Experimental model of facial transplant

Preclinical Animal Models in Facial Transplantation

The technical feasibility and clinical applicability of facial transplantation (FT) have been demonstrated, yet animal models with different technical nuances and allograft compositions continue to be developed. We sought to provide a comprehensive appraisal of the current scope and value of animal models in FT.

Animal models for basic and translational research in reconstructive transplantation

Reconstructive transplantation represents a bona fide option for select patients with devastating tissue loss, which could better restore the appearance, anatomy, and function than any other conventional treatment currently available. Despite favorable outcomes, broad clinical application of reconstructive transplantation is limited by the potential side effects of chronic multidrug immunosuppression. Thus, any reconstructive measures to improve these non-life-threatening conditions must address a delicate balance of risks and benefits. Today, several exciting novel therapeutic strategies, such as the implementation of cellular therapies including bone marrow or stem cells that integrate the concepts of immune regulation with those of nerve regeneration, are on the horizon. The development of reliable and reproducible small and large animal models is essential for the study of the unique immunological and biological aspects of vascularized composite allografts and to translate such novel immunoregulatory and tolerance-inducing strategies and therapeutic concepts from the bench to bedside. This review provides an overview of the multitude of small and large animal models that have been particularly designed for basic and translational research related to reconstructive transplantation.

Facial transplantation

The face has functional and aesthetic importance. It represents the most identifiable aspect of an individual's physical being. Its role in a person's identity and ability to communicate can therefore not be overstated. The face also plays an important role in certain functional needs such as speech, communicative competence, eye protection, and emotional expressiveness. The latter function bears significant social and psychological import, because two thirds of our communication takes place through nonverbal facial expressions. Accordingly, the significance of reconstruction of the face is indisputable. Yet despite application of meticulous techniques and the development of innovative approaches, full functional and aesthetic reconstruction of the face remains challenging. This is because optimal reconstruction of specialized units of the face have to address both the functional and aesthetic roles of the face.

[From the first face replants operations to the first total face transplant: the history of surgical prowess]

Composite tissue allografts of the face were considered as science-fiction just a decade ago. They have become wonderful realities in our hospitals. Face transplantation is one of the great scientific adventures of the 21(th) century that history will remember. Physicians dreamed to give a new face to disfigured patients. Allografts of the face have become a reality thanks to breakthroughs in anatomy and plastic surgery, HLA system research, microsurgery, neurology, and immunosuppressive molecules. In 2010, two teams performed the first total face transplants in the world. They represent technical milestones in the history of transplantation. These face transplants, which have raised a lot of controversy and ethical questions, open the way for other surgical perspectives, allowing medicine to write new history, and show that progress is also made through transgression.

[Facial graft, archetype of microsurgical innovation?]

Is innovation breaking of the way of thinking, breaker of taboos, concretisation of chimeras or simple benefit of an ineluctable evolution? The surgical act should be considered as innovation itself? From the first facial allotransplantation, innovation is declined in various ways, which could constitute the different answers regarding the planning and management to prepare such surgery, the realisation of the transplantation and also the multiple developments in terms of science and medicine. It is exactly in that meaning that could be really mentioned the term archetypal.

Human facial allotransplantation: a 2-year follow-up study

BACKGROUND

Progress in composite tissue allotransplantation could provide a new treatment for patients with severe facial disfigurements. We did a partial facial allotransplantation in 2006, and report here the 2 year follow-up of the patient.

METHODS

The recipient, a 30-year-old man from China, had his face severely injured by a bear in October, 2004. Allograft composite tissue transplantation was done in April, 2006, after careful systemic preparation. The surgery included anastomosis of the right mandibular artery and anterior facial vein, whole repair of total nose, upper lip, parotid gland, front wall of the maxillary sinus, part of the infraorbital wall, and zygomatic bone. Facial nerve anastomosis was done during the surgery. Quadruple immunomodulatory therapy was used, containing tacrolimus, mycophenolate mofetil, corticosteroids, and humanised IL-2 receptor monoclonal antibody. Follow-up included T lymphocyte subgroups in peripheral blood, pathological and immunohistochemical examinations, functional progress, and psychological support.

FINDINGS

Composite tissue flap survived well. There were three acute rejection episodes at 3, 5, and 17 months after transplantation, but these were controlled by adjustment of the tacrolimus dose or the application of methylprednisolone pulse therapy. Hepatic and renal functions were normal, and there was no infection. The patient developed hyperglycaemia on day 3 after transplantation, which was controlled by medication.

