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Zeidan T, Kassouf E, Ahmadieh N, Nassar A, Jabbour G, Sleilati F. The Different Surgical Approaches to Maxillofacial Reconstruction after Ballistic Trauma. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e6066. [PMID: 39139837 PMCID: PMC11321747 DOI: 10.1097/gox.0000000000006066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 06/21/2024] [Indexed: 08/15/2024]
Abstract
Background Ballistic trauma to the face is a challenge, combining complex bone injury with severe soft tissue loss. The various surgical methods available are influenced by the extent of injuries. This study compares different operative modalities and their outcomes with different variables, aiming to define the ideal therapeutic approach. Methods We retrospectively compared reconstructive modalities used to treat facial ballistic trauma cases at Hôtel-Dieu de France Hospital, Beirut, Lebanon, for a 12-year span. Statistical analysis was used to determine correlation between several factors and satisfactory results. Results Eighteen patients were included, with varying degrees of bone and soft tissue loss. After conservative debridement, fractures were treated by different modalities: open reduction and internal fixation, maxillomandibular fixation, and osteosynthesis with a reconstruction plate. Although primary closure was sufficient in 10 cases, severe loss of tissues was reconstructed with a fibular free flap in five cases, radial free forearm flap in two cases, and free parascapular flap in one case. Two others received an iliac bone graft as secondary reconstruction. The average follow-up was 2.45 years. Most cases achieved good aesthetic and functional results after several secondary operations, with few late complications. Early reconstruction and younger patients were associated with better outcomes. Conclusions We favor early debridement and reconstruction. Free flaps were ideal for extensive tissue loss. Bone grafting was needed secondarily. A single surgical procedure seldom led to satisfactory functional and aesthetic outcomes, and secondary operations were inevitable.
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Affiliation(s)
- Toufic Zeidan
- From the Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Elia Kassouf
- From the Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Nizar Ahmadieh
- From the Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Aref Nassar
- From the Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Georges Jabbour
- From the Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Fadi Sleilati
- From the Faculty of Medicine, Saint Joseph University, Beirut, Lebanon
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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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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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Tacrolimus before CTLA4Ig and rapamycin promotes vascularized composite allograft survival in MGH miniature swine. Transpl Immunol 2022; 75:101696. [PMID: 35987329 DOI: 10.1016/j.trim.2022.101696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/11/2022] [Accepted: 08/11/2022] [Indexed: 11/21/2022]
Abstract
BACKGROUND We evaluated the outcome of vertical rectus abdominus myocutaneous flap (VRAM) allotransplantation in a mini-pig model, using a combined co-stimulation blockade (Co-SB) and mechanistic target of rapamycin inhibition (mTORi)-based regimen, with or without preceding calcineurin inhibition (CNI). MATERIALS AND METHODS VRAM allotransplants were performed between SLA-mismatched MGH miniature swine. Group A (n = 2) was treated continuously with the mTOR inhibitor rapamycin from day -1 in combination with the Co-SB agent cytotoxic T lymphocyte antigen 4-Ig (CTLA4-Ig) from post-operative day (POD) 0. In group B (n = 3), animals received tacrolimus daily from POD 0 to POD 13, followed by rapamycin daily from POD 7 and CTLA4-Ig weekly from POD 7-28. Graft rejection was determined by Banff criteria and host cellular and humoral immunity monitored. RESULTS In group A, allografts developed grade-I acute rejection by POD 2 and POD 7, and reached grade-IV by POD 17 and POD 20, respectively. By contrast, in group B, two allografts demonstrated grade-I rejection on POD 30 and grade-IV on POD 74, while the third exhibited grade-I rejection starting on POD 50, though this animal had to be euthanized on POD 58 due to Pneumocystis jirovecii infection. Time-to-event incidence of grade-I rejection was significantly lower in group A compared to group B. During the first 3 weeks post-transplant, no significant differences in anti-donor immunity were observed between the groups. CONCLUSION A short course of CNI, followed by combined Co-SB and mTORi significantly delays acute rejection of VRAM allografts in SLA-mismatched miniature swine.
