Evolution of indications for facial transplantation

Recipient Selection Criteria for Facial Transplantation: A Systematic Review

BACKGROUND

Recipient selection is an important determinant of surgical outcomes in facial transplantation (FT). Appropriately, each FT program develops their own guidelines for recipient selection criteria. Currently, there is no resource to simultaneously assess and identify similarities and differences between these guidelines. Such information could be useful in distinguishing areas of FT that are well understood from those that could benefit from further exploration.

METHODS

We performed a systematic review of the scientific literature from inception to June 18, 2021, using Pubmed, Embase, Cochrane Library, and Scopus to identify articles pertaining to recipient selection criteria. Clinical trials were identified through the Clinicaltrials.gov registry. United States and international program websites were reviewed for patient-facing information.

RESULTS

Our systematic review yielded 90 suitable articles, 8 clinical trials, and 7 program websites containing the recipient selection criteria of 24 different FT programs. The most reported on recipient criteria were age, positive human immunodeficiency viral status (HIV+), positive hepatitis C viral status, psychosocial stability, and medical compliance. Other criteria were rarely addressed, such as blindness and recipient immune status.

CONCLUSIONS

Guidelines among different face transplant programs are changing over time. We found consensus on certain recipient selection criteria, but the majority remain program or surgeon dependent, emphasizing that FT is still an evolving procedure. Although most programs reported on their recipient selection criteria, the rationale was often missing. Further discussion about recipient selection criteria and the reasoning behind employing or changing them will help advance the field.

Modified Le Fort II approach of adequate vascularization preservation in midface allotransplantation: Mock surgery

INTRODUCTION

It is critical to preserve adequate vascularization in midface allotransplantation, the major complication of which is inadequate blood supply in palate area supplying mainly by internal maxillary artery. Therefore, the aim of this study is to explore a modified Le Fort II approach entailing midface vascularization enhancement.

MATERIALS AND METHODS

Ten cadaveric heads were used in mock surgery. A conventional approach was used on seven cadaveric heads to harvest external carotid artery-facial artery-internal maxillary artery axis. On the remaining three cadaveric heads, modified Le Fort II approach was applied where the internal maxillary artery was harvested after cutting off zygomatic arches and rami of the mandible.

RESULTS

The conventional approach had difficulty harvesting internal maxillary artery, which left the facial artery the only blood supply to midface. Modified Le Fort II approach with Computerized surgical planning (CSP) assisted, on the other hand, could completely unveil and harvest intact internal maxillary artery after osteotomy of mandibular ramus.

CONCLUSION

The modified Le Fort II approach with CSP and ultrasonic bone cutter assisted can maximally preserve internal maxillary system with ease. This approach optimizes midface allotransplantation in clinical practice in future.

Implementation and Validation of Free Flaps in Acute and Reconstructive Burn Care

Microsurgical free flap reconstruction in acute burn care offers the option of reconstructing even challenging defects in a single stage procedure. Due to altered rheological and hemodynamic conditions in severely burned patients, it bears the risk of a higher complication rate compared to microsurgical reconstruction in other patients. To avoid failure, appropriate indications for free flap reconstruction should be reviewed thoroughly. Several aspects concerning timing of the procedure, individual flap choice, selection and preparation of the recipient vessels, and perioperative measures must be considered. Respecting these specific conditions, a low complication rate, comparable to those seen in microsurgical reconstruction of other traumatic limb defects, can be observed. Hence, the free flap procedure in acute burn care is a relatively safe and reliable tool in the armamentarium of acute burn surgery. In reconstructive burn care, microsurgical tissue transfer is routinely used to treat scar contractures. Due to the more robust perioperative condition of patients, even lower rates of complication are seen in microsurgical reconstruction.