INTERPRETATION

Facial transplantation could be successful in the short term, but the procedure was not without complications. However, promising results could mean that this procedure might be an option for long-term restoration of severe facial disfigurement.

[Experimental and clinical experience of composite tissues allotransplantation in reconstructive surgery]

Composite tissue allotransplantation (CTA) is a new concept in reconstructive surgery to improve major physical defects with no current solution. Although not a life-saving procedure, tissue replacement by CTA offers great potential for improving quality of life but relies on lifelong immunotherapy. This new practice has become achievable with the refinement of microsurgical techniques, with experience gained from limb and scalp replantations, with the development of organ transplantation and the release of new immunosuppressive drugs. Experimental and clinical research made it possible. The first human cases of CTA proved the reality and the feasibility of the concept. While the early functional results of these allografts are encouraging, they will need to be assessed in the long-term, and development of less toxic - more efficient immonu-suppressive drugs will be a permanent requisite to the broadening of CTA. Although long-term outcome and potential adverse effects of chronic immunosuppression remain uncertain, as for organ transplantation, CTA is already a potential solution for some highly selected patients carrying physical disabilities such as large facial defects and bilateral hand amputation.

Research and Events Leading to Facial Transplantation

Facial transplantation has long captured the interest and imagination of scientists, the media, and the lay public. Facial transplantation could provide an excellent alternative to current treatments for facial disfigurement caused by burns, trauma, cancer extirpation, or congenital birth defects. This article discusses the major technical, immunologic, psychosocial and ethical hurdles that have been overcome to bring facial transplantation from an idea to a clinical reality by providing the reader with a chronologic overview of the research and events that have led this exciting new treatment into the clinical arena.

Cross-leg tibial posterior perforator flap

BACKGROUND

In the lower leg posttraumatic pathology, we are frequently confronted with tissue defects that are difficult to cover by local or distance means, because of either the poor tissue quality or the precarious local vessels. One of the still available methods for solving these cases remains the cross-leg flap. The authors will try to demonstrate the advantages of this method, by using the cross-leg flap based on perforator vessels.

METHODS

We are presenting two cases for which we practiced a cross-leg perforator flap, based on perforator vessels emerging from the posterior tibial artery.

RESULTS

The results were favorable, demonstrated by immobilization in a comfortable position, perfect flap integration, pedicle flap's division at 14-21 days, early postsurgery ambulation.

CONCLUSIONS

The cross-leg perforator flap diminishes many of the disadvantages created by the classic cross-leg flap and can be successfully used in cases in which other procedures are prohibited.

Scalp and Forehead Reconstruction

The reconstruction of defects that involve the scalp and forehead presents unique aesthetic and functional challenges. This article reviews the surgical anatomy of these regions and presents an algorithm for decision making in reconstructive surgery. Nonmicrosurgical techniques are briefly reviewed. The microsurgical reconstruction of scalp and forehead defects differs from the more common oropharyngeal reconstructions in several ways, including flap choices, choices for recipient vessels, and the opportunity to use conventional and microsurgical techniques simultaneously to improve outcomes. Each of these considerations is reviewed and the authors' preferred techniques presented.

Allotransplantation of the Face: How Close Are We?

Reconstruction of patients with severe facial disfigurements due to burns, trauma, or cancer is a challenging task for plastic surgeons. Currently, available reconstructive options rarely result in satisfactory functional and aesthetic outcomes. In this article the authors present the rationale and experimental basis for the introduction of composite facial allograft transplantation in humans. They outline the ethical, social, and media-related issues in facial allograft transplantation.

Face Transplantation: Where Do We Stand?

The recent clinical cases of hand and composite tissue allotransplantation opened a new era in the practice of reconstructive surgery. Some have suggested that face (allo)transplantation could be the next step to benefit patients whose conditions cannot be addressed by conventional techniques of reconstructive surgery using autologous tissues. This article reviews the current status of science regarding the prospect of human face transplantation. The main issues fall into three categories: (1) the surgical challenge of the procedure, specifically regarding vascular viability and functional recovery of the graft; (2) the risks of side effects from life-long immunosuppression necessary to prevent graft rejection; and (3) the ethical debate and the effects of the procedure on the population. Although face transplantation could one day be performed and extend the boundaries of reconstructive surgery, there are currently many obstacles that need to be overcome first.