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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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6
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Special Considerations in Face Transplantation: A Systematic Review. J Craniofac Surg 2022; 33:1352-1357. [PMID: 35758507 DOI: 10.1097/scs.0000000000008484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 01/11/2022] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT Vascularized composite allotransplantation of the face is an exceedingly complex procedure, requiring extensive planning and surgical precision in order to successfully manage patients with facial disfigurements. This review aims to present an overview of the salient anatomic considerations in facial transplantation, as well as give attention to unique patient populations and special considerations.A literature review was performed in search of articles pertaining to considerations in facial transplantation using the databases PubMed, Web of Science, and Cochrane. Articles selected for further review included full-text articles with an emphasis on specific anatomic defects and how they were addressed in the transplant process, as well as management of special patient populations undergoing facial transplantation. In total, 19 articles were deemed appropriate for inclusion.The use of computer-assisted technologies for the planning portion of the procedure, as well as intraoperative efficiency, has yielded favorable results and can be considered as part of the operative plan. The ultimate outcome is dependent upon the synchronization of subunits of the allograft and the desired functional outcomes, including osseous, ocular, oral, and otologic considerations. Management of specific pathology and subgroups of patients are critical aspects. Although pediatric face transplantation has not yet been performed, it is a likely a future step in the evolution of this procedure.When performing a face transplantation, many components must be considered pre-, intra-, and post-operatively. This systematic review presents specific anatomic considerations, as well as information about special patient populations within this crosssection of multidisciplinary microsurgery, psychiatry, and transplant immunology.
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Azher S. Facial Transplantation: An Ethical Debate. THE JOURNAL OF CLINICAL ETHICS 2021. [DOI: 10.1086/jce2021323256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Bélanger ME, Borsuk DE, Clairoux A, Fortier LP, Nguyen A, Georgescu M, Richebé P, Tanoubi I, Verdonck O, Gobert Q. Face transplantation: anesthesia and other organizational considerations. Can J Anaesth 2021; 68:868-875. [PMID: 34002361 PMCID: PMC8128356 DOI: 10.1007/s12630-021-01940-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 11/12/2020] [Accepted: 11/13/2020] [Indexed: 11/30/2022] Open
Abstract
In 2005, the first facial vascularized composite allotransplant was performed in France. In May 2018, our team at Maisonneuve-Rosemont Hospital, Montreal, Quebec, had the privilege to participate in the first facial transplant in Canada. Interdisciplinary collaboration, coordination, and communication formed the cornerstone of this medical undertaking and, ultimately, its success. This report details the anesthetic and organizational considerations of our experience.
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Affiliation(s)
- Marie-Eve Bélanger
- Department of Anesthesiology and Pain Medicine, Université de Montréal, CIUSSS de l'Est-de-l'Île-de-Montréal, Maisonneuve-Rosemont Hospital, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada.
| | - Daniel E Borsuk
- Department of Surgery, Université de Montréal, CIUSSS de l'Est-de-l'Île-de-Montréal, Maisonneuve-Rosemont Hospital, Montréal, QC, Canada
| | - Ariane Clairoux
- Department of Anesthesiology and Pain Medicine, Université de Montréal, CIUSSS de l'Est-de-l'Île-de-Montréal, Maisonneuve-Rosemont Hospital, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada
| | - Louis-Philippe Fortier
- Department of Anesthesiology and Pain Medicine, Université de Montréal, CIUSSS de l'Est-de-l'Île-de-Montréal, Maisonneuve-Rosemont Hospital, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada
| | - Anh Nguyen
- Department of Anesthesiology and Pain Medicine, Université de Montréal, CIUSSS de l'Est-de-l'Île-de-Montréal, Maisonneuve-Rosemont Hospital, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada
| | - Mihai Georgescu
- Department of Anesthesiology and Pain Medicine, Université de Montréal, CIUSSS de l'Est-de-l'Île-de-Montréal, Maisonneuve-Rosemont Hospital, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada
| | - Philippe Richebé
- Department of Anesthesiology and Pain Medicine, Université de Montréal, CIUSSS de l'Est-de-l'Île-de-Montréal, Maisonneuve-Rosemont Hospital, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada
