the last 10 years, a big change to the approach in craniofacial deformities is a procedure known as distraction. It was once very popularized and may have been overdone, but now it has “settled” into relatively better indications for craniofacial anomalies.

Distraction osteogenesis (DO) is a well-established technique used for years by orthopedic surgeons in the repair of long bone defects. In 1992, the first clinical results of craniofacial DO were reported in a small series of patients with congenital mandible deformities.

Distraction is used in conjunction with another procedure called orthognathics, which is where you move the bones exactly where you want them. It is used as an adjunct therapy. The distraction procedure entails cutting the bones and letting them heal to a certain extent. Then the healing zone bone is more like taffy, so you can stretch out that bone a millimeter a day. I think distraction used with premaxillary molding has really helped [in treating] cleft palate deformities.

PSP: Can you expand on the history of distraction and the indications for its use?

Papay: Distraction of the midface and of the upper and lower portions of the jaw has some good indications. This procedure we actually borrowed from a Russian orthopedic surgeon, the Ilizarov technique. He would cut the bones in the lower extremities of dwarfs and gradually stretch them out. The orthopedic surgeons from the US picked that up from them, and Joe McCarthy, who was a plastic surgeon from NYU, picked it up from the orthopedic surgeons. It is a method that was popularized elsewhere but adapted into our field with good results.

PSP: What does the future hold for these types of procedures?

Papay: I think the future lies in the control of bony healing. By that I mean by using biologics or with a drug delivery system, healing the bony cuffs in addition to the healing of cranial deformities.

Currently, there is extensive research going on in bone substitutes as drug delivery systems for these biologics. That probably will happen in the next 4 to 5 years. Right now we are seeing it approach the clinical end. That is going to be balanced by the cost-effectiveness of treating patients with severe craniofacial deformities in light of what is going on with changing reimbursement in the United States for health care.

With cleft lip and cleft palate, things have been more toward the preventive end, according to Papay.

PSP: How will these changes affect plastic surgery, particularly pediatric plastic surgery?

Papay: I think when we talk about advances to craniofacial surgery, plastic and reconstructive surgery, the caveat is going to be how are advancements going to be made in light of potential governmental changes to Medicaid and Medicare and third-party payor reimbursements.

We are looking very carefully at the Obama administration and what they propose for these children. These children don’t really have a voice. It is up to the doctors and the parents of these children to be their voices. I’m concerned about this. Looking at the VA system and Medicaid may be a telltale sign of what the future may hold, not just for the reimbursement end but also as a signal to the end of innovation. Innovation has some risks, and there’s some cost to it. If costs are being scrutinized and limited, I can also see innovation being limited.

PSP: Are you using a lot of bone substitutes at this point, and what is the goal of using them?

Papay: The goal is trying to mimic what the bone lays down as is grows and heals. The reoperation rate when we were using calcium triphosphates was very, very high, so we have limited ourselves and don’t perform as much of that kind of bone reconstruction. But that opens up a door for innovation and advancements. The key is really to accelerate how the bone heals using biologics in a cascade manner with a particular drug delivery system. This is going to be the key in how we operate and distract the bones to heal in a certain manner.

You won’t see much advancement in how the surgery is done, just maybe using micro-endoscopy, minimally invasive surgery, and maybe robotics. But I think what it will be is careful planning with the use of biologics and vector forces within the face, such as distraction, and using helmets on the kids.

PSP: Tell us about craniosynostosis and how it is treated.

Papay: This is a condition characterized by the locking in of the sutures of the skull. They close prematurely, causing deformity and potentially increased intracranial pressure.

What we do surgically is release that suture, cut it out, and try to position the skull to as near a normal appearance as possible and prevent it from growing back too quickly. In Europe, they have tried putting in spring-like devices to distract the bones out, but I don’t think the indications for that are very good. I think we can do a good job surgically.

PSP: There has been a lot of media coverage lately on young people, certainly considered a part of the pediatric population, having elective cosmetic surgery. Do you perform these surgeries in addition to the reconstructive and restorative procedures?

Papay: Because of the trend of younger media stars getting plastic surgery, we are getting an increased demand for pediatric cosmetic surgery, especially from young girls. It has been tempered lately because of the economic downturn. A lot of the plastic surgery shows have also popularized it. The shows imply that plastic surgery is like getting a haircut, and they don’t really show the trauma, the morbidity, or the possibility of morbidity of such procedures. Only a few shows did that.

There’s an increase in adolescent cosmetic surgery at younger and younger ages. I do perform these procedures. It depends on the patient, their maturity, and realistic expectations that they have. It also depends on what stage of growth they are in. For instance, if it is a young girl with excessively large breasts that give her issues with back pain or discomfort, excessive sweating or her bra straps are cutting into her shoulders, or if it is destroying her self-esteem, I will do a breast reduction.