The four category systematic approach for selecting patients for face transplantation

There is a need for a systematic approach to evaluate patients for potential face transplantation (FT). Ten patients with severe facial defects treated between 1995 and 2017 formed the study group. Data was collected from patient charts and clinical, radiological and laboratory examinations. Facial deficiencies were subdivided into four different categories: anatomical region (10 facial subunits), facial function, aesthetic defect (range 0-9-worst), and impact on health-related quality of life (HRQoL) (15D questionnaire, range 0-1). Immunological status and possible contraindications were also evaluated. Defect aetiology consisted of burns (4), ballistic injury (3), blunt injury (1), blast injury (1), and neurofibromatosis type I (1). All patients had central facial deficiencies and 6 patients had 8 to 10 injured facial subunits. All patients had at least partial loss of facial function. The mean aesthetic disfigurement score was 6.4. The median lowering of 15D score was -0.107. None were significantly sensitized although four patients had relative contraindications and one patient had an absolute contraindication for FT. Three patients with a severe overall facial deficiency were considered as potential FT candidates. We herein propose a comprehensive and systematic tool to evaluate potential candidates for FT. This approach includes assessment of 4 key categories: anatomical regions affected, facial function, aesthetics, and HRQoL.

The 2020 Facial Transplantation Update: A 15-Year Compendium

Over the past 15 years, landmark achievements have established facial transplantation (FT) as a feasible reconstructive option for otherwise irreparable craniofacial defects. However, as the field matures and long-term outcomes begin to emerge, FT teams around the world are now facing new challenges. Data for this review were identified by searches of the PubMed/MEDLINE database from inception through August 2020. All English-language articles pertaining to FT were included. Significant advances in candidate selection, technology, operative technique, posttransplant care, and immunosuppressive management have contributed to the tremendous expansion of the field, culminating in the execution in the past 3 years of 2 facial re-transplantations, and most recently the world’s first successful combined face and double hand transplant in August 2020. Despite these achievements, the allograft donor pool remains limited, with long wait times, requiring surgical experimentation with cross-sex FT. Immunosuppressive management has improved, but significant adverse events continue to be reported. Most recently, the COVID-19 pandemic has placed an unprecedented strain on the healthcare system, with various implications for the practice of reconstructive transplantation. In this article, we provide the most comprehensive and up-to-date FT review, highlighting fundamental lessons learned and recent advancements, while looking toward the challenges ahead. Over the past 15 years, extensive multidisciplinary efforts have been instrumental to the establishment of FT as a feasible reconstructive option. As novel challenges are beginning to emerge, continued collaborative and multispecialty research efforts are needed to further this field.

Oral findings and treatment of patients with face transplants in Helsinki

OBJECTIVES

Oral health and balanced occlusion are important aspects of a well-functioning face transplant. This study describes the oral and dental status, dental management, and sialoendoscopy of the first 2 patients in Helsinki who underwent face transplantations.

STUDY DESIGN

Two patients received near-full face transplantations in 2016 and 2018, respectively. The transplanted tissues included a Le Fort type II maxilla, angle-to-angle mandible, all oral mucosa, ventral tongue tissue, and the muscles of the floor of the mouth. Comprehensive oral examinations and all required dental treatment, including follow-up examinations, were performed for both patients after the transplantations.

RESULTS

Both patients rehabilitated well, and their quality of life improved. Stable, functioning dentition and occlusion were achieved for both patients. Hyposalivation and dental caries were issues for both patients. Patient 1 also experienced infections in the jaws. Implants were placed in the transplanted jaws of patient 2 with successful osseointegration.

CONCLUSIONS

We report successful tooth-bearing face transplantations in 2 patients. Patient selection, particularly regarding oral health, is crucial in avoiding posttransplantation complications. Moreover, the oral and dental status of the donor should be examined by a dentist before transplantation, and regular follow-up dental examinations should be performed after transplantation.

Ocular Considerations in Face Transplantation: Report of 2 Cases and Review of the Literature

PURPOSE

Periorbital injuries are common in face transplantation (FT) candidates. It is therefore essential that the ophthalmologist play a central role in the multidisciplinary treatment of these patients. In this study, the authors perform a comprehensive review of all procedures involving periorbital components, provide an update for the ophthalmology community regarding the current state of the field, and present 2 cases.

METHODS

A comprehensive review of the literature for all FT procedures including periorbital components was performed. The authors also present 2 patients who received FT including periorbital components for extensive facial disfigurement. One patient sustained high-energy avulsive ballistic injury and underwent a total face, double jaw, and tongue transplant in 2012. The second patient received a total face, eyelids, ears, and skeletal subunits transplant for extensive facial burns in 2015.