| | - Issam Tanoubi
- Department of Anesthesiology and Pain Medicine, Université de Montréal, CIUSSS de l'Est-de-l'Île-de-Montréal, Maisonneuve-Rosemont Hospital, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada
| | - Olivier Verdonck
- Department of Anesthesiology and Pain Medicine, Université de Montréal, CIUSSS de l'Est-de-l'Île-de-Montréal, Maisonneuve-Rosemont Hospital, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada
| | - Quentin Gobert
- Department of Anesthesiology and Pain Medicine, Université de Montréal, CIUSSS de l'Est-de-l'Île-de-Montréal, Maisonneuve-Rosemont Hospital, 5415 Boulevard de l'Assomption, Montréal, QC, H1T 2M4, Canada
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Norrman A, Nylund K, Ruokonen H, Mauno J, Mesimäki K, Haapaniemi A, Lassus P, Helenius-Hietala J. Oral findings and treatment of patients with face transplants in Helsinki. Oral Surg Oral Med Oral Pathol Oral Radiol 2021; 132:44-51. [PMID: 33563570 DOI: 10.1016/j.oooo.2021.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 01/04/2021] [Accepted: 01/04/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Oral health and balanced occlusion are important aspects of a well-functioning face transplant. This study describes the oral and dental status, dental management, and sialoendoscopy of the first 2 patients in Helsinki who underwent face transplantations. STUDY DESIGN Two patients received near-full face transplantations in 2016 and 2018, respectively. The transplanted tissues included a Le Fort type II maxilla, angle-to-angle mandible, all oral mucosa, ventral tongue tissue, and the muscles of the floor of the mouth. Comprehensive oral examinations and all required dental treatment, including follow-up examinations, were performed for both patients after the transplantations. RESULTS Both patients rehabilitated well, and their quality of life improved. Stable, functioning dentition and occlusion were achieved for both patients. Hyposalivation and dental caries were issues for both patients. Patient 1 also experienced infections in the jaws. Implants were placed in the transplanted jaws of patient 2 with successful osseointegration. CONCLUSIONS We report successful tooth-bearing face transplantations in 2 patients. Patient selection, particularly regarding oral health, is crucial in avoiding posttransplantation complications. Moreover, the oral and dental status of the donor should be examined by a dentist before transplantation, and regular follow-up dental examinations should be performed after transplantation.
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Affiliation(s)
- Annika Norrman
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland.
| | - Karita Nylund
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
| | - Hellevi Ruokonen
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
| | - Jari Mauno
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland; Department of Plastic Surgery, Helsinki University Hospital
| | - Karri Mesimäki
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
| | - Aaro Haapaniemi
- Department of Ear, Nose and Throat Diseases, Helsinki University Hospital
| | - Patrik Lassus
- Department of Plastic Surgery, Helsinki University Hospital
| | - Jaana Helenius-Hietala
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
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10
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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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11
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Upper extremity and craniofacial vascularized composite allotransplantation: ethics and immunosuppression. Emerg Top Life Sci 2019; 3:681-686. [PMID: 32915212 DOI: 10.1042/etls20190060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/02/2019] [Accepted: 10/14/2019] [Indexed: 12/17/2022]
Abstract
Vascularized composite allotransplantation (VCA) is the name most often used to refer to the transplantation of anatomical units composed of multiple tissue types (skin, bone, muscle, tendon, nerves, vessels, etc.) when such transplants do not have the primary purpose of extending life, as is the case in the more familiar field of solid organ transplantation (SOT). A serious interest in VCA developed in the late twentieth century following advances in immunosuppression which had led to significant improvements in short and medium-term survival among SOT recipients. Several ethical concerns have been raised about VCA, with many being connected in one way or another to the limitations, burdens, and risks associated with immunosuppression. This article will focus on upper extremity and craniofacial VCA, beginning with a brief review of the history of VCA including reported outcomes, followed by a discussion of the range of ethical concerns, before exploring in greater detail how immunological issues inform and shape several of the ethical concerns.
