The Face Transplantation Update: 2016. Plast Reconstr Surg. 2016;137:1841-1850. [PMID: 27219239 DOI: 10.1097/prs.0000000000002149]

Advancing Face Transplantation: A Critical Analysis of Revisions and Long-Term Surgical Outcomes in 10 Cases

BACKGROUND

Face transplantation has emerged as a viable solution for reconstructing the most complex facial injuries. Previous work has demonstrated that surgical revisions are necessary to optimize outcomes. The authors' group has updated the previous report of revisions in their cohort, quantified and described which revisions were performed for functional, aesthetic, or mixed indications, and described the rationale, safety, and long-term outcomes of these revisions.

METHODS

A retrospective analysis of the authors' 10 face transplants from April of 2009 to February of 2023 was performed. The patients' medical records, preoperative facial defects, and operative reports (index and secondary revisions) were reviewed.

RESULTS

Nine patients were included. One patient underwent irreversible acute-on-chronic allograft rejection and received a second face transplant. The average number of revisions was 5.2 per patient (range, 2 to 11 procedures). The median time interval from transplantation to first revision was 4 months (range, 1 to 21 months). Median follow-up was 106 months (range, 39 to 142 months). Most interventions consisted of debulking the allograft or revising the periorbital tissues.

CONCLUSIONS

In the current study, the authors report longer-term data on revision procedures needed in face transplant recipients. Patients should expect to undergo revisions for both functional and aesthetic considerations. Although the majority of revisions are performed within 2 years after transplantation, revisions can be safely performed at any time point. Shared decision-making between the patient and provider team is essential in deciding which revisions are performed and when.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

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.

Long-term outcomes and future challenges in face transplantation

Face transplant (FT) has emerged as a groundbreaking option for patients with severe facial deformities, resulting from congenital disorders, trauma, or tumor ablation. Although reconstructive surgery has made significant strides, the challenges of restoring both form and function remain, particularly in centrally located defects. This review explored the long-term outcomes of FT, addressing its challenges and potential pitfalls. A systematic review following the PRISMA guidelines was conducted, encompassing articles published in English from November 2005 to January 2023, which were searched across PubMed, MEDLINE, and EMBASE databases. Keywords included "face transplant," "face transplant outcomes," and "face transplant long-term." Data on surgical teams, patient demographics, transplant specifics, rejection episodes, additional surgeries, and patient-reported outcomes were extracted and analyzed. In total, 34 articles met the inclusion criteria. Over the 2 decades, 48 FT procedures were performed, with 23 patients followed for at least 3 years. Predominantly, patients were men (80%), averaging 31 years in age. Ballistic trauma (44.6%) and burns (25.5%) were common causes of injury. Chronic rejection emerged as a significant concern, leading to graft loss and necessitating retransplantation in 2 patients. Additional surgical procedures were often required. FT offers a remarkable solution for individuals with extensive facial disfigurement. Successful outcomes depend on factors, such as patient selection, multidisciplinary collaboration, psychiatric evaluation, and post-operative care. Nevertheless, challenges persist, including the need for lifelong immunosuppression and risk of chronic rejection. Although FT has transformed lives, continued success in this evolving field hinges on the ongoing research and vigilant patient management.

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.

Self-inflicted craniomaxillofacial gunshot wounds: management, reconstruction, and outcomes

Suicide by firearm remains one of the leading causes of violence-related injury death in the United States each year. The mortality rate from these injuries is high, resulting in a paucity of outcome data in the literature regarding injuries to the maxillofacial region. This has largely been attributed to a lack of funding for research in this area compared to other leading causes of mortality in the United States. The aim of this study was to detail the authors' experience and approach to complex maxillofacial reconstruction using both local reconstructive methods and microvascular free tissue transfer. A retrospective cohort study was designed, including patients who sustained self-inflicted gunshot wounds to the maxillofacial region between January 1, 2012 and May 1, 2020. Forty-one patients met the inclusion criteria. The majority of the patients were male (87.8%). Mean patient age was 44.2 ± 16.6 years. Alcohol or drugs, and a psychiatric history were present in a majority of the cases. The most involved anatomical region was the midface (75.6% of cases). Seven patients required free tissue transfer for reconstruction, with many needing multiple flaps. Self-inflicted gunshot wounds represent challenging reconstruction scenarios, often in the setting of severe psychological trauma, and require a multidisciplinary team to ensure the optimal outcome.

