Allotransplantation of the Face: How Close Are We?

Lancet, 2009

Background Multiple reconstructive procedures are common for the reconstruction of complex facial deformities of skin, soft tissues, bony structures, and functional subunits, such as the nose, lips, and eyelids. However, the results have been unsatisfactory. An innovative approach entailing a single surgical procedure of face allograft transplantation is a viable alternative and gives improved results.

Plastic and Reconstructive Surgery, 2010

International Journal of Surgery, 2004

The ability to reconstruct complex facial injuries is still a considerable challenge despite the development of microsurgical techniques. The recon-structive options for conditions such as pan-facial burns are severely limited. The result after multiple surgical procedures in this group is often poor in terms of function and cosmesis. Facial transplantation provides a potential solution, but opinion is currently divided about the extent to which the potential benefits to the quality of life can be justified when weighed against the technical, psychological and immunological risks. This paper reviews the current status of the debate and argues that a rigorous research strategy is the only logical basis for countering the ethical objections to a procedure that offers considerable benefits over existing reconstructive options.

Polish Journal of Surgery, 2008

The face allotransplantation is a unique procedure, requiring a lifetime immunosuppressive therapy, and as such brings an ethical debate among medical societies and general public. The indications for this procedure have to be considered when the classic reconstructive procedures failed, and the patients are left with debilitating defects precluding them from normal social life. The transplantation protocol must be approved and registered by the institutional review board and health agencies. It is crucial that a thorough assessment of the patient for each indication will be performed by a multidisciplinary team and panel of experts in the field of plastic and reconstructive surgery, maxillo facial surgery, immunology of transplantations and psychiatry. The thorough psychiatric and psychological evaluation of potential candidates is mandatory, as well as evaluation by ethic experts. Numerous experimental models and extensive anatomical studies in cadaver model lead to the clinical success of face transplantation, raising a complex ethical question despite the fact that it is an important progress in plastic and reconstructive surgery. Three face transplantations have been performed since 2005. The transplants differed and were tailored, to match the extend of each patient facial defect. In this article we present the clinical cases of face transplantation based on our experience and dissections studies and a literature review.

The ability to reconstruct complex facial injuries is still a considerable challenge despite the development of microsurgical techniques. The reconstructive options for conditions such as pan-facial burns are severely limited. The result after multiple surgical procedures in this group is often poor in terms of function and cosmesis. Facial transplantation provides a potential solution, but opinion is currently divided about the extent to which the potential benefits to the quality of life can be justified when weighed against the technical, psychological and immunological risks. This paper reviews the current status of the debate and argues that a rigorous research strategy is the only logical basis for countering the ethical objections to a procedure that offers considerable benefits over existing reconstructive options.

2014

Journal of Korean Medical Science, 2015

Severely disfiguring facial injuries can have a devastating impact on the patient's quality of life. During the past decade, vascularized facial allotransplantation has progressed from an experimental possibility to a clinical reality in the fields of disease, trauma, and congenital malformations. This technique may now be considered a viable option for repairing complex craniofacial defects for which the results of autologous reconstruction remain suboptimal. Vascularized facial allotransplantation permits optimal anatomical reconstruction and provides desired functional, esthetic, and psychosocial benefits that are far superior to those achieved with conventional methods. Along with dramatic improvements in their functional statuses, patients regain the ability to make facial expressions such as smiling and to perform various functions such as smelling, eating, drinking, and speaking. The ideas in the 1997 movie "Face/Off" have now been realized in the clinical field. The objective of this article is to introduce this new surgical field, provide a basis for examining the status of the field of face transplantation, and stimulate and enhance facial transplantation studies in Korea.

