International consensus recommendations on face transplantation: A 2-step Delphi study

Face transplantation is a viable reconstructive approach for severe craniofacial defects. Despite the evolution witnessed in the field, ethical aspects, clinical and psychosocial implications, public perception, and economic sustainability remain the subject of debate and unanswered questions. Furthermore, poor data reporting and sharing, the absence of standardized metrics for outcome evaluation, and the lack of consensus definitions of success and failure have hampered the development of a "transplantation culture" on a global scale. We completed a 2-round online modified Delphi process with 35 international face transplant stakeholders, including surgeons, clinicians, psychologists, psychiatrists, ethicists, policymakers, and researchers, with a representation of 10 of the 19 face transplant teams that had already performed the procedure and 73% of face transplants. Themes addressed included patient assessment and selection, indications, social support networks, clinical framework, surgical considerations, data on patient progress and outcomes, definitions of success and failure, public image and perception, and financial sustainability. The presented recommendations are the product of a shared commitment of face transplant teams to foster the development of face transplantation and are aimed at providing a gold standard of practice and policy.

18 years of face transplantation: Adverse outcomes and challenges

BACKGROUND

Since the first procedure performed in 2005, face transplantation has been debated as viable approach for the treatment of severe craniofacial defects. Despite the benefits provided, the experience in face allotransplantation has brought to light a significant risk of complications, including allograft removal or loss, and mortality. The present study is intended to provide an updated review on complications and major challenges witnessed over 18 years of experience in the field.

METHODS

A systematic review of PubMed, MEDLINE, Cochrane, Google, and Google Scholar databases on face transplantation was conducted according to PRISMA guidelines up to April 2023. Articles providing details on cases of face allograft loss, removal, and patient death were included. Online articles and media reports were assessed to include information not disclosed in peer-reviewed literature. Face transplant centers were contacted to have updated follow-up information on single-face transplant cases.

RESULTS

The search yielded 1006 reports, of which 28 were included. On a total of 48 procedures performed in 46 patients, adverse outcomes were gleaned in 14 cases (29%), including seven allograft losses (14.6%), and the death of ten patients (21.7%). Chronic rejection was the leading cause of allograft loss, with a median time from transplant to irreversible rejection of 90 months (IQR 88.5-102). The main causes of death were infectious complications, followed by malignancies, non-compliance to immunosuppression, and suicide. The median time to death was 48.5 months (IQR 19-122).

CONCLUSIONS

To the best of our knowledge, this is the first study providing a comprehensive review of adverse outcomes in face transplantation. Considering the high rate of major complications, the heterogeneity of cases and single-center approaches, and the absence of published standards of care, the development of a consensus by face transplant teams holds the key to the field's advancement.

Facial Expression after Face Transplant: An International Face Transplant Cohort Comparison

BACKGROUND

Assessment of motor function restoration following face transplant (FT) is difficult, as standardized, bilateral tests are lacking. This study aims to bolster support for software-based analysis through international collaboration.

METHODS

FaceReader (Noldus, Wageningen, The Netherlands), a facial expression analysis software, was used to analyze posttransplant videos of eight FT patients from Boston, Massachusetts (range, 1 to 9 years after transplant), two FT patients from Helsinki, Finland (range, 3 to 4 years after transplant), and three FT patients from Antalya, Turkey (range, 6.5 to 8.5 years after transplant). Age-matched healthy controls from respective countries had no history of prior facial procedures. Videos contained patients and controls performing facial expressions evaluated by software analysis using the Facial Action Coding System. Facial movements were assigned intensity score values between 0 (absent) and 1 (fully present). Maximum values were compared with respective healthy controls to calculate percentage restoration.

RESULTS

Of 13 FT patients, eight patients were full FT, five patients were partial FT, and two patients were female patients. Compared with healthy controls, the median restoration of motor function was 36.9% (interquartile range, 28.8% to 52.9%) for all patients with FT ( P = 0.151). The median restoration of smile was 37.2% (interquartile range, 31.5% to 52.7%) for all patients with FT ( P = 0.065). When facial nerve coaptation was performed at the distal branch level, average motor function restoration was 42.7% ± 3.61% compared with 27.9% ± 6.71% at the proximal trunk coaptation level ( P = 0.032). Use of interpositional nerve grafts had no influence on motor outcomes.

