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Mookerjee VG, Kauke-Navarro M, Hauc SC, Huelsboemer L, Formica RN, Pomahac B. Advancing Face Transplantation: A Critical Analysis of Revisions and Long-Term Surgical Outcomes in 10 Cases. Plast Reconstr Surg 2024; 154:577e-584e. [PMID: 37699110 DOI: 10.1097/prs.0000000000011058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
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.
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Affiliation(s)
- Vikram G Mookerjee
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine
| | - Martin Kauke-Navarro
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine
| | - Sacha C Hauc
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine
| | - Lioba Huelsboemer
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine
| | | | - Bohdan Pomahac
- From the Division of Plastic Surgery, Department of Surgery, Yale School of Medicine
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2
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Hadjiandreou M, Pafitanis G, Butler PM. Outcomes in facial transplantation - a systematic review. Br J Oral Maxillofac Surg 2024; 62:404-414. [PMID: 38637216 DOI: 10.1016/j.bjoms.2024.02.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 02/22/2024] [Accepted: 02/24/2024] [Indexed: 04/20/2024]
Abstract
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.
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Affiliation(s)
- Michalis Hadjiandreou
- UCL Division of Surgery and Interventional Science, Royal Free Hospital, London, UK; Department of Plastic Surgery, Emergency Care and Trauma Division, The Royal London Hospital, Barts Health NHS Trust, London, UK.
| | - Georgios Pafitanis
- Department of Plastic Surgery, Emergency Care and Trauma Division, The Royal London Hospital, Barts Health NHS Trust, London, UK; University of Cyprus, Nicosia, Cyprus
| | - Peter M Butler
- UCL Division of Surgery and Interventional Science, Royal Free Hospital, London, UK
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Van Dieren L, Tawa P, Coppens M, Naenen L, Dogan O, Quisenaerts T, Lancia HH, Oubari H, Dabi Y, De Fré M, Thiessen Ef F, Cetrulo CL, Lellouch AG. Acute Rejection Rates in Vascularized Composite Allografts: A Systematic Review of Case Reports. J Surg Res 2024; 298:137-148. [PMID: 38603944 DOI: 10.1016/j.jss.2024.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 01/20/2024] [Accepted: 02/29/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION Vascularized Composite Allografts (VCA) are usually performed in a full major histocompatibility complex mismatch setting, with a risk of acute rejection depending on factors such as the type of immunosuppression therapy and the quality of graft preservation. In this systematic review, we present the different immunosuppression protocols used in VCA and point out relationships between acute rejection rates and possible factors that might influence it. METHODS This systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. We systematically searched Medline (PubMed), Embase, and The Cochrane Library between November 2022 and February 2023, using following Mesh Terms: Transplant, Transplantation, Hand, Face, Uterus, Penis, Abdominal Wall, Larynx, and Composite Tissue Allografts. All VCA case reports and reviews describing multiple case reports were included. RESULTS We discovered 211 VCA cases reported. The preferred treatment was a combination of antithymocyte globulins, mycophenolate mofetil (MMF), tacrolimus, and steroids; and a combination of MMF, tacrolimus, and steroids for induction and maintenance treatment, respectively. Burn patients showed a higher acute rejection rate (P = 0.073) and were administered higher MMF doses (P = 0.020). CONCLUSIONS In contrast to previous statements, the field of VCA is not rapidly evolving, as it has encountered challenges in addressing immune-related concerns. This is highlighted by the absence of a standardized immunosuppression regimen. Consequently, more substantial data are required to draw more conclusive results regarding the immunogenicity of VCAs and the potential superiority of one immunosuppressive treatment over another. Future efforts should be made to report the VCA surgeries comprehensively, and muti-institutional long-term prospective follow-up studies should be performed to compare the number of acute rejections with influencing factors.
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Affiliation(s)
- Loïc Van Dieren
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Faculty of Medicine and Health Sciences, Antwerp, Belgium; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Pierre Tawa
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts; Shriners Hospitals for Children-Boston, Boston, Massachusetts
| | - Marie Coppens
- Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Laura Naenen
- Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | - Omer Dogan
- Faculty of Medicine and Health Sciences, Antwerp, Belgium
| | | | - Hyshem H Lancia
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Haïzam Oubari
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Yohann Dabi
- Department of Obstetrics, Gynecology and Reproductive Medicine, Sorbonne University, Tenon Hospital (AP-HP), Paris, France
| | - Maxime De Fré
- Department of Plastic, Reconstructive and Aesthetic Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Filip Thiessen Ef
- Department of Plastic, Reconstructive and Aesthetic Surgery, Antwerp University Hospital, Antwerp, Belgium
| | - Curtis L Cetrulo
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts; Shriners Hospitals for Children-Boston, Boston, Massachusetts
| | - Alexandre G Lellouch
- Vascularized Composite Allotransplantation Laboratory, Center for Transplantation Sciences, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts; Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Boston, Massachusetts; Shriners Hospitals for Children-Boston, Boston, Massachusetts.
