OPTN/SRTR 2022 Annual Data Report: Vascularized Composite Allograft

This year's chapter on vascularized composite allograft (VCA) encompasses reviews of data collected from 2014 (when VCA was included in the Final Rule) through 2022. The present Annual Data Report shows that the number of VCA recipients in the United States continues to be small and has remained consistent from the prior report. The data continue to be limited by sample size, with trends persistently demonstrating a predominance of White males in the young/middle-aged population as both donors and recipients for nonuterus VCA transplants, and White women younger than 35 years as the predominant recipients of uterus transplant. Similar to the 2021 report, there were only eight failed uterus grafts and one failed nonuterus VCA graft reported from 2014 through 2022. Standardization of definitions of success and failure as well as outcome measures for the different VCA types remain unmet needs in VCA transplantation.

Application possibilities of artificial intelligence in facial vascularized composite allotransplantation-a narrative review

Facial vascularized composite allotransplantation (FVCA) is an emerging field of reconstructive surgery that represents a dogmatic shift in the surgical treatment of patients with severe facial disfigurements. While conventional reconstructive strategies were previously considered the goldstandard for patients with devastating facial trauma, FVCA has demonstrated promising short- and long-term outcomes. Yet, there remain several obstacles that complicate the integration of FVCA procedures into the standard workflow for facial trauma patients. Artificial intelligence (AI) has been shown to provide targeted and resource-effective solutions for persisting clinical challenges in various specialties. However, there is a paucity of studies elucidating the combination of FVCA and AI to overcome such hurdles. Here, we delineate the application possibilities of AI in the field of FVCA and discuss the use of AI technology for FVCA outcome simulation, diagnosis and prediction of rejection episodes, and malignancy screening. This line of research may serve as a fundament for future studies linking these two revolutionary biotechnologies.

Cortical reintegration after facial allotransplantation

Neural plasticity of the brain or its ability to reorganize following injury has likely coincided with the successful clinical correction of severe deformity by facial transplantation since 2005. In this study, we present the cortical reintegration outcomes following syngeneic hemifacial vascularized composite allograft (VCA) in a small animal model. Specifically, changes in the topographic organization and unit response properties of the rodent whisker-barrel somatosensory system were assessed following hemifacial VCA. Clear differences emerged in the barrel-cortex system when comparing naïve and hemiface transplanted animals. Neurons in the somatosensory cortex of transplanted rats had decreased sensitivity albeit increased directional sensitivity compared with naïve rats and evoked responses in transplanted animals were more temporally dispersed. In addition, receptive fields were often topographically mismatched with the indication that the mismatched topography reorganized within adjacent barrel (same row-arc bias following hemifacial transplant). These results suggest subcortical changes in the thalamus and/or brainstem play a role in hemifacial transplantation cortical plasticity and demonstrate the discrete and robust data that can be derived from this clinically relevant small animal VCA model for use in optimizing postsurgical outcomes.NEW & NOTEWORTHY Robust rodent hemifacial transplant model was used to record functional changes in somatosensory cortex after transplantation. Neurons in the somatosensory cortex of face transplant recipients had decreased sensitivity to stimulation of whiskers with increased directional sensitivity vs. naive rats. Transplant recipient cortical unit response was more dispersed in temporary vs. naive rats. Despite histological similarities to naive cortices, transplant recipient cortices had a mix of topographically appropriate and inappropriate whiskered at barrel cortex relationships.

Virtual Surgical Planning and 3D-Printed Surgical Guides in Facial Allotransplantation

The complex three-dimensional (3D) anatomy in facial allotransplantation creates a unique challenge for surgical reconstruction. Evolution of virtual surgical planning (VSP) through computer-aided design and computer-aided manufacturing has advanced reconstructive outcomes for many craniomaxillofacial indications. Surgeons use VSP, 3D models, and surgical guides to analyze and to trial surgical approaches even prior to entering the operating room. This workflow allows the surgeon to plan osteotomies and to anticipate challenges, which improves surgical precision and accuracy, optimizes outcomes, and should reduce operating room time. We present the development, evolution, and utilization of VSP and 3D-printed guides in facial allotransplantation at our institution, from guide conception to first clinical case.

Policies and Price Tags: The Public's Perception of Face Transplantation and Its Funding

Study Design

Survey study.

Objective

Facial vascularized composite allotransplantation (FVCA) can cost over 1 million dollars per procedure and is usually not covered by insurance, yet this financial burden and public opinion surrounding this procedure are not well understood. This study is the first to evaluate the layperson's opinions on the allocation of financial responsibility for FVCA and its inclusion in organ donation registries.

Methods

Eight hundred and fifteen laypersons were surveyed through MTurk to assess their agreement with 11 statements about FVCA perceptions, funding, and inclusion on organ donation registries. Responses were analyzed with the Wilcoxon Signed-Rank test, the Kruskal-Wallis test, and the Dunn's test.