CONCLUSIONS

Software-based analysis is suitable to assess motor function after FT. International collaboration strengthens outcome data for FT.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Comprehensive outcome analysis in two composite face transplants in Helsinki. Have we succeeded?

INTRODUCTION

There is a need to define what is success after face transplantation (FT). We have previously created a four-component criteria tool to define indications for FT. In this study, we used the same criteria to evaluate the overall outcome of our first two patients after FT.

PATIENTS AND METHODS

Preoperative analysis of our two bimaxillary FT patients was compared to the results at four and six years post-transplantation. The facial deficiency impact was divided into four categories: (1) anatomical regions, (2) facial functions (mimic muscles, sensation, oral functions, speech, breathing, periorbital functions), (3) esthetics, and (4) impact on health-related quality of life (HRQoL). Immunological status and complications were also evaluated.

RESULTS

For both patients, near-normal anatomical restoration of almost all the facial regions (except the periorbital and intraoral regions) was achieved. The majority of the facial function parameters improved in both patients (patient 2 to a near-normal level). The esthetic score improved from severely disfigured to impaired (patient 1) and to near to normal (patient 2). Quality of life was severely lowered prior to FT and improved after FT but was still affected. Neither patient has experienced acute rejection episodes during follow-up.

CONCLUSIONS

We conclude that our patients have benefitted from FT, and we have succeeded. Time will reveal whether we have achieved long-term success.

The Mandible Ameliorates Facial Allograft Rejection and Is Associated with the Development of Regulatory T Cells and Mixed Chimerism

Vascularized composite allografts contain various tissue components and possess relative antigenicity, eliciting different degrees of alloimmune responses. To investigate the strategies for achieving facial allograft tolerance, we established a mouse hemiface transplant model, including the skin, muscle, mandible, mucosa, and vessels. However, the immunomodulatory effects of the mandible on facial allografts remain unclear. To understand the effects of the mandible on facial allograft survival, we compared the diversities of different facial allograft-elicited alloimmunity between a facial osteomyocutaneous allograft (OMC), including skin, muscle, oral mucosa, and vessels, and especially the mandible, and a myocutaneous allograft (MC) including the skin, muscle, oral mucosa, and vessels, but not the mandible. The different facial allografts of a BALB/c donor were transplanted into a heterotopic neck defect on fully major histocompatibility complex-mismatched C57BL/6 mice. The allogeneic OMC (Allo-OMC) group exhibited significant prolongation of facial allograft survival compared to the allogeneic MC group, both in the presence and absence of FK506 immunosuppressive drugs. With the use of FK506 monotherapy (2 mg/kg) for 21 days, the allo-OMC group, including the mandible, showed prolongation of facial allograft survival of up to 65 days, whereas the myocutaneous allograft, without the mandible, only survived for 34 days. The Allo-OMC group also displayed decreased lymphocyte infiltration into the facial allograft. Both groups showed similar percentages of B cells, T cells, natural killer cells, macrophages, and dendritic cells in the blood, spleen, and lymph nodes. However, a decrease in pro-inflammatory T helper 1 cells and an increase in anti-inflammatory regulatory T cells were observed in the blood and lymph nodes of the Allo-OMC group. Significantly increased percentages of donor immune cells were also observed in three lymphoid organs of the Allo-OMC group, suggesting mixed chimerism induction. These results indicated that the mandible has the potential to induce anti-inflammatory effects and mixed chimerism for prolonging facial allograft survival. The immunomodulatory understanding of the mandible could contribute to reducing the use of immunosuppressive regimens in clinical face allotransplantation including the mandible.

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 decade of face transplant outcomes

At the 10th year anniversary of the first face transplantation, 37 patients worldwide, were the recipients of faces coming from human donors. Five patients died due to complications, noncompliance with immunosuppressive medications and development of cancer. Despite the initial debates and ethical concerns, face transplantation became a clinical reality with satisfactory functional outcomes. The areas of controversy still include the impact of life-long immunosuppression on otherwise healthy patients as well as the selection process of face transplant candidates. Other concerns include financial support for this new generation of transplants as well as social re-integration and patients return to work after face transplantation. Based on over 20 years of research experience in the field of vascularized composite allotransplantation (VCA), and clinical experience as a leading surgeon of the US first face transplantation, this review will summarize the well-known facts as well as unexpected outcomes and challenges of face transplantation.