First Composite Woman-to-Woman Facial Transplantation in Turkey: Challenges and Lessons to Be Learned

ABSTRACT

After the first face transplantation from woman to woman we performed in our clinic, it was aimed to eliminate the lack of knowledge about the subject in the literature by transferring our experiences and long-term results to the problems we had with the patient. A 20-year-old patient underwent partial osteomyocutaneous facial transplant (22nd facial transplant), which included 2 functional units of the face. The patient had no major problems in the early period and had a good aesthetic appearance. In the postoperative period, the patient ended her social isolation and adopted the transplanted face.In the late period, secondary surgical interventions, management of the problems caused by immunosuppression, and the patient's living in a remote location to our clinic were the difficulties encountered. Six revision surgeries were performed after the transplantation. Due to immunosuppression, opportunistic infections and metabolic problems required intermittent hospitalization. The patient died at the end of 56 months because of complications secondary to immunosuppression.A successful transplant involves the management of long-term problems rather than a successful tissue transfer in the early period. In today's conditions, long-term success can be achieved with a good patient compliance, as well as each team member should take an active role in the team at the transplantation centers. More case series are needed to adapt the standard treatment and follow-up protocols for solid organ transplantations for composite tissue allotransplantations. This will be possible by sharing the results and experiences transparently in the centers where face transplantation is performed worldwide.

Maxillary and Mandibular Healing After Facial Allotransplantation

INTRODUCTION

Facial transplantation has emerged as a viable option in treating devastating facial injuries.Despite the high healing rate of Le Fort III and bilateral sagittal split osteotomies (BSSO) in nontransplant patients, few studies have reported assessment of maxillary and mandibular healing in face transplant patients compared with nontransplant patients. The aim of this study was to examine differences in bone healing in our patients.

PATIENTS AND METHODS

A retrospective chart review was conducted of facial allotransplantation patients at the Cleveland Clinic from December 2008 to inception. Demographics such as age, date of birth, and sex were recorded. Additional variables included procedures, revisions, reoperations, medications, and bone stability and healing. Computed tomography (CT) images assessed the alignment of skeletal components, bony union quality, and stability of fixation.

RESULTS

Three patients were included: 2 had Le Fort III segment transplantation, and 1 had transplantation of both a Le Fort III segment and mandibular BSSO. The Le Fort III segment in all patients exhibited mobility and fibrous union at the Le Fort III osteotomy on CT. In contrast, the BSSO healed uneventfully after transplantation and revision surgery, with bony union confirmed by both CT and histology of the fixation area between the donor and recipient mandible bilaterally. No patients with midfacial fibrous union required revision of the nonunion as they were clinically asymptomatic.

CONCLUSION

Le Fort osteotomy demonstrates inferior healing in facial transplantation compared with the nontransplant population. In contrast, the successful healing in the mandible is likely owing to the high density of rich cancellous bone.

Face Transplant: Indications, Outcomes, and Ethical Issues-Where Do We Stand?

Background: The addition of face allotransplantation (FT) to the head and neck reconstructive surgery arsenal has started a true revolution. This study is aimed at providing an extensive analysis of the current practice of composite tissue allotransplantation. Moreover, a thorough description of pre-procedural, intra-operative, and post-procedural settings, indications, contraindications, outcomes, ethical considerations, and future perspectives is provided. Methods: The authors’ experience was supplemented with a literature review performed by using the PubMed, MEDLINE, and Embase databases on 21 February 2022. The search terms used were “face transplantation indications”, “face transplantation complications”, and “face transplantation ethical issues”. Results: The most recent achievements and long-term clinical sequelae of FT are classified and summarized. A large number of records (4435) were identified. Seventy-five articles were assessed for eligibility. Publications without new data and reports with a patient follow-up < 5 years were excluded. Nineteen articles met the criteria for inclusion. Conclusions: The most recent achievements in the field of FT may be combined with cutting-edge regenerative medicine procedures and innovative immunological processing. It is paramount to build strong international networks between the world FT experts in order to achieve higher-level outcomes and reduce the complication rate. Nevertheless, the utmost caution is required in patient selection, clinical assessment, strict follow-up, and rejection management.

'That is the skin of my brother': alterity, hybridity and media representations of facial transplantation

In this paper, I explore the 2012 face transplant performed on US recipient Richard Norris and how it was represented by the media as a 'makeover story'. Informed by press coverage from the date of the transplant to the present day, I examine a widely viewed and critically acclaimed investigative report that aired on CBS's 60 Minutes entitled 'My Brother's Keeper'. Through a close reading of both its form and content, I claim that the report's makeover story consists of four key themes: heroic medicine and miraculous science; appearance-based stigma and social alienation; appearance-based conformity and social assimilation; and subjective alterity and embodied hybridity. In doing so, I contend that the report's themes contain the widespread ambivalence about facial transplantation by confirming prevailing assumptions about medical science and how it creates normal people who live good lives. That said, I also contend that the report's themes complicate these assumptions by highlighting how facial transplantation invariably involves immediate encounters with otherness and corporeal interconnectedness. I conclude that the report's makeover story-characterised as it is by the constraints of the before-and-after format-must be rethought and, ultimately, reworked if we wish to do justice to face transplant recipients.

