Facial Transplantation

Reconstruction of severe facial deformities poses a unique surgical challenge: restoring the aesthetic form and function of the face. Facial transplantation has emerged over the last decade as an option for reconstruction of these defects in carefully selected patients. As the world experience with facial transplantation grows, debate remains regarding whether such a highly technical, resource-intensive procedure is warranted, all to improve quality of life but not necessarily prolong it. This article reviews the current state of facial transplantation with focus on the current controversies and challenges, with particular attention to issues of technique, immunology, and ethics.

Key points

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Computed tomography angiography is helpful preoperatively for assessment of recipient vessel targets to plan for typically 2 arterial and 2 venous anastomoses to support the transplant.
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Skin is highly antigenic; acute rejection of facial transplants is common, if not universal, but chronic rejection is rare.
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Typical 3 drug immunosuppression exposes patients to risks of infection and development of malignancies, both of which can be deadly.
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Careful patient selection, thoughtful informed consent, and consideration of the psychosocial impact of facial transplant are necessary to keep the procedure ethically sound.

Introduction

Conventional approaches to facial reconstruction are largely dictated by the extent of the defect. Although smaller defects may be amenable to local flaps, more extensive defects often require free tissue transfer or large split-thickness skin grafts. These techniques may suffice to provide coverage and occasionally restore function. However, in terms of both cosmesis and functionality, traditional reconstruction options fall short for patients with the most severe whole face deformities, often resulting in a patchwork appearance that reflects the sometimes dozens of surgeries these patients endure in pursuit of the elusive goal of achieving an acceptable appearance and quality of life ( Fig. 1 ).

Over the last 10 years, facial transplantation, a form of composite tissue allotransplantation (CTA), has emerged as a viable option for reconstruction of the most severe facial deformities in carefully selected patients. There have been 31 cases of facial transplantation reported in the world literature since the first case in 2005, with good results overall ( Table 1 ). However, facial transplantation was controversial at its inception; despite growing experience with this procedure, significant controversies persist.

Table 1

Facial transplants performed worldwide to date

Number	Month/Year	City & Team Leader	R Sex, Age (y)	D Age (y)	Indication	Type	SD (h)
1	11/2005	Devauchelle, Amiens, France	F, 38	46	Animal attack	Partial myocutaneous	15
2	04/2006	Guo, Xian, China	M, 30 ^a	25	Animal attack	Partial osteomyocutaneous	13
3	01/2007	Lantieri, Paris, France	M, 29	65	NF 1	Partial myocutaneous	11
4	12/2008	Siemionow, Cleveland, United States	F, 45	44	Gunshot injury	Partial osteomyocutaneous	22
5	03/2009	Lantieri, Paris, France	M, 27	43	Gunshot injury	Partial osteomyocutaneous	19
6	04/2009	Lantieri, Paris, France	M, 37 ^a	59	Burns	Partial myocutaneous	13
7	04/2009	Pomahac, Boston, United States	M, 59	60	Burns	Partial osteomyocutaneous	17
8	08/2009	Lantieri, Paris, France	M, 33	55	Gunshot injury	Partial osteomyocutaneous	16
9	08/2009	Cavadas, Valencia, Spain	M, 42 ^a	35	Radiotherapy	Partial osteomyocutaneous	15
10	11/2009	Devauchelle, Amiens, France	M, 27	—	Burns	Partial osteomyocutaneous	19
11	01/2010	Gomez-Cia, Seville, Spain	M, 35	30	NF 1	Partial myocutaneous	22
12	04/2010	Barret, Barcelona, Spain	M, 31	41	Gunshot injury	Full osteomyocutaneous	—
13	07/2010	Lantieri, Paris, France	M, 37	—	NF 1	Full myocutaneous	14
14	03/2011	Pomahac, Boston, United States	M, 25	48	Burns	Full myocutaneous	17
15	04/2011	Lantieri, Paris, France	M, 45	—	Gunshot injury	Partial osteomyocutaneous	—
16	04/2011	Lantieri, Paris, France	M, 41	—	Gunshot injury	Partial osteomyocutaneous	—
17	04/2011	Pomahac Boston, United States	M, 30	31	Burns	Full myocutaneous	14
18	05/2011	Pomahac, Boston, United States	F, 57	42	Animal attack	Full osteomyocutaneous	19
19	01/2012	Özkan, Antalya, Turkey	M, 19	39	Burns	Full osteomyocutaneous	9
20	01/2012	Blondeel, Gent, Belgium	N/A	N/A	N/A	Partial osteomyocutaneous	20
21	02/2012	Nazir, Ankara, Turkey	M, 25	40	Burns	Full face transplant	—
22	03/2012	Özmen, Ankara, Turkey	F, 20	28	Burns	Partial face transplant	—
23	03/2012	Rodriguez, Baltimore, United States	M, 37	21	Gunshot injury	Full osteomyocutaneous	36
24	05/2012	Özkan, Antalya, Turkey	M, 27	19	Burns	Full face transplant	—
25	01/2013	Pomahac, Boston, United States	F, 44	—	Burns	Full myocutaneous	15
26	05/2013	Özkan, Antalya, Turkey	M 27	19	Gunshot injury	Partial osteomyocutaneous	—
27	07/2013	Maciejewski, Warsaw, Poland	M, 33	42	Crush trauma	Partial osteomyocutaneous	27
28	07/2013	Özkan, Antalya, Turkey	M, 27	—	Ballistic trauma	Full osteomyocutaneous	—
29	08/2013	Özkan, Antalya, Turkey	M, 54 ^a	—	Ballistic trauma	Partial osteomyocutaneous	—
30	12/2013	Özkan, Antalya, Turkey	M, 22	—	Ballistic trauma	Partial osteomyocutaneous	—
31	12/2013	Maciejewski, Warsaw, Poland	F, 26	—	Neurofibromatosis	Full myocutaneous	—

Abbreviations: D, donor; F, female; M, male; N/A, not applicable; NF 1, neurofibromatosis type I; R, recipient; SD, surgery duration.

