Anaesthesia and intensive care management of face transplantation

Face transplantation: anesthesia and other organizational considerations

In 2005, the first facial vascularized composite allotransplant was performed in France. In May 2018, our team at Maisonneuve-Rosemont Hospital, Montreal, Quebec, had the privilege to participate in the first facial transplant in Canada. Interdisciplinary collaboration, coordination, and communication formed the cornerstone of this medical undertaking and, ultimately, its success. This report details the anesthetic and organizational considerations of our experience.

Vascularized Composite Allotransplantation in Burn Reconstruction: Systematic Review and Meta-analysis

Vascularized composite allotransplantation has been successfully employed for burn reconstruction since 2003. However, its safety in this population has been questioned due to high levels of alloimmunization from burn care-related tissue exposures. To investigate this, a systematic review of vascularized composite allotransplantation employed for burn reconstruction was conducted, evaluating literature from January 2000 to September 2019. Articles containing vascularized composite allotransplantation, composite tissue allotransplantation, and burn reconstructive surgery were included; articles without published outcomes were excluded. Observational meta-analysis of pooled mortality and acute rejection episodes relative to allograft type (face vs extremity) and reconstruction type (burn vs non-burn) was performed. Twenty-four of the 63 identified articles met the criteria for inclusion, with 5 more articles added after secondary review. To date, 152 allotransplantations have been performed in 117 patients: 45 face transplants and 107 extremity transplants. Of these, 34 (22%) were performed for burn reconstruction in 25 patients (21%) with an overall higher 1-year mortality rate (12.0% vs 1.1%, P  = .030). Of these deaths, 75% received three or more simultaneous allografts. Additionally, more episodes of acute rejection occurred compared to non-burn patients (4.4 vs 2.4, P  = .035). Vascularized composite allotransplantation performed for burn reconstruction was found to be associated with a greater risk of 1-year mortality and nearly twice the number of episodes of acute rejection. Future studies should seek to identify unique risk factors of burn patients undergoing this operation and evaluate the relationship between antigenic burden and surgical outcomes.

Anesthetic Considerations in Facial Transplantation: Experience at NYU Langone Health and Systematic Review

Anesthetic considerations are integral to the success of facial transplantation (FT), yet limited evidence exists to guide quality improvement. This study presents an institutional anesthesia protocol, defines reported anesthetic considerations, and provides a comprehensive update to inform future directions of the field.

Anaesthetic Management for Face Transplantations: The Experience of Akdeniz University

Objective

Solid organ transplantation is a rescue therapy, whereas face transplantation, as well as other composite tissue allotransplantations, offers treatment options to enhance the quality of life. Difficult airway, severe haemorrhage and prolonged operative length are among the frequently encountered complications of anaesthetic management in patients with a history of multiple reconstructive surgeries.

Methods

Five face allotransplants that were performed in our institute, arising from four full and one partial face transplantations, were reviewed. The pitfalls encountered before, during and following surgery were then summarised.

Results

Two of our patients (patients 3 and 4) underwent permanent tracheostomy preoperatively. Transplantation was initiated after surgical tracheostomy under local anaesthesia and under sedation in cases 2 and 5. Patient 1 was orally intubated without difficulty under general anaesthesia and was operated following tracheal cannulation via surgical tracheostomy. Thirteen units of red blood cells were transfused each for patients 2 and 4. Two other patients (patients 1 and 4) each received 5 units of red blood cells. Patient 5, who underwent mid-face transplantation lasting for 7.5 h, was not transfused. No major life-threatening complications were observed intraoperatively or following surgery.

Conclusion

Face transplantation is a surgical procedure in which anaesthetic management may be problematic. The anaesthetist may encounter difficulties, such as difficult airway, severe bleeding, a prolonged operative time and postoperative complications. Side effects and complications may be reduced by strict follow-up and haemodynamic monitoring of patients.

Anesthesia and Perioperative Care in Reconstructive Transplantation

Reconstructive transplantation of vascularized composite allografts (VCAs), such as upper extremity, craniofacial, abdominal, lower extremity, or genitourinary transplants, has emerged as a cutting-edge specialty, with more than 50 programs in the United States and 30 programs across the world performing these procedures. Most VCAs involve complicated technical planning and preparation, protracted surgery, and complex immunosuppressive or immunomodulatory protocols, each associated with unique anesthesiology challenges. This article outlines key procedural, patient, and protocol-related aspects of VCA relevant to anesthesiology management with the goal of ensuring patient safety and optimizing surgical, immunologic, and functional outcomes.

