Total Face, Double Jaw, and Tongue Transplantation: An Evolutionary Concept

The Face Transplantation Update: 2016

BACKGROUND

Ten years after the first face transplantation, the available data in peer-reviewed literature, various media outlets, and recent specialty meetings and courses are conflicting and inconsistently reported. The purpose of this study was to consolidate the available data by means of multiple sources to reflect an accurate and current state of facial vascularized composite allotransplantation as of December of 2015.

METHODS

Using applied search terms pertaining to face transplantation, a systematic PubMed search, Google search, and review of Plastic Surgery Education Network News Connection e-mailed newsletters were performed, and data presented at three meetings (i.e., the most recent American Society of Reconstructive Transplantation biennial meeting, the American Society of Reconstructive Microsurgery annual meeting, and the biennial AO North America State of the Art: Face Reconstruction and Transplantation course) were consolidated to capture the most contemporary and accurate data in face transplantation.

RESULTS

A total of 37 face transplants have been performed (20 partial and 17 full face) from 2005 to December of 2015. A discrepancy between actual transplantations performed and peer-reviewed reports exists at multiple time points, with a propensity for underreporting. Ten cases were described through media outlets but were not reported by the surgical teams in peer-reviewed literature. Two clinical cases were not described in peer-reviewed literature or media. There have been a total of five deaths, and posttransplant malignancy and revision surgery have been underreported.

CONCLUSIONS

This serves as the most contemporary and all-inclusive face transplantation review. There is a critical need for timely reporting and outcome transparency in the reconstructive transplant community.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

A review of the world's published face transplant cases: ethical perspectives

The highly publicised case of the first ever partial facial transplant in 2005 sparked fierce ethical debates, moral arguments and strong opinions, both within the medical community as well as the general public and mass media. As more patients have undergone facial transplantation over the last decade, some of this initial scepticism has given way to a wider acceptance of this significant reconstructive development. However, despite an improved understanding of the perioperative technicalities and postoperative perils, the risks remain significant and the long-term outcomes are still largely unknown. This article examines the major ethical challenges that have accompanied facial allo-transplantation since its inception. We discuss these ethical dilemmas in the context of the patients, donor families, healthcare professionals and society as a whole, while evaluating some of the emerging evidence and outcomes associated with the physical and psycho-emotional risks linked to this procedure.

Combining Virtual Surgical Planning, Intraoperative Navigation, and 3-Dimensional Printing in Prosthetic-Based Bilateral Microtia Reconstruction

Reconstructing auricular deformities for bilateral microtia is a demanding challenge especially after failed autologous reconstruction. This case report presents a novel application of virtual surgical planning, computer-assisted design, and intraoperative surgical navigation to preplan and execute placement of custom-tailored silicone auricular prostheses and titanium osseointegrated implants for a bone-anchored hearing aid system in a patient with Treacher Collins syndrome in whom autologous reconstruction had previously failed. Through a collaborative approach between the reconstructive surgeon and anaplastologist, the implementation of advanced digital technologies may offer a superior esthetic and functional outcome to patients with previously failed reconstruction.

3D-Printing Technologies for Craniofacial Rehabilitation, Reconstruction, and Regeneration

The treatment of craniofacial defects can present many challenges due to the variety of tissue-specific requirements and the complexity of anatomical structures in that region. 3D-printing technologies provide clinicians, engineers and scientists with the ability to create patient-specific solutions for craniofacial defects. Currently, there are three key strategies that utilize these technologies to restore both appearance and function to patients: rehabilitation, reconstruction and regeneration. In rehabilitation, 3D-printing can be used to create prostheses to replace or cover damaged tissues. Reconstruction, through plastic surgery, can also leverage 3D-printing technologies to create custom cutting guides, fixation devices, practice models and implanted medical devices to improve patient outcomes. Regeneration of tissue attempts to replace defects with biological materials. 3D-printing can be used to create either scaffolds or living, cellular constructs to signal tissue-forming cells to regenerate defect regions. By integrating these three approaches, 3D-printing technologies afford the opportunity to develop personalized treatment plans and design-driven manufacturing solutions to improve aesthetic and functional outcomes for patients with craniofacial defects.