Data from Smeets R, Rendenbach C, Birkelbach M, et al. Face transplantation: on the verge of becoming clinical routine? Biomed Res Int 2014;2014:1–9; and Roche NA, Blondeel PN, Van Lierde KM, et al. Facial transplantation: history and update. Acta Chir Belg 2015;115(2):99–103.

a Patient died.

In this article, the authors focus on the current controversies, challenges, and questions that confront facial transplantation while highlighting the lessons learned and challenges overcome through experience thus far. The discussion focuses on 3 main topics: technical issues, issues of facial transplantation immunology, and ethical concerns.

Introduction

Conventional approaches to facial reconstruction are largely dictated by the extent of the defect. Although smaller defects may be amenable to local flaps, more extensive defects often require free tissue transfer or large split-thickness skin grafts. These techniques may suffice to provide coverage and occasionally restore function. However, in terms of both cosmesis and functionality, traditional reconstruction options fall short for patients with the most severe whole face deformities, often resulting in a patchwork appearance that reflects the sometimes dozens of surgeries these patients endure in pursuit of the elusive goal of achieving an acceptable appearance and quality of life ( Fig. 1 ).

Over the last 10 years, facial transplantation, a form of composite tissue allotransplantation (CTA), has emerged as a viable option for reconstruction of the most severe facial deformities in carefully selected patients. There have been 31 cases of facial transplantation reported in the world literature since the first case in 2005, with good results overall ( Table 1 ). However, facial transplantation was controversial at its inception; despite growing experience with this procedure, significant controversies persist.

Table 1

Facial transplants performed worldwide to date

Number	Month/Year	City & Team Leader	R Sex, Age (y)	D Age (y)	Indication	Type	SD (h)
1	11/2005	Devauchelle, Amiens, France	F, 38	46	Animal attack	Partial myocutaneous	15
2	04/2006	Guo, Xian, China	M, 30 ^a	25	Animal attack	Partial osteomyocutaneous	13
3	01/2007	Lantieri, Paris, France	M, 29	65	NF 1	Partial myocutaneous	11
4	12/2008	Siemionow, Cleveland, United States	F, 45	44	Gunshot injury	Partial osteomyocutaneous	22
5	03/2009	Lantieri, Paris, France	M, 27	43	Gunshot injury	Partial osteomyocutaneous	19
6	04/2009	Lantieri, Paris, France	M, 37 ^a	59	Burns	Partial myocutaneous	13
7	04/2009	Pomahac, Boston, United States	M, 59	60	Burns	Partial osteomyocutaneous	17
8	08/2009	Lantieri, Paris, France	M, 33	55	Gunshot injury	Partial osteomyocutaneous	16
9	08/2009	Cavadas, Valencia, Spain	M, 42 ^a	35	Radiotherapy	Partial osteomyocutaneous	15
10	11/2009	Devauchelle, Amiens, France	M, 27	—	Burns	Partial osteomyocutaneous	19
11	01/2010	Gomez-Cia, Seville, Spain	M, 35	30	NF 1	Partial myocutaneous	22
12	04/2010	Barret, Barcelona, Spain	M, 31	41	Gunshot injury	Full osteomyocutaneous	—
13	07/2010	Lantieri, Paris, France	M, 37	—	NF 1	Full myocutaneous	14
14	03/2011	Pomahac, Boston, United States	M, 25	48	Burns	Full myocutaneous	17
15	04/2011	Lantieri, Paris, France	M, 45	—	Gunshot injury	Partial osteomyocutaneous	—
16	04/2011	Lantieri, Paris, France	M, 41	—	Gunshot injury	Partial osteomyocutaneous	—
17	04/2011	Pomahac Boston, United States	M, 30	31	Burns	Full myocutaneous	14
18	05/2011	Pomahac, Boston, United States	F, 57	42	Animal attack	Full osteomyocutaneous	19
19	01/2012	Özkan, Antalya, Turkey	M, 19	39	Burns	Full osteomyocutaneous	9
20	01/2012	Blondeel, Gent, Belgium	N/A	N/A	N/A	Partial osteomyocutaneous	20
21	02/2012	Nazir, Ankara, Turkey	M, 25	40	Burns	Full face transplant	—
22	03/2012	Özmen, Ankara, Turkey	F, 20	28	Burns	Partial face transplant	—
23	03/2012	Rodriguez, Baltimore, United States	M, 37	21	Gunshot injury	Full osteomyocutaneous	36
24	05/2012	Özkan, Antalya, Turkey	M, 27	19	Burns	Full face transplant	—
25	01/2013	Pomahac, Boston, United States	F, 44	—	Burns	Full myocutaneous	15
26	05/2013	Özkan, Antalya, Turkey	M 27	19	Gunshot injury	Partial osteomyocutaneous	—
27	07/2013	Maciejewski, Warsaw, Poland	M, 33	42	Crush trauma	Partial osteomyocutaneous	27
28	07/2013	Özkan, Antalya, Turkey	M, 27	—	Ballistic trauma	Full osteomyocutaneous	—
29	08/2013	Özkan, Antalya, Turkey	M, 54 ^a	—	Ballistic trauma	Partial osteomyocutaneous	—
30	12/2013	Özkan, Antalya, Turkey	M, 22	—	Ballistic trauma	Partial osteomyocutaneous	—
31	12/2013	Maciejewski, Warsaw, Poland	F, 26	—	Neurofibromatosis	Full myocutaneous	—