Results

The majority of respondents were supportive of FVCA in 10 out of 11 statements (P < 0.0001). They would be willing to undergo FVCA if they suffered from facial disfigurement; believe FVCA is as important as other organ transplants; believe faces should be included on the organ donation registry; support insurance companies providing coverage for FVCA regardless of trauma etiology; support tax dollars funding the procedure; and believe FVCA improves physical appearance and quality of life. Although respondents generally supported their tax dollars funding the procedure, fewer supported this for self-inflicted trauma (P > 0.01).

Conclusions

This study highlights a disconnect between public preference for insurance coverage of FVCA and current lack of coverage in practice. Respondents' acceptance of including faces in organ donation registries may help alleviate the issue of locating a donor, and increasing financial coverage may broaden this procedure's accessibility to a wider range of individuals.

In the face of change: Which coping strategies predict better psychosocial outcomes in face transplant recipients?

OBJECTIVES

Face transplantation aims to improve patients' quality of life and psychosocial functioning in patients with a disfiguring injury. With 40 cases worldwide, little is known about coping strategies predicting resilient outcomes.

DESIGN

Six patients followed in Boston, completed the Brief COPE (Carver, 1997) along with validated measures of depression, self-esteem, and quality of life - every 3 months during the first year post-transplant and every 6 months thereafter, up to 36 months post-transplant.

ANALYSES

Due to sample size and distribution of the data, nonparametric tests were used to characterize the relation of coping strategies with psychosocial outcomes.

RESULTS

As expected, active coping strategies were associated with better mental health pre-transplant, while avoidant coping strategies were associated with poorer mental health. Patients using support-based strategies reported better mental health at baseline. Post-transplant, the pattern reversed such that avoidant strategies appeared protective, when looking at mental health trajectories over 18 months. Importantly, trends identified during the first 18 months matched the trajectories of all patients with existing data up to 36 months post-transplant, for all outcomes measured.

CONCLUSION

Different coping strategies support optimal outcomes in the pre-versus post-transplant phases. Pre-transplant data may better inform interventions supporting mental health of transplant candidates than predict post-transplant behavior. Early post-transplant data seems to provide promising insight in long term psychosocial outcomes.

CLINICAL IMPLICATIONS

Our data stresses the need for pre-transplant assessment of coping and post-transplant coping training. Research aiming to optimize post-transplant psychosocial outcomes should consider coping as a promising target for intervention.

OPTN/SRTR 2020 Annual Data Report: VCA

The first vascularized composite allograft (VCA) transplant in the United States was performed in 1998 in a 40-year-old man who received a laryn-geal transplant after experiencing severe trauma to the throat 20 years before. The following VCA was a hand transplant in 1999 in a 37-year-old man who lost his left hand 13 years before. Since then, the field of VCA transplantation has made significant strides. On July 3, 2014, the Or gan Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) oversight of VCA procurement and transplant in the United States went into effect. In the last decade, the number of candidates listed for and transplanted with VCA has increased. While patient demographic data, whether listed candidates or patients undergoing VCA transplant, is limited by sample size, the trend is a predominance toward a young/middle-aged, White population. Overall outcomes data have been promising, with the vast majority of VCA transplants resulting in functioning grafts.

Face Transplants: An International History

Face transplants have attracted global media and public attention since the 1990s. The first recipient, Isabelle Dinoire, found herself at the centre of a dramatic episode of surgical innovation after her transplant was announced in November 2005. Subsequently 47 transplants have been conducted worldwide (including two retransplants) up to August 2020, and these have been accompanied by extensive news coverage. Hundreds of papers on the medical, physical, psychological, and ethical implications of the procedure have been published in the scientific literature, disproportionate to the incidence of the procedure. Face transplants have also featured in films, television, and fiction, indicating an appetite for interrogating the social and interpersonal implications of facial difference. However, the history of facial transplantation has largely been unexplored. This article provides the first international history of the global development and implementation of facial transplantation. Using published medical literature, media coverage, and oral history interviews with key participants as source material, it situates the experimental transplant in national, institutional, and professional contexts. It argues that charting the history of face transplants over a 30 year period from initial discussions in 1991 to the present provides a valuable case study through which to consider surgical cultures and discourses of medical innovation in the twenty-first century.