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4
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Cavaliere A, Rega U, Grimaldi S, Esposito G, Pensato R, D'Andrea F, Longo B, Coiante E, Hersant B, Meningaud JP, La Padula S. Long-term outcomes and future challenges in face transplantation. J Plast Reconstr Aesthet Surg 2024; 92:87-103. [PMID: 38513344 DOI: 10.1016/j.bjps.2024.02.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 02/06/2024] [Accepted: 02/26/2024] [Indexed: 03/23/2024]
Abstract
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.
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Affiliation(s)
- Annachiara Cavaliere
- Department of Plastic and Reconstructive Surgery, Università degli studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | - Umberto Rega
- Department of Plastic and Reconstructive Surgery, Università degli studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | - Sebastiano Grimaldi
- Department of Plastic and Reconstructive Surgery, Università degli studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | - Giuseppe Esposito
- Department of Plastic and Reconstructive Surgery, Università degli studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | - Rosita Pensato
- Department of Plastic and Reconstructive Surgery, Università degli studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | - Francesco D'Andrea
- Department of Plastic and Reconstructive Surgery, Università degli studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy
| | - Benedetto Longo
- Department of Plastic and Reconstructive Surgery, Università di Roma Tor Vergata, Viale Oxford, 81, 00133 Roma, Italy
| | - Edoardo Coiante
- Department of Plastic, Reconstructive and Maxillo facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Barbara Hersant
- Department of Plastic, Reconstructive and Maxillo facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Jean Paul Meningaud
- Department of Plastic, Reconstructive and Maxillo facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France
| | - Simone La Padula
- Department of Plastic and Reconstructive Surgery, Università degli studi di Napoli Federico II, Via Pansini 5, 80131 Napoli, Italy; Department of Plastic, Reconstructive and Maxillo facial Surgery, Henri Mondor Hospital, University Paris XII, 51 Avenue du Maréchal de Lattre de Tassigny, 94000 Créteil, France.
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Huelsboemer L, Boroumand S, Kochen A, Dony A, Moscarelli J, Hauc SC, Stögner VA, Formica RN, Pomahac B, Kauke-Navarro M. Immunosuppressive strategies in face and hand transplantation: a comprehensive systematic review of current therapy regimens and outcomes. FRONTIERS IN TRANSPLANTATION 2024; 3:1366243. [PMID: 38993787 PMCID: PMC11235358 DOI: 10.3389/frtra.2024.1366243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 02/21/2024] [Indexed: 07/13/2024]
Abstract
Background Recipients of Vascularized Composite Allotransplants require effective immunosuppressive therapy to prevent graft rejection. This systematic review summarizes the current body of literature on immunosuppressive regimens used in face and hand transplants while summarizing their outcome in terms of rejection, renal failure, and infections. Methods A systematic search of electronic databases was conducted to identify relevant studies from 1998 until July 1st, 2023. We included all studies that discussed immunosuppressive strategies in face and hand transplant recipients according to PRISMA. Results The standard triple maintenance therapy was mostly adjusted due to nephrotoxicity or high incidence of rejection. The most common alternative treatments utilized were sirolimus (25/91; 27.5%) or everolimus (9/91; 9.9%) following hand- and photophoresis (7/45; 15.6%), sirolimus (5/45; 11.1%) or belatacept (1/45; 2.2%) following face transplantation. Episodes of rejection were reported in 60 (65.9%) of hand- and 33 (73%) of face transplant patients respectively. Graft loss of 12 (13.2%) hand and 4 (8.9%) face transplants was reported. Clinical CMV infection was observed in 6 (6.6%) hand and 7 (15.5%) face transplant recipients. Conclusions Based on the herein presented data, facial grafts exhibited a heightened incidence of rejection episodes and CMV infections. Facial mucosa adds complexity to the immunological graft composition highlighting the need of individualized immunosuppressive regimens and further research.