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12
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Farber SJ, Latham KP, Kantar RS, Perkins JN, Rodriguez ED. Reconstructing the Face of War. Mil Med 2019; 184:e236-e246. [DOI: 10.1093/milmed/usz103] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Revised: 03/18/2019] [Indexed: 11/14/2022] Open
Abstract
AbstractIntroductionOngoing combat operations in Iraq, Afghanistan, and other theaters have led to an increase in high energy craniomaxillofacial (CMF) wounds. These challenging injuries are typically associated with complex tissue deficiencies, evolving areas of necrosis, and bony comminution with bone and ballistic fragment sequestrum. Restoring form and function in these combat-sustained CMF injuries is challenging, and frequently requires local and distant tissue transfers. War injuries are different than the isolated trauma seen in the civilian sector. Donor sites are limited on patients with blast injuries and they may have preferences or functional reasons for the decisions to choose flaps from the available donor sites.MethodsA case series of patients who sustained severe combat-related CMF injury and were treated at Walter Reed National Military Medical Center (WRNMMC) is presented. Our study was exempt from Institutional Review Board review, and appropriate written consent was obtained from all patients included in the study for the use of representative clinical images.ResultsFour patients treated by the CMF team at Walter Reed National Military Medical Center are presented. In this study, we highlight their surgical management by the CMF team at WRNMMC, detail their postoperative course, and illustrate the outcomes achieved using representative patient clinical images. We also supplement this case series demonstrating military approaches to complex CMF injuries with CMF reconstructive algorithms utilized by the senior author (EDR) in the management of civilian complex avulsive injuries of the upper, mid, and lower face are thoroughly reviewed.ConclusionWhile the epidemiology and characteristics of military CMF injuries have been well described, their management remains poorly defined and creates an opportunity for reconstructive principles proven in the civilian sector to be applied in the care of severely wounded service members. The War on Terror marks the first time that microsurgery has been used extensively to reconstruct combat sustained wounds of the CMF region. Our manuscript reviews various options to reconstruct these devastating CMF injuries and emphasizes the need for steady communication between the civilian and military surgical communities to establish the best care for these complex patients.
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Affiliation(s)
- Scott J Farber
- University of Texas Health Science Center San Antonio, Texas, Division of Plastic and Reconstructive Surgery, 7703 Floyd Curl Drive, MC 7844, San Antonio, TX
| | - Kerry P Latham
- Walter Reed National Military Medical Center Bethesda, MD, Division of Plastic Surgery, 4494 North Palmer Road, Bethesda, MD
| | - Rami S Kantar
- NYU Langone Health New York, NY, Hansjorg Wyss Department of Plastic Surgery, 307 E 33rd Street, New York, NY
| | - Jonathan N Perkins
- Walter Reed National Military Medical Center Bethesda, MD, Department of Otolaryngology-Head & Neck Surgery, 4494 North Palmer Road, Bethesda, MD
| | - Eduardo D Rodriguez
- NYU Langone Health New York, NY, Hansjorg Wyss Department of Plastic Surgery, 307 E 33rd Street, New York, NY
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13
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Leonard DA. Commentary on "An experimental rodent model of whole eye transplantation for assessment of viability and immunological outcomes". J Plast Reconstr Aesthet Surg 2019; 72:1651-1652. [PMID: 31175033 DOI: 10.1016/j.bjps.2019.05.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 10/26/2022]
Affiliation(s)
- David A Leonard
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Castle Street, Glasgow, United Kingdom.
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14
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Prabhu V, Plana NM, Hagiwara M, Diaz-Siso JR, Lui YW, Davis AJ, Sliker CW, Shapiro M, Moin AS, Rodriguez ED. Preoperative Imaging for Facial Transplant: A Guide for Radiologists. Radiographics 2019; 39:1098-1107. [PMID: 31125293 DOI: 10.1148/rg.2019180167] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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 .