Total Face, Eyelids, Ears, Scalp, and Skeletal Subunit Transplant Cadaver Simulation: The Culmination of Aesthetic, Craniofacial, and Microsurgery Principles

BACKGROUND

The application of aesthetic, craniofacial, and microsurgical principles in the execution of face transplantation may improve outcomes. Optimal soft-tissue face transplantation can be achieved by incorporating subunit facial skeletal replacement and subsequent tissue resuspension. The purpose of this study was to establish a reconstructive solution for a full face and scalp burn and to evaluate outcome precision and consistency.

METHODS

Seven mock face transplants (14 cadavers) were completed in the span of 1 year. Components of the vascularized composite allograft included the eyelids, nose, lips, facial muscles, oral mucosa, total scalp, and ears; and skeletal subunits of the zygoma, nasal bone, and genial segment. Virtual surgical planning was used for osteotomy selection, and to evaluate postoperative precision of hard- and soft-tissue elements.

RESULTS

Each transplant experience decreased each subsequent transplant surgical time. Prefabricated cutting guides facilitated a faster dissection of both donor and recipient tissue, requiring minimal alteration to the allograft for proper fixation of bony segments during inset. Regardless of donor-to-recipient size discrepancy, ample soft tissue was available to achieve tension-free allograft inset. Differences between virtual transplant simulation and posttransplant measurements were minimal or insignificant, supporting replicable and precise outcomes.

CONCLUSIONS

This facial transplant model was designed to optimize reconstruction of extensive soft-tissue defects of the craniofacial region representative of electrical, thermal, and chemical burns, by incorporating skeletal subunits within the allograft. The implementation of aesthetic, craniofacial, and microsurgical principles and computer-assisted technology improves surgical precision, decreases operative time, and may optimize function.

Long-term Tolerance Toward Haploidentical Vascularized Composite Allograft Transplantation in a Canine Model Using Bone Marrow or Mobilized Stem Cells

BACKGROUND

The development of safe and reliable protocols for the transplantation of the face and hands may be accomplished with animal modeling of transplantation of vascularized composite allografts (VCA). Previously, we demonstrated that tolerance to a VCA could be achieved after canine recipients were simultaneously given marrow from a dog leukocyte antigen-identical donor. In the present study, we extend those findings across a dog leukocyte antigen mismatched barrier.

METHODS

Eight recipient dogs received total body irradiation (4.5 cGy), hematopoietic cell transplantation (HCT), either marrow (n = 4) or granulocyte-colony stimulating factor mobilized peripheral blood stem cells (n = 4), and a VCA transplant from the HCT donor. Post grafting immunosuppression consisted of mycophenolate mofetil (28 days) and cyclosporine (35 days).

RESULTS

In 4 dogs receiving bone marrow, 1 accepted both its marrow transplant and demonstrated long-term tolerance to the donor VCA (>52 weeks). Three dogs rejected both their marrow transplants and VCA at 5 to 7 weeks posttransplant. Dogs receiving mobilized stem cells all accepted their stem cell transplant and became tolerant to the VCA. However, 3 dogs developed graft-versus-host disease, whereas 1 dog rejected its stem cell graft by week 15 but exhibited long-term tolerance toward its VCA (>90 weeks).

CONCLUSIONS

The data suggest that simultaneous transplantation of mobilized stem cells and a VCA is feasible and leads to tolerance toward the VCA in a haploidentical setting. However, there is a higher rate of donor stem cell engraftment compared with marrow HCT and an increase in the incidence of graft-versus-host disease.

