Large and spacious operating rooms are recommended for reconstructive allotransplantation. In general terms, rooms exceeding 40 square metres are advised. During face transplantation, a large number of transplantation teams are working together at the same time. It is not uncommon to join together at any given time two anaesthesiologist, two scrub nurses, four surgeons and two circulating nurses. Enough working space is necessary, to accommodate human resources and the necessary equipment (microscope, anaesthesia carts, instrumentarium, blood requirements, craniomaxillary instruments, etc.; see Fig. 14.1).

As soon as the team is warned that the transplant may be imminent, the head nurse should be informed in order to make ready all surgical instruments and blood products, prepare the OR nurse team and organise the shifts. It is advised to organise the team with two scrub nurses per shift and rotate them every 2–3 h. A total of 3–4 nurses may be necessary to provide enough rest during the procedure. In addition, the nursing team is completed with enough circulating personnel to provide external support.

Quick and thorough preparation of the anaesthesiology team is performed simultaneously. The head anaesthesiologist is informed of the proposed transplant procedure in order to make the team and the necessary material available. It is recommended that a minimum of two anaesthesiologists are present in the operating theatre at any given time. Major bleeding and difficult airway management is expected, and prompt decisions and manoeuvres may be necessary. In our experience, the anaesthesiology team should be completed with a third anaesthesiologist (minimum) in order to provide the necessary rest for the team. It is not uncommon for face transplantation procedures to last between 18 and 30 h. Under these circumstances, it is mandatory to rotate team members in order to maintain a safe environment and provide a good progress of the operation.

The surgical team should be formed by team players that are readily available all year round. Face transplantation is an urgent procedure that is carried out any time when a compatible multiple-organ donor is approached and informed consent from relatives is obtained. In comparison to other solid organ transplantation programmes, it is not feasible to have an on-call team on a 24-h basis, since donors are not commonly available and the number of patients in the waiting list for VCA is very low. Therefore, it is extremely important to build a strong team of enthusiastic surgeons that shall guarantee the successful development of a VCA procedure. Once the operation is planned, the team of surgeons should be organised in shifts, similarly to anaesthesia and nursing teams. Our approach consists of three to four plastic surgeons per shift (depending on the complexity of the phase of the operation) that rotate every 2–3 h (Table 14.2). The team leader takes the responsibility to organise all rotations and it is his/her responsibility to oversee the good progression of the operation. It is advisable to name an assistant team leader in order to provide the necessary rest for the team leader at any given time. The master plan for the operation should be outlined before the patient is taken to operation room and all difficult points revised.

The head anaesthesiologist, head nurse and team leader must revise and make sure that all necessary equipment, materials, blood products and necessary support from other services are ready and available before the recipient is taken to the operating room. Other necessary and mandatory team members include transplant coordinators (at least one coordinator should be present during the whole procedure), infectious diseases/immunologists and transplant surgeons (these team members shall help in infectious disease prophylaxis, induction immunosuppressant therapy and technical pitfalls during the transplantation). It is not absolutely necessary that they are present in the operating room, although it is mandatory that they can be reached within minutes. Other support services include porters, housekeeping, ward nurses, pharmacy, mass media coordination and tissue/blood banking. The rest of the team members (Table 14.3) should be informed of an imminent transplant since their assistance will be necessary from day 1.

The organisation of the operating room within the hospital differs depending on the type of the expected donation. If the donor is located in the same hospital, our advice is to follow the Boston approach if possible: the donor’s and recipient’s operating rooms should be run in parallel. With this approach, the graft is procured in the operating room next door, and it can be transported within seconds to the recipient’s room (which is normally located a few metres on the room next door). With this organisation, complex and cumbersome packaging in a container with preservation fluid is avoided and the graft is manipulated as any other routine free flap. Once the VCA graft is detached from the donor (after preservation fluid infusion), the graft is transported to the recipient’s site in the standard fashion. If this approach is selected, one must remember, though, that a third parallel room (on the other side of the donor’s theatre) may be required to perform bank surgery on solid organs (Fig. 14.2). This approach, when feasible, saves time and helps with the organisation and coordination of both the donor’s and the recipient’s transplant teams. On the other hand, if the donor is not located in the same hospital or, given the architecture of the hospital (commonly in health science centres, when different hospitals form the complex), the donation must be contemplated as a distant donor, both the donor’s and recipient’s theatres being distant and the transportation of the VCA graft must be performed in a container with preservation fluid and secured and transferred to the recipient’s operation room as in any standard solid organ transplantation procedure. When this approach has to be implemented, cold ischaemia time should be kept to a minimum and the organisation and coordination of both teams is much more complicated. Direct communication between both theatres’ teams is essential to couple both surgeries; as soon as the procurement process is considered to progress in good condition, the recipient’s team should start the procedure to induce the immunosuppressant protocol, secure the airway and prepare the recipient’s vessels.