The masks of Lorenzo Tenchini: their anatomy and surgical/bioengineering clues

An academic, anatomist, and Lombrosian psychiatrist active at the University of Parma in Italy at the end of the 19th century, Lorenzo Tenchini produced ceroplastic-like masks that are unique in the anatomical Western context. These were prepared from 1885 to 1893 with the aim of 'cataloguing' the behaviour of prison inmates and psychiatric patients based on their facial surface anatomy. Due to the lack of any reference to the procedure used to prepare the masks, studies were undertaken by our group using X-ray scans, infrared spectroscopy, bioptic sampling, and microscopy analysis of the mask constituents. Results showed that the masks were stratified structures including plaster, cotton gauze/human epidermis, and wax, leading to a fabrication procedure reminiscent of 'additive layer manufacturing'. Differences in the depths of these layers were observed in relation to the facial contours, suggesting an attempt to reproduce, at least partially, the three-dimensional features of the facial soft tissues. We conclude the Tenchini masks are the first historical antecedent of the experimental method for face reconstruction used in the early 2000s to test the feasibility of transferring a complete strip of face and scalp from a deceased donor to a living recipient, in preparation for a complete face transplant. In addition, the layering procedure adopted conceptually mimics that developed only in the late 20th century for computer-aided rapid prototyping, and recently applied to bioengineering with biomaterials for a number of human structures including parts of the skull and face. Finally, the masks are a relevant example of mixed ceroplastic-cutaneous preparations in the history of anatomical research for clinical purposes.

Autologous Reconstruction of a Face Transplant Candidate

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.

Innovations in reconstructive microsurgery: Reconstructive transplantation

In the past 20 years, reconstructive transplantation (RT) has emerged as a viable reconstructive option for carefully selected patients. More than 100 upper extremity and 40 face transplants have been performed worldwide to date. Concomitantly, the portfolio of reconstructive transplantation has been extended by additional procedures such as lower extremities, abdominal wall, neck, uterus, genitourinary, and pediatric transplants. In the present review article, we aim to summarize the current state of knowledge about this exciting field.

Perioperative Nursing Management of Donor and Recipient Patients Undergoing Face Transplantation

Individuals with debilitating facial injuries and deformities have achieved significant improvement of aesthetic form and function after undergoing a face transplantation. The involvement of surgical technologists and perioperative nurses in the care of the recipient and donor plays a critical role in the success of these procedures. There are unique challenges that staff members may be presented with when caring for a donor and recipient undergoing a face transplantation, including less comfort with and knowledge of the surgical procedure and instrumentation, an increased amount of equipment and personnel in the OR, donor and recipient admission and discharge care, and increased shift length. At New York University Langone Medical Center, New York, we have developed a comprehensive process to prepare staff members to care for patients undergoing face transplantation.

Preliminary development of a workstation for craniomaxillofacial surgical procedures: introducing a computer-assisted planning and execution system

INTRODUCTION

Facial transplantation represents one of the most complicated scenarios in craniofacial surgery because of skeletal, aesthetic, and dental discrepancies between donor and recipient. However, standard off-the-shelf vendor computer-assisted surgery systems may not provide custom features to mitigate the increased complexity of this particular procedure. We propose to develop a computer-assisted surgery solution customized for preoperative planning, intraoperative navigation including cutting guides, and dynamic, instantaneous feedback of cephalometric measurements/angles as needed for facial transplantation and other related craniomaxillofacial procedures.

METHODS

We developed the Computer-Assisted Planning and Execution (CAPE) workstation to assist with planning and execution of facial transplantation. Preoperative maxillofacial computed tomography (CT) scans were obtained on 4 size-mismatched miniature swine encompassing 2 live face-jaw-teeth transplants. The system was tested in a laboratory setting using plastic models of mismatched swine, after which the system was used in 2 live swine transplants. Postoperative CT imaging was obtained and compared with the preoperative plan and intraoperative measures from the CAPE workstation for both transplants.

RESULTS

Plastic model tests familiarized the team with the CAPE workstation and identified several defects in the workflow. Live swine surgeries demonstrated utility of the CAPE system in the operating room, showing submillimeter registration error of 0.6 ± 0.24 mm and promising qualitative comparisons between intraoperative data and postoperative CT imaging.

CONCLUSIONS

The initial development of the CAPE workstation demonstrated that integration of computer planning and intraoperative navigation for facial transplantation are possible with submillimeter accuracy. This approach can potentially improve preoperative planning, allowing ideal donor-recipient matching despite significant size mismatch, and accurate surgical execution for numerous types of craniofacial and orthognathic surgical procedures.

Research in burns - Present and future

There have been tremendous advances in burns care over the past 50 years. Much of this, but not all, can be attributed to basic science and clinically related research. Out of the best centres in the world, centres that are fully funded and richly resourced, best practice guidelines result in impressive outcomes not only in terms of survival but also in terms of a quality of survival. Indeed the remaining clinical challenges in these centres are the elderly, the inhalational burns, and the very extensive burns. There are however other challenges when looking at burns care in a global context and in particular is the provision of even minimal standards of acceptable care for burns patients in many parts of the world. Whilst the justification for research funding in the wealthy countries becomes increasingly esoteric, for example looking at the immunology of face transplantation, the global health challenges of burns care still remain. Perhaps, the greatest research challenge in burns care in the 21st century lies not in furthering our understanding of the phenomenon we observe but the global application of the knowledge we already possess.