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Affiliation(s)
- Vinay Prabhu
- From the Department of Radiology (V.P., M.H., Y.W.L., A.J.D., M.S.) and Hanjörg Wyss Department of Plastic Surgery (N.M.P., J.R.D.S., E.D.R.), New York University Langone Health, 550 First Ave, New York, NY 10016; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (C.W.S., A.S.M.); and Department of Radiology, MedStar Health, Baltimore, Md (A.S.M.)
| | - Natalie M Plana
- From the Department of Radiology (V.P., M.H., Y.W.L., A.J.D., M.S.) and Hanjörg Wyss Department of Plastic Surgery (N.M.P., J.R.D.S., E.D.R.), New York University Langone Health, 550 First Ave, New York, NY 10016; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (C.W.S., A.S.M.); and Department of Radiology, MedStar Health, Baltimore, Md (A.S.M.)
| | - Mari Hagiwara
- From the Department of Radiology (V.P., M.H., Y.W.L., A.J.D., M.S.) and Hanjörg Wyss Department of Plastic Surgery (N.M.P., J.R.D.S., E.D.R.), New York University Langone Health, 550 First Ave, New York, NY 10016; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (C.W.S., A.S.M.); and Department of Radiology, MedStar Health, Baltimore, Md (A.S.M.)
| | - J Rodrigo Diaz-Siso
- From the Department of Radiology (V.P., M.H., Y.W.L., A.J.D., M.S.) and Hanjörg Wyss Department of Plastic Surgery (N.M.P., J.R.D.S., E.D.R.), New York University Langone Health, 550 First Ave, New York, NY 10016; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (C.W.S., A.S.M.); and Department of Radiology, MedStar Health, Baltimore, Md (A.S.M.)
| | - Yvonne W Lui
- From the Department of Radiology (V.P., M.H., Y.W.L., A.J.D., M.S.) and Hanjörg Wyss Department of Plastic Surgery (N.M.P., J.R.D.S., E.D.R.), New York University Langone Health, 550 First Ave, New York, NY 10016; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (C.W.S., A.S.M.); and Department of Radiology, MedStar Health, Baltimore, Md (A.S.M.)
| | - Adam J Davis
- From the Department of Radiology (V.P., M.H., Y.W.L., A.J.D., M.S.) and Hanjörg Wyss Department of Plastic Surgery (N.M.P., J.R.D.S., E.D.R.), New York University Langone Health, 550 First Ave, New York, NY 10016; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (C.W.S., A.S.M.); and Department of Radiology, MedStar Health, Baltimore, Md (A.S.M.)
| | - Clint W Sliker
- From the Department of Radiology (V.P., M.H., Y.W.L., A.J.D., M.S.) and Hanjörg Wyss Department of Plastic Surgery (N.M.P., J.R.D.S., E.D.R.), New York University Langone Health, 550 First Ave, New York, NY 10016; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (C.W.S., A.S.M.); and Department of Radiology, MedStar Health, Baltimore, Md (A.S.M.)
| | - Maksim Shapiro
- From the Department of Radiology (V.P., M.H., Y.W.L., A.J.D., M.S.) and Hanjörg Wyss Department of Plastic Surgery (N.M.P., J.R.D.S., E.D.R.), New York University Langone Health, 550 First Ave, New York, NY 10016; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (C.W.S., A.S.M.); and Department of Radiology, MedStar Health, Baltimore, Md (A.S.M.)
| | - Adnaan S Moin
- From the Department of Radiology (V.P., M.H., Y.W.L., A.J.D., M.S.) and Hanjörg Wyss Department of Plastic Surgery (N.M.P., J.R.D.S., E.D.R.), New York University Langone Health, 550 First Ave, New York, NY 10016; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (C.W.S., A.S.M.); and Department of Radiology, MedStar Health, Baltimore, Md (A.S.M.)
| | - Eduardo D Rodriguez
- From the Department of Radiology (V.P., M.H., Y.W.L., A.J.D., M.S.) and Hanjörg Wyss Department of Plastic Surgery (N.M.P., J.R.D.S., E.D.R.), New York University Langone Health, 550 First Ave, New York, NY 10016; Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, Md (C.W.S., A.S.M.); and Department of Radiology, MedStar Health, Baltimore, Md (A.S.M.)
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