Management of Facial Burns, Acute Versus Long-Term, Surgical Versus Non-surgical Face Transplant

Fig. 35.1

Deep partial thickness burns. Aspect before enzymatic debridement

../images/188491_2_En_35_Chapter/188491_2_En_35_Fig2_HTML.jpg — Fig. 35.2

Same wound after enzymatic debridement. Note that all dead tissues have been removed with the protection of living tissue

35.5 Face Transplantation

The modern history of vascularised composite tissue allotransplantation began in 1998, when the first human hand transplantation became a reality. Few years afterwards, in 2005, the first human face transplantation was attempted with success by Devauchelle and Dubernard in France [14].

Facial transplantation is a new achievement of transplantation medicine and microvascular reconstructive plastic surgery. During the past years, an important activity in the specialty of plastic and reconstructive surgery has been registered. In particular, a real revolution in reconstruction has occurred. The not-so-old dream of restorative surgery, namely the replacement of damaged parts of the body by new unharmed pre-formed tissues has become reality. The development of techniques aimed at the transplantation of vascularised composite tissues (VCA, composite vascularised allografts) has provided clinicians with a new robust tool for the reconstruction of deformities that were, no so long ago, impossible to achieve. History, development and classical attempts for VCA are not new. More than four decades ago, doctors in Ecuador attempted the transplantation of a hand limb. The transplant failed, but the dream survived. Pioneering laboratory work in experimental animals showed the path to clinicians for the achievement of human CVA. On the other hand, VCA has opened a new era not only in reconstructive surgery but also in transplant surgery. To date, there have been reports of successful transplantations of the knee joint, hand (unilateral and bilateral), arms (uni and bilateral), face (partial and total), abdominal wall, larynx, penis, digits and lower limbs; all recipients presented with deformities and/or amputations that were not amenable to be reconstructed by means of classical or traditional techniques. Such deformities affected non-vital parts and/or organs, and all of them had in common the impossibility to restore form, function, and cosmesis by means of conventional techniques and reconstructive surgery. The results of facial transplantation in humans demonstrate that facial transplantation is no longer an abstraction but a clinical reality. It has been implemented in the latest years with increasing interest and great success. The limits of indications are still, though, desperate catastrophic facial disfigurement. Today, we are in a position to say that it has been possible to perform facial transplantation both in animals and humans in a short period of time (Figs. 35.3 and 35.4).

../images/188491_2_En_35_Chapter/188491_2_En_35_Fig3_HTML.jpg — Fig. 35.3

Facial deformity after gun-shot injury to the face. Scarring, anatomic destruction including facial skeleton is common

../images/188491_2_En_35_Chapter/188491_2_En_35_Fig4_HTML.jpg — Fig. 35.4

Same patient after full-face transplantation including facial skeleton (type V-b face transplant)

Similar to that learnt in many other transplant and plastic surgery disciplines, the development of Facial Transplantation Programs calls for a strong team approach, building a multidisciplinary team that involves all necessary and diverse specialists to make a robust protocol and an experienced team that warrants excellency in outcomes. This multidisciplinary team is formed by all transplant disciplines usually involved in transplant medicine (surgeons, immunologists, infectious disease specialists and renal diseases specialists) but should include also experienced health professionals more involved in the plastic and reconstructive scenario, namely rehabilitation specialists, physiotherapists, occupational therapists, psychologists, psychiatrists and social workers. VCA procedures must be organised in tertiary centres with a strong commitment to transplant surgery and medicine. Such institutions have in common the required laboratory, clinical services and research units that are necessary to perform this new clinical discipline [15, 16].

35.5.1 Indications of Face Transplantation

The indication of facial transplantation resides on important deformities that affect different structures of the human face. They normally involve muscle sphincters (oral, ocular sphincter) and exhibit an important functional impact (impossibilities to speak, feed normally or breathe). The psychosocial impact of the deformity is extremely high, preventing them from functioning as normal human beings. Patients normally experience the facial deformity as health status worse than being death. The motivation of patients’ concentrates on becoming “normal” again and being able to resume their pre-morbid lifestyle.

The usual aetiologies considered for facial transplantation include