Successes and lessons learned after more than a decade of upper extremity and face transplantation

Outcomes in facial transplantation - a systematic review

Facial transplantations have become a clinical reality as the last reconstructive option in severely disfigured patients. To date, clinical outcomes remain unclear. The purpose of this paper was to analyse the outcomes in facial transplantation (FT) and determine the risks and benefits of FT based on short- and long-term outcomes. An electronic literature search was performed across PubMed, EMBASE and the Cochrane Central Register for Controlled Trials (CENTRAL) databases to capture all the relevant records relating to outcomes in FTs from 2005 to 2021. Articles for inclusion were decided upon pre-defined inclusion and exclusion criteria. A total of 48 FTs has been performed to date. A total of 90 studies met the eligibility criteria and were included in the outcome analysis. Studies were analysed based on each of the 48 cases and outcomes categorised into short-term (<36 months) and long-term (>36 months) outcomes. Primary outcomes included patient and graft survival and secondary outcomes included functional, surgical revision events, immunological, medical complications, aesthetics, psychosocial and quality of life. Mortality rate, infection and malignancy incidence remain high, and patients should be fully informed of the potential life-threatening complications. FTs improve outcomes such as quality of life and psychosocial recovery in the short- and long-term. Outcomes remain under-reported in peer-review journals.

Skull and Scalp En-Bloc Harvest Protects Calvarial Perfusion: A Cadaveric Study

BACKGROUND

 Calvarial defects are severe injuries that can result from a wide array of etiologies. Reconstructive modalities for these clinical challenges include autologous bone grafting or cranioplasty with biocompatible alloplastic materials. Unfortunately, both approaches are limited by factors such as donor site morbidly, tissue availability, and infection. Calvarial transplantation offers the potential opportunity to address skull defect form and functional needs by replacing "like-with-like" tissue but remains poorly investigated.

METHODS

 Three adult human cadavers underwent circumferential dissection and osteotomy to raise the entire scalp and skull en-bloc. The vascular pedicles of the scalp were assessed for patency and perfused with color dye, iohexol contrast agent for computed tomography (CT) angiography, and indocyanine green for SPY-Portable Handheld Imager assessment of perfusion to the skull.

RESULTS

 Gross changes were appreciated to the scalp with color dye, but not to bone. CT angiography and SPY-Portable Handheld Imager assessment confirmed perfusion from the vessels of the scalp to the skull beyond midline.

CONCLUSION

 Calvarial transplantation may be a technically viable option for skull defect reconstruction that requires vascularized composite tissues (bone and soft tissue) for optimal outcomes.

Skull and Scalp En-Bloc Harvest Protects Calvarial Perfusion: A Cadaveric Study

BACKGROUND

 Calvarial defects are severe injuries that can result from a wide array of etiologies. Reconstructive modalities for these clinical challenges include autologous bone grafting or cranioplasty with biocompatible alloplastic materials. Unfortunately, both approaches are limited by factors such as donor site morbidly, tissue availability, and infection. Calvarial transplantation offers the potential opportunity to address skull defect form and functional needs by replacing "like-with-like" tissue but remains poorly investigated.

METHODS

 Three adult human cadavers underwent circumferential dissection and osteotomy to raise the entire scalp and skull en-bloc. The vascular pedicles of the scalp were assessed for patency and perfused with color dye, iohexol contrast agent for computed tomography (CT) angiography, and indocyanine green for SPY-Portable Handheld Imager assessment of perfusion to the skull.

RESULTS

 Gross changes were appreciated to the scalp with color dye, but not to bone. CT angiography and SPY-Portable Handheld Imager assessment confirmed perfusion from the vessels of the scalp to the skull beyond midline.

DISCUSSION/CONCLUSION

 Calvarial transplantation may be a technically viable option for skull defect reconstruction that requires vascularized composite tissues (bone and soft tissue) for optimal outcomes.

Reciprocal Donor-Recipient Strain Combinations Present Different Vascularized Composite Allotransplantation Outcomes in Rodent Models

BACKGROUND

Although vascularized composite allotransplantation (VCA) has been the focus of many animal studies, further research is needed to determine the potential for a generalized model and immunosuppression regimen that applies across different donor-recipient combinations. In this study, the authors evaluated the outcome of VCAs performed on reciprocal rodent donor-recipient combinations.