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Affiliation(s)
- Lioba Huelsboemer
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Sam Boroumand
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Alejandro Kochen
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
- Regenerative Wound Healing Center, Yale School of Medicine, New Haven, CT, United States
| | - Alna Dony
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
- School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Jake Moscarelli
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Sacha C Hauc
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Viola A Stögner
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Richard N Formica
- Department of Medicine, Section of Nephrology and Transplantation, Yale School of Medicine, New Haven, CT, United States
| | - Bohdan Pomahac
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Martin Kauke-Navarro
- Division of Reconstructive and Plastic Surgery, Yale School of Medicine, New Haven, CT, United States
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Panayi AC, Knoedler S, Kauke-Navarro M, Haug V, Obed D, Pomahac B. Face transplantation: a bibliometric analysis of the top 100 most cited articles. EUROPEAN JOURNAL OF PLASTIC SURGERY 2023. [DOI: 10.1007/s00238-023-02045-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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7
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Ozmen S, Findikcioglu K, Sibar S, Tuncer S, Ayhan S, Guz G, Unal Y, Aslan S. First Composite Woman-to-Woman Facial Transplantation in Turkey: Challenges and Lessons to Be Learned. Ann Plast Surg 2023; 90:87-95. [PMID: 36534107 DOI: 10.1097/sap.0000000000003323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Selahattin Ozmen
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, Koç University Hospital, Istanbul
| | | | - Serhat Sibar
- Departments of Plastic, Reconstructive and Aesthetic Surgery
| | - Serhan Tuncer
- Departments of Plastic, Reconstructive and Aesthetic Surgery
| | - Suhan Ayhan
- Departments of Plastic, Reconstructive and Aesthetic Surgery
| | | | | | - Selcuk Aslan
- Psychiatry, Gazi University Hospital, Ankara, Turkey
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Aravind P, Frost C, Javia V, Cooney DS, Brandacher G, Shores JT, Cooney CM. Special Considerations for Secondary Surgery After Upper Extremity Transplantation. Hand (N Y) 2022; 17:969-974. [PMID: 33190550 PMCID: PMC9465781 DOI: 10.1177/1558944720966723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Upper extremity (UE) transplantation is a complex undertaking that may require emergent or elective secondary surgery (SS) days to years following transplant. Various patient and transplantation may help determine what SS is needed. In this study, we characterize the SS needed by our UE transplant patients. METHODS We retrospectively reviewed 6 patients who underwent hand and UE transplantation by one of the authors. Transplantation and SS details were obtained from medical records. Hand and arm function was quantified both subjectively (patient-reports) and objectively (Disabilities of the Arm, Shoulder, and Hand Score; Carroll test; Action Research Arm Tests; Box and Block test). RESULTS Six patients underwent transplantation for a total of 10 transplanted limbs. Five transplants were performed below and 5 above the elbow. Mean time post-transplantation at last follow-up was 5 years (range: 1-9 years). In all, 66.7% of the patients required SS: total 7 surgeries comprising 13 procedures. The most common procedures were to improve hand function-nerve decompressions and tendon transfer, both in above-elbow transplant. Both patients showed a mean improvement of 15 points on Carroll scores. One above-elbow transplant had a brachioplasty for excess skin and another had a hematoma evacuation immediately after transplantation. Procedures in the below-elbow transplants included multiple incision and drainages for a septic wrist and an open reduction and internal fixation for a forearm fracture. CONCLUSION Patients receiving UE transplantation often require one or more secondary procedures which may vary with level of transplantation. Secondary surgery should be an important aspect of pretransplant planning and cost-effectiveness determinations. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Pathik Aravind
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | | | - Vidhi Javia
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
| | - Damon S. Cooney
- Johns Hopkins University School of
Medicine, Baltimore, MD, USA
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9
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Parker A, Chaya BF, Rodriguez-Colon R, Hao Y, Kurian K, Trilles J, Boczar D, Brydges H, Rodriguez ED. Recipient Selection Criteria for Facial Transplantation: A Systematic Review. Ann Plast Surg 2022; 89:105-112. [PMID: 35749814 DOI: 10.1097/sap.0000000000003255] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Recipient selection is an important determinant of surgical outcomes in facial transplantation (FT). Appropriately, each FT program develops their own guidelines for recipient selection criteria. Currently, there is no resource to simultaneously assess and identify similarities and differences between these guidelines. Such information could be useful in distinguishing areas of FT that are well understood from those that could benefit from further exploration. METHODS We performed a systematic review of the scientific literature from inception to June 18, 2021, using Pubmed, Embase, Cochrane Library, and Scopus to identify articles pertaining to recipient selection criteria. Clinical trials were identified through the Clinicaltrials.gov registry. United States and international program websites were reviewed for patient-facing information. RESULTS Our systematic review yielded 90 suitable articles, 8 clinical trials, and 7 program websites containing the recipient selection criteria of 24 different FT programs. The most reported on recipient criteria were age, positive human immunodeficiency viral status (HIV+), positive hepatitis C viral status, psychosocial stability, and medical compliance. Other criteria were rarely addressed, such as blindness and recipient immune status. CONCLUSIONS Guidelines among different face transplant programs are changing over time. We found consensus on certain recipient selection criteria, but the majority remain program or surgeon dependent, emphasizing that FT is still an evolving procedure. Although most programs reported on their recipient selection criteria, the rationale was often missing. Further discussion about recipient selection criteria and the reasoning behind employing or changing them will help advance the field.