Facial transplantation. An update of results and perspectives from tissue engineering

BACKGROUND/AIM

Facial transplantation is a revolutionary procedure developed recently, which is indicated if autologous transfers fail to restore human appearance. More than 30 patients have undergone facial transplantation in different centers worldwide. Here, we provide an update on its main anatomical, surgical, immunological, ethical, and follow- up aspects. We also provide innovative perspectives of regenerative medicine and tissue engineering that could hold promise for this emerging surgical field.

METHODS

Through careful review of the anatomical, surgical, and tissue-engineering literature, we documented the main aspects of this innovative surgical procedure and its potential improvements in regenerative plastic surgery.

RESULTS

Compatibility for the major blood groups (ABO) and human leukocyte antigen system between donor and recipient is critical to transplantation success. Major complications are tissue rejection and side effects of immunosuppression. The functional outcomes of facial transplantation are encouraging, with slow recovery of motor and sensory functions. Psychological impact on the family of the donor and recipient is essential for the success of facial transplantation.

CONCLUSIONS

Uncertainty of long-term outcomes, immunosuppression-related concerns and ethical debates limit worldwide application of facial allotransplantation. However, in selected patients it is a unique reconstruction method with promising outcomes. Recent developments in regenerative medicine open a new frontier for application of patient-tailored, biocompatible and engineered reproductions of the various anatomical components of the face, and their application to transplant technology. Further research in transplant immunology, survival and conservation of grafts, and regenerative treatments of lesioned and/or transplanted tissues hold the key to advances in this emerging surgical option.

KEY WORDS

Facial transplantation, Plastic surgery, Reconstructive surgery, , Regenerative medicine, Tssue engineering.

[Planning and organization of allo-grafting performed on the soldier's face]

Planning and organisation of allo-grafting performed on the soldier's face. According to the experience of military conflicts facial trauma with the Ioss of person's social function occurs in 4,5-5% of patients with such injury. In most cases, these injuries can be fixed with the help of reconstructive plastic surgery using their own tissue. However, some of the wounded to various reasons the use of autologous tissue is not possible or does not allow adequately restoring the appearance and function of the person. In such cases the only way is a donor allograft. There are just over 3 dozens of such successful operations, which indicates of their uniqueness and complexity. In May 2015 at the S.M.Kirov Military Medical Academy for the first time in our country made a successful transplantation of a difficult graft to a conscript, who was injured during the duty. The article presents the basic directions of the planning and organization of this unique operation.

A new total hemiface allotransplantation model in rats

INTRODUCTION

Vascularized composite allotransplantation (VCA), a new reconstructive option for patients suffering from extensive facial defects leads to superior functional and aesthetic outcomes compared to the standard autologous reconstruction. Among VCA recipients, each case involves different facial structures and tissues depending on the patient's injury, thus drawing conclusions on the mechanism of immune interactions between the donor and recipient is challenging. This study introduces a new total hemiface VCA model, including scalp, external ear, mystacial pad, premaxilla, upper/lower lids, nose, and upper/lower lips to evaluate the effect of transplantation of multitissue VCA on the recipient's immune response.

MATERIAL AND METHODS

Ten hemiface allotransplantations were performed in two groups between Lewis-Lewis (isograft) and LBN-Lewis (allograft) rats. Cyclosporine A (CsA) monotherapy was applied in the allograft group to prevent rejection.

RESULTS

All flaps survived up to 100 days post-transplant. The mean warm ischemia time was 45 minutes. Histological analysis revealed normal bone, cartilage (ear and nose), conjunctiva, palpebra, and eyelashes. Flow cytometry confirmed donor-specific chimerism for T cells (CD4/RT1(n) and CD8/RT1(n)) and B cells (CD45RA/RT1(n)) in the peripheral blood of all rats in the allotransplantation group. At post-transplant day 7, chimerism levels were at 1.68% for CD4/RT1(n) , 0.46% for CD8/RT1(n) and 0.64% for CD45RA/RT1(n). However, chimerism levels for CD4/RT1(n), CD8/RT1(n), and CD45RA/RT1(n) populations decreased at long-term follow-up (at post-transplant day 100) to 0.08%, 0.04%, and 0.23%, respectively.