RESULTS

Literature review demonstrated that 22 (54%) of the 41 patients undergoing FT received allografts containing periorbital components. Only 14 cases (64%) reported on the presence of ocular and periocular complications. The most common complications consisted of lower eyelid ectropion and lagophthalmos, and nearly all required revisional procedures. Both patients presented with significant periorbital scarring and demonstrated good visual acuity and aesthetic outcomes at postoperative follow up between 6 and 28 months.

CONCLUSIONS

Face transplantation can address extensive facial and periorbital disfigurement with satisfactory functional and aesthetic outcomes. The majority of FT performed to date have included periorbital components, and postoperative ocular and periocular complications are common. It is critical for ophthalmologists to play a central role in the care of these patients.

Pediatric face transplantation: a viable option?

PURPOSE OF REVIEW

Face transplantation is no longer a young field. Reported outcomes suggest that this life-enhancing transplantation is viable and ethically justified for appropriate patients. Given that pediatric hand transplantation has been performed with promising reported outcomes, it is time to consider how to properly expand the field of face transplantation into pediatric patients.

RECENT FINDINGS

Appropriate collaboration between adult and pediatric colleagues can mitigate risks associated with expanding surgical innovation between respective patient demographics. The reported outcomes of the first pediatric hand transplant question the appropriateness of increasing immunosuppression burden to a patient on an existing regimen for prior solid organ allotransplantion. Young donor allografts prove to be more resilient, however, implying that managing rejection episodes is key to long-term viability. Expanding face transplants into a younger population must consider the social functions of the face, and may facilitate healthy personal development given the cultural value appearance has in real life and in social media.

SUMMARY

We believe that pediatric face transplantation is not just a viable option, but an ethically reasonable one as long as the field proceeds with cautious optimism.

Analysis of factors involved in brain-death donor processing for face transplantation in Korea: How much time is available from brain death to transplantation?

Background

Face transplantation has naturally evolved from reconstructive procedures. However, few institutions perform face transplantations, because it is time-consuming and it is necessary to justify non-vital organ transplantation. We investigated the process of organ donation from brain-dead patients and the possibility of incorporating face transplantation into the donation process.

Methods

A retrospective review was performed of 1,074 brain-dead patients from January 2015 to December 2016 in Korea. We analyzed the time intervals from admission to brain death decisions (first, second, and final), the causes of brain death, and the state of the transplanted organs.

Results

The patient base (n=1,074) was composed of 747 males and 327 females. The average period between admission to the first brain death decision was 8.5 days (±15.3). The average time intervals between the first brain death decision and medical confirmation using electroencephalography and between the first brain death decision and the final determination of brain death were 16 hours 58 minutes (±14 hours 50 minutes) and 22 hours 57 minutes (±16 hours 16 minutes), respectively. The most common cause of brain death was cerebral hemorrhage/stroke (42.3%), followed by hypoxia (30.1%), and head trauma (25.2%).

Conclusions

When face transplantation is performed, the transplantation team has 22 hours 57 minutes on average to prepare after the first brain death decision. The cause of brain death was head trauma in approximately one-fourth of cases. Although head trauma does not always imply facial trauma, surgeons should be aware that the facial tissue may be compromised in such cases.

Self-Inflicted Gunshot Wound as a Consideration in the Patient Selection Process for Facial Transplantation

Facial transplantation is emerging as a therapeutic option for self-inflicted gunshot wounds. The self-inflicted nature of this injury raises questions about the appropriate role of self-harm in determining patient eligibility. Potential candidates for facial transplantation undergo extensive psychosocial screening. The presence of a self-inflicted gunshot wound warrants special attention to ensure that a patient is prepared to undergo a demanding procedure that poses significant risk, as well as stringent lifelong management. Herein, we explore the ethics of considering mechanism of injury in the patient selection process, referring to the precedent set forth in solid organ transplantation. We also consider the available evidence regarding outcomes of individuals transplanted for self-inflicted mechanisms of injury in both solid organ and facial transplantation. We conclude that while the presence of a self-inflicted gunshot wound is significant in the overall evaluation of the candidate, it does not on its own warrant exclusion from consideration for a facial transplantation.