Clinical and preclinical tolerance protocols for vascularized composite allograft transplantation

The field of vascularized composite allografts (VCAs) has undergone significant advancement in recent decades, and VCAs are increasingly common and accepted in the clinical setting, bringing hope of functional recovery to patients with debilitating injuries. A major obstacle facing the widespread application of VCAs is the side effect profile associated with the current immunosuppressive regimen, which can cause a wide array of complications such as infection, malignancy, and even death. Significant concerns remain regarding whether the treatment outweighs the risk. The potential solution to this dilemma would be achieving VCA tolerance, which would allow recipients to receive allografts without significant immunosuppression and its sequelae. Promising tolerance protocols are being studied in kidney transplantation; four major trials have attempted to withdraw immunosuppressive treatment with various successes. The common theme in all four trials is the use of radiation treatment and donor cell transplantation. The knowledge gained from these trials can provide valuable insight into the development of a VCA tolerance protocol. Despite similarities, VCAs present additional barriers compared to kidney allografts regarding tolerance induction. VCA donors are likely to be deceased, which limits the time for significant pre-conditioning. VCA donors are also more likely to be human leukocyte antigen–mismatched, which means that tolerance must be induced across major immunological barriers. This review also explores adjunct therapies studied in large animal models that could be the missing element in establishing a safe and stable tolerance induction method.

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.

Software-based Detection of Acute Rejection Changes in Face Transplant

BACKGROUND

 An objective, non-invasive method for redness detection during acute allograft rejection in face transplantation (FT) is lacking.

METHODS

 A retrospective cohort study was performed with 688 images of 7 patients with face transplant (range, 1 to 108 months post-transplant). Healthy controls were matched to donor age, sex, and had no prior facial procedures. Rejection state was confirmed via tissue biopsy. An image-analysis software developed alongside VicarVision (Amsterdam, Netherlands) was used to produce R, a measure of differences between detectable color and absolute red. R is inversely proportional to redness, where lower R values correspond to increased redness. Linear mixed models were used to study fixed effect of rejection state on R values. Estimated marginal means of fitted models were calculated for pairwise comparisons.

RESULTS

 Of 688 images, 175, 170, 202, and 141 images were attributable to Banff Grade 0,1,2, and 3, respectively. Estimated change in R value of facial allografts decreased with increasing Banff Grade (p = 0.0001). The mean R value of clinical rejection (Banff Grade ⅔) (16.67, 95% Confidence Interval [CI] 14.79-18.58) was lower (p = 0.005) than non-rejection (Banff Grade 0/1) (19.38, 95%CI 17.43-21.33). Both clinical and non-rejection mean R values were lower (p = 0.0001) than healthy controls (24.12, 95%CI 20.96-27.28).

CONCLUSION

 This proof-of-concept study demonstrates that software-based analysis can detect and monitor acute rejection changes in FT. Future studies should expand on this tool's potential application in telehealth and as a screening tool for allograft rejection.

Early recognition of chronic rejection in a face allotransplant patient with alopecia

The features of chronic rejection (CR) in full-face vascularized composite allotransplantation (VCA) are not well-known. Herein, we report a full-face transplant patient that experienced two episodes of acute rejection (AR) and three episodes of AR/CR over the course of 6-years. The patient noticed a small, round patch of hair loss in his beard 9 months after the second AR episode, which occurred 21 months post-transplantation. Biopsy of the alopecic patch showed lichen-planopilaris-like features, which was suggestive of early CR. Despite an increase in immunosuppressive dosages, the alopecia progressed. Following the second and third AR/CR episodes, the alopecia became more pronounced, with the addition of hyperpigmentation as well as sclerosis and telangiectasia. The findings of multiple biopsies showed CR. Based on these findings we think that alopecia with lichen-planopilaris-like histopathological features similar to grade III AR features, particularly in hair follicles appears to be an early finding of CR in the presented patient. The findings further indicate that follicular involvement may be a significant feature of CR in VCA patients and that it can present prior to sclerosis, vasculopathy, or loss of adnexa. The present case is uniquely important because of the distinctive presentation of CR, with hair follicles clinically and histopathologically affected, leading to progressive and irreversible alopecia with lichen-planopilaris-like histopathology.

Facial Transplantation: Principles and Evolving Concepts

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Appreciate the evolution and increasing complexity of transplanted facial allografts over the past two decades. 2. Discuss indications and contraindications for facial transplantation, and donor and recipient selection criteria and considerations. 3. Discuss logistical, immunologic, and cost considerations in facial transplantation, in addition to emerging technologies used. 4. Understand surgical approaches and anatomical and technical nuances of the procedure. 5. Describe aesthetic, functional, and psychosocial outcomes of facial transplantation reported to date.

