Face transplantation can provide improved quality of life to patients with extensive burn injuries. Facial vascularized composite allotransplantation (VCA) offers a new paradigm of treatment options, serving as a powerful reconstructive tool to restore facial form and function. Although currently facial VCA patients must follow a lifelong regimen of immunosuppression medications and suffer a risk of rejection, in properly selected patients, facial VCA can be a transformative operation and can improve quality of life. Research efforts continue to optimize immunosuppression and surgical technique and serve as evidence of the procedure’s growing role in reconstructive surgery for critically injured patients.
Key points
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Facial disfigurement from burns proves to be a difficult reconstructive challenge.
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Patients with facial disfigurement experience limited quality of life (function, appearance, and social distress).
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Traditional reconstructive techniques commonly yield to unsatisfactory functional and aesthetic results.
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Facial vascularized composite allotransplantation (VCA) has the potential to restore functional and aesthetic derangements beyond conventional reconstructive options.
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Despite the benefits of facial VCA, several issues must be addressed, including patient selection, donor identification, and adverse effects of lifelong immunosuppression, incidence of cancer, infections, and end-organ toxicity.
Introduction
Facial burns can result in severe disfigurement and represent a difficult reconstructive challenge. Extensive scarring following burn injury not only causes functional impairment, limiting patients’ ability to perform daily activities, but also results in dissatisfaction with appearance and social distress. In general, the face is highly specialized and performs key social functions. Postburn scarring can significantly impact each of these functions, impairing patients’ respiratory function, vision, oral continence, and the ability to express their own individuality and emotions. Like all patients with facial disfigurement, this deeply limits quality of life. Conventional reconstructive techniques following extensive facial burns commonly yield unsatisfactory functional and aesthetic results. Reconstruction of burn defects involving the central units of face and/or uniquely complex facial structures, such as the eyelids, are particularly challenging. In these cases, facial vascularized composite allotransplantation (VCA) has the potential to restore functional and aesthetic derangements beyond that which conventional reconstructive options currently allow. Facial VCA refers to en bloc replacement of anatomically complex facial structures, including soft tissue and the skeletal framework between 2 nonrelated persons. The benefits of facial VCA must, however, be weighed against the need for lifelong immunosuppression, risk of rejection, and unique psychosocial and ethical issues. In properly selected patients, facial VCA can be a transformative operation and can offer improved quality of life.
Introduction
Facial burns can result in severe disfigurement and represent a difficult reconstructive challenge. Extensive scarring following burn injury not only causes functional impairment, limiting patients’ ability to perform daily activities, but also results in dissatisfaction with appearance and social distress. In general, the face is highly specialized and performs key social functions. Postburn scarring can significantly impact each of these functions, impairing patients’ respiratory function, vision, oral continence, and the ability to express their own individuality and emotions. Like all patients with facial disfigurement, this deeply limits quality of life. Conventional reconstructive techniques following extensive facial burns commonly yield unsatisfactory functional and aesthetic results. Reconstruction of burn defects involving the central units of face and/or uniquely complex facial structures, such as the eyelids, are particularly challenging. In these cases, facial vascularized composite allotransplantation (VCA) has the potential to restore functional and aesthetic derangements beyond that which conventional reconstructive options currently allow. Facial VCA refers to en bloc replacement of anatomically complex facial structures, including soft tissue and the skeletal framework between 2 nonrelated persons. The benefits of facial VCA must, however, be weighed against the need for lifelong immunosuppression, risk of rejection, and unique psychosocial and ethical issues. In properly selected patients, facial VCA can be a transformative operation and can offer improved quality of life.
History and overview
The first face transplant was performed in 2005 by Dr Jean-Michel Dubernard and Dr Bernard Devauchelle at Amiens Hospital in Amiens, France for a 38-year-old woman who was disfigured after being mauled by her dog. Her facial injuries included amputation of her distal nose, lips, and superficial chin. Functional deficits as a direct result of her injury included an inability to eat, drink, or speak normally. Her VCA consisted of anastomosis of the facial arteries and veins, mucosal repair of oral and nasal vestibules, neuropathies of sensory and motor nerves, and restoration of the facial musculature. Five years after VCA, the patient showed an almost complete recovery of sensory and motor functions of the face, no signs of chronic rejection, and an excellent aesthetic outcome. Unfortunately, she died 10 years following VCA secondary to long-standing complications from recurrent malignancy.