Face transplantation for the blind: more than being blind in a sighted world

Face transplantation (FT) is a landmark in reconstructive surgery involving vascularised composite allotransplantation. A recent issue of FT for patients who are blind has arisen. Some bioethicists recommend not excluding a patient who is blind, as this may amount to discrimination. From an ethical standpoint, FT for those with blindness is appropriate in selected candidates. This article seeks to add to the clinical evidence supporting FT for those with blindness by detailing a complementary psychosocial perspective. Currently, there is little relevant research about the subjectivity of the blind. This is critical since the arguments against FT for the blind refer to their inability to see their face and to view the reaction of others to their disfigured faces. We begin with a brief look at examples of FT involving blindness and associated arguments. The next part is a multidisciplinary investigation of the experiences of the blind. These are gleaned from a close reading of the literature and drawing inferences, as direct studies are rare. The discussion analyses identity themes of the blind in relation to their faces: as they experience it; the face they wish to show to the world; and how others perceive and react to their face in a saturated environment of imagery and visual communication. Disability and the blind person's experience of faces are well-founded considerations for medical practitioners and ethics boards in the process of FT decision-making.

The Effect of MHC Antigen Matching Between Donors and Recipients on Skin Tolerance of Vascularized Composite Allografts

The emergence of skin-containing vascularized composite allografts (VCAs) has provided impetus to understand factors affecting rejection and tolerance of skin. VCA tolerance can be established in miniature swine across haploidentical MHC barriers using mixed chimerism. Because the deceased donor pool for VCAs does not permit MHC antigen matching, clinical VCAs are transplanted across varying MHC disparities. We investigated whether sharing of MHC class I or II antigens between donors and recipients influences VCA skin tolerance. Miniature swine were conditioned nonmyeloablatively and received hematopoietic stem cell transplants and VCAs across MHC class I (n = 3) or class II (n = 3) barriers. In vitro immune responsiveness was assessed, and VCA skin-resident leukocytes were characterized by flow cytometry. Stable mixed chimerism was established in all animals. MHC class II-mismatched chimeras were tolerant of VCAs. MHC class I-mismatched animals, however, rejected VCA skin, characterized by infiltration of recipient-type CD8⁺ lymphocytes. Systemic donor-specific nonresponsiveness was maintained, including after VCA rejection. This study shows that MHC antigen matching influences VCA skin rejection and suggests that local regulation of immune tolerance is critical in long-term acceptance of all VCA components. These results help elucidate novel mechanisms underlying skin tolerance and identify clinically relevant VCA tolerance strategies.

Vascularized Composite Allotransplantation: Medical Complications

The objective of this review is to summarize the collective knowledge regarding the risks and complications in vascularized composite tissue allotransplantation (VCA), focusing on upper extremity and facial transplantation. The field of VCA has entered its second decade with an increasing experience in both the impressive good outcomes, as well as defining challenges, risks, and experienced poor results. The limited and selective publishing of negative outcomes in this relatively new field makes it difficult to conclusively evaluate outcomes of graft and patient survival and morbidities. Therefore, published data, conference proceedings, and communications were summarized in an attempt to provide a current outline of complications. These data on the medical complications of VCA should allow for precautions to avoid poor outcomes, data to better provide informed consent to potential recipients, and result in improvements in graft and patient outcomes as VCA finds a place as a therapeutic option for selected patients.

Facial transplantation: worth the risks? A look at evolution of indications over the last decade

PURPOSE OF REVIEW

The first face transplant was performed 10 years ago by Dubernard and his team in France. Since then, surgeons have continued to push the frontiers of vascularized composite allotransplantation and broaden the indications for face transplantation. In this review, we summarize some of the recent successes and failures in facial transplantation from the point of view of indications.

RECENT FINDINGS

Recent literature includes case reports on face transplants in sensitized patient, with simultaneous bilateral upper extremity transplants, positive HIV status, and postmalignancy. Additionally, we summarize some of the outcomes of face transplants, including chronic rejection and latent viral infections.

SUMMARY

Facial injuries vary widely, thus candidacy for face transplant should be assessed based on current guidelines, and a case-by-case basis. Although sensitization to donor-specific antigens should not be an absolute contraindication for facial allotransplantation, along with other comorbidities such as positive HIV status, history of malignancy should be evaluated cautiously. Additionally, multiple case studies advice against simultaneous transplantation of multiple vascularized composite allotransplantations. Other considerations include psychological health, social support, and availability for long-term follow-up. Ultimately, face transplant is not simply a surgery; it is a lifelong commitment between a patient and his/her medical team.