SUMMARY

This CME article highlights principles and evolving concepts in facial transplantation. The field has witnessed significant advances over the past two decades, with more than 40 face transplants reported to date. The procedure now occupies the highest rung on the reconstructive ladder for patients with extensive facial disfigurement who are not amenable to autologous reconstructive approaches, in pursuit of optimal functional and aesthetic outcomes. Indications, contraindications, and donor and recipient considerations for the procedure are discussed. The authors also review logistical, immunologic, and cost considerations of facial transplantation. Surgical approaches to allograft procurement and transplantation, in addition to technical and anatomical nuances of the procedure, are provided. Finally, the authors review aesthetic, functional, and psychosocial outcomes that have been reported to date.

Public Perceptions of Cross-Sex Vascularized Composite Allotransplantation

BACKGROUND

Cross-sex vascularized composite allotransplantation has been performed in cadaveric facial transplantation and clinical extremity transplantation. Understanding the challenge of appropriate donor-recipient matching, this study sought to characterize the public's perception of cross-sex vascularized composite allotransplantation.

METHODS

Participants were surveyed in New York City. Data collected included demographics and willingness to donate vascularized composite allografts (VCAs) of various types. Similar questions were asked in the context of same-sex and cross-sex donation.

RESULTS

A total of 101 participants (male: 56.4%; age ≤35 years: 62.4%) were surveyed. The majority expressed willingness to donate to recipients of a different sex (hand: 78.2%, face: 56.4%, penis or uterus: 69.3%, lower limb: 81.2%, abdominal wall: 80.2%, larynx: 81.2%, and solid organs: 85.2%). Among VCAs, willingness to donate facial allografts was significantly different in same-sex versus cross-sex contexts (64.4% vs 56.4%; P = 0.008). Participants were also significantly more likely to donate VCAs to same-sex recipients on behalf of themselves versus loved ones (P < 0.05). There was significantly lower willingness to receive cross-sex versus same-sex facial (P = 0.022) and genital allografts (P = 0.022). Education on the preservation of recipient masculinity or femininity in cross-sex facial transplantation increased participants' willingness to receive a cross-sex face transplant from 56.4% to 71.3% (P = 0.001).

CONCLUSIONS

This study highlights the urban public's acceptance of VCA donation or reception regardless of sex mismatch. There is increased willingness to receive a cross-sex face transplant after education, highlighting opportunities for future focused interventions to increase public awareness and ultimately the donor pool.

Face Transplant: Current Update and First Canadian Experience

SUMMARY

Facial vascularized composite allotransplantation has emerged as a groundbreaking reconstructive solution for patients with severely disfiguring facial injuries. The authors report on the first Canadian face transplant. A 64-year-old man sustained a gunshot wound, which resulted in extensive midface bony and soft-tissue damage involving the lower two-thirds of the face. In May of 2018, he underwent a face transplant consisting of Le Fort III and bilateral sagittal split osteotomies in addition to skin from the lower two-thirds of the face and neck. Virtual surgical planning was used to fabricate osteotomy guides and stereolithographic models. Microsurgical anastomoses of the facial (three branches) and infraorbital nerves were performed bilaterally. At 18-month follow-up, the aesthetic outcome was excellent. Partial restoration of light touch sensation had been observed over the majority of the allograft. Although significantly affected, animation, speech, mastication, and deglutition were continuously improving with intensive therapy. Nevertheless, the patient was now tracheostomy and gastrostomy free. Despite these limitations, he reported a high degree of satisfaction with the procedure and had reintegrated into the community. Four grade I episodes of acute rejection with evidence of endotheliitis were successfully treated. Postoperative complications were mainly infectious, including mucormycosis of the left thigh, treated with surgical resection and antifungal therapy. Undoubtedly, immunosuppression represents the greatest obstacle in the field and limits the indications for facial vascularized composite allotransplantation. Continuous long-term follow-up is mandatory for surveillance of immunosuppression-related complications and functional assessment of the graft.

Facial Transplantation

Facial transplantation represents a unique surgical solution for challenging facial injury patterns in which conservative reconstructive techniques fail to provide a satisfactory functional and aesthetic result. With advances in the field of vascularized composite allotransplantation over the past 15 years, more than 40 of these procedures have been performed worldwide with two recent reports of facial re-transplantation. In this article we discuss the multidisciplinary approach that is required for successful transplantation as well as the surgical techniques used and postoperative management. With ongoing research, recent technological innovation, and increased efforts to promote greater generalizability and transparency in this field, patients with these complex injuries will continue to see improvements in their treatment options, and thus quality of life.