Technology and vascularized composite allotransplantation (VCA)-lessons learned from the first bilateral pediatric hand transplant

The reconstructive principle of replacing "like with like" is best met with vascularized composite allotransplantation in which the components of an existing defect are "matched" to the greatest extent possible in a single stage restoration. Hand transplantation is a labor-intensive and time-intensive process and can be conceptualized into distinct phases that include (1) patient selection and preoperative preparation, (2) technical execution of the procedure, and (3) postoperative rehabilitation and follow-up. The advent of technological innovations, such as 3D printing technology, novel implant technology, as well as innovative imaging technology, such as functional magnetic resonance imaging have the potential of favorably affecting all phases of this process, thus contributing to improved outcomes. The use of these technologies in the world's first case of bilateral hand transplantation in a pediatric patient is discussed.

Face transplant: long-term follow-up and results of a prospective open study

BACKGROUND

More than 30 face transplantations have been done worldwide since 2005 but no documented long-term follow-up has been reported in the literature. We aimed to answer remaining question about the long-term risks and benefits of face transplant.

METHODS

In this single-centre, prospective, open study, we assessed 20 patients presenting with facial defects. Ten patients were selected, and, after three were secondarily excluded, seven were transplanted: two with neurofibromatosis 1, one with a burn, and four with self-inflicted facial gunshot injuries. We report the long-term outcomes of six face allotransplant recipients at an average of 6 years (range 3·4-9 years) after the transplantation. All admissions to hospital except for planned revisions and immunosuppressive follow-up therapy were reported as adverse events (safety endpoint). Predefined immunological, metabolic, surgical, and social integration endpoints were collected prospectively. Patients underwent quantitative health-related quality of life assessments through Short Form 36 health questionnaires. This study was registered with ClinicalTrials.gov, number NCT00527280.

FINDINGS

Two of seven patients died: one at 65 days due to transplant destruction with concomitant pseudomonas infection and the second at 3·4 years after transplantation by suicide. The six patients alive at long-term follow-up presented with functional transplants. Safety endpoints were related to infection in the first month, acute rejection from 1 day to 7 years after transplantation, or side-effects of immunosuppressive therapy. Recurrent rejection episodes justified maintenance therapy with high-dose steroids at high levels in all patients at last follow-up, yet none of the patients developed diabetes. Three patients were found to have hypertension with one requiring therapy. All patients had a noticeable reduction in glomerular filtration rate. All recipients and their families accepted their transplant. Improvements in social integration and quality of life were highly variable among the patients and depended on baseline levels and psychiatric comorbidities.

INTERPRETATION

These long-term results show the crucial effect of patients' social support and pre-existing psychiatric conditions on the risk-benefit ratio of facial transplantation. Careful preoperative patient selection and long-term postoperative follow-up programmes under strict institutional review board controls should be used for any future grafts of this type.

FUNDING

Protocole Hospitalier de Recherche Clinique (PHRC) National.

The Ever-Evolving State of the Art: A Look Back at the AONA Facial Reconstruction and Transplantation Meetings

Historically, periodic academic meetings held by surgical societies have set the stage for discussion and exchange of ideas, which in turn have led to advancement of clinical practices. Since 2007, the AONA State of the Art: Facial Reconstruction and Transplantation Meeting (FRTM) has been organized to provide a forum for specialists around the world to engage in open conversation about the approaches currently at the forefront of facial reconstruction. Review of registration data of FRTM iterations from 2007 to 2015 was performed. The total number of participants, along with their level of medical training, location of practice, and medical specialty, was recorded. Additionally, academic programs and 2015 participant feedback were evaluated. From 2007 to 2011, there was a decrease in the overall number of participants, with a slight increase in the number of clinical specialties present. In 2013, a sharp increase in total participants, international attendance, and represented clinical specialties was observed. This trend continued in 2015. Adjustments to academic programs have included reorganization of lectures and optimization of content. FRTM is a unique forum for multidisciplinary professionals to discuss the evolving field of facial reconstruction and join forces to accelerate progress and improve patient care.

