Incidence of Preventable Nonfatal Craniofacial Injuries and Implications for Facial Transplantation:

Management of Avulsive Soft Tissue Ballistic Facial Injuries

Ballistic facial injuries are rare yet challenging cases for plastic surgeons that often comprise of avulsive tissue loss. They require in-depth assessment and staged reconstruction after patient stabilization. Each anatomic region of the face holds specific considerations that should be prioritized during reconstruction. Soft tissue repair techniques of facial gunshot wounds are widely variable and range from primary closure to multistage free flaps. Large, devastating facial defects after ballistic trauma previously posed significant challenges for reconstruction; however, advances in composite tissue transplant and allografts have expanded plastic surgeons' reconstructive arsenals. The goal of this review is to focus on the fundamentals of soft tissue management and reconstruction after ballistic facial injury. Through sound surgical principles, patients may achieve optimal aesthetic and functional outcomes despite experiencing highly morbid facial ballistic injuries.

Design and validation of a preclinical model for oral commissure and lower eyelid thermal injury

INTRODUCTION

Oral commissure stenosis and lower eyelid ectropion from burns are functionally impairing and challenging to treat. Evaluation of various treatment modalities is limited by a lack of preclinical models. Described is a method for inducing controlled, titratable oral commissure and lower eyelid burns in swine for future treatment research.

METHODS

Burn wounds 3 cm in diameter were applied to the lower eyelid and oral commissure of seven anesthetized Yorkshire swine for 10, 15, 20, or 30 s at 100 °C with a custom designed thermocouple-controlled burn device and observed for 3, 30, or 90 days. Tissue underwent laser speckle imaging (LSI) to assess vascular perfusion and histologic analysis after harvest. Statistical comparisons were calculated using Wilcoxon rank-sum tests.

RESULTS

Subdermal extension was noted in oral commissure and lower eyelid burns with contact time of 20 s or greater. Wound area progressively contracted from post-operative day (POD) 0 to 90 in both sites, but this was not statistically significant based on contact time or burn site (p > 0.20). Burns of 20-30 s demonstrated increased neutrophil influx for oral commissure injuries (p < 0.01) and leukocyte and macrophage influx for lower eyelid injuries (p = 0.02). Degree of vascular congestion increased with 20-30 second burns in both the oral commissure (p = 0.015) and lower eyelid (p = 0.04). Normalized LSI readings showed increased speckle size in both oral commissure (4.0-fold increase, p < 0.01) and lower eyelid (3.2-fold increase, p < 0.01) burns on POD 90 compared to pre-injury. No change in oral or ocular function was noted in any of the groups (p = 0.96).

CONCLUSION

Oral commissure and lower eyelid burns create scars which may be modified by burn duration. This model may evaluate a therapeutic's ability to limit functional impairment from burns.

Long-term outcomes and future challenges in face transplantation

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

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

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

Recipient Selection Criteria for Facial Transplantation: A Systematic Review

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.

Facial Transplantation: Principles and Evolving Concepts

LEARNING OBJECTIVES

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

SUMMARY

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

Equity in access to facial transplantation

We examine ethical considerations in access to facial transplantation (FT), with implications for promoting health equity. As a form of vascularised composite allotransplantation, FT is still considered innovative with a relatively low volume of procedures performed to date by a small number of active FT programmes worldwide. However, as numbers continue to increase and institutions look to establish new FT programmes, we anticipate that attention will shift from feasibility towards ensuring the benefits of FT are equitably available to those in need. This manuscript assesses barriers to care and their ethical implications across a number of considerations, with the intent of mapping various factors relating to health equity and fair access to FT. Evidence is drawn from an evolving clinical experience as well as published scholarship addressing several dimensions of access to FT. We also explore novel concerns that have yet to be mentioned in the literature.