Prefabricated Expanded Flap Combined With Expanded Scalp Flap for Total Face Resurfacing

ABSTRACT

Reconstruction of total facial deformities and defects has been a major challenge of reconstructive surgery. Allotransplantation is limited by the number of donors and the need for life-long immunosuppression. Autotransplantation, where multiple autogenous tissue grafts from various donor sites are used to repair facial defects, inevitably leaves conspicuous patchwork scars. A prefabricated monoblock flap, although the preferred treatment modality, is limited by insufficient blood supply and the large size of the flap. In the Journal of Craniofacial Surgery (2014;25:21-25), Li et al applied the technique of flap prefabrication and stem cell-assisted tissue expansion to reconstruct total facial injuries, but the operations were complicated and the final expanded flap area was also uncertain. This article introduces an approach to reconstruct total facial injuries with a prefabricated expanded thoracic flap combined with an expanded scalp flap (called combined flaps), which not only solves the limitations of blood supply and expanded volume but also reduces patchwork scars. The approach is a simple, feasible, and effective surgical method for total face resurfacing.

The characteristics of regulatory macrophages and their roles in transplantation

Regulatory macrophages (Mregs) are a subtype of macrophages that are involved in regulating immune responses and inhibiting activated T lymphocyte proliferation. With advances in our basic understanding of Mregs and the revelation of their biological characteristics, Mregs have become a focus of research. In addition to promoting malignant tumor progression, Mregs also play an immunosuppressive role in inflammatory diseases and transplantation. Recent studies have shown that Mregs are closely associated with the induction of transplantation immune tolerance. Immune regulatory cell treatment as an adjunct immunosuppressive therapy offers new insights into the mechanism by which transplantation immune tolerance is established. The application of Mreg-based cellular immunotherapy has shown promise in clinical solid organ transplantation. Here, we provide a comprehensive overview of Mreg morphology, phenotype, induction and negative immunoregulatory function and discuss the role of Mregs in different transplantation models as well as their potential application value in clinical organ transplantation.

Facial Transplantation: Complications, Outcomes, and Long-Term Management Strategies

Within the past two decades, vascularized facial composite allotransplantation has evolved into a viable option in the reconstructive surgeons' armamentarium for patients with extensive facial disfigurements. As it has expanded the frontiers of microsurgical reconstructive techniques, facial transplantation has come to garner widespread interest within both the medical community and the general public. The procedure has established itself as an amalgamation of the forefronts of reconstructive microsurgery, immunology, and transplantation science. Therein too lies its complexity as multifaceted scientific developments are met with ethical and social issues. Both patients and physicians are faced with the everlasting challenges of immunosuppression regimens and their inherent complications, long-term aesthetic and functional considerations, the role of revision procedures, and the inevitable psychosocial implications. This article reflects on the medical and surgical advancements in facial transplantation surgery and highlights anticipated future challenges. It aims to encourage discussion regarding anticipated barriers to current practice and suggest future directions as we transition into the next phase of facial allograft transplantation.

Local immunosuppression in vascularized composite allotransplantation (VCA): A systematic review

BACKGROUND

Local immunosuppression in vascularized composite allotransplantation (VCA) aims to minimize immunosuppressant-related toxic and malignant side effects. Promising allograft survival data have been published by multiple workgroups. In this systematic review, we examine preclinical animal studies that investigated local immunosuppression in VCA.

MATERIAL AND METHODS

We conducted a systematic review of manuscripts listed in the MEDLINE and PubMed database concerning preclinical VCA models. Papers included had to be available as full-text and written in English. Non-VCA studies, human trials, and studies using cell-based therapy strategies were excluded. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

Literature research retrieved 980 articles. Ten studies published between 2010 and 2019 met the inclusion and exclusion criteria. Seven out of ten articles demonstrated a significant prolongation of allograft survival by using local immunosuppression. Five articles employed tacrolimus (TAC) as the main immunosuppressive agent. Seven studies performed hind-limb VCA in a rat model.

CONCLUSION

The easily accessible location of skin containing VCAs makes it an ideal candidate for local immunosuppression. Published preclinical data are very promising in terms of improved allograft survival and reduced systemic toxicity.

A Comparison of Immunosuppression Regimens in Hand, Face, and Kidney Transplantation

BACKGROUND

Authors have speculated that vascularized composite allotransplantation (VCA) recipients may require greater maintenance immunosuppression than solid organ transplant (SOT) recipients due to the higher antigenicity of skin. However, detailed comparisons of VCA and SOT immunosuppression regimens have been limited.

METHODS

Hand and face VCA recipient immunosuppression data were collected through a systematic literature review. Kidney recipient data were obtained through a retrospective chart review of the authors' institution. Prednisone and mycophenolate mofetil (MMF) doses were compared between VCA and kidney recipients at predefined follow-up intervals (<1, 1-5, and >5 y). Tacrolimus target trough levels (TTTL) were compared at follow-up intervals of 1-5 and >5 y, and stratified into our institution's kidney transplant risk-based target ranges (4-6 ng/mL, 6-8 ng/mL) or higher (>8 ng/mL).