I hesitate to do breast augmentations unless the adolescent has a deformity or a significant difference in breast size, like one is an A cup, the other a C cup. Plastic surgeons have to be a little like psychologists—self-taught in many cases—and discern the difference between narcissism and low self-esteem.

Our society tends to be a “me, me, me” society, and so I think narcissism runs high in our culture. With young men, it’s a little different. The breast buds and hormone levels are taken into account. If the receptors don’t decrease over a couple of years, boys with gynecomastia then need surgery due to the detrimental effects it can have on their self-esteem.

It’s a balance of how these kids are changing hormonally, how they are growing, how they are going through puberty, the potential morbidity and sequelae, and the effects of the surgery on not disturbing their growth. It’s about balance and it depends on the patient, the severity of the cosmetic defect and how fast it is growing, or if it is a true anomaly causing a disturbance in growth. We also consider the psychological capability of the child and the psychosocial ramifications for the child and the family.

PSP: Are there additional certifications or education required to be a pediatric plastic surgeon?

Papay: I am a fellow of the American Academy of Pediatrics. A lot of plastic surgeons can do pediatric plastic surgery, but these tend to be soft-tissue procedures rather than the more complicated bony/craniofacial procedures.

See also “Plastic Surgery, Teenagers, and the Media” by Frederick N. Lukash, MD, FACS, in the June 2007 issue of PSP.

PlasticSurgeryPractice.com

As you get more into the nature of the problem, the intracranial and orbital—in addition to the maxillofacial work needed for craniofacial reconstruction—[physicians] do need further fellowship training beyond their residency for this because of the technical capabilities required. There is no further actual certification required. There is no testing for board certification of pediatric plastic surgery.

PSP: What about one of your latest inventions, an implantable device to treat migraine headaches?

Papay: It is a device implanted at the base of the skull to control the reception of headache pain, especially of migraines and cluster headaches. My job is to design surgical approaches to the device using microendoscopy technology and special instruments.

PSP: What is next for you?

Papay: I am working on my doctorate degree in executive management. My thesis is called “Entrepreneurs in Medicine, Innovations in Medicine.” The key to that is how can we allow donor tissue to be accepted by a patient without all the trauma and antirejection meds—the caustic chemotherapy like drugs and immunosuppressive agents, and the steroids that lower the immune system of the patient. That is the Holy Grail. If we are able to control the tolerance of other tissues, we’ll have a home run and be able to more easily perform transplants.


Connie Jennings is a contributing writer for PSP. She can be reached at [email protected]

NONE MORE HONORABLE

Frank Papay, MD, says that he chose the medical field because he sees it as a very honorable profession. The combination of medicine and science has allowed him to incorporate all his interests from early on in life to form a remarkable career.

Papay believes a true purpose in one’s life is to leave behind a legacy that indicates a strong passion about understanding and caring for people. As he has young sons, he strives to encourage them to develop their own passions, as he did as a child. He leads them to visits to museums, exposure to the arts and music, involvement in the Boy Scouts, and outdoor activities such as canoeing. His goal is to create in them the awe he felt as a child, that he still feels today.

At Cleveland Clinic’s Department of Innovations, Papay can incorporate innovation, invention, and the arts into projects—for example, an adaptation of the patient, the electronics, and electrical or mechanical engineering, and biomaterials is adapted to the problem. The newness from each of these fields is then combined to solve a complex medical problem. This is readily exemplified through the successful completion of the face transplant, the treatment of chronic wound infections caused by resistant bacteria, and the ongoing development of an implantable device to minimize or eliminate migraine headaches.

Yet, above all, he sees the importance of time with his family. However, even outside the clinic arena, his passion is evident through his hobbies. He exercises his artistic abilities through painting, and he still “tinkers” every chance he gets. He enjoys fly-fishing, downhill skiing, and dinners with a few friends and good discussions. Topics may include new health care reforms, religion, and philosophy.

Currently working toward a doctorate degree in medical management, Papay is passionate about biotechnical engineering and learning to be a good entrepreneur. One can be a good inventor but not necessarily a good entrepreneur, he claims.

Being a successful entrepreneur is all about the transference of risk, he says, adding that in medicine risks must be taken, but what is the best way to transfer it? His thesis is actually, “How can serial entrepreneurs quantize risks, and what constitutes the transference of risks in entrepreneurial new ventures?”

His favorite quote, by Bernadine Healy: ”What’s important is really who is important. The people that are important in your life, they are the people that you are at their bedside at their death, and they are at your bedside at your death.”

Papay makes every attempt to surround himself with his family and be as close to them as much as possible, reminding himself it is so very important to ensure what or, more significantly, who is important to him.

—CJ