CONCLUSION

The feasibility and long-term survival of the new hemiface VCA transplantation model was confirmed, donor-specific chimerism and post-transplant tissue changes were evaluated.

BASIC PRINCIPLES OF MODELLIND OF FACIAL COMPOSITE TISSUE ALLOGRAFTS

The article presents the results of anatomical studies aimed to develop modelling of facial allografts taking into account the peculiarities of blood supply. The allografts should meet both aesthetic and functional needs of the recipient for further use in clinical practice. There were selected 3 facial composite tissue allografts out of 50 modifications, which are more suitable for required parameters. On basis of these data, there was successfully performed the facial composite tissue allograft transplantation on the patient.

Facial transplantation surgery introduction

Severely disfiguring facial injuries can have a devastating impact on the patient's quality of life. During the past decade, vascularized facial allotransplantation has progressed from an experimental possibility to a clinical reality in the fields of disease, trauma, and congenital malformations. This technique may now be considered a viable option for repairing complex craniofacial defects for which the results of autologous reconstruction remain suboptimal. Vascularized facial allotransplantation permits optimal anatomical reconstruction and provides desired functional, esthetic, and psychosocial benefits that are far superior to those achieved with conventional methods. Along with dramatic improvements in their functional statuses, patients regain the ability to make facial expressions such as smiling and to perform various functions such as smelling, eating, drinking, and speaking. The ideas in the 1997 movie "Face/Off" have now been realized in the clinical field. The objective of this article is to introduce this new surgical field, provide a basis for examining the status of the field of face transplantation, and stimulate and enhance facial transplantation studies in Korea.

Facial transplantation: the first 9 years

Since the first facial transplantation in 2005, 28 have been done worldwide with encouraging immunological, functional, psychological, and aesthetic outcomes. Unlike solid organ transplantation, which is potentially life-saving, facial transplantation is life-changing. This difference has generated ethical concerns about the exposure of otherwise young and healthy individuals to the sequelae of lifelong, high-dose, multidrug immunosuppression. Nevertheless, advances in immunomodulatory and immunosuppressive protocols, microsurgical techniques, and computer-aided surgical planning have enabled broader clinical application of this procedure to patients. Although episodes of acute skin rejection continue to pose a serious threat to face transplant recipients, all cases have been controlled with conventional immunosuppressive regimens, and no cases of chronic rejection have been reported.

Computer-assisted, Le Fort-based, face-jaw-teeth transplantation: a pilot study on system feasiblity and translational assessment

PURPOSE

Le Fort-based face-jaw-teeth transplantation (FJTT) attempts to marry bone and teeth geometry of size-mismatched face-jaw-teeth segments to restore function and form due to severe mid-facial trauma. Recent development of a computer-assisted planning and execution (CAPE) system for Le Fort-based FJTT in a pre-clinical swine model offers preoperative planning, and intraoperative navigation. This paper addresses the translation of the CAPE system to human anatomy and presents accuracy results.

METHODS

Single-jaw, Le Fort-based FJTTs were performed on plastic models, one swine and one human, and on a human cadaver. Preoperative planning defined the goal placement of the donor's Le Fort-based FJTT segment on the recipient. Patient-specific navigated cutting guides helped achieve planned osteotomies. Intraoperative cutting guide and donor fragment placement were compared with postoperative computed tomography (CT) data and the preoperative plan.

RESULTS

Intraoperative measurement error with respect to postoperative CT was less than 1.25 mm for both mock transplants and 3.59 mm for the human cadaver scenario. Donor fragment placement (as compared to the planned position) was less accurate for the human model test case (2.91 mm) compared with the swine test (2.25 mm) and human cadaver (2.26 mm).

CONCLUSION

The results indicate the viability of the CAPE system for assisting with Le Fort-based FJTT and demonstrate the potential in human surgery. This system offers a new path forward to achieving improved outcomes in Le Fort-based FJTT and can be modified to assist with a variety of other surgeries involving the head, neck, face, jaws and teeth.