RESULTS

Immunosuppression data were available for 57 VCA and 98 kidney recipients. There were no significant differences in prednisone doses between groups at all follow-up intervals. VCA recipient mean MMF dose was significantly greater at <1-y (1.71 ± 0.58 versus 1.16 ± 0.55 gm/d; P = 0.01). For VCA recipients, there was a significant difference (P = 0.02) in TTTL distribution over the three predefined therapeutic ranges (4-6 ng/mL, 6-8 ng/mL, and >8 ng/mL) between 1 and 5 y (24.0%, 20.0%, 56.0%, respectively) and >5 y (28.6%, 42.9%, 28.6%).

CONCLUSIONS

At longer follow-up, VCA and kidney recipients receive comparable MMF/prednisone doses, and most VCA recipients are treated with TTTL similar to kidney recipients. Further research may improve our understanding of VCA's complex risk/benefit ratio, and enhance informed consent.

Innovations and Future Directions in Head and Neck Microsurgical Reconstruction

Head and neck reconstructive microsurgery is constantly innovating because of a combination of multidisciplinary advances. This article examines recent innovations that have affected the field as well as presenting research leading to future advancement. Innovations include the use of virtual surgical planning and three-dimensional printing in craniofacial reconstruction, advances in intraoperative navigation and imaging, as well as postoperative monitoring, development of minimally invasive reconstructive microsurgery techniques, integration of regenerative medicine and stem cell biology with reconstruction, and the dramatic advancement of face transplant.

The interest of "ortho-plastic" collaboration in management of complex limb injury

Constantly evolving knowledge on fracture management, soft tissue coverage, microsurgery and vasculo-nervous repair now permits salvage of limbs that previously would have had to be amputated. Management of complex limb injuries of which the severity inevitably entails functional and esthetic sequelae calls for mastery of the full spectrum of bone and soft tissue reconstruction. Such mastery is rarely attainable by a single surgical specialty; individually and isolatedly, an orthopedic or plastic surgeon cannot ensure optimal management of the above-mentioned patients. While the orthopedist performs a key function in provisional or definitive fixation, the plastic surgeon's expertise is essential to restoration of the cutaneous envelope. Collaboration between the two specialties from the outset and throughout treatment characterizes the modern-day concept of "ortho-plastic" surgery. Through unification of the theoretical competence and practical skills of orthopedists and plastic surgeons, it provides a patient with the best possible functional and esthetic results in a wide range of clinical situations. In this article, we present a review of the literature illustrating the interest of "ortho-plastic" collaboration in management of complex limb injury; concrete examples will be given through evocation of clinical cases encountered by the team that was put together in August 2015 at the university hospital (CHU) of Lille.

Before and After: What Has Changed in the Attitude of Turkish Society Regarding Face Transplantations?

Face transplantation is one of the most popular and controversial subjects of plastic surgery today. Although there are various surveys on the subject, there is no study comparing the past and the present social viewpoint and behavioral preferences for face transplantations across the world. In this study, we aimed to investigate the changes in the views of the Turkish society with respect to face transplantation from past to present. For this purpose, 1000 volunteer participants were questioned in terms of demographics and their perspective and preferences on organ and face transplantation. The results of the study were compared with the past data, and based on the results, the level of consciousness and awareness of the Turkish society about the subject has increased; the rate risk taking for immunosuppression has decreased, and instead, the rate of having an undecided stance has increased, and this attitude continues even if the risk is resolved. With these results, we can conclude that the greatest handicap for face transplantation in the Turkish society today is immunosuppression and the associated risks. We believe that new drug protocols and monitoring of patient outcomes for longer periods as well as more extensive clinical applications may be beneficial in addressing this issue.

Local Immunosuppression for Vascularized Composite Allografts: Application of Topical FK506-TyroSpheres in a Nonhuman Primate Model

Transplantation of vascularized composite allografts (VCAs) provides a means of restoring complex anatomical and functional units following burns and other disfigurement otherwise not amenable to conventional autologous reconstructive surgery. While short- to intermediate-term VCA survival is largely dependent on patient compliance with medication, the myriad of side effects resulting from lifelong systemic immunosuppression continue to pose a significant challenge. Topical immunosuppression is therefore a logical and attractive alternative for VCA. Current formulations are limited though, by poor skin penetration but this may be mitigated by conjugation of immunosuppressive drugs to TyroSpheres for enhanced delivery. Therefore, we investigated the topical application of FK506-TyroSpheres (in the form of a gel dressing) in a clinically relevant nonhuman primate VCA model to determine if allograft survival could be prolonged at reduced levels of maintenance systemic immunosuppression. Six Major Histocompatibility Complex (MHC)-mismatched cynomolgus macaques (Macaca fascicularis) served as reciprocal donors and recipients of radial forearm fasciocutaneous flaps. Standard Bacitracin ointment and FK506-TyroSpheres were applied every other day to the VCAs of animals in groups 1 (controls, n = 2) and 2 (experimental, n = 4), respectively, before gradual taper of systemic FK506. Clinical features of VCA rejection still developed when systemic FK506 fell below 10 ng/ml despite application of FK506-TyroSpheres and prolonged VCA survival was not achieved. However, unwanted systemic FK506 absorption was avoided with TyroSphere technology. Further refinement to optimize local drug delivery profiles to achieve and maintain therapeutic delivery of FK506 with TyroSpheres is underway, leveraging significant experience in controlled drug delivery to mitigate acute rejection of VCAs.

