Cadaveric comparison of two facial flap-harvesting techniques for alloplastic facial transplantation

Facial Resurfacing With Prefabricated Induced Expanded Skin Flap

Massive facial damages extremely affect the facial appearance and function. In existing publications, the surgical flap transfer was still prior to other methods in repairing the facial injury. Among them, the prefabricated induced expanded skin flap seems more effective based on the facial specific features and damage range. In this study, a literature research was carried out in the database of PubMed. A total of 85 patients were included and all of them underwent the method of prefabricated expanded flap to reconstruct the massive facial defects. The prefabricated induced expanded skin flaps harvested from the neck and chest area have prominent advantage in resetting massive facial deformities. All the flaps survived demonstrated an excellent texture and color match with the facial defects areas. However, the unsolved problems are still existed in these flaps and further research is necessary to obtain a satisfactory outcome for both patients and surgeons.

Verification of Embolic Channel Causing Blindness Following Filler Injection

BACKGROUND

Ocular complications following cosmetic filler injections are serious situations. This study provided scientific evidence that filler in the facial and the superficial temporal arteries could enter into the orbits and the globes on both sides. We demonstrated the existence of an embolic channel connecting the arterial system of the face to the ophthalmic artery.

METHODS

After the removal of the ocular contents from both eyes, liquid dye was injected into the cannulated channel of the superficial temporal artery in six soft embalmed cadavers and different color dye was injected into the facial artery on both sides successively. The interior sclera was monitored for dye oozing from retrograde ophthalmic perfusion.

RESULTS

Among all 12 globes, dye injections from the 12 superficial temporal arteries entered ipsilateral globes in three and the contralateral globe in two arteries. Dye from the facial artery was infused into five ipsilateral globes and in three contralateral globes. Dye injections of two facial arteries in the same cadaver resulted in bilateral globe staining but those of the superficial temporal arteries did not. Direct communications between the same and different arteries of the four cannulated arteries were evidenced by dye dripping from the cannulating needle hubs in 14 of 24 injected arteries. Compression of the orbital rim at the superior nasal corner retarded ocular infusion in 11 of 14 arterial injections.

CONCLUSION

Under some specific conditions favoring embolism, persistent interarterial anastomoses between the face and the eye allowed filler emboli to flow into the globe causing ocular complications.

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.

Vascular communications between donor and recipient tissues after successful full face transplantation

The vascular reorganization after facial transplantation has important implications on future surgical planning. The purpose of this study was to evaluate blood flow (BF) after full face transplantation using wide area-detector computed tomography (CT) techniques. Three subjects with severe craniofacial injury who underwent full face transplantation were included. All subjects underwent a single anastomosis bilaterally of the artery and vein, and the recipient tongue was preserved. Before and after surgery, dynamic volume CT studies were analyzed for vascular anatomy and blood perfusion. Postsurgical CT showed extensive vascular reorganization for external carotid artery (ECA) angiosome; collateral flows from vertebral, ascending pharyngeal or maxillary arteries supplied the branches from the recipient ECAs distal to the ligation. While allograft tissue was slightly less perfused when the facial artery was the only donor artery when compared to an ECA-ECA anastomosis (4.4 ± 0.4% vs. 5.7 ± 0.7%), allograft perfusion was higher than the recipient normal neck tissue. BF for the recipient tongue was maintained from contralateral/donor arteries when the lingual artery was sacrificed. Venous drainage was adequate for all subjects, even when the recipient internal jugular vein was anastomosed in end-to-end fashion on one side. In conclusion, dynamic CT identified adequate BF for facial allografts via extensive vascular reorganization.

Three patients with full facial transplantation

Unlike conventional reconstruction, facial transplantation seeks to correct severe deformities in a single operation. We report on three patients who received full-face transplants at our institution in 2011 in operations that aimed for functional restoration by coaptation of all main available motor and sensory nerves. We enumerate the technical challenges and postoperative complications and their management, including single episodes of acute rejection in two patients. At 6 months of follow-up, all facial allografts were surviving, facial appearance and function were improved, and glucocorticoids were successfully withdrawn in all patients.

Feasibility, reproducibility, risks and benefits of face transplantation: a prospective study of outcomes

Composite tissue allotransplantations can be indicated when autologous transfers fail to restore human appearance. We report the reproducibility, difficulties, serious adverse events and outcomes of our patients. Five patients were included in a registered clinical research protocol after thorough screenings assessed by an independent expert committee systematically discussing the alternative options. One patient suffered from plexiform neurofibromas, two from third degree burns and two from gunshot injuries. They were included on a national waiting list with a dedicated face procurement procedure. Transplants were harvested from heart beating brain-dead donors before other tissues and organs. Induction immunosuppressive therapy included antithymocyte globulins, steroids, mycophenolate mophetil and tacrolimus. Maintenance therapy included the last three ones associated with extracorporeal-photopheresis. Four patients were transplanted with 7- to 38-month follow-up. One could not due to multiple panel reactive antibodies after 18 months on waiting list. Acute cellular rejections were controlled by conventional treatment. Opportunistic infections affected all patients and lead one patient to die two month after the transplantation. Voluntary facial activity appeared from 3 to 5 month. Face transplantation has been reproducible under conventional immunosuppression. Major improvements in facial aesthetic and function allowed patients to recover social relations and improved their quality of life.

Some results of our research on composite facial allograft transplantation in dogs

Composite facial allograft transplantation is a complicated surgical procedure, requiring evaluation of several questions. How should the facial allograft be preserved? What are the proper surgical skills to reduce surgery duration? Can composite facial allograft transplantation rebuild the motor functions of the facial muscles? In our research, University of Wisconsin (UW) solution was used to preserve canine facial tissue. We manipulated the surgical procedures of complete facial allograft transplantation on cadavers to improve surgery skills Canine facial allograft models with neuromuscular motor units were performed to evaluate nerve regeneration after allotransplantation. We observed that canine facial allografts could be preserved in UW solution for at least 18 hours. Superficial temporal artery and facial artery bipedicle flaps were safer and saved more time than single pedicle flaps from the external carotid artery. Facial neuromuscular activities were shown in the canine model by the blinking reflex.