Vascularized composite allotransplant in the realm of regenerative plastic surgery

Vascularized composite allotransplant (VCA) has led to new treatment options for patients with severe upper extremity and facial injuries. Although VCA can restore form and function, it exposes the patient to the risks associated with lifelong immunosuppression. Hopefully, ongoing advances in regenerative medicine will someday obviate the need for VCA, but until that time, VCA remains an immediate means of reconstructing otherwise unreconstructable defects. We review the outcomes of hand and face transplants, as well as the recent developments in immunosuppression as it relates to the field of VCA.

Burns in children: standard and new treatments

Outcomes of patients with burns have improved substantially over the past two decades. Findings from a 2012 study in The Lancet showed that a burn size of more than 60% total body surface area burned (an increase from 40% a decade ago) is associated with risks and mortality. Similar data have been obtained in adults and elderly people who have been severely burned. We discuss recent and future developments in burn care to improve outcomes of children.

Facial transplants in Xenopus laevis embryos

Craniofacial birth defects occur in 1 out of every 700 live births, but etiology is rarely known due to limited understanding of craniofacial development. To identify where signaling pathways and tissues act during patterning of the developing face, a 'face transplant' technique has been developed in embryos of the frog Xenopus laevis. A region of presumptive facial tissue (the "Extreme Anterior Domain" (EAD)) is removed from a donor embryo at tailbud stage, and transplanted to a host embryo of the same stage, from which the equivalent region has been removed. This can be used to generate a chimeric face where the host or donor tissue has a loss or gain of function in a gene, and/or includes a lineage label. After healing, the outcome of development is monitored, and indicates roles of the signaling pathway within the donor or surrounding host tissues. Xenopus is a valuable model for face development, as the facial region is large and readily accessible for micromanipulation. Many embryos can be assayed, over a short time period since development occurs rapidly. Findings in the frog are relevant to human development, since craniofacial processes appear conserved between Xenopus and mammals.

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.

Learning curve in hemifacial transplantation in rats

INTRODUCTION

The aim of this study was to emphasize the learning curve of hemifacial transplantation in rats by comparison between 2 operators: medical student trained in basic microsurgery and an experienced microsurgeon.

MATERIALS AND METHODS

A total number of 15 hemifacial transplants between Brown Norway as donors and Wistar as receiver rats were performed by two operators: experienced microsurgeon (group II, n=5) and the medical student (group III, n=10). Warm ischemia time and operative time were used as instrument for comparison. All the rats received immunosuppressive treatment with cyclosporine A in monotherapy for 30 days. Results were processed statistically using Microsoft Excel.

RESULTS

Transplantation procedure duration time performed by experienced microsurgeon began from 420 min and decreased to 330 min after 5 transplantations, with confidence interval (95% probability)382 ± 37.9 min and the warm ischemia time decreased from 140 min to 50 min, confidence interval of the warm ischemia time being 90 ± 33.52 min. After transplantation the rats were treated with cyclosporine A and monitored for 30 days. Medical student tended to equalize the operative time and warm ischemia time, approximately, after 9 transplantations, from 660 min to 330 min and warm ischemia time from 190 min to 60 min. The confidence interval (95%) of the procedure by duration of the surgery was 467 ± 80.66 min and 133.5 ± 31.44 min for the warm ischemia time. Most of the rats (n=11) survived in both transplanted groups (group II and group III) performed by microsurgeon and student. By analyzing learning curves using two parameters (operative time and warm ischemia time) and survival rates no statistically significant difference was found (p 0.05).

CONCLUSION

Hemifacial transplantation model in rats is a useful tool for preparing experimental and clinical application of the facial transplantation. It is a good model for training young specialists for future transplantation surgery. It is important to notice that the medical student had previous experience in microsurgery and the learning curve was applied only for this specific procedure. Even young specialists in microsurgery could perform such a complex procedure after an appropriate training period (in our study after 9 consecutive transplantations) in the same fashion and with the same results as an experienced microsurgeon. Usage of cyclosporine A as monotherapy gave good immunosuppression results in rats' transplantations for the studied duration of time (30 days).

