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








  • 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.



  • Skin is highly antigenic; acute rejection of facial transplants is common, if not universal, but chronic rejection is rare.



  • Typical 3 drug immunosuppression exposes patients to risks of infection and development of malignancies, both of which can be deadly.



  • 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 ).




Fig. 1


A 37-year-old man before injury ( A ), before face vascularized composite allotransplantation ( B ), 6 days ( C ) and 7 months ( D ) following allotransplantation of the face.

( From Murphy BD, Zuker RM, Borschel GH. Vascularized composite allotransplantation: an update on medical and surgical progress and remaining challenges. J Plast Reconstr Aesthet Surg 2013;66(11):1453; with permission.)


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 ).




Fig. 1


A 37-year-old man before injury ( A ), before face vascularized composite allotransplantation ( B ), 6 days ( C ) and 7 months ( D ) following allotransplantation of the face.

( From Murphy BD, Zuker RM, Borschel GH. Vascularized composite allotransplantation: an update on medical and surgical progress and remaining challenges. J Plast Reconstr Aesthet Surg 2013;66(11):1453; with permission.)


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

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Feb 8, 2017 | Posted by in General Surgery | Comments Off on Facial Transplantation
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