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Affiliation(s)
| | - Bachar F Chaya
- Hansjörg Wyss Department of Plastic Surgery, New York University, New York, NY
| | | | - Yvonne Hao
- From the New York University Grossman School of Medicine
| | - Keerthi Kurian
- California Northstate University, College of Medicine, Elk Grove, CA
| | - Jorge Trilles
- Hansjörg Wyss Department of Plastic Surgery, New York University, New York, NY
| | - Daniel Boczar
- Hansjörg Wyss Department of Plastic Surgery, New York University, New York, NY
| | - Hilliard Brydges
- Hansjörg Wyss Department of Plastic Surgery, New York University, New York, NY
| | - Eduardo D Rodriguez
- Hansjörg Wyss Department of Plastic Surgery, New York University, New York, NY
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10
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Facial Transplantation. Facial Plast Surg Clin North Am 2022; 30:255-269. [DOI: 10.1016/j.fsc.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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11
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Kiukas EL, Manninen A, Lindford A, Lassus P. The Second Helsinki Face Transplantation and the World Experience of Revision Surgery During the First Posttransplantation Year. Ann Plast Surg 2022; 88:223-232. [PMID: 34611098 DOI: 10.1097/sap.0000000000002987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION We conducted a review of all surgical interventions performed during the first postoperative year in published face transplantation (FT) cases. In addition, we herein present our second FT patient, a full-face composite FT with an emphasis on surgical revisions after transplantation. MATERIALS AND METHODS A literature review was conducted and resulted in 376 publications of which 33 included reference to surgical interventions during the first post-FT year. For our second FT patient, a thorough review of all medical records was performed. RESULTS Among the first 41 FTs, 32 FT patients had reports with reference to corrective surgery during the first year (22 composite and 10 soft-tissue FTs). Soft-tissue FTs had a median of 2 procedures (range, 1-8 procedures), and composite FTs, 3 procedures per patient (range, 1-9 procedures). Nearly all early interventions (<1 month) were performed in composite FT patients (anastomotic occlusion, hematoma, sialocele, palatinal dehiscence). The most common late interventions were scar corrections, tissue suspensions, periorbital corrections, osseal and dental procedures, and interventions for palatinal dehiscence and sialocele. Our second FT patient has recovered well and has undergone 3 surgical interventions during the first year. CONCLUSIONS Surgical interventions are very common during the first postoperative year after FT, and composite FTs are more prone to complications necessitating surgical intervention than soft-tissue FTs. There is a wide variety of complications reflecting the heterogeneity of FT allografts. Corrective surgery in FT patients appears safe with only a few reported complications.
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Affiliation(s)
- Emma-Lotta Kiukas
- From the Department of Plastic Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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12
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Tchiloemba B, Kauke M, Haug V, Abdulrazzak O, Safi AF, Kollar B, Pomahac B. Long-term Outcomes After Facial Allotransplantation: Systematic Review of the Literature. Transplantation 2021; 105:1869-1880. [PMID: 33148976 DOI: 10.1097/tp.0000000000003513] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Facial vascularized composite allotransplantation (fVCA) represents a reconstructive approach that enables superior improvements in functional and esthetic restoration compared with conventional craniomaxillofacial reconstruction. Outcome reports of fVCA are usually limited to short-term follow-up or single-center experiences. We merge scientific literature on reported long-term outcome data to better define the risks and benefits of fVCA. METHODS We conducted a systematic review of PubMed/MEDLINE databases in accordance with PRISMA guidelines. English full-text articles providing data on at least 1 unique fVCA patient, with ≥3 years follow-up, were included. RESULTS The search yielded 1812 articles, of which 28 were ultimately included. We retrieved data on 23 fVCA patients with mean follow-up of 5.3 years. More than half of the patients showed improved quality of life, eating, speech, and motor and sensory function following fVCA. On average, the patients had 1 acute cell-mediated rejection and infectious episode per year. The incidence rates of acute rejection and infectious complications were high within first-year posttransplant but declined thereafter. Sixty-five percent of the patients developed at least 1 neoplastic or metabolic complication after transplantation. Chronic vascular rejection was confirmed in 2 patients, leading to allograft loss after 8 and 9 years. Two patient deaths occurred 3.5 and 10.5 years after transplant due to suicide and lung cancer, respectively. CONCLUSIONS Allograft functionality and improvements in quality of life suggest a positive risk-benefit ratio for fVCA. Recurrent acute rejection episodes, chronic rejection, immunosuppression-related complications, and heterogeneity in outcome reporting present ongoing challenges in this field.
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Affiliation(s)
- Bianief Tchiloemba
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Martin Kauke
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Obada Abdulrazzak
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Ali-Farid Safi
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Branislav Kollar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
- Department of Plastic and Hand Surgery, University of Freiburg Medical Center, Medical Faculty of the University of Freiburg, Freiburg, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Abstract
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.
