Face Graft Procurement

and Veronica Tomasello²

(1)

Department of Plastic Surgery and Burns, University Hospital Vall d’Hebron, Barcelona, Spain

(2)

Cannizzaro Hospital, Catania, Italy

Abstract

Face transplantation consists in the extirpation of face tissues of a donor with the diagnosis of brain death (solid organ donor) and its transplantation to a patient to reconstruct his/her face defect. All deformed and scarred recipient face tissues are removed and replaced by normal tissues, which restore anatomy and function.

Keywords

ProcurementPreservationDonation process

The main difference between classical microvascular autologous reconstruction and vascularised composite tissue allotransplantation relies on the procurement of the required tissues for reconstruction from a donor and the mandatory immunosuppression. Face tissues are obtained following allotransplantation concepts. It may incorporate an important quantity of composite tissues with arteries and veins that support the vascularisation of the transplanted face, similarly to that observed in autologous transplantation. The overall process follows similar tenets of autologous microsurgery utilised in reconstructive surgery. However, the participation of two patients in the whole process (the donor and the recipient) makes necessary the participation of two surgical teams and two operating rooms.

The donation of face tissues follows the same directives of solid organ donation. Donors shall be haemodynamically stable, although there is no contraindication for the use of vasopressors (the face is a highly vascularised organ). Donor relatives shall be informed of the tissues that are to be procured and they must provide informed consent for such donation (Appendix 13.1). Inclusion criteria for face donors are very selective because it has to be individualised for each recipient. In general terms, these criteria include:

Multiorgan donor with confirmed diagnosis of brain death

Signed informed consent from relatives for face donation

Compatibility of gender, skin tone, age, ABO blood group and rhesus and morphometrics

Exclusion criteria are very selective. They follow the same protocol existing for solid organ donation, although certain specific criteria are included (Table 13.1)

Table 13.1

Exclusion criteria for face donation

1. Sepsis and septic shock

2. HIV

3. Hepatitis B and/or C (with the exception of hepatitis B/C recipients)

4. Viral encephalitis

5. Cancer

6. Active IV drug abuse

7. Tattoos in the last 6 months

8. Inherited peripheral neuropathies

9. Inflammatory of infectious neuropathies

10. Systemic infections with associated neuropathies

11. Toxic neuropathies

12. Neurological neoplasms

13. Rheumatoid arthritis

14. Autoimmune diseases

15. Diseases of the collagen

16. Acute face trauma

17. Severe face deformity

18. Face paralysis

As soon as a donor has been identified and the recipient is confirmed (there may be more than one possible recipient in active search), the following steps must be performed:

Confirm donation and recipient match.

Activate preoperative protocol (Table 13.2).

Table 13.2

Face VCA preoperative protocol

Blood test	Complete blood count, coagulation tests, general biochemistry, liver function tests, total proteins, calcium
Inform infectious disease specialist	On arrival
CMV and EPV serology	If CMV-/EPV-
Blood typing and cross-matching	Reserve minimum of 10 packed red blood cells, 10 units of FFP and 3 units of platelets
PRA	Not necessary if performed <3 months
Tissue typing	All patients
Antibiotics	According to institution’s protocols
Chest X-ray	On arrival
Blood, urine, pharynx, tracheotomy microbiology cultures	On arrival before surgery
Inform and consult anaesthesiology	On arrival
Induction immunosuppression	Prepare and infuse induction medication according to institutional protocol (see Table 13.3)
If PRA >50 %	IV immunoglobulin complex G 2 g/kg

Call infectious diseases department to rule out any active infection.
Obtain IV lines.
Prepare operating room and all necessary equipment.
Alert VCA multidisciplinary team.

Start immunosuppression induction protocol (Table 13.3).

