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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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Haug V, Kollar B, Obed D, Kiwanuka H, Turk M, Wo L, Tasigiorgos S, Kueckelhaus M, Riella LV, Pomahac B. The Evolving Clinical Presentation of Acute Rejection in Facial Transplantation. JAMA FACIAL PLAST SU 2020; 21:278-285. [PMID: 30998810 DOI: 10.1001/jamafacial.2019.0076] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance Acute rejection is one of the most frequent complications in facial transplantation, with potentially severe consequences for the recipient if overlooked. Clinical signs, such as erythema or edema, are helpful to diagnose acute rejection in the early follow-up stage; however, it is not well known whether these clinical signs remain reliable markers of acute rejection beyond the second posttransplant year. Objective To determine the diagnostic value of clinical signs of acute rejection after facial transplantation over time. Design, Setting, and Participants A retrospective, single-center cohort study was conducted of patients who underwent facial transplantation at Brigham and Women's Hospital between April 2009 and October 2014, with up to an 8-year follow-up. Medical records were reviewed until September 30, 2017. The medical records from 104 encounters with 7 patients who underwent partial or full facial transplantation were analyzed for symptoms of rejection, immunosuppressive therapy, and histopathologic findings. Main Outcomes and Measures The occurrence of 5 clinical signs of acute rejection were evaluated: erythema, edema, exanthema, suture line erythema, and mucosal lesions. Odds ratios (ORs) were calculated to determine the statistically significant association of these signs with the histopathologic diagnosis of rejection. In addition, tacrolimus blood levels, as a surrogate marker of immunosuppressive therapy, were evaluated. Results Of the 7 patients included in the study, 5 were men. The mean follow-up was 66 months (range, 35-101). Of 104 clinical encounters, 46 encounters (44.2%) represented rejection episodes and 58 encounters (55.8%) represented no-rejection episodes. Beyond 2 years posttransplantation, only erythema (OR, 6.53; 95% CI, 1.84-20.11; P = .004) and exanthema (OR, ∞; 95% CI, 2.2-∞; P = .004) were demonstrated to be reliable clinical signs of acute rejection in facial transplantation. There was also a statistically significant association of subtherapeutic tacrolimus levels with late rejection episodes (OR, 3.79; 95% CI, 1.25-12.88; P = .03). In addition, the occurrence of subclinical rejection was more frequent during later follow-up times (7 [24.1%] late rejections vs 1 [5.9%] early rejection). Five of 8 subclinical rejections (62.5%) were associated with subtherapeutic tacrolimus levels. Conclusions and Relevance Clinical signs of acute rejection in facial transplantation appear to be of limited diagnostic value, particularly after the second postoperative year. Until alternative biomarkers for rejection are identified, protocol skin biopsies will remain necessary for guiding assessments of allograft rejection. Level of Evidence 3.
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Affiliation(s)
- Valentin Haug
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.,Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Branislav Kollar
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Doha Obed
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Harriet Kiwanuka
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Marvee Turk
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Luccie Wo
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sotirios Tasigiorgos
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Maximillian Kueckelhaus
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Leonardo V Riella
- Schuster Transplantation Research Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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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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