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Vincent AG, Gunter AE, Ducic Y, Reddy L. Maxillofacial Bony Considerations in Facial Transplantation. Facial Plast Surg 2021; 37:735-740. [PMID: 33878799 DOI: 10.1055/s-0041-1726443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
Alloplastic facial transplantation has become a new rung on the proverbial reconstructive ladder for severe facial wounds in the past couple of decades. Since the first transfer including bony components in 2006, numerous facial allotransplantations across many countries have been successfully performed, many incorporating multiple bony elements of the face. There are many unique considerations to facial transplantation of bone, however, beyond the considerations of simple soft tissue transfer. Herein, we review the current literature and considerations specific to bony facial transplantation focusing on the pertinent surgical anatomy, preoperative planning needs, intraoperative harvest and inset considerations, and postoperative protocols.
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Affiliation(s)
| | - Anne E Gunter
- Department of Otolaryngology, Head and Neck Surgery, Madigan Army Medical Center, Tacoma, Washington
| | | | - Likith Reddy
- Department of Oral and Maxillofacial Surgery, Texas A&M Health Science Center, Dallas, Texas
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15
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Shokri T, Saadi R, Wang W, Reddy L, Ducic Y. Facial Transplantation: Complications, Outcomes, and Long-Term Management Strategies. Semin Plast Surg 2020; 34:245-253. [PMID: 33380909 DOI: 10.1055/s-0040-1721760] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Tom Shokri
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Robert Saadi
- Department of Otolaryngology - Head & Neck Surgery, Penn State Health, Hershey, Pennsylvania
| | - Weitao Wang
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Likith Reddy
- Department of Oral and Maxillofacial Surgery, Texas A&M College of Dentistry, Dallas, Texas
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
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16
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Park JJ, Diep GK, Alfonso AR, Berman ZP, Hoffman AF, Mills EC, Wolfe EM, Felsenheld JH, Ramly EP, Rodriguez ED. Have We Achieved Optimal Skin Color Matching in Partial Facial Transplantation? A Survey Study of the General Public and Medical Professionals. J Craniofac Surg 2020; 31:2213-2216. [PMID: 33136857 DOI: 10.1097/scs.0000000000006895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Skin color matching is an essential factor in achieving optimal aesthetic outcome in partial facial transplantation. However, there is no published literature evaluating the success of color matching to date. Furthermore, a medical professional's perception of an optimal color match may not necessarily translate to that of the general public. The purpose of our study was to evaluate skin color matching between the donor allograft and recipient native tissue in partial facial transplantations to determine the level of success perceived by the general public and medical professionals. METHODS Published photographs of partial face transplant recipients were used to create a survey where recipient native and donor allograft skin samples were juxtaposed. Thirty-three members of the general public and 30 medical professionals were asked to rate skin color match on a scale from "excellent match" to "not a match." RESULTS Overall, 47% of given ratings were positive, indicating an "excellent" or "good match," and 53% of ratings were negative, indicating a "poor match" or "lack of match" between the skin sample pairings shown. Of the 19 partial face transplant patients who were rated, 9 patients received >50% positive ratings, and 10 patients received <50% positive ratings. Medical professionals consistently gave more positive ratings, with statistically significant differences in 7 of the 19 rated patients (P < 0.05). CONCLUSION The results suggest that there is need for improvement in color matching in partial facial transplantation, and that the general public is more critical of skin color matching compared to medical professionals.
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Affiliation(s)
- Jenn J Park
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, NY
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17
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Anesthetic Considerations in Facial Transplantation: Experience at NYU Langone Health and Systematic Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2955. [PMID: 32983760 PMCID: PMC7489595 DOI: 10.1097/gox.0000000000002955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/08/2020] [Indexed: 01/18/2023]
Abstract
Anesthetic considerations are integral to the success of facial transplantation (FT), yet limited evidence exists to guide quality improvement. This study presents an institutional anesthesia protocol, defines reported anesthetic considerations, and provides a comprehensive update to inform future directions of the field.
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18
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Diep GK, Ramly EP, Alfonso AR, Berman ZP, Rodriguez ED. Enhancing Face Transplant Outcomes: Fundamental Principles of Facial Allograft Revision. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e2949. [PMID: 32983759 PMCID: PMC7489753 DOI: 10.1097/gox.0000000000002949] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/08/2020] [Indexed: 11/25/2022]
Abstract
Facial transplantation (FT) has become a feasible reconstructive solution for patients with devastating facial injuries. Secondary revisions to optimize functional and aesthetic outcomes are to be expected, yet the optimal timing and approach remain to be determined. The purpose of this study was to analyze all facial allograft revisions reported to date, including the senior author's experience with 3 FTs. Methods A literature review was performed, with 2 reviewers independently conducting title and abstract screening, followed by a full-text review. All articles mentioning FT revision surgeries were evaluated. The medical records of the senior author's 3 FT recipients were additionally reviewed. Results Initially, 721 articles were captured and 37 were included in the final analysis. Thirty-two FTs were reported to have involved posttransplant allograft revisions, with FT recipients undergoing a mean of 4.8 ± 4.6 revision procedures. The mean duration between FT and the first revision procedure was 149 ± 179 days. A wide spectrum of revisions was identified and categorized as involving the soft tissues, craniofacial skeleton, dentition, oronasal cavity, salivary glands, facial nerve, or ocular region. In the senior author's experience, when indicated, posttransplant occlusal changes and integrity of the donor-recipient intraoral interface were successfully addressed with secondary procedures without allograft compromise or loss. Conclusions The worldwide experience shows that secondary procedures are nearly ubiquitous after FT and can be safely performed at various timepoints. The authors thereby establish 5 distinct categories of facial allograft revisions and define 7 critical principles to optimize posttransplant procedures.