Optimizing Reconstruction with Periorbital Transplantation: Clinical Indications and Anatomic Considerations

Complex periorbital subunit reconstruction is challenging because the goals of effective reconstruction vary from one individual to another. The purpose of this article is to explore the indications and anatomic feasibility of periorbital transplantation by reviewing our institutional repository of facial injury.

METHODS

Institutional review board approval was obtained at the R Adams Cowley Shock Trauma Center for a retrospective chart review conducted on patients with periorbital defects. Patient history, facial defects, visual acuity, and periorbital function were critically reviewed to identify indications for periorbital or total face (incorporating the periorbital subunit) vascularized composite allotransplantation. Cadaveric allograft harvest was then designed and performed for specific patient defects to determine anatomic feasibility. Disease conditions not captured by our patient population warranting consideration were reviewed.

RESULTS

A total of 7 facial or periorbital transplant candidates representing 6 different etiologies were selected as suitable indications for periorbital transplantation. Etiologies included trauma, burn, animal attack, and tumor, whereas proposed transplants included isolated periorbital and total face transplants. Allograft recovery was successfully completed in 4 periorbital subunits and 1 full face. Dual vascular supply was achieved in 5 of 6 periorbital subunits (superficial temporal and facial vessels).

CONCLUSIONS

Transplantation of isolated periorbital structures or full face transplantation including periorbital structures is technically feasible. The goal of periorbital transplantation is to re-establish protective mechanisms of the eye, to prevent deterioration of visual acuity, and to optimize aesthetic outcomes. Criteria necessary for candidate selection and allograft design are identified by periorbital defect, periorbital function, ophthalmologic evaluation, and defect etiology.

Aesthetic reconstruction of the severely disfigured burned face: a creative strategy for a "natural" appearance using pre-patterned autogenous free flaps

The author reviews his pioneering work in aesthetic restoration of the severely disfigured burn face first introduced in 1995 and refined over the past two decades. The reader will be exposed to the step by step approach to achieving cosmetic enhancement and functional rehabilitation of advanced facial burns. The "keystone" of the autogenous reconstruction is the pre-patterned, sculpted microvascular free flap designed to fit like the "piece of a puzzle" into the aesthetic units of the face to replace disfiguring burn scars. Aggressive intraoperative "sculpting" is employed both "in situ" at the donor site and during the flap transfer to simulate the normal facial contours and planes. Comparisons of the author's approach are made to the whole spectrum of reconstructive modalities ranging from conventional grafting to expanded pre-fabricated flaps and even to CTA face transplants; advantages/disadvantages of each are discussed. The pre-patterned, sculpted microvascular (MV) free flap offers the benefit of a single-stage transfer of composite skin/soft tissue hiding the seams at the junction of facial planes. When harvested from distant donor sites, the donor deformities can easily be concealed. The MV free tissue transfer offers the substrate that can be sculpted into nuanced facial components as well as the "palette" upon which the face can be painted with creative camouflage makeup. The soft contour and texture of the autogenous patterned transfers translates into a "natural" facial appearance while preserving fluid motions of facial expression.

45 Years of Simultaneous Le Fort III and Le Fort I Osteotomies: A Systematic Literature Review

Objective

To review and collectively summarize our knowledge of simultaneous Le Fort III and Le Fort I osteotomies.

Design

A PubMed search using “Le Fort III,” “simultaneous Le Fort III and Le Fort I,” “combined Le Fort III and Le Fort I,” “dual midface,” and “segmental midface” was performed. Articles with relevant abstracts were obtained for formal review. A new case of simultaneous Le Fort III and Le Fort I is presented to describe and discuss specific operative indications and surgical decisions.

Results

There were 14 articles that met inclusion criteria with reports of simultaneous Le Fort III and Le Fort I osteotomies. A total of 20 cases were present in the literature. No major complications were reported. We performed combined Le Fort III with Le Fort I osteotomies in a 25-year-old patient with Crouzon syndrome who had undergone a previous Le Fort III at the age of 4 years. The patient tolerated the procedure well, and postoperatively, her exophthalmos and class III malocclusion were corrected.