METHODS

VCA was performed in rats using Lewis and Brown Norway (BN) donor-recipient pairs, under the previously reported antilymphocyte serum/cyclosporine/adipose-derived stem cell regimen. Similarly, a published co-stimulatory blockade/rapamycin regimen was performed on the mouse VCA model between Balb/C and C57BL/6 strains.

RESULTS

To accommodate the active behaviors of BN recipients, the allograft had to be modified and inset to the neck instead of to the groin. The tolerogenic regimen did not provide the same benefits for BN rats as it did for Lewis recipients. Increasing antilymphocyte serum dose and extending the duration of cyclosporine administration from 10 to 21 days significantly prolonged allograft survival and induced donor-specific tolerance. In mice, the co-stimulatory blockade/rapamycin regimen produced inferior VCA outcomes in BALB/c recipients than in C57BL/6 recipients. In both rats and mice, the authors identified an association between the tolerance outcome and the peripheral chimerism measured on postoperative day 30.

CONCLUSIONS

Reciprocal donor-recipient combinations led to different responses toward the immunosuppression regimen and varied VCA outcomes. Sustained donor chimerism that remained in circulation for 1 month after surgery supported long-term VCA survival. Modification of the model and immunosuppression regimen accordingly is recommended.

CLINICAL RELEVANCE STATEMENT

Various donor-recipient combinations respond differently to the immunosuppression regimens. Maintaining donor chimerism for 30 days after surgery improves VCA survival. It is recommended to tailor the immunosuppression regimen based on the recipient's background to optimize outcomes.

IL-10 modified mRNA monotherapy prolongs survival after composite facial allografting through the induction of mixed chimerism

Vascularized composite allotransplantation has great potential in face transplantation by supporting functional restoration following tissue grafting. However, the need for lifelong administration of immunosuppressive drugs still limits its wide use. Modified mRNA (modRNA) technology provides an efficient and safe method to directly produce protein in vivo. Nevertheless, the use of IL-10 modRNA-based protein replacement, which exhibits anti-inflammatory properties, has not been shown to prolong composite facial allograft survival. In this study, IL-10 modRNA was demonstrated to produce functional IL-10 protein in vitro, which inhibited pro-inflammatory cytokines and in vivo formation of an anti-inflammatory environments. We found that without any immunosuppression, C57BL/6J mice with fully major histocompatibility complex (MHC)-mismatched facial allografts and local injection of IL-10 modRNA had a significantly prolonged survival rate. Decreased lymphocyte infiltration and pro-inflammatory T helper 1 subsets and increased anti-inflammatory regulatory T cells (Tregs) were seen in IL-10 modRNA-treated mice. Moreover, IL-10 modRNA induced multilineage chimerism, especially the development of donor Treg chimerism, which protected allografts from destruction because of recipient alloimmunity. These results support the use of monotherapy based on immunomodulatory IL-10 cytokines encoded by modRNA, which inhibit acute rejection and prolong allograft survival through the induction of donor Treg chimerism.

Bionic Prostheses: The Emerging Alternative to Vascularised Composite Allotransplantation of the Limb

Twenty years have surpassed since the first vascularised composite allotransplantation (VCA) of the upper limb. This is an opportunity to reflect on the position of VCA as the gold standard in limb reconstruction. The paucity of recipients, tentative clinical outcomes, and insufficient scientific progress question whether VCA will remain a viable treatment option for the growing numbers of amputees. Bionic technology is advancing at a rapid pace. The prospect of widely available, affordable, safely applied prostheses with long-standing functional benefit is appealing. Progress in the field stems from the contributions made by engineering, electronic, computing and material science research groups. This review will address the ongoing reservations surrounding VCA whilst acknowledging the future impact of bionic technology as a realistic alternative for limb reconstruction.