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.

Facial transplantation surgery introduction

Severely disfiguring facial injuries can have a devastating impact on the patient's quality of life. During the past decade, vascularized facial allotransplantation has progressed from an experimental possibility to a clinical reality in the fields of disease, trauma, and congenital malformations. This technique may now be considered a viable option for repairing complex craniofacial defects for which the results of autologous reconstruction remain suboptimal. Vascularized facial allotransplantation permits optimal anatomical reconstruction and provides desired functional, esthetic, and psychosocial benefits that are far superior to those achieved with conventional methods. Along with dramatic improvements in their functional statuses, patients regain the ability to make facial expressions such as smiling and to perform various functions such as smelling, eating, drinking, and speaking. The ideas in the 1997 movie "Face/Off" have now been realized in the clinical field. The objective of this article is to introduce this new surgical field, provide a basis for examining the status of the field of face transplantation, and stimulate and enhance facial transplantation studies in Korea.

Facial transplantation: historical developments and future directions

Objective:

To present the clinical outcomes obtained by the first facial transplant teams worldwide, reviewing current practice and addressing controversies.

Methods:

A bibliographic search of Medline and Embase databases was performed, and a comparative analysis of all articles published from 1980 to the present was conducted. Two independent investigators screened the manuscripts in accordance with pre-defined criteria.

Results:

A total of 12 partial and 5 full facial transplants were recorded in the literature. Procedures included partial and near-total facial myocutaneous flaps, and complex osteomyocutaneous grafts. Fifteen patients had fully vascularised grafts, and two patients died of transplant-related and infectious complications.

Conclusion:

Facial transplantation can restore quality of life and enable the social re-integration of recipients. Results published by the first facial transplant teams are promising. However, long-term reports of aesthetic and functional outcomes are needed to more precisely define outcomes. In addition, significant technical, medical and ethical issues remain to be solved.

Utility of sentinel flaps in assessing facial allograft rejection

BACKGROUND

Skin biopsies are critical for histologic evaluation of rejection and proper treatment after facial allotransplantation. Many facial allografts provide only limited skin area, and frequent biopsies may also compromise aesthetic outcome. Sentinel flaps, recovered as free fasciocutaneous radial forearm flaps, have been used for remote-site rejection monitoring. They maintain their axial blood supply, similar to facial allografts. The correlation between facial allografts and sentinel flaps in cases of rejection is presented.

METHODS

The authors analyzed the experience of the Boston team's use of four sentinel flaps. Rejection was evaluated and results were compared for each time point. Sentinel flaps were used as functional flaps whenever possible.

RESULTS

Results showed a reliable correlation between biopsy specimens taken from the facial allograft and sentinel flaps. During severe rejection episodes in 100 percent of biopsy pairs, both sites displayed a similar grade of rejection. In one case, clinical findings suggested rejection in the facial allograft but were unraveled as rosacea, because clinically there was no rejection displayed in the sentinel flap.

CONCLUSIONS

The sentinel flap shows a reliable correlation to the facial allograft in cases of severe rejection, therefore providing a valuable tool for rejection monitoring in facial allotransplantation. Advantages of using these flaps include the avoidance of further surgical procedures to the primary vascularized composite allotransplant, additional use of the sentinel flap to repair damaged nonfacial sites, and its utility as both a clinical and histopathologic barometer of rejection and predictor of the potential existence of facial dermatitis unrelated to rejection.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

The volar forearm fasciocutaneous extension: a strategy to maximize vascular outflow in post-burn injury hand transplantation

SUMMARY

Patients with circumferential extremity burns may have a deficiency of cutaneous veins, which presents a challenge for both autologous reconstruction and vascularized composite allotransplantation. The authors present a 44-year-old, left-hand-dominant man with metacarpal level amputation of his left hand secondary to burn injury. Extensive prior débridement and skin grafting resulted in nearly total absence of cutaneous veins in the forearm. The patient underwent unilateral left hand transplantation with an allograft designed to include a volar forearm fasciocutaneous extension supplied by the radial artery and including the basilic vein to permit augmented venous drainage by means of anastomosis at the antecubital fossa. The volar forearm fasciocutaneous extension can increase vessel caliber and possibly improve reliability in the setting of hand transplantation and should be considered following severe burn injury.

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.