Conclusions

Simultaneous Le Fort III and Le Fort I can correct differential upper and lower midface hypoplasia and is a well-tolerated procedure in the mature facial skeleton. This systematic review improves our understanding of the surgical technique and indications for a procedure that can correct complex midfacial deformities.

Craniofacial Measurements of Donors and Recipients Correlate with Aesthetic Outcome in Virtual Face Transplantation

Background:

Face transplantation is an increasingly feasible option for patients with severe disfigurement. Donors and recipients are currently matched based on immune compatibility, skin characteristics, age, and gender. Aesthetic outcomes of the match are not always optimal and not possible to study in actual cases due to ethical and logistical challenges. We have used a reproducible and inexpensive three-dimensional virtual face transplantation (VFT) model to study this issue.

Methods:

Sixty-one VFTs were performed using reconstructed high-resolution computed tomography angiographs of male and female subjects aged 20–69 years. Twenty independent reviewers evaluated the level of disfigurement of the posttransplant models. Absolute differences in 9 soft-tissue measurements and 16 bony cephalometric measurements from each of the VFT donor and recipient pretransplant model pairs were correlated to the reviewers’ evaluation of disfigurement after VFT through a multivariate logistic regression model.

Results:

Five soft-tissue measurements and 3 bony measurements were predictive of the rating of disfigurement after VFT (odds ratio; 95% confidence interval): trichion-to-nasion facial height (1.106; 1.066–1.148), endocanthal width (1.096; 1.051–1.142), exocanthal width (1.067; 1.036–1.099), mouth/chelion width (1.064; 1.019–1.110), subnasale-to-menton facial height (1.029; 1.003–1.056), inner orbit width (1.039; 1.009–1.069), palatal plane/occlusal plane angle (1.148; 1.047–1.258), and sella-nasion/mandibular plane angle (1.079; 1.013–1.150).

Conclusions:

This study provides early evidence for the importance of soft-tissue and bony measurements in planning of facial transplantation. With future improvements to immunosuppressive regimens and increased donor availability, these measurements may be used as an additional criterion to optimize posttransplant outcomes.

Initial experience of dual maintenance immunosuppression with steroid withdrawal in vascular composite tissue allotransplantation

Current immunosuppression in VCA is largely based on the experience in solid organ transplantation. It remains unclear if steroids can be reduced safely in VCA recipients. We report on five VCA recipients who were weaned off maintenance steroids after a median of 2 months (mean: 4.8 months, range 2-12 months). Patients were kept subsequently on a low dose, dual maintenance consisting of tacrolimus and mycophenolate mofetil/mycophenloic acid with a mean follow-up of 43.6 months (median = 40 months, range 34-64 months). Early and late acute rejections responded well to temporarily augmented maintenance, topical immunosuppression, and/or steroid bolus treatment. One late steroid-resistant acute rejection required treatment with thymoglobulin. All patients have been gradually weaned off steroids subsequent to the treatment of acute rejections. Low levels of tacrolimus (<5 ng/mL) appeared as a risk for acute rejections. Although further experience and a cautious approach are warranted, dual-steroid free maintenance immunosuppression appears feasible in a series of five VCA recipients.

Acute rejection in vascularized composite allotransplantation

PURPOSE OF REVIEW

Acute rejection is the most common complication after vascularized composite allotransplantation (VCA). This review provides a state-of-the-art analysis of prevention, diagnosis and treatment of acute rejection episodes and highlights recent findings with the potential to improve patient care and enhance understanding of the underlying biologic processes.

RECENT FINDINGS

Recent reports suggest that maintenance immunosuppression dose reduction and steroid withdrawal are realistic goals in VCA, despite the known high immunogenicity of the skin component. It appears that utilization of sentinel flaps, in-depth histological analyses and application of novel biomarkers have facilitated early diagnosis and characterization of acute rejection episodes, leading to timely institution of appropriate therapy. The successful management of the first highly sensitized face transplant recipient suggests the possibility of carefully considering these high-risk VCA candidates for transplantation.