International Journal of Surgery, 2006

Journal of Burn Care & Research, 2013

The authors reviewed their 10-year experience of performing face grafts in children with burns. They sought to compare different methods for aesthetic outcome and need for reconstruction. In addition, they determined the efficacy of using allograft skin or Integra as temporary covers. They performed a review of 160 pediatric patients who underwent acute facial excision and grafting for burns between 2000 and 2010. Of the 160 patients with a mean age of 5.8 ± 4.8 years, 96 were males. The mean burn size was 39.4 ± 24.61%, of which 36.5 ± 25.4% was third degree. Overall length of stay was 72.1 days, intensive care unit length of stay was 44.2 days, and the mortality rate was 13.75%. Ninety patients had their entire face burned, 42 burned half, 15 burned their foreheads, and seven had other combinations. The interval between injury and grafting was 13.9 ± 13.19 days. Sixty-three percent patients required one face graft, 23% had two, 8% had three, and 6% four or more. For their initial procedure, 105 patients underwent autografting, 28 had allografting, and 23 received Integra. The authors performed a two-stage procedure in 20.4% and a 1-day procedure in 79.6%. Ten patients had a contiguous "U-shaped" graft wrapped around the face. At least partial regrafting was performed in 21.1%. Allograft and Integra were used for massive burns (69.9 ± 14.5%, 62.6 ± 18.3%, respectively). Of these, 39% died, 17% developed an Integra infection, and 43% required regrafting before autografting. Overall, 24.5% of patients underwent facial reconstruction during their first admission, and 57.1% during subsequent admissions. No difference in the rate of reconstructive surgery was noted between patients receiving Integra or autografting. Autografting face burns as an initial, one-stage procedure works well. The "wrap-around" autograft leads to excellent cosmetic results. When there is a shortage of autograft, allograft or Integra are good options but Integra does not reduce the need for reconstructive surgery.

Current Problems in Surgery, 2011

Plastic and Reconstructive Surgery, 2010

Plastic and Reconstructive Surgery, 2008

Background: Most articles on face composite tissue allotransplantation have considered ethical and immunologic aspects. Few have dealt with the technical aspects of graft procurement. The authors report the technical difficulties involved in procuring a lower face graft for allotransplantation. Methods: After a preclinical study of 20 fresh cadavers, the authors carried out an allotransplantation of the lower two-thirds of the face on a patient in January of 2007. The graft included all the perioral muscles, the facial nerves (VII, V2, and V3) and, for the first time, the parotid glands. Results: The preclinical study and clinical results confirm that complete revascularization of a graft consisting of the lower two-thirds of the face is possible from a single facial pedicle. All dissections were completed within 3 hours. Graft procurement for the clinical study took 4 hours. The authors harvested the soft tissues of the face en bloc to save time and to prevent tissue injury. They restored the donor's face within approximately 4 hours, using a resin mask colored to resemble the donor's skin tone. All nerves were easily reattached. Voluntary activity was detected on clinical examination 5 months postoperatively, and electromyography confirmed nerve regrowth, with activity predominantly on the left side. The patient requested local anesthesia for biopsies performed in month 4. Conclusions: Partial facial composite tissue allotransplantation of the lower twothirds of the face is technically feasible, with a good cosmetic and functional outcome in selected clinical cases. Flaps of this type establish vascular and neurologic connections in a reliable manner and can be procured with a rapid, standardized procedure.

Seminars in Plastic Surgery

Within the past two decades, vascularized facial composite allotransplantation has evolved into a viable option in the reconstructive surgeons' armamentarium for patients with extensive facial disfigurements. As it has expanded the frontiers of microsurgical reconstructive techniques, facial transplantation has come to garner widespread interest within both the medical community and the general public. The procedure has established itself as an amalgamation of the forefronts of reconstructive microsurgery, immunology, and transplantation science. Therein too lies its complexity as multifaceted scientific developments are met with ethical and social issues. Both patients and physicians are faced with the everlasting challenges of immunosuppression regimens and their inherent complications, long-term aesthetic and functional considerations, the role of revision procedures, and the inevitable psychosocial implications. This article reflects on the medical and surgical advancements ...

Plastic and Reconstructive Surgery, 2012

Background: After organ retrieval, restoration of the donor is a legal and ethical necessity; this is particularly true in facial transplantation. However, very few data are available regarding this procedure. Methods: This article reviews the seven facial masks produced during seven consecutive face transplants carried out at Henri Mondor Hospital in Paris, France. The time of production, morphologic outcome, and donor family feedback were recorded. Technical tips and pitfalls are also discussed. Results: Recording an impression of the donor's face with alginate required less than 25 minutes and, in all cases, the production of a resin mask was completed before the surgical harvesting was finished. Although all morphologic results were satisfactory or very satisfactory, the best outcomes were achieved using a total face mask, avoiding color discrepancies. Family feedback was positive, and none of the funeral ceremonies was disturbed by the procedure. Conclusions: The production of a full-face resin mask is a reliable and reproducible technique. This procedure restores donor integrity and gives a very satisfactory morphologic and aesthetic outcome.