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Affiliation(s)
- Gustave K Diep
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, N.Y
| | - Elie P Ramly
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, N.Y
| | - Allyson R Alfonso
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, N.Y
| | - Zoe P Berman
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, N.Y
| | - Eduardo D Rodriguez
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, N.Y
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19
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Ocular Considerations in Face Transplantation: Report of 2 Cases and Review of the Literature. Ophthalmic Plast Reconstr Surg 2020; 35:218-226. [PMID: 30550500 DOI: 10.1097/iop.0000000000001296] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE Periorbital injuries are common in face transplantation (FT) candidates. It is therefore essential that the ophthalmologist play a central role in the multidisciplinary treatment of these patients. In this study, the authors perform a comprehensive review of all procedures involving periorbital components, provide an update for the ophthalmology community regarding the current state of the field, and present 2 cases. METHODS A comprehensive review of the literature for all FT procedures including periorbital components was performed. The authors also present 2 patients who received FT including periorbital components for extensive facial disfigurement. One patient sustained high-energy avulsive ballistic injury and underwent a total face, double jaw, and tongue transplant in 2012. The second patient received a total face, eyelids, ears, and skeletal subunits transplant for extensive facial burns in 2015. RESULTS Literature review demonstrated that 22 (54%) of the 41 patients undergoing FT received allografts containing periorbital components. Only 14 cases (64%) reported on the presence of ocular and periocular complications. The most common complications consisted of lower eyelid ectropion and lagophthalmos, and nearly all required revisional procedures. Both patients presented with significant periorbital scarring and demonstrated good visual acuity and aesthetic outcomes at postoperative follow up between 6 and 28 months. CONCLUSIONS Face transplantation can address extensive facial and periorbital disfigurement with satisfactory functional and aesthetic outcomes. The majority of FT performed to date have included periorbital components, and postoperative ocular and periocular complications are common. It is critical for ophthalmologists to play a central role in the care of these patients.
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20
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Re: "Ocular Considerations in Face Transplantation". Ophthalmic Plast Reconstr Surg 2020; 36:99. [PMID: 31904674 DOI: 10.1097/iop.0000000000001527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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21
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Ramly EP, Kantar RS, Diaz-Siso JR, Alfonso AR, Shetye PR, Rodriguez ED. Outcomes After Tooth-Bearing Maxillomandibular Facial Transplantation: Insights and Lessons Learned. J Oral Maxillofac Surg 2019; 77:2085-2103. [DOI: 10.1016/j.joms.2019.05.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 05/20/2019] [Accepted: 05/20/2019] [Indexed: 12/31/2022]
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22
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Rifkin WJ, David JA, Plana NM, Kantar RS, Diaz-Siso JR, Gelb BE, Ceradini DJ, Rodriguez ED. Achievements and Challenges in Facial Transplantation. Ann Surg 2019; 268:260-270. [PMID: 29489486 DOI: 10.1097/sla.0000000000002723] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
: 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.
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Affiliation(s)
- William J Rifkin
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - Joshua A David
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - Natalie M Plana
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - Rami S Kantar
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - J Rodrigo Diaz-Siso
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - Bruce E Gelb
- Division of Transplant Surgery, NYU Langone Health, New York, NY
| | - Daniel J Ceradini
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
| | - Eduardo D Rodriguez
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health. New York, NY
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23
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Rifkin WJ, Bellamy JL, Kantar RS, Farber SJ, Diaz-Siso JR, Brecht LE, Rodriguez ED. Autologous Reconstruction of a Face Transplant Candidate. Craniomaxillofac Trauma Reconstr 2018; 12:150-155. [PMID: 31073366 DOI: 10.1055/s-0038-1675844] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 09/28/2018] [Indexed: 01/05/2023] Open
Abstract
Since 2005, facial transplantation has emerged as a viable reconstructive option for the most severe defects not amenable to conventional reconstructive techniques, with promising aesthetic and functional outcomes to date. Key facial subunits and midface structures such as the eyelids, lips, and nose are now able to be successfully replaced rather than reconstructed, enabling adequate functional outcomes in even the most extensive defects. However, even in cases of severe facial disfigurement, the decision to proceed with transplantation versus autologous reconstruction remains a source of debate, with no current consensus regarding precise indications and inclusion/exclusion criteria. This report details the case of a candidate referred for face transplantation who ultimately underwent autologous facial reconstruction. Through this representative case, our objective is to clarify the criteria that make a patient a suitable face transplant candidate, as well as to demonstrate the outcomes achievable with a conventional autologous reconstruction, using a methodically planned, multistaged approach.