SUMMARY

Acute rejection is higher in VCA than in any other organ in the field of transplantation, although most episodes are controlled by high-dose steroids and optimization of maintenance immunosuppression. Because of limitations in patient number and the duration of follow-up, the long-term safety and effectiveness of VCA remain unclear. Moreover, the tests currently used to diagnose acute rejection are of limited value. Better diagnostic tools and a better understanding of the immunologic events during acute rejection are therefore needed to improve diagnosis, treatment and outcomes of this life-changing restorative surgery.

Restoration of the donor face after facial allotransplantation: digital manufacturing techniques

INTRODUCTION

Current protocols for facial transplantation include the mandatory fabrication of an alloplastic "mask" to restore the congruency of the donor site in the setting of "open casket" burial. However, there is currently a paucity of literature describing the current state-of-the-art and available options.

METHODS

During this study, we identified that most of donor masks are fabricated using conventional methods of impression, molds, silicone, and/or acrylic application by an experienced anaplastologist or maxillofacial prosthetics technician. However, with the recent introduction of several enhanced computer-assisted technologies, our facial transplant team hypothesized that there were areas for improvement with respect to cost and preparation time.

RESULTS

The use of digital imaging for virtual surgical manipulation, computer-assisted planning, and prefabricated surgical cutting guides-in the setting of facial transplantation-provided us a novel opportunity for digital design and fabrication of a donor mask. The results shown here demonstrate an acceptable appearance for "open-casket" burial while maintaining donor identity after facial organ recovery.

CONCLUSIONS

Several newer techniques for fabrication of facial transplant donor masks exist currently and are described within the article. These encompass digital impression, digital design, and additive manufacturing technology.

Bone Tissue Engineering Challenges in Oral & Maxillofacial Surgery

Over the past decades, there has been a substantial amount of innovation and research into tissue engineering and regenerative approaches for the craniofacial region. This highly complex area presents many unique challenges for tissue engineers. Recent research indicates that various forms of implantable biodegradable scaffolds may play a beneficial role in the clinical treatment of craniofacial pathological conditions. Additionally, the direct delivery of bioactive molecules may further increase de novo bone formation. While these strategies offer an exciting glimpse into potential future treatments, there are several challenges that still must be overcome. In this chapter, we will highlight both current surgical approaches for craniofacial reconstruction and recent advances within the field of bone tissue engineering. The clinical challenges and limitations of these strategies will help contextualize and inform future craniofacial tissue engineering strategies.

Facial transplantation: the first 9 years

Since the first facial transplantation in 2005, 28 have been done worldwide with encouraging immunological, functional, psychological, and aesthetic outcomes. Unlike solid organ transplantation, which is potentially life-saving, facial transplantation is life-changing. This difference has generated ethical concerns about the exposure of otherwise young and healthy individuals to the sequelae of lifelong, high-dose, multidrug immunosuppression. Nevertheless, advances in immunomodulatory and immunosuppressive protocols, microsurgical techniques, and computer-aided surgical planning have enabled broader clinical application of this procedure to patients. Although episodes of acute skin rejection continue to pose a serious threat to face transplant recipients, all cases have been controlled with conventional immunosuppressive regimens, and no cases of chronic rejection have been reported.

Computer-assisted, Le Fort-based, face-jaw-teeth transplantation: a pilot study on system feasiblity and translational assessment

PURPOSE

Le Fort-based face-jaw-teeth transplantation (FJTT) attempts to marry bone and teeth geometry of size-mismatched face-jaw-teeth segments to restore function and form due to severe mid-facial trauma. Recent development of a computer-assisted planning and execution (CAPE) system for Le Fort-based FJTT in a pre-clinical swine model offers preoperative planning, and intraoperative navigation. This paper addresses the translation of the CAPE system to human anatomy and presents accuracy results.