The Mandible Ameliorates Facial Allograft Rejection and Is Associated with the Development of Regulatory T Cells and Mixed Chimerism

Vascularized composite allografts contain various tissue components and possess relative antigenicity, eliciting different degrees of alloimmune responses. To investigate the strategies for achieving facial allograft tolerance, we established a mouse hemiface transplant model, including the skin, muscle, mandible, mucosa, and vessels. However, the immunomodulatory effects of the mandible on facial allografts remain unclear. To understand the effects of the mandible on facial allograft survival, we compared the diversities of different facial allograft-elicited alloimmunity between a facial osteomyocutaneous allograft (OMC), including skin, muscle, oral mucosa, and vessels, and especially the mandible, and a myocutaneous allograft (MC) including the skin, muscle, oral mucosa, and vessels, but not the mandible. The different facial allografts of a BALB/c donor were transplanted into a heterotopic neck defect on fully major histocompatibility complex-mismatched C57BL/6 mice. The allogeneic OMC (Allo-OMC) group exhibited significant prolongation of facial allograft survival compared to the allogeneic MC group, both in the presence and absence of FK506 immunosuppressive drugs. With the use of FK506 monotherapy (2 mg/kg) for 21 days, the allo-OMC group, including the mandible, showed prolongation of facial allograft survival of up to 65 days, whereas the myocutaneous allograft, without the mandible, only survived for 34 days. The Allo-OMC group also displayed decreased lymphocyte infiltration into the facial allograft. Both groups showed similar percentages of B cells, T cells, natural killer cells, macrophages, and dendritic cells in the blood, spleen, and lymph nodes. However, a decrease in pro-inflammatory T helper 1 cells and an increase in anti-inflammatory regulatory T cells were observed in the blood and lymph nodes of the Allo-OMC group. Significantly increased percentages of donor immune cells were also observed in three lymphoid organs of the Allo-OMC group, suggesting mixed chimerism induction. These results indicated that the mandible has the potential to induce anti-inflammatory effects and mixed chimerism for prolonging facial allograft survival. The immunomodulatory understanding of the mandible could contribute to reducing the use of immunosuppressive regimens in clinical face allotransplantation including the mandible.

Mechanical Irritation in Vascularized Composite Tissue Allotransplantation Triggers Localized Skin Rejection

BACKGROUND

Mechanical and thermal stress has been observed to trigger skin rejection in hand-transplanted patients. This study aims to investigate this phenomenon.

METHODS

Syngeneic and allogeneic orthotopic hindlimb transplantations were performed using male rats (Brown Norway to Lewis). Using a specially designed device, standardized mechanical skin irritation at a force of 5 N was applied to the planta pedis of the transplanted limb for 10 days, 4 times daily for 10 minutes. Biopsies, taken on day 10 and after a 5-day observational period, were assessed for macroscopic alterations using a standardized scale, by histopathology and immunohistochemistry, and for inflammatory protein expression using Luminex technology.

RESULTS

Allogeneic animals displayed significant aggravated macroscopic skin alterations compared with naive (P < 0.0001) and syngeneic controls (P = 0.0023). Histopathology showed a trend toward higher rejection/inflammation grades in allogeneic animals compared with syngeneic controls. Minor skin alterations in syngeneic limbs recovered quickly; however, in allogeneic limbs, macroscopic skin alterations were significantly more pronounced (P < 0.0001) 5 days after irritation. Interleukin-1b and interferon-γ levels were upregulated in skin of allogeneic limbs.

CONCLUSIONS

Mechanical skin irritation in vascularized composite allotransplantation can trigger localized skin inflammation consistent with rejection.

The landscape of vascularized composite allograft donation in the United States

PURPOSE OF REVIEW

Vascularized composite allograft (VCA) donation and transplantation has now demonstrated feasibility and impact to the lives of patients suffering from devastating and traumatic injury. This review summarizes the current landscape of VCA donation in the United States.

RECENT FINDINGS

VCA donations are nonlife-saving allografts, for nonlife-saving transplants - and therefore, conservative donor selection focused on the optimization of donors for the lowest risk to transplant recipients is paramount. VCA donors in the United States are a demographically and clinically diverse group that largely reflects the characteristics of the VCA candidates waiting for transplants. Public opinion about VCA donation is generally supportive, but has lower support for VCA transplants than for solid organ transplants.

SUMMARY

As an emerging area of transplantation, VCA donation is evolving in the United States with growing interest by the public, and those suffering from catastrophic injury for which reconstructive transplantation may offer excellent outcomes and a high quality of life.