Three patients with full facial transplantation

Unlike conventional reconstruction, facial transplantation seeks to correct severe deformities in a single operation. We report on three patients who received full-face transplants at our institution in 2011 in operations that aimed for functional restoration by coaptation of all main available motor and sensory nerves. We enumerate the technical challenges and postoperative complications and their management, including single episodes of acute rejection in two patients. At 6 months of follow-up, all facial allografts were surviving, facial appearance and function were improved, and glucocorticoids were successfully withdrawn in all patients.

A historical, clinical, and ethical overview of the emerging science of facial transplantation

In the past 5 years, a total of 16 facial transplantation surgeries have been performed in France, China, Spain, and the United States. Facial transplantation has become a surgical option in clinical situations in which soft tissue and bone loss is accompanied by severe cosmetic, sensory, and functional deficiencies due to disease, trauma, or congenital malformations. With the introduction of facial tissue transplantation surgery came complex clinical, technological, and ethical patient care issues. These complex issues included determining patient selection criteria, refining donor tissue procurement techniques, predicting expected functional outcomes, appreciating the limitations of obtaining a fully informed consent for an innovative procedure, and deliberating the immunological response and postoperative immunosuppressant requirements of the recipient. In addition, psychological implications for the patient, societal consequences, and ethical concerns have been discussed. The short-term results have been positive. Results to date indicate that the clinical, technical, and immunological patient care issues in this emerging science appear to mirror those of other reconstructive and organ transplantation procedures. The long-term physical, emotional, and psychological effects on the recipient patient, as well as long-term consequences to the donor's family, are yet to be validated.

[Surgical treatment of posttraumatic deformity of the orbital floor]

The article is devoted to an actual problem of surgical treatment of patients with posttraumatic deformities of the orbital floor. On the material of 21 observations it was shown that for the successful treatment of deformities of the orbit bottom autogenous costal cartilage graft should be used as a plastic material. Removal of enophthalmos in longstanding fractures can be reached only by reducing the volume of the orbit which can be achieved by retrobulbar placement of the graft. An analysis of the results demonstrated high efficiency of this method in the treatment of such patients.

[Facial graft, archetype of microsurgical innovation?]

Is innovation breaking of the way of thinking, breaker of taboos, concretisation of chimeras or simple benefit of an ineluctable evolution? The surgical act should be considered as innovation itself? From the first facial allotransplantation, innovation is declined in various ways, which could constitute the different answers regarding the planning and management to prepare such surgery, the realisation of the transplantation and also the multiple developments in terms of science and medicine. It is exactly in that meaning that could be really mentioned the term archetypal.

Facial reconstruction by biosurgery: cell transplantation versus cell homing

The face distinguishes one human being from another. When the face is disfigured because of trauma, tumor removal, congenital anomalies, or chronic diseases, the patient has a strong desire for functional and esthetic restoration. Current practice of facial reconstruction using autologous grafts, synthetic fillers, and prostheses is frequently below the surgeon's and patient's expectations. Facial reconstruction is yet to take advantage of recent advances in seemingly unrelated fields of stem cell biology, chemical engineering, biomaterials, and tissue engineering. "Biosurgery," a new concept that we propose, will incorporate novel principles and strategies of bioactive cues, biopolymers, and/or cells to restore facial defects. Small facial defects can likely be reconstructed by cell homing and without cell transplantation. A critical advantage of cell homing is that agilely recruited endogenous cells have the potential to harness the host's innate capacity for regeneration, thus accelerating the rate of regulatory and commercialization processes for product development. Large facial defects, however, may not be restorable without cell delivery per our understanding at this time. New breakthrough in biosurgery will likely originate from integrated strategies of cell biology, cytokine biology, chemical engineering, biomaterials, and tissue engineering. Regardless of cell homing or cell delivery approaches, biosurgery not only will minimize surgical trauma and repetitive procedures, but also produce long-lasting results. At the same time, caution must be exercised against the development of products that lack scientific basis or dogmatic combination of cells, biomaterials, and biomolecules. Together, scientifically derived biosurgery will undoubtedly develop into new technologies that offer increasingly natural reconstruction and/or augmentation of the face.