METHODS

Single-jaw, Le Fort-based FJTTs were performed on plastic models, one swine and one human, and on a human cadaver. Preoperative planning defined the goal placement of the donor's Le Fort-based FJTT segment on the recipient. Patient-specific navigated cutting guides helped achieve planned osteotomies. Intraoperative cutting guide and donor fragment placement were compared with postoperative computed tomography (CT) data and the preoperative plan.

RESULTS

Intraoperative measurement error with respect to postoperative CT was less than 1.25 mm for both mock transplants and 3.59 mm for the human cadaver scenario. Donor fragment placement (as compared to the planned position) was less accurate for the human model test case (2.91 mm) compared with the swine test (2.25 mm) and human cadaver (2.26 mm).

CONCLUSION

The results indicate the viability of the CAPE system for assisting with Le Fort-based FJTT and demonstrate the potential in human surgery. This system offers a new path forward to achieving improved outcomes in Le Fort-based FJTT and can be modified to assist with a variety of other surgeries involving the head, neck, face, jaws and teeth.

Establishing cephalometric landmarks for the translational study of Le Fort-based facial transplantation in Swine: enhanced applications using computer-assisted surgery and custom cutting guides

BACKGROUND

Le Fort-based, maxillofacial allotransplantation is a reconstructive alternative gaining clinical acceptance. However, the vast majority of single-jaw transplant recipients demonstrate less-than-ideal skeletal and dental relationships, with suboptimal aesthetic harmony. The purpose of this study was to investigate reproducible cephalometric landmarks in a large-animal model, where refinement of computer-assisted planning, intraoperative navigational guidance, translational bone osteotomies, and comparative surgical techniques could be performed.

METHODS

Cephalometric landmarks that could be translated into the human craniomaxillofacial skeleton, and that would remain reliable following maxillofacial osteotomies with midfacial alloflap inset, were sought on six miniature swine. Le Fort I- and Le Fort III-based alloflaps were harvested in swine with osteotomies, and all alloflaps were either autoreplanted or transplanted. Cephalometric analyses were performed on lateral cephalograms preoperatively and postoperatively. Critical cephalometric data sets were identified with the assistance of surgical planning and virtual prediction software and evaluated for reliability and translational predictability.

RESULTS

Several pertinent landmarks and human analogues were identified, including pronasale, zygion, parietale, gonion, gnathion, lower incisor base, and alveolare. Parietale-pronasale-alveolare and parietale-pronasale-lower incisor base were found to be reliable correlates of sellion-nasion-A point angle and sellion-nasion-B point angle measurements in humans, respectively.

CONCLUSIONS

There is a set of reliable cephalometric landmarks and measurement angles pertinent for use within a translational large-animal model. These craniomaxillofacial landmarks will enable development of novel navigational software technology, improve cutting guide designs, and facilitate exploration of new avenues for investigation and collaboration.

Face transplantation: on the verge of becoming clinical routine?

Introduction. Face transplantation (FT) is an innovative achievement of modern reconstructive surgery and is on the verge of becoming a common surgical opportunity. This review article was compiled to provide an update on this surgical field, especially regarding clinical outcomes, benefits, and complications implied. Methods. We performed an extensive research on all English-language Medline articles, case reports, and reviews published online until September 15, 2013. Used search terms were “face transplantation,” “face transplant,” “facial transplantation,” “facial transplant,” “face allograft,” and “facial allograft.” Results. To date 27 FTs have been performed worldwide. 19 of these cases have been published in the Medline database. Long-term follow-up reports of FT cases are rare. Three deaths associated with the procedure have occurred to date. The clinical outcomes of FT are satisfying. Reinnervation of sensation has been faster than motor recovery. Extensive functional improvements have been observed. Due to strict immunosuppression protocols, no case of hyperacute or chronic rejection and no graft-versus-host disease have occurred to date. Conclusions. As studies on long-term outcomes are missing, particularly regarding immunosuppression-related complications, FT will stay experimental for the next years. Nevertheless, for a small group of patients, FT already is a feasible reconstructive option.