Facial transplantation in a blind patient: psychologic, marital, and family outcomes at 15 months follow-up

BACKGROUND

Quality of life has frequently been reported to improve after vascularized composite allotransplantation of the face. However, psychosocial functioning of the partner or of particular patient groups such as blind patients are until now less well investigated.

OBJECTIVE

The aim of this study is to investigate psychologic, marital, and family functioning of a blind 54-year-old patient, Mr. A, and his partner after facial transplantation.

METHODS

Depressive and anxiety symptoms, hopelessness, personality, coping, resilience, illness cognitions, marital support, dyadic adjustment, family functioning, and quality of life of Mr. A and his partner were assessed before and after facial transplantation and at 15 months follow-up. Reliable change index (RCI) was further calculated to evaluate the magnitude of change.

RESULTS

Most psychologic, marital, and family scores of both Mr. A and his partner were within a normative and healthy range before and after transplant and at 15 months follow-up. Resilience (RCI: 3.6), affective responsiveness (RCI: -3.6), and disease benefits (RCI: 2.6) of Mr. A further improved at 15 months follow-up whereas the physical quality of life (RCI: -14.8) strongly decreased. Only marital support (RCI: -2.1) and depth (RCI: -2.0) of the partner decreased at 15 months.

CONCLUSIONS

The results of this study point to positive psychosocial outcomes in a blind patient after facial transplantation. Further, they may underscore the importance of good psychosocial functioning before transplantation of both partners and of their involvement in psychologic and psychiatric treatment.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Evolution and limitations of conventional autologous reconstruction of the head and neck

Conventional reconstruction in the head and neck has undergone a revolution as microsurgery has evolved and expanded our ability to reconstruct the most difficult defects. Vascularized composite allotransplantation (VCA) has provided a new paradigm of options to restore in 1 stage what in the past has been performed in multiple stages with multiple combinations of free flaps and local flap options. This review demonstrates an evolving perspective of head and neck reconstructive surgery incorporating the indications and advantages gained over a career that has developed in parallel with microsurgery, prefabrication, prelamination, and face transplant. All current conventional reconstructions for the most severe defects often involve multistage procedures, using every rung of the reconstructive ladder, and the end results can still be lacking despite our best efforts. Despite all the tailoring and planning of these multiple flap and multiple-stage reconstructions, in our experience, these interventions never quite exactly recapitulate the face and fall short of full restoration. The early experience with VCA has been very promising and yields results that are superior to those achieved using conventional methods of reconstruction. However, it will be synergistic efforts in both VCA and conventional reconstruction to take us to the next level of full face restoration.

Facial appearance transfer and persistence after three-dimensional virtual face transplantation

BACKGROUND

Facial appearance transfer from donor to recipient in face transplantation is a concern. Previous studies of facial appearance transfer and facial appearance persistence (preservation of the recipient's facial likeness) in face transplants simulated using two-dimensional photographic manipulations found low facial appearance transfer (2.6 percent) and high facial appearance persistence (66 percent). Three-dimensional computer simulation of complex facial transplant patterns may improve the accuracy of facial appearance transfer and facial appearance persistence estimations.

METHODS

Three-dimensional virtual models of human faces were generated from deidentified computed tomographic angiographs and used as "donors" or "recipients" for virtual face transplantation. Surgical planning software was used to perform 73 virtual face transplantations by creating specific facial defects (mandibular, midface, or large) in the recipient models and restoring them with allografts extracted from the donor models. Twenty independent reviewers evaluated the resemblance of each resulting posttransplant model to the donor (facial appearance transfer) and recipient (facial appearance persistence). The results were analyzed using tests for equal results with one-sample and pairwise Rao-Scott Pearson chi-square testing, correcting for clustering and multiple testing.

RESULTS

Overall rates of facial appearance persistence and facial appearance transfer were high (69.2 percent) and low (32.4 percent), respectively. The mandibular pattern had the highest rates of facial appearance persistence and lowest rates of facial appearance transfer. Facial appearance persistence and transfer were similar across sexes.

CONCLUSIONS

Facial appearance persistence is high and facial appearance transfer is low after virtual face transplantation. Appearance transfer and persistence after virtual face transplantation are more dependent on the anatomy than on the size of transplanted facial aesthetic units. This information may reassure recipients of partial face transplants and donor families.