Near-total human face transplantation for a severely disfigured patient in the USA

BACKGROUND

Multiple reconstructive procedures are common for the reconstruction of complex facial deformities of skin, soft tissues, bony structures, and functional subunits, such as the nose, lips, and eyelids. However, the results have been unsatisfactory. An innovative approach entailing a single surgical procedure of face allograft transplantation is a viable alternative and gives improved results.

METHODS

On Dec 9, 2008, a 45-year-old woman with a history of severe midface trauma underwent near-total face transplantation in which 80% of her face was replaced with a tailored composite tissue allograft. We addressed issues of immunosuppressive therapy, psychological and ethical outcomes, and re-integration of the patient into society.

FINDINGS

After the operation, the patient did well physically and psychologically, and tolerated immunosuppression without any major complication. Routine biopsy on day 47 after transplantation showed rejection of graft mucosa; however, a single bolus of corticosteroids reversed rejection. During the first 3 weeks after transplantation, the patient accepted her new face; 6 months after surgery, the functional outcome has been excellent. In contrast to her status before transplantation, the patient can now breathe through her nose, smell, taste, speak intelligibly, eat solid foods, and drink from a cup.

INTERPRETATION

We show the feasibility of reconstruction of severely disfigured patients in a single surgical procedure using composite face allotransplantation. Therefore, this should be taken in consideration as an early option for severely disfigured patients.

FUNDING

None.

Human facial allotransplantation: a 2-year follow-up study

BACKGROUND

Progress in composite tissue allotransplantation could provide a new treatment for patients with severe facial disfigurements. We did a partial facial allotransplantation in 2006, and report here the 2 year follow-up of the patient.

METHODS

The recipient, a 30-year-old man from China, had his face severely injured by a bear in October, 2004. Allograft composite tissue transplantation was done in April, 2006, after careful systemic preparation. The surgery included anastomosis of the right mandibular artery and anterior facial vein, whole repair of total nose, upper lip, parotid gland, front wall of the maxillary sinus, part of the infraorbital wall, and zygomatic bone. Facial nerve anastomosis was done during the surgery. Quadruple immunomodulatory therapy was used, containing tacrolimus, mycophenolate mofetil, corticosteroids, and humanised IL-2 receptor monoclonal antibody. Follow-up included T lymphocyte subgroups in peripheral blood, pathological and immunohistochemical examinations, functional progress, and psychological support.

FINDINGS

Composite tissue flap survived well. There were three acute rejection episodes at 3, 5, and 17 months after transplantation, but these were controlled by adjustment of the tacrolimus dose or the application of methylprednisolone pulse therapy. Hepatic and renal functions were normal, and there was no infection. The patient developed hyperglycaemia on day 3 after transplantation, which was controlled by medication.

INTERPRETATION

Facial transplantation could be successful in the short term, but the procedure was not without complications. However, promising results could mean that this procedure might be an option for long-term restoration of severe facial disfigurement.

Repair of the lower and middle parts of the face by composite tissue allotransplantation in a patient with massive plexiform neurofibroma: a 1-year follow-up study

BACKGROUND

The risk to benefit ratio of face transplantation with a composite tissue allograft remains debatable, although this procedure is technically feasible. We report here a 1-year follow-up of a patient who underwent face transplantation with a composite tissue allograft.

METHODS

On Jan 21, 2007, a 29-year-old man with neurofibromatosis type 1 underwent resection of a massive plexiform neurofibroma diffusely infiltrating the middle and lower part of his face. The main goal was to restore both the cutaneous appearance and function of the face, including, in particular, control of orbicularis oculi and oris muscle contraction. The issues of immunosuppressive therapy, psychological outcome, and social reintergration were addressed, together with the monitoring of graft rejection by biopsies of the skin and mucosa.

FINDINGS

The initial postoperative course was uncomplicated. Two episodes of clinical rejection occurred on days 28 and 64. The second episode was associated with cytomegalovirus infection. Both episodes resolved favourably, with no further clinical signs of rejection, making the reduction of immunosuppressive treatment possible. A year after surgery, the functional outcome was very good, with successful sensory and motor reinnervation in the transplanted territory. Psychological recovery was excellent, with complete social reintegration.

INTERPRETATION

This case demonstrates the feasibility of surgically removing a large part of the face and replacing it with a composite tissue allograft. This facial repair procedure, which seems to have a satisfactory risk to benefit ratio, could be offered in rare and selected cases.