Table 13.3

HUVH induction immunosuppression protocol

If VCA is imminent with positive donor, start induction protocol with a minimum of 2 h before transplantation:

1. Thymoglobulin (ATG) 2 mg/kg on slow infusion rate

2. Premedicate 30 min before infusion with:

(a) Prednisone 1 g IV

(b) Diphenhydramine (Benadryl®) 50 mg IV

In general terms, face VCA procedures utilise a two-team technique approach—donor’s and recipient’s teams—similarly to that employed in SOT, especially in heart and lung allotransplantation (these two organs are very sensitive to ischaemia, and two-team approaches are normally implemented, where they work simultaneously to shorten the overall transplantation time).

As soon as a donor has been confirmed, the recipient is informed and he/she is admitted to the hospital. All preparations for surgery are then started. At the same time, the team in charge for face procurement is dispatched in order to obtain the face VCA. Tissue requirement varies, depending on the defect to reconstruct (partial or full face transplant), and so does the approach for the surgical procurement and the technique utilised during donation. However, regardless of the type of donation and technique utilised for the procurement, the fabrication of a face prosthesis must precede any VCA procedure (limbs, face, etc.). Maintaining the dignity of the patient during the whole donation process is mandatory, and bioethics during procurement call for excellency in the care of the donor.

It is recommended to obtain an impression of the face in the intensive care unit well before the patient is transported to the operating room (Fig. 13.1a, b). Alternatively, the impression can be obtained before the donor operation, although logistics may be more cumbersome in this scenario (timing, space, surgical teams’ pressure). Obtaining the face impression in the ICU has other positive points. It allows obtaining the impression unhurried and provides plenty of time for the prosthetics to manufacture a silicone or resin-like mask ready to use at the end of the procurement. The overall goal is not to produce a replica of the donor’s face, but to provide dignity and an aesthetic closure of the face remnants. Relatives shall be informed that a close coffin funeral will be necessary, regardless of the perfection of the face prosthetic mask provided for the donor’s reconstruction.

Fig. 13.1

(a, b) Face mask impression is necessary to maintain bioethics during face transplantation. It is best obtained in the ITU before the donor is transported to the operating room

Another important issue in the logistics and the strategy for face VCA procurement is the type and timing of the operation. In general terms, similarly to many other face VCA teams, we recommend a heart-beating donation. It shortens the ischaemia time, reduces the impact of ischaemia–reperfusion injury and allows for correct haemostasis during the face procurement operation. However, other teams have implemented a non-heart-beating procurement (at the end of the multiorgan procurement), although experience has shown that it may produce a massive haemorrhage at the time of reperfusion and will prolong ischaemia time.

If the VCA team contemplates a heart-beating donation, good collaboration among all multidisciplinary team members and the rest of SOT teams is necessary. A multiple-organ donation in a heart-beating donor can be organised with two different approaches:

Face VCA procurement at the beginning of the operation (before all other organs have been procured—nonsynchronous procurement)

Simultaneous procurement of the face and internal organs (synchronous procurement)

13.1 Nonsynchronous Procurement

Under this strategy, face VCA procurement is performed at the beginning of the operation. Plastic surgeons obtain the face allograft in a similar manner to that executed in reconstructive flap procurement in autologous composite microvascular flap surgery. Face VCA retrieval is given priority and the rest of the teams wait for completion of the plastic part of the donation. At the end of the face VCA procurement operation, the face is perfused in a side table with cold (4 °C) preservation fluid, and it is transported to the recipient’s operating theatre. Closure of the defect is performed in the usual manner by means of the application of a face prosthesis. The rest of the multiple-organ donation is then carried out. This approach has the convenience of an unhurried, relaxed face procurement, although it poses a significant risk for the rest of the internal organs and raises significant ethical questions. In fact, internal organ (lungs, heart, and liver) donation is intended to save lives, and as such it is the belief of transplantation medicine that it should be given priority. It is not uncommon to experience important blood loss and haemodynamic instability during face procurement, which could lead to cardiac arrest.

13.2 Synchronous Procurement

This is our technique of choice and it is our ordinary approach for VCA procurement. During our first face VCA (world’s first full face transplantation), we proved this technique to be safe, feasible and effective. We believe that this technique follows bioethics guidelines and preserves the whole philosophy of transplantation medicine. Table 13.4

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