Evolution and trends in reconstructive facial surgery: an update

Surgical correction of congenital and acquired facial deformities has transcended the primitive era of using non biologic materials to current attempts at own face growing through biotechnology. A summative account of this trend is still lacking in the literature. The objective of this article is to present an update on current knowledge in the strides to achieve functionally and aesthetically perfect facial reconstruction. It highlights the impact of advancements in 3D imaging, stereolithographic biomodelling, microvascular surgical tissue transplantation and tissue biotechnology in the surgical efforts to solve the problems of facial disfigurement whether congenital or acquired.

Current principles of facial allotransplantation: the Brigham and Women's Hospital Experience

BACKGROUND

Facial allotransplantation is a revolutionary operation that has at last introduced the possibility of nearly normal facial restoration to patients afflicted by the most severe cases of facial disfigurement.

METHODS

The facial transplantation team at Brigham and Women's Hospital evaluated more than 20 patients as potential face transplant recipients; of these, six became face transplant candidates and underwent full screening procedures. The team performed facial allotransplantations in four of these patients between April of 2009 and May of 2011. This is the largest clinical volume of facial transplant recipients in the United States to date.

RESULTS

The authors have learned important lessons from each of these four unique cases and from the more than 20 patients that they have evaluated as potential face transplant recipients. The authors have translated lessons learned through direct experience into a set of fundamental surgical principles of the operation.

CONCLUSIONS

The authors' surgical principles emphasize safety, technical feasibility, preservation of functional facial units, and return of motor and sensory function. This article describes each of these principles along with their rationale and, in some instances, illustrates their application.

Vascularized composite allotransplantation: an update on medical and surgical progress and remaining challenges

BACKGROUND

In vascularized composite allotransplantation, multiple types of tissue are transferred from donor to recipient as a single functional unit. This technique has been performed for upper extremity, face, and abdominal wall transplants, among many others.

OBJECTIVE

To review the existing cases of face and upper extremity vascularized composite allotransplantation performed to date and to describe the functional outcomes and challenges associated with this new procedure. We also review the immune suppression protocols required for these procedures.

METHODS

A literature review was performed using PubMed and online registries where available to identify patients who have undergone upper extremity and face transplant procedures. These were compiled and cross-referenced to abstracts, conference presentations, and press releases in the media to create a list of procedures performed to date.

RESULTS

More than seventy patients have undergone upper extremity transplantation with very good functional outcomes routinely achieved. Twenty-five face transplants were identified that have been completed to date and details regarding patient outcome are included. One cases of human face allotransplantation with pre- and post-operative images is included as an example of what can be achieved with this technique.

CONCLUSIONS

Vascularized composite allotransplantation is an emerging field that provides an exciting new avenue for reconstructive procedures and achieves functional and cosmetic outcomes not previously possible with existing techniques. However, it is not without its challenges and considerable work is still required prior to widespread adoption of these new reconstructive techniques.

Facial transplantation: a concise update

Objectives: Update on clinical results obtained by the first worldwide facial transplantation teams as well as review of the literature concerning the main surgical, immunological, ethical, and follow-up aspects described on facial transplanted patients. Study design: MEDLINE search of articles published on “face transplantation” until March 2012. Results: Eighteen clinical cases were studied. The mean patient age was 37.5 years, with a higher prevalence of men. Main surgical indication was gunshot injuries (6 patients). All patients had previously undergone multiple conventional surgical reconstructive procedures which had failed. Altogether 8 transplant teams belonging to 4 countries participated. Thirteen partial face transplantations and 5 full face transplantations have been performed. Allografts are varied according to face anatomical components and the amount of skin, muscle, bone, and other tissues included, though all were grafted successfully and remained viable without significant postoperative surgical complications. The patient with the longest follow-up was 5 years. Two patients died 2 and 27 months after transplantation. Conclusions: Clinical experience has demonstrated the feasibility of facial transplantation as a valuable reconstructive option, but it still remains considered as an experimental procedure with unresolved issues to settle down. Results show that from a clinical, technical, and immunological standpoint, facial transplantation has achieved functional, aesthetic, and social rehabilitation in severely facial disfigured patients.

Key words:Face transplantation, composite tissue transplantation, face allograft, facial reconstruction, outcomes and complications of face transplantation.

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.