The Ethics of Facial Allotransplantation: A Systematic Review

Supplemental Digital Content is available in the text.

Currently, there are more than 40 cases of facial allotransplantation performed by 13 different groups in 10 countries. Although it has become a potential option to reconstruct and restore the function and appearance of severely facially disfigured individuals, the ethical concerns of facial allotransplantation remain unsolved. We conducted a systematic review to better understand the ethical concerns on facial allotransplantation and the changing trends of the ethical debate over time.

Ethicists' Opinions Regarding the Permissibility of Face Transplant

BACKGROUND

Face transplantation can offer functional and aesthetic restoration to patients who have exhausted their reconstructive options, improving quality of life and psychosocial integration. Ethical issues in face transplantation abound, including questions of patient selection and evaluation before transplantation. To date, there has been no study of ethicists' opinions regarding face transplantation.

METHODS

An online survey of attendees of the 2015 International Conference on Clinical Ethics Consultation (n = 401) assessed ethicists' opinions about face transplantation. Questions examined the risk-to-benefit ratio of immunosuppression; permissibility of face transplantation in subpopulations (including children and blind patients); donor-recipient age, sex, and ethnicity mismatches; and ethical oversight.

RESULTS

Most ethicists (84 percent) agreed that it is permissible to perform a face transplantation on an adult in the absence of clear medical contraindications. Most respondents also agreed that it is permissible to perform a face transplantation on a child (62 percent) or a blind patient (61 percent), yet demonstrated less consensus regarding the permissibility of performing a face transplantation on patients with an increased risk of immune rejection. Respondents were generally supportive of age, sex, and ethnicity mismatches, with 43 percent indicating that it is permissible to have a sex mismatch. The majority answered that face transplantation should be covered by federal insurance (74 percent).

CONCLUSIONS

This study provides insight into clinical ethicists' views regarding face transplantation. Most ethicists support the ethical permissibility of face transplantation, and did not have concerns about age, sex, and ethnicity mismatches. These findings highlight emerging areas of consensus regarding the ethical permissibility of face transplantation.

Changes in Articulatory Control Pre- and Post-Facial Transplant: A Case Report

Purpose Facial transplantation involves partial or total replacement of neuromuscular and skeletal structures of the face, head, and neck using donor tissues and is among the most extensive facial reconstructive procedures. This case report compares changes in speech production and articulator movement in a 44-year-old man from pretransplant to a 13-month posttransplant period. Method Speech production and articulator movement data were examined at 5 time points, once pretransplant and 4 times posttransplant (4, 7, 10, and 13 months), and compared to 4 healthy controls. A motion capture system was used to track jaw and vertical/horizontal lip movement during nonspeech and speech tasks. Speech intelligibility, jaw displacement, lip aperture, and movement variability were measured. Results Speech intelligibility varied across the study period and was restored to control status by 7 months posttransplant. Jaw displacement and lip aperture in the vertical plane significantly increased over time for nonspeech and speech tasks. Changes in horizontal lip movements over time were minimal. Jaw and lip movement variability fluctuated over time and was greater than the controls by 13 months posttransplant. Discussion Findings quantify changes in articulator movement and contributions to improved speech production following facial transplant. Changes reflect the adaptability of the speech motor system and are discussed in relation to pretransplant speech motor control patterns.

Utility of IL-2 Complexes in Promoting the Survival of Murine Orthotopic Forelimb Vascularized Composite Allografts

BACKGROUND

Vascularized composite allografts (VCA) are novel, life-enhancing forms of transplantation (Tx). However, host immune responses to the various VCA components, especially those involving skin, are complex and make selection of appropriate therapy challenging. Although the interplay between Foxp3+ T regulatory (Treg) cells and CD4 and CD8 effector T cells is of central importance in determining the acceptance or rejection of solid organ allografts, there is little information available concerning the contribution of Treg cells to VCA survival. In addition, the effects of therapeutic expansion in vivo of host Treg cell populations on VCA survival are unknown.

METHODS

We established a fully major histocompatibility complex-disparate (BALB/c- > C57BL/6) murine orthotopic forelimb Tx model to explore the benefits of pre- and post-Tx IL-2/anti-IL-2 monoclonal antibody complex (IL-2C) administration to expand the host Treg cell population and thereby attempt to promote Treg cell-dependent VCA survival.