A functional periorbital subunit allograft: vascular, anatomic, and technical considerations for future subunit facial transplantation

BACKGROUND

Injury to the face can result in the loss of critical specialized structures (the eyelids, lips, ears and nose). Vascularized composite allotransplantation (VCA) allows the surgeon to replace exactly what has been lost. The success of the clinical face transplants suggests the possibility of transplanting specialized units of the face. In this study we explore the neurovascular anatomy and technical specifics for harvest of a functional composite eyelid subunit flap.

METHODS

12 fresh cadaver heads were studied, each yielding two flaps (N = 24). The facial (FA) and superficial temporal arteries (STA) were cannulated and injected with a gelatin/acrylic dye mixture. 6 cadaver heads were evaluated via high-resolution three-dimensional CT scans with contrast.

RESULTS

The dye injected into the STA uniformly stained the tissue of the eyelid/periorbital subunit. Injection into the FA resulted in staining of the skin and soft tissues in the medial canthal region and superior eyelid skin in 66% of specimens. CT scan studies confirm our findings with injection into the STA resulting in contrast infiltration of the palpebral arterial arcades in all cases. Injection of the FA resulted in contrast infiltration of the palpebral arterial arcades in 2 of 3 cases.

CONCLUSIONS

Based this study, a periorbital flap can be based on the STA. Motor innervation of the flap is via the zygomatic and buccal branches of the facial nerve with sensory innervation via the infraorbital, supraorbital and supratrochlear nerves. FA could be used, but its ability to perfuse the entire flap was inconsistent.

Facial and hand allotransplantation

Vascularized composite allotransplantation (VCA) is a novel therapeutic option for treatment of patients suffering from limb loss or severe facial disfigurement. To date, 72 hand and 19 facial transplantations have been performed worldwide. VCA in hand and facial transplantation is a complex procedure requiring a multidisciplinary team approach and extensive surgical planning. Despite good functional outcome, courses after hand and facial transplantation have been complicated by skin rejection. Long-term immunosuppression remains a necessity in VCA for allograft survival. To widen the scope of these quality-of-life-improving procedures, minimization of immunosuppression to limit risks and side effects is needed.

Found in space: computer-assisted orthognathic alignment of a total face allograft in six degrees of freedom

PURPOSE

Full facial osteomyocutaneous transplantation requires correct 3-dimensional (3D) alignment of donor osseous structures to a new cranial base with minimal reference points and 6 degrees of potential movement. We investigated whether computer-assisted design and manufacturing (CAD/CAM) could enable accurate placement of the facial skeleton.

MATERIALS AND METHODS

A prospective single-cohort study of Le Fort III-based maxillary-mandibular segment allotransplantation was performed in 5 cadaver pairs and 1 clinical pair. The osteotomies were modeled using computed tomography (CT) data and 3D modeling software and then translated to the donor-recipient pairs using surgical navigation and osteotomy cutting guides. The predicted values were calculated about all rotational axes (pitch, yaw, and roll) and along all translational axes (vertical, horizontal, and anteroposterior) and used as the independent variable. The primary outcome variable of the actual postoperative CT values was compared for fidelity to the prediction using the intraclass correlation coefficient (ICC). The similarity to the donor versus recipient values was calculated as a secondary independent variable, and both predicted and actual measurements were compared with it as a percentage.

RESULTS

The postoperative fidelity to the plan was adequate to excellent (ICC 0.520 to 0.975) with the exception of lateral translation (2.94 ± 1.31 mm predicted left vs 3.92 ± 2.17 mm right actual displacement; ICC 0.243). The predicted and actual values were not consistently skewed toward the donor or recipient values.

CONCLUSIONS

We have demonstrated a novel application of CAD/CAM that enables orthognathic alignment of a maxillary-mandibular segment to a new cranial base. Quantification of the alignment in all 6 degrees of freedom delivers precise control compared with the planned changes and allows postoperative quality control.