[Facial allograft transplantation: fiction or reality? Surgical techniques in a fresh human cadaver model]

BACKGROUND

The aim of this study was to describe two methods of face-harvesting techniques -- a skin and soft tissue flap and a combined osteocutaneous flap -- and to demonstrate the compatibility between donor and recipient in a human fresh cadaver model.

METHODS

In fresh human cadavers the skin and soft tissue of the face (type 1) and a combined osteocutaneous flap (including a le Fort III segment, type 2) were harvested. The faces were subsequently exchanged among the donor crania, simulating full-face transplantation.

RESULTS

Both flaps are based on the external blood supply of the faciotemporal vessels and the external jugular vein. The end branches of the trigeminal nerve could potentially be used for restoration of sensation (type 1 flap). With type 2 flaps the facial expression may be restored with the inclusion of the facial nerve. Four morphological parameters determine the donor/recipient compatibility: skin color and texture, anthropometric head dimensions, specific soft tissue components (nose, lip, cheek, and eyebrow), and gender.

CONCLUSION

Apart from ethical considerations, long-term immunosuppression will remain the limiting factor of full facial transplantation in the near future.

Outcomes 18 months after the first human partial face transplantation

BACKGROUND

We performed the first human partial face allograft on November 27, 2005. Here we report outcomes up to 18 months after transplantation.

METHODS

The postsurgical induction immunosuppression protocol included thymoglobulins combined with tacrolimus, mycophenolate mofetil, and prednisone. Donor hematopoietic stem cells were infused on postoperative days 4 and 11. Sequential biopsy specimens were taken from a sentinel skin graft, the facial skin, and the oral mucosa. Functional progress was assessed by tests of sensory and motor function performed monthly. Psychological support was provided before and after transplantation.

RESULTS

Sensitivity to light touch, as assessed with the use of static monofilaments, and sensitivity to heat and cold had returned to normal at 6 months after transplantation. Motor recovery was slower, and labial contact allowing complete mouth closure was achieved at 10 months. Psychological acceptance of the graft progressed as function improved. Rejection episodes occurred on days 18 and 214 after transplantation and were reversed. A decrease in inulin clearance led to a change in immunosuppressive regimen from tacrolimus to sirolimus at 14 months. Extracorporeal photochemotherapy was introduced at 10 months to prevent recurrence of rejection. There have been no subsequent rejection episodes. At 18 months, the patient is satisfied with the aesthetic result.

CONCLUSIONS

In this patient who underwent the first partial face transplantation, the functional and aesthetic results 18 months after transplantation are satisfactory.

[Avatars in face transplants]

Avatar carries a pejorative connotation often related to an unfortunate hazard. In face transplants, incarnations were numerous. The analysis of their evolution through time and increasing sophistication of procedures turn out to be informative regarding the wide disrepairs in the craniofacial area. The authors report the principal constraints of face transplant and the evolution in minds to deal with it.

[Strategy study of harvesting total facial flap and donor choice for allograft transplantation in cadaver]

OBJECTIVE

To explore the operational strategy of harvesting total facial allograft by autopsy.

METHODS

Twelve fresh human cadavers were dissected. They were divided into two groups randomly. The total facial-scalp flap of the group I was elevated by the bi-pedicle method, the group II was operated with single-pedicle method. Both were dissected at the deep plane of the SMAS. : the time of facial flap harvesting, length of the artery vein and nerve pedicles of the donor were measured and marked, after operation, in each group we transferred one facial allograft to another. Then the free graft of group I was poured through artery by methylthioninium chloride to study vascular territories.

RESULTS

Mean harvesting time of the group I (46 +/- 11) minutes, group II (111 +/- 7) minutes, P < 0.01. Perfusion result shows that unilateral superficial temporal artery and the opposite side of the facial artery can supply blood for whole face. The pedicle was long enough for anastomosis. Post-operation appearance: the face looks like neither the donor nor the recipient primarily, It's mainly due to the characteristics of the skeleton and the soft tissues.

CONCLUSIONS

The bi-pedicle method of the harvesting total facial allograft is concise, fast, safe can be widely applied in clinical.