RESULTS

Both strategies expanded the Treg cell population in vivo and prolonged VCA survival (P < 0.001), but IL-2C administration pre-Tx led to significantly longer survival compared with IL-2C administration post-Tx (P < 0.01). In addition, compared with post-Tx therapy, pre-Tx therapy resulted in an increased ratio of Treg cells to CD8+ T cells (P < 0.001), reduced proliferation of CD4 and CD8 effector T cells, and reduced production of IFN-γ. Optimal effects were seen when combined with rapamycin therapy, whereas the combination of IL-2C therapy plus calcineurin inhibitor was counterproductive.

CONCLUSIONS

Our studies involving different IL-2C-mediated Treg cell expansion strategies demonstrate that pre-Tx IL-2C therapy may be a useful component for developing strategies to promote VCA survival.

Bioimaging of alloantigen-stimulated regulatory T cells in rat vascularized composite allotransplantation

Background

Tipping the balance toward regulatory T cells (Tregs) through adoptive cell therapy has shown promise to induce transplantation tolerance. Although such strategy has been explored in many mice organ transplantation studies, less knowledge was available in rat systems. Furthermore, the behaviors of the transferred cells have not been well studied in real-time fashion.

Methods

Tregs from naïve LEW rats were purified in two steps with the autoMACS system. Immunosuppression potential of these cells was examined with mixed lymphocyte reaction. Following stimulation by the alloantigen in vitro, the purified Tregs were infused into the recipients of vascularized composite allotransplantation (VCA). Secondary allogeneic skin grafting challenge was performed on the recipients with long-term survived VCA. Live optical imaging was performed to track luciferase-expressing Tregs following infusion to the VCA recipients. Expression of relevant molecules was studied by flow cytometry or quantitative RT-PCR.

Results

Rat Tregs were enriched following two-step cell sorting and showed immunosuppressive capacity. Upon infusion into the VCA recipients that have been treated with antilymphocyte serum and short-term Cyclosporin A, the antigen-stimulated Tregs significantly prolonged VCA survival and induced donor-specific tolerance. Tracking of the infused bioluminescent Tregs showed their specific homing to lymph nodes, and then to the VCAs. Following secondary skin grafting, Tregs specifically gathered at the donor-derived skin that was not rejected by the recipient. The in vivo migratory pattern coincided with the altered expression of cell surface molecules of CD62L, CD103, CD134, and CD278, following donor-antigen stimulation. Elevated expression of CCR4 and CCL22 in allograft may also participate in recruiting Tregs for maintenance of VCA survival and promoting donor-specific tolerance.

Conclusion

Sorted Tregs induced donor-specific tolerance to VCA in rats. Live cell tracking demonstrated that activated CD4⁺CD25⁺FoxP3⁺ Tregs targeted primarily to the lymph nodes and VCA. The Tregs migrated to the secondary grafted donor skin and contributed to the maintenance of donor-specific tolerance. These behaviors were associated with phenotypic changes induced by donor antigen stimulation. Increased expression of CCR4 and CCL22 in VCA skin may also be relevant.

Vascularized Composite Allograft Donation and Transplantation: A Survey of Public Attitudes in the United States

Vascularized composite allograft (VCA) transplantation has emerged as a groundbreaking surgical intervention to return identity and function following traumatic injury, congenital deformity, or disfigurement. While public attitudes toward traditional organ/tissue donation are favorable, little is known about attitudes toward VCA donation and transplantation. A survey was conducted of 1485 U.S. residents in August 2016 to assess VCA donation attitudes. Participants also completed the Revised Health Care System Distrust Scale. Most respondents were willing to donate hands/forearms (67.4%) and legs (66.8%), and almost half (48.0%) were willing to donate the face. Three-quarters (74.4%) of women were willing to donate the uterus; 54.4% of men were willing to donate the penis. VCA donation willingness was more likely among whites and Hispanics (p < 0.001), registered organ/tissue donors (p < 0.001), and those with less health care system distrust (p < 0.001) and media exposure to VCA transplantation (p = 0.003). Many who opposed VCA donation expressed concerns about psychological discomfort, mutilation, identity loss, and the reaction of others to seeing familiar body parts on a stranger. Attitudes toward VCA donation are favorable overall, despite limited exposure to VCA messaging and confusion about how VCA donation occurs. These findings may help guide the development and implementation of VCA public education campaigns.