The histocompatibility and immunogenetics of hand transplantation

This short review will be concerned with the literature that has developed connected with the immunogenetic and tissue compatibility aspects of hand transplantation and will also draw on connected work in the more general area of vascularized composite allotransplantation (VCA) which includes face, abdominal wall uterus and larynx.

First Russian Experience of Composite Facial Tissue Allotransplantation

The facial allotransplantation technique was first introduced to the general public in 2005. The definition of the face as a complex system of organs that perform social functions made possible the adaptation of this operation into clinical practice. The year 2010 was the starting point for initial research in the Russian Federation. Based on previous achievements and existing world experience in this field, facial allotransplantation was used for the first time in 2015 in St. Petersburg. The goal of this operation was to reconstruct a soldier's central facial area after an electric burn; he was injured in the military line of duty. This article describes complications faced regarding the preparation for this operation, the issues encountered for facial tissue removal, as well as donor selection criteria. Each stage of the composite facial allotransplantation, complications that can occur during operation, milestone results, as well as the subsequent rehabilitation and immunosuppressive therapy during the 4-year patient observation period following surgery, including the description of a single episode of cell-humoral rejection of transplanted tissue, are described in detail. The experience gained from the first facial allotransplantation performed in Russia shows the possibility of using a new composite allograft to correct deformities in the central area of the face with the achievement of a successfully functioning and aesthetically pleasing result after the operation. After 4 years of dynamic observation and individual rehabilitation programs, the main goal of the facial transplantation, that is, social re-adaptation of the patient, was achieved.

Facial Transplantation for an Irreparable Central and Lower Face Injury: A Modernized Approach to a Classic Challenge

BACKGROUND

Facial transplantation introduced a paradigm shift in the reconstruction of extensive facial defects. Although the feasibility of the procedure is well established, new challenges face the field in its second decade.

METHODS

The authors' team has successfully treated patients with extensive thermal and ballistic facial injuries with allotransplantation. The authors further validate facial transplantation as a reconstructive solution for irreparable facial injuries. Following informed consent and institutional review board approval, a partial face and double jaw transplantation was performed in a 25-year-old man who sustained ballistic facial trauma. Extensive team preparations, thorough patient evaluation, preoperative diagnostic imaging, three-dimensional printing technology, intraoperative surgical navigation, and the use of dual induction immunosuppression contributed to the success of the procedure.

RESULTS

The procedure was performed on January 5 and 6, 2018, and lasted nearly 25 hours. The patient underwent hyoid and genioglossus advancement for floor-of-mouth dehiscence, and palate wound dehiscence repair on postoperative day 11. Open reduction and internal fixation of left mandibular nonunion were performed on postoperative day 108. Nearly 1 year postoperatively, the patient demonstrates excellent aesthetic outcomes, intelligible speech, and is tolerating an oral diet. He remains free from acute rejection.

CONCLUSIONS

The authors validate facial transplantation as the modern answer to the classic reconstructive challenge imposed by extensive facial defects resulting from ballistic injury. Relying on a multidisciplinary collaborative approach, coupled with innovative emerging technologies and immunosuppression protocols, can overcome significant challenges in facial transplantation and reinforce its position as the highest rung on the reconstructive ladder.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

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.

Achievements and Challenges in Facial Transplantation

: The first facial transplantation in 2005 ushered in a new era in reconstructive surgery, offering new possibilities for the repair of severe disfigurements previously limited by conventional techniques. Advances in allograft design, computerized preoperative planning, surgical technique, and postoperative revisions have helped push the boundaries in this new frontier of vascularized composite allotransplantation. Over the past 12 years, 40 of these procedures have been performed across the world, offering the field the opportunity to reflect on current outcomes. Successes achieved in the brief history of facial transplantation have resulted in a new set of obstacles the field must now overcome. In this review, we aim to highlight the achievements, major challenges, and future directions of this rapidly evolving field.

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.

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.