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.

Postoperative Management of Composite Tissue Graft Transplantation

Composite tissue allotransplantation (CTA) is the transplantation of body structures such as the limbs, larynx, abdominal wall, tendons, and face. This chapter discusses the general and specific postoperative management of patients following CTA.

Face transplantation: Anesthetic challenges

Face transplantation is a complex vascular composite allotransplantation (VCA) surgery. It involves multiple types of tissue, such as bone, muscles, blood vessels, nerves to be transferred from the donor to the recipient as one unit. VCAs were added to the definition of organs covered by the Organ Procurement and Transplantation Network Final Rule and National Organ Transplant Act. Prior to harvest of the face from the donor, a tracheostomy is usually performed. The osteotomies and dissection of the midface bony skeleton may involve severe hemorrhagic blood loss often requiring transfusion of blood products. A silicon face mask created from the facial impression is used to reconstruct the face and preserve the donor’s dignity. The recipient airway management most commonly used is primary intubation of an existing tracheostoma with a flexometallic endotracheal tube. The recipient surgery usually averages to 19-20 h. Since the face is a very vascular organ, there is usually massive bleeding, both in the dissection phase as well as in the reperfusion phase. Prior to reperfusion, often, after one sided anastomosis of the graft, the contralateral side is allowed to bleed to get rid of the preservation solution and other additives. Intraoperative product replacement should be guided by laboratory values and point of care testing for coagulation and hemostasis. In face transplantation, bolus doses of pressors or pressor infusions have been used intraoperatively in several patients to manage hypotension. This article reviews the anesthetic considerations for management for face transplantation, and some of the perioperative challenges faced.

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.

Influence of using a single facial vein as outflow in full-face transplantation: A three-dimensional computed tomographic study

BACKGROUND

The aim of this study was to evaluate the contribution of a single unilateral facial vein in the venous outflow of total-face allograft using three-dimensional computed tomographic imaging techniques to further elucidate the mechanisms of venous complications following total-face transplant.

METHODS

Full-face soft-tissue flaps were harvested from fresh adult human cadavers. A single facial vein was identified and injected distally to the submandibular gland with a radiopaque contrast (barium sulfate/gelatin mixture) in every specimen. Following vascular injections, three-dimensional computed tomographic venographies of the faces were performed. Images were viewed using TeraRecon Software (Teracon, Inc., San Mateo, CA, USA) allowing analysis of the venous anatomy and perfusion in different facial subunits by observing radiopaque filling venous patterns.

RESULTS

Three-dimensional computed tomographic venographies demonstrated a venous network with different degrees of perfusion in subunits of the face in relation to the facial vein injection side: 100% of ipsilateral and contralateral forehead units, 100% of ipsilateral and 75% of contralateral periorbital units, 100% of ipsilateral and 25% of contralateral cheek units, 100% of ipsilateral and 75% of contralateral nose units, 100% of ipsilateral and 75% of contralateral upper lip units, 100% of ipsilateral and 25% of contralateral lower lip units, and 50% of ipsilateral and 25% of contralateral chin units.

CONCLUSION

Venographies of the full-face grafts revealed better perfusion in the ipsilateral hemifaces from the facial vein in comparison with the contralateral hemifaces. Reduced perfusion was observed mostly in the contralateral cheek unit and contralateral lower face including the lower lip and chin units.

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.

What is the future of 'organ transplantation' in the head and neck?

PURPOSE OF REVIEW

To update readers on the current state and future of head and neck tissue transplantation.

RECENT FINDINGS

Many exciting advances have recently occurred in the field of head and neck transplantation and regenerative medicine. Larynx, face, and trachea transplants have all been successfully performed. Significant advancements in tissue engineering have occurred, including the ability to generate three-dimensional tissue structures. Transplantation of regenerated tissues has been successfully incorporated into airway reconstruction.

SUMMARY

These exciting advancements set the foundation to expand reconstructive options for dysfunctional tissues and to improve a patient's quality of life.

Vascularized composite allotransplant in the realm of regenerative plastic surgery

Vascularized composite allotransplant (VCA) has led to new treatment options for patients with severe upper extremity and facial injuries. Although VCA can restore form and function, it exposes the patient to the risks associated with lifelong immunosuppression. Hopefully, ongoing advances in regenerative medicine will someday obviate the need for VCA, but until that time, VCA remains an immediate means of reconstructing otherwise unreconstructable defects. We review the outcomes of hand and face transplants, as well as the recent developments in immunosuppression as it relates to the field of VCA.