Hand Transplantation: Current concepts and management algorithm

Introducción. El trasplante de mano ha sido uno de los retos del siglo XXI, cuyo primer caso reportado ocurrió en 1964. En este campo se han hecho estudios y avances que permitieron explorar nuevas alternativas para el manejo del paciente con trasplante de mano, por lo que diversos centros de referencia han realizado análisis basados en sus experiencias, las cuales permitieron lograr la viabilidad de este tipo de trasplante.Objetivo. Esta revisión busca dar una visión general sobre el trasplante de mano y proponer un algoritmo de manejo.Materiales y métodos. La selección de candidatos requiere una serie de criterios, tales como evaluación clínica, paraclínica y psicosocial, desarrollados por un equipo multidisciplinario. La inmunosupresión busca evitar el rechazo y los inmunosupresores deben tener los niveles séricos apropiados para reducir sus efectos adversos. Se han reportado casos de rechazo agudo clásico y atípico, donde la piel es el principal tejido blanco, y rechazo crónico, en el cual se afectan los vasos sanguíneos. El seguimiento se realiza con varias pruebas, de modo que la de oro es la biopsia de piel.Resultados. Las complicaciones del tratamiento farmacológico derivan de la toxicidad de los medicamentos y se manifiestan como alteraciones metabólicas, infecciones oportunistas y neoplasias. La rehabilitación y los aspectos sociales, como el grado de satisfacción del paciente, deben ser evaluados durante la recuperación para asegurar adherencia al tratamiento. En 2011 el registro internacional de alotransplante compuesto de mano reportó 39 casos de trasplante de extremidades superiores con resultados variables; todo esto evidencia que para lograr un resultado óptimo y viable del trasplante debe realizarse seguimiento por un equipo multidisciplinario, red de apoyo del paciente y motivación del mismo, junto con el cumplimiento del manejo farmacológico.Conclusión. Se espera que nuevas investigaciones puedan crear estrategias para desarrollar tolerancia y, de esta forma, reducir el manejo mediante inmunosupresión.

Looking the World in the Face

Total bilateral blindness in the setting of facial transplantation is a controversial matter. Some transplant teams exclude these candidates, while others accept them onto their facial transplant waiting list. Using 3 cases, the clinical and ethical complexity of total bilateral blindness is explored. Guidance (medical, psychological, and social) for total bilateral blindness as both an inclusion and exclusion criterion is provided, with the stipulation that total bilateral blindness should not be an automatic exclusion criterion for facial transplantation. Additionally, guidance for corneal transplant in facial transplant candidates is discussed. Suggestions for posttransplant disability assistance for patients with total bilateral blindness are also provided.

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.

Emerging Implications for Extracellular Matrix-Based Technologies in Vascularized Composite Allotransplantation

Despite recent progress in vascularized composite allotransplantation (VCA), limitations including complex, high dose immunosuppression regimens, lifelong risk of toxicity from immunosuppressants, acute and most critically chronic graft rejection, and suboptimal nerve regeneration remain particularly challenging obstacles restricting clinical progress. When properly configured, customized, and implemented, biomaterials derived from the extracellular matrix (ECM) retain bioactive molecules and immunomodulatory properties that can promote stem cell migration, proliferation and differentiation, and constructive functional tissue remodeling. The present paper reviews the emerging implications of ECM-based technologies in VCA, including local immunomodulation, tissue repair, nerve regeneration, minimally invasive graft targeted drug delivery, stem cell transplantation, and other donor graft manipulation.

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.

