Large tertiary institutions that have a long tradition in transplantation medicine and run a robust programme in plastic and reconstructive surgery normally host face transplantation programmes. Level I trauma centres, burn units or centres and superregional craniomaxillofacial programmes are usually normal referral units in such institutions.

The initial referral visit for face transplantation should not differ much to that usually in place for face reconstructive surgery. In practice, it is recommended that all patients be referred to the face reconstructive outpatient clinic for a complete initial visit where he/she may meet all surgical team members and a complete analysis of the problem be made. The rationale behind this approach resides on the basis that face transplantation is not a plain composite tissue allotransplantation venture but a complex reconstructive option, in which the reconstruction is performed by means of the allotransplantation of face units/anatomy and function. Evaluation of patients with severe face deformities then follow a step-wise manner in which all reconstructive options are taken into account and a final master plan for any given patient is delineated. It may include different classical techniques that may render a good final outcome of a definitive indication for face transplantation.

There exist few initial steps that need to be explored and fulfilled in order to plan a comprehensive evaluation for a face transplantation. During the initial visit, team members check all the inclusion and exclusion criteria for face transplantation; explore and analyse the patient’s deformity, possible plastic surgery indications and required techniques; and list all patient’s complaints, aesthetic, functional deficits and patient’s expectations (Fig. 6.1). During this initial visit, a complete blood test is run in order to rule out any formal contraindication for face transplantation. During this initial(s) visit(s) (it may be necessary to have different interviews with the patient), the patient is provided with all necessary information. It is mandatory that the patient receives all information regarding the positive, negative aspects of the procedure, risks and benefits and that he/she understand the experimental aspect of vascularised composite tissue allotransplantation. An introduction to the multidisciplinary team is also enforced and the requirement of different interviews with the core members of different specialists that will be required. Patients are also informed of the whole selection process and the administrative steps that must be followed:

Patients that are considered candidates for face transplantation are then admitted to the hospital. They are informed and warned that a hospital admission for a 2–3-week period may be necessary to fulfil all the tests and requirements according to the VCA face protocol. We have found that admitting patients to the plastic surgery ward is very valuable for both performing all necessary examinations and interviews in a timely fashion and for a good interaction of patients and their families with the transplantation team and ward nurses. During all long “stand-by” hours between tests and interviews, patient behaviour, social interaction, resilience and stress response can be evaluated. The report of caring nurses is extremely valuable to make a general picture of the psychosocial status of the patients and his/her social environment. Strong and weak points may be detected and encouraged or treated accordingly.

It cannot be overstated that the initial(s) visit(s) is a key element of the evaluation process. During these visits the surgeon-in-chief and team members evaluate the face deformity and obtain a clear picture of the anatomic deformity, the functional impact and the general psychosocial status of the patients. Full information of the goals of face transplantation, benefits, risks and possible side effects, including death, are discussed. Patients reaching the evaluation process have understood and accepted the overall principles and goals of face transplantation, accepting a full examination with its possible positive or negative outcomes.

Different specialists, units and services are involved during the evaluation process. It is a thorough medical and surgical workup; hence, a case manager and a surgeon-in-chief that control the process and lead the process must pilot it. Plastic surgery specialists evaluate all questions and issues regarding the surgical aspect of the deformity (anatomic areas to be extirpated and donor tissue requirements). The former includes a full anthropomorphic evaluation, physical examination (including radiologic evaluation) and skin phototype. Medical specialists of the face transplant team should evaluate the health status and well-being, paying a special attention to those conditions that currently contraindicate a vascularised composite tissue allotransplantation (malignant neoplasm, renal failure, hepatic insufficiency, ASA III or IV classification, etc.) and other medical conditions that merit attention in order to improve or treat them before the transplant. Some of these conditions may exacerbate with immunosuppression or contraindicate certain drug regimens. Psychologists and psychiatrists transplant specialists evaluate all patients. Special attention is focused to pre-existing pathology, normal or superior intelligence coefficient, previous adhesion to medications and medical treatments, etc. The psychological–psychiatric evaluation is then directed to develop a patient’s profile, with an emphasis on the risk of abandon for immunosuppression, family and social support, pre- and posttransplant education, and produce an analysis and recommendations. A negative report from the transplant psychologist and psychiatrist contraindicates a face transplantation and is a formal exclusion criterion.