In 2009, the first facial VCA for a burn injury was led by Dr Bohdan Pomahac at the Brigham and Women’s Hospital in Boston, Massachusetts. The patient was a 55-year-old man who suffered a high-voltage electrical burn to his midface, resulting in a complex bony and soft tissue defect. He previously underwent multiple reconstructive procedures over a 4-year period but remained functionally limited. He was unable to chew, experienced constant drooling, and his speech was incomprehensible. Three years following VCA, the patient recovered near-normal sensation in most of his allograft, along with improved appearance, increased functional ability, and improved social interaction. Fig. 1 shows preoperative and postoperative photos in relation to his transplantation. On March of 2010, the first full-face VCA was led by Dr Joan-Pere Barret at the Vall d’Hebron hospital in Barcelona, Spain, which included both soft tissue and underlying bone, on a 31-year-old man following ballistic trauma.
To date, a total of 37 facial VCAs have been performed worldwide. Severe facial burns remain one of the common indications. These early experiences demonstrate the technical feasibility of the VCA procedure but also highlight several challenges. Functional recovery is slow and often incomplete. However, aesthetic results are uniformly better than traditional reconstructive options and functional recovery continues to improve even 3 years following the operation.
In addition, several reports of acute and chronic rejection have been documented. Tailored immunosuppression regimens (as depicted in Fig. 2 ) improve rates of complications with fewer rejection episodes. Persistent vigilance, longitudinal follow-up, and the effort of a multidisciplinary team are necessary for optimal outcomes. After VCA, there have been 5 reported mortalities, related to immunosuppressive complications, sepsis, or recurrent malignancies.
Indications
The indications for facial VCA continue to evolve but can be loosely defined as patients with a severe facial defect not amenable to conventional reconstructive techniques. Specifically, burns that can cause severe facial injury can include high-voltage electrical burns, blast injuries, chemical burns, and thermal injury. A VCA patient with significant facial injuries following exposure to lye is shown in Fig. 3 and serves as an example of the severity of injury that can result from burns.
Specific indications for facial VCA, currently, include facial tissue comprising at least 25% of the face or the involvement of central facial structures not amenable to reconstruct with traditional reconstructive methods because of their complex form and/or function. Loss of more than one central facial unit, such as nose, eyelid, or lips, and their respective functions is another indication for consideration for facial VCA. Furthermore, failure to adequately reconstruct facial features following multiple reconstructive procedures may indicate a need for VCA. Current indications are summarized in Box 1 .
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Severe disfigurement, encompassing soft tissue loss more than 25% of facial surface area, and/or involves loss of one of the central facial parts
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Loss of multiple central facial units considered difficult to reconstruct, including nose, eyelids, and lips
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Loss of multiple facial functions, including eating, drinking, expressing or communicating, breathing, and devastating aesthetic defects
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Multiple failed reconstructive facial operations performed without satisfactory aesthetic or functional outcome
Patient selection
In patients for whom facial VCA is being considered, choosing appropriate candidates is a rigorous process. Patient understanding of risks and benefits regarding facial VCA must be analyzed in an individualized manner but may be difficult to assess. Preoperative screening, including psychosocial evaluation focused on medical compliance, coping skills, expectations, support network, and informed consent, must be completed for all potential VCA candidates. Moreover, a physician panel consisting of plastic surgeons, oral-maxillofacial surgeons, head and neck surgeons, psychiatrists, transplant surgeons, and transplant medicine physicians are necessary to comprehensively evaluate patients to determine their eligibility for undergoing VCA and define technical details of their reconstructive plan. A plan for salvage must also be thought out and communicated to patients in the event of allograft failure. It is important to note that screening also includes a social worker, patient advocate, and rehabilitation specialist, all of whom must also clear patients for an operation. Overall outcome is determined by much more than the technical details of the procedure and requires patient availability, cooperation, and effort.
Many diagnostic tests must be completed to ensure VCA feasibility. Imaging modalities, such as computerized tomography scans of the maxillofacial area with 3-dimensional formatting, angiographic studies of head and neck areas, as well as preoperative chest radiography and echocardiography, are all used for better planning and to create an operative road map.
Aside from the extent of facial injury and screening described earlier, general inclusion criteria for standard organ-transplant guidelines are used for VCA screening. Specific exclusion criteria include a history of psychiatric illness actively treated with medications and pregnancy until after 6 months postpartum. Patients with cancer in remission for more than 5 years, those who are blind, and those with concomitant upper extremity amputations are not excluded from consideration. Facial VCA has not been performed in children so far because of implications of lifelong immunosuppression. Box 2 summarizes preoperative screening criteria.
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