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Affiliation(s)
- William J Rifkin
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Justin L Bellamy
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Rami S Kantar
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Scott J Farber
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - J Rodrigo Diaz-Siso
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
| | - Lawrence E Brecht
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York.,Jonathan and Maxine Ferencz Advanced Education Program in Prosthodontics, New York University College of Dentistry, New York, New York
| | - Eduardo D Rodriguez
- Hansjörg Wyss Department of Plastic Surgery, NYU Langone Health, New York, New York
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24
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Abstract
BACKGROUND Trismus can be a challenging consequence of ballistic trauma to the face, and has rarely been described in the setting of face transplantation. Almost half of all current face transplant recipients in the world received transplantation to restore form and function after a ballistic injury. Here we report our experience and challenges with long standing trismus after face transplantation. METHODS We reviewed the medical records of our face transplant recipients whose indication was ballistic injury. We focused our review on trismus and assessed the pre-, peri- and postoperative planning, surgery and functional outcomes. RESULTS Two patients received partial face transplantation, including the midface for ballistic trauma. Both patients suffered from impaired mouth opening, speech intelligibility, and oral competence. Severe scarring of the temporomandibular joint (TMJ) required intraoperative release in both patients, and additional total condylectomy on the left side 6 months posttransplant for 1 patient. Posttransplant, both patients achieved an improvement in mouth opening; however, there was persistent trismus. One year after transplantation, range of motion of the jaw had improved for both patients. Independent oral food intake was possible 1 year after surgery, although spillage of liquids and mixed consistency solids persisted. Speech intelligibility testing showed impairments in the immediate postoperative period, with improvement to over 85% for both patients at 1 year posttransplant. CONCLUSIONS Ballistic trauma to the face and subsequent reconstructive measures can cause significant scarring and covert injuries to structures such as the TMJ, resulting in long standing trismus. Meticulous individual planning prior to interventions such as face transplantation must take these into account. We encourage intraoperative evaluation of these structures as well as peri- and postoperative treatment when necessary. Due to the nature of the primary injury, functional outcomes after face transplantation in these patients may differ substantially from those of other indications.
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25
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Fischer S, Diehm Y, Dorante MI, Kotsougiani D, Kueckelhaus M, Alhefzi M, Bueno EM, Pomahac B. Software-based video analysis of functional outcomes of face transplantation. Microsurgery 2018; 39:53-61. [PMID: 30159931 DOI: 10.1002/micr.30360] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 05/24/2018] [Accepted: 06/20/2018] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Assessment of outcomes after face transplantation (FT) is necessary to provide sound evidence on the benefits of this life-giving surgery. Current methods for outcomes assessment, however, are imprecise or prone to subjectivity. Software-based video analysis may allow fast, objective and retrospective assessment of restoration of facial movements and functions after FT. PATIENTS AND METHODS We recorded videos of 7 subjects before as well as every 3-6 months after facial transplantation. Patients performed the same sequence of facial movements in every video: smile, open mouth, purse lips, wrinkle nose, frown, close eyes, and lift eyebrows. The videos were retrospectively analyzed using EMOTIENT software, which is capable of automatic tracking and detailed measurements of facial movements and expressions. These measurements were subsequently compared to the same patient at different time points, as well as to the normal population. RESULTS Open mouth, wrinkle nose and smile functions significantly improved in all patients when compared to pre-transplant functions; this improvement was significant at 3, 6, and 12 months after transplant, respectively. Lip purse, eye closure and frown functions improved by 6, 9, and 18 months after transplantation, respectively; however, improvement in these particular functions was not significantly with respect to pre-transplant. Face transplantation did not improve any of the patients' ability to lift their eyebrows. Most remarkably, mouth opening and smiling functions both reached values comparable to the normal population at 3 and 12 months after transplantation, respectively. CONCLUSION Software-based video analysis provides a valuable assessment tool capable of objective, precise and reproducible analysis of facial movements and functions after FT.