Functional outcomes of face transplantation

In this study we provide a compilation of functional impairments before and improvements after face transplantation (FT) of five FT recipients of our institution and all FTs reported in current literature. Functional outcome included the ability to smell, breath, eat, speak, grimace and facial sensation. Before FT, all our patients revealed compromised ability to breath, eat, speak, grimace and experience facial sensation. The ability to smell was compromised in two of our five patients. Two patients were dependent on tracheostomy and one on gastrostomy tubes. After FT, all abilities were significantly improved and all patients were independent from artificial air airways and feeding tubes. Including data given in current literature about the other 24 FT recipients in the world, the abilities to smell, eat and feel were enhanced in 100% of cases, while the abilities of breathing, speaking and facial expressions were ameliorated in 93%, 71% and 76% of cases, respectively. All patients that required gastrostomy and 91% of patients depending on tracheostomy were decannulated after FT. Unfortunately, outcomes remain unreported in all other cases and therefore we are unable to comment on improvements.

Longitudinal progress of overall intelligibility, voice, resonance, articulation and oromyofunctional behavior during the first 21 months after Belgian facial transplantation

PURPOSE

The purpose of this study is to document the longitudinal progress of speech intelligibility, speech acceptability, voice, resonance, articulation and oromyofunctional behavior in a male facial transplant patient 8 days, 15 days, 5 months, 12 months and, finally, 21 months after surgery.

METHOD

Identical objective (Dysphonia Severity Index, nasometry, acoustic analysis) and subjective (consensus perceptual evaluation, Dutch speech intelligibility test; flexible videolaryngostroboscopy/naso-endoscopy) assessment techniques and questionnaires (speech and voice handicap index, oral health impact profile, facial disability index) were used during each of the five postsurgical assessments.

RESULTS

The pattern of results shows a longitudinal progress of speech intelligibility and acceptability and of the interactive processes underpinning overall speech intelligibility. Vocal quality is normal and resonance is characterized by hypernasality. The phonetic inventory is complete but four phonetic disorders remain. Outcomes pertaining to articulation (formant analysis) show evident progress over time. Lip functions are improving but still decreased.

CONCLUSIONS

Transplantation of the face in this patient has largely restored speech. To what extent resonance, articulation, and lip functions can be enhanced by the permanent use of a palatal obturator, by specialized facial and lip movement exercises in combination with motor-oriented speech therapy, is subject for further research. Learning outcomes Facial transplantation: Readers will be able to (1) describe the relationship between facial transplantation and the impact on speech and oromyofunctional behavior, (2) identify variables that influence the outcome after facial transplantation, (3) define an assessment protocol after facial transplantation, (4) define facial transplantation.

Vascularized Composite Allografts: Procurement, Allocation, and Implementation

Vascularized composite allotransplantation is a continuously evolving area of modern transplant medicine. Recently, vascularized composite allografts (VCAs) have been formally classified as 'organs'. In this review, key aspects of VCA procurement are discussed, with a special focus on interaction with the procurement of classical solid organs. In addition, options for a matching and allocation system that ensures VCA donor organs are allocated to the best-suited recipients are looked at. Finally, the different steps needed to promote VCA transplantation in society in general and in the medical community in particular are highlighted.

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.

Vascularization of the facial bones by the facial artery: implications for full face allotransplantation

BACKGROUND

The maxillary artery is recognized as the main vascular supply of the facial bones; nonetheless, clinical evidence supports a codominant role for the facial artery. This study explores the extent of the facial skeleton within a facial allograft that can be harvested based on the facial artery.

METHODS

Twenty-three cadaver heads were used in this study. In 12 heads, the facial, superficial temporal, and maxillary arteries were injected. In one head, facial artery angiography was performed. Ten facial allografts were raised. The soft tissues were dissected to show the arterial anastomotic connections. Radiographs and computed tomographic scans were obtained.

RESULTS

Constant anastomosis between the facial, inferior alveolar, and infraorbital arteries at the mental and infraorbital foramina were found. The facial artery vascularized the homolateral mandibular symphysis, body, and ramus. The condylar and coronoid processes were vascularized in 67 percent of the allografts. The homolateral maxilla was contrasted in all allografts. The alveolar and palatine processes contained the contrast in 83 percent of specimens. The maxillary process of the zygomatic bone was perfused in all allografts, followed by the body, frontal (83 percent), and temporal processes (67 percent). The nasal lateral wall and septum were vascularized in 83 percent of the allografts. The medial and lateral orbital walls and the orbital floor were stained in all specimens. The zygomatic process of the temporal bone was the least perfused bone.

CONCLUSION

A composite allograft containing 90 to 95 percent of the facial bones can be based on bilateral facial arteries.