Preoperative Imaging for Facial Transplant: A Guide for Radiologists

Facial transplant (FT) is a viable option for patients with severe craniomaxillofacial deformities. Transplant imaging requires coordination between radiologists and surgeons and an understanding of the merits and limitations of imaging modalities. Digital subtraction angiography and CT angiography are critical to mapping vascular anatomy, while volume-rendered CT allows evaluation of osseous defects and landmarks used for surgical cutting guides. This article highlights the components of successful FT imaging at two institutions and in two index cases. A deliberate stepwise approach to performance and interpretation of preoperative FT imaging, which consists of the modalities and protocols described here, is essential to seamless integration of the multidisciplinary FT team. ^©RSNA, 2019 See discussion on this article by Lincoln .

Are We Prepared for the Inevitable? A Survey on Defining and Managing Failure in Face Transplantation

Supplemental Digital Content is available in the text.

Background:

Facial transplantation (FT) experience has grown but success in this innovative and complex field has yet to be defined. The purpose of this study is to determine attitudes regarding the failures in FT and the appropriate management of these failures.

Methods:

An anonymous, 20-question survey elicited opinions regarding FT failure management. This survey was administered to attendees of 2 FT-focused national meetings. Demographics included sex, age, and personal/institutional FT experience. Attitudes related to FT recipient education, definition of FT failure, and management of complications were gathered.

Results:

Eighty of 271 attendees completed the survey (29.5%). Respondents were predominantly male (81.3%) and 50 years of age or younger (80.5%). Thirty-eight percentage previously performed an FT and 53.8% were a part of an institution with a vascularized composite allotransplantation (VCA)-related Institutional Review Board (IRB). Respondents almost unanimously agreed it was “absolutely essential” to discuss possibility of FT failure (93.8%), mortality (91.1%), and treatment for chronic rejection (78.8%). However, uncertainty of failure rate existed, with 56.4% citing failure rate as unknown, 25.6% citing <25% and 18.0% citing >25%. 51.2% of those with direct FT experience lacked clear criteria for defining FT success or an institutional protocol for managing chronic rejection. 78.8% believed failed FT patients should be considered for retransplantation, but only about 25% cited functional concerns or esthetic dissatisfaction as appropriate indications.

Conclusion:

There is a lack of consensus regarding definition of FT failure and rates mortality amongst experts. Even institutions with FT experience lack protocols for managing chronic rejection. Expert consensus and institutional regulations surrounding these issues are warranted.

A Review on the Orthoplastic Approach to Lower Limb Reconstruction

Just as in the craft of carpentry, a stable foundation and framework are absolutely essential to the final function of a building, but no more important than the drywall, trim, and paint that make the building functional, durable, and livable. Reconstruction of the lower extremity is similar; the orthopaedic surgeon must obtain stable fixation of the damaged or diseased bone once a thorough debridement of nonviable bone is performed, while the plastic or orthopaedic soft tissue surgeon must provide vascularized, stable coverage. These two components are complementary and both contribute to the success or failure of functional limb restoration. The stability of bone repair will predict the ultimate functional status, while the vascularized envelope will enhance the biology of bone and soft tissue healing. When both components are properly attended to, the result is often a functional limb with an acceptable appearance. While a single surgeon need not perform both of these tasks (although some may choose to do so), the orthopaedic and plastic surgeon involved in this care must have a clear understanding of each other's role and their importance for a good outcome. This is what we call the orthoplastic approach to reconstructive surgery of the extremities, that is, the application of principles and practice of both specialties applied simultaneously to optimize the outcomes in limb reconstruction. In this review article, we discuss the history of orthoplastic surgery, the key elements of orthoplastic surgery, and thoughts on factors that lead to good outcomes through select cases.

Chronic rejection of human face allografts

Face vascularized composite allografts (FVCAs) have helped patients with severe facial disfigurement, with acute rejection now largely controlled through iatrogenic immunosuppression. However, little is known regarding the incidence and mechanism(s) of more long-term pathologic alterations in FVCAs that may affect function and graft durability. Protocol surveillance biopsy specimens for up to an 8-year interval in 7 patients who received FVCAs at our institution revealed histopathologic evidence of chronic rejection. Clinical manifestations included features of premature aging, mottled leukoderma accentuating suture lines, telangiectasia, and dryness of nasal mucosa. Pathologic changes consisted of epidermal thinning accompanied by discrete foci of lymphocyte-mediated cytotoxicity, hyperkeratosis, follicular plugging, vascular ectasia, and sclerosis beneath the epidermal layer associated with collagen type I deposition. Genomic interrogation and immunohistochemistry of sclerotic zones revealed upregulation of the AP-1 pathway components, JunB and c-Fos, previously implicated in overproduction of type I dermal collagen in the setting of systemic sclerosis. We conclude that some patients develop chronic rejection in FVCAs with striking similarities to alterations seen in certain autoimmune cutaneous disorders (lupus erythematosus and scleroderma/chronic sclerodermoid graft-versus-host disease). Identification of relevant pathways and genes, such as JunB and c-Fos, may provide new targets for preventative therapies for chronic immune-mediated changes in vascularized composite allografts.