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Affiliation(s)
- Sebastian Fischer
- Brigham and Women's Hospital, Department of Surgery, Division of Plastic Surgery, Harvard Medical School, Boston, Massachusetts.,BG Clinic Ludwigshafen, Department of Hand, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, Ludwigshafen, Germany
| | - Yannick Diehm
- Brigham and Women's Hospital, Department of Surgery, Division of Plastic Surgery, Harvard Medical School, Boston, Massachusetts.,BG Clinic Ludwigshafen, Department of Hand, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, Ludwigshafen, Germany
| | - Miguel I Dorante
- Brigham and Women's Hospital, Department of Surgery, Division of Plastic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Dimitra Kotsougiani
- BG Clinic Ludwigshafen, Department of Hand, Plastic and Reconstructive Surgery, Burn Center, University of Heidelberg, Ludwigshafen, Germany
| | - Maximilian Kueckelhaus
- Brigham and Women's Hospital, Department of Surgery, Division of Plastic Surgery, Harvard Medical School, Boston, Massachusetts.,Fachklinik Hornheide, Department of Plastic Surgery, Munster, Germany
| | - Muayyad Alhefzi
- Brigham and Women's Hospital, Department of Surgery, Division of Plastic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Ericka M Bueno
- Brigham and Women's Hospital, Department of Surgery, Division of Plastic Surgery, Harvard Medical School, Boston, Massachusetts
| | - Bohdan Pomahac
- Brigham and Women's Hospital, Department of Surgery, Division of Plastic Surgery, Harvard Medical School, Boston, Massachusetts
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27
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Anatomic Considerations for Temporomandibular Joint Vascularized Composite Allotransplantation. J Craniofac Surg 2018; 29:871-877. [PMID: 29498981 DOI: 10.1097/scs.0000000000004397] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Concomitant temporomandibular joint (TMJ) transplantation is an obvious advancement in the reconstructive armamentarium for face transplantation in scenarios involving TMJ ankylosis. This study investigates the fidelity of mandibular morphology and explores the feasibility of bilateral mandibular condyle transfer in facial vascularized composite allotransplantation. Geometric analysis was performed on 100 skeletally mature maxillofacial computed tomography scans. Exclusion criteria included mandibular trauma and dentoalveolar disease. Parameters measured were posterior height, ramus tilt, anterior height, intercondylar widths, condyle height, coronoid height, interglenoid distances, symphyseal and gonial angles, condyle and glenoid volumes, and condyle shapes. Parameters were compared by gender and ethnicity using χ, independent sample t tests, and one-way ANOVA. Correlation with age was assessed using Pearson correlation coefficients. Bilateral measurements were compared using paired-sample t tests. Mean intercondylar width was 102.5 mm (SD 7.0 mm), anterior height 21.5 mm (5.5), and posterior height 65.3 mm (7.7), Males demonstrate larger geometric parameters, for example, intercondylar width (4 mm mean difference, P = 0.005), anterior height (2.3 mm, P = 0.032), posterior height (5 mm, P = 0.001). Asians demonstrated statistically larger intercondylar width (8 mm difference to Caucasians, P < 0.001). Increased age was associated with greater anterior height, gonial angle, and symphyseal angle; decreased glenoid height; and change in condyle shape. Despite significant disparity of laterality measurements within individuals, posterior height, glenoid, and condyle volumes are equivalent. Mandibular morphology is highly variable. However, transplantation of a facial allograft including the mandible and bilateral condyles is technically and anatomically feasible in patients with concomitant TMJ pathology.
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28
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Kollar B, Pomahac B. Facial restoration by transplantation. Surgeon 2018; 16:245-249. [PMID: 29490887 DOI: 10.1016/j.surge.2018.01.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 01/12/2018] [Indexed: 12/16/2022]
Abstract
Hundred years ago, Sir Harold Gillies laid a foundation to the modern plastic surgery trying to reconstruct facial defects of severely disfigured soldiers of World War I. Some years later, Joseph Murray experimented with rejection of skin grafts aimed for treatment of burned patients who sustained their injuries on battlefields of World War II. In 1954, the acquired expertise and intensive research allowed him to perform the first successful kidney transplantation in the world at Peter Bent Brigham Hospital in Boston. For his achievements in organ transplantation he was awarded Nobel Prize in 1990. The face transplantation appears to be a natural evolution of the work of these two extraordinary plastic surgeons. The first case of partial face transplant from 2005 in France revealed the world that facial restoration by transplantation is superior to conventional reconstruction methods. Since 2009, our team has performed 7 cases of face transplantation at Brigham and Women's Hospital, which is to our best knowledge the largest living single center face transplant cohort in the world. In this article, we want to reflect on the experience with face transplantation at our institution from the past years. We aim to briefly review the key points of the know-how which was given to us from the care of these unique patients.
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Affiliation(s)
- Branislav Kollar
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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29
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Tasigiorgos S, Kollar B, Krezdorn N, Bueno EM, Tullius SG, Pomahac B. Face transplantation-current status and future developments. Transpl Int 2018; 31:677-688. [DOI: 10.1111/tri.13130] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 12/21/2017] [Accepted: 02/02/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Sotirios Tasigiorgos
- Division of Plastic Surgery; Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Branislav Kollar
- Division of Plastic Surgery; Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Nicco Krezdorn
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery; Hannover Medical School; Hannover Germany
| | - Ericka M. Bueno
- Division of Plastic Surgery; Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Stefan G. Tullius
- Division of Transplant Surgery; Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Bohdan Pomahac
- Division of Plastic Surgery; Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
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