Face transplantation is used to reconstruct large facial defects that cannot be reconstructed with traditional techniques. The deficit should involve at least 25% of the facial area with loss of at least one central facial feature such as the eyelids, nose, or lips. Although relatively rare, over 40 face transplants have been performed since the first procedure was carried out in France in 2005. Face transplant has been combined with other vascularized composite autograft (VCA) surgery and deaths after face transplant have been reported. Overall, there have been 5 deaths reported of 41 reported face transplants. One patient had a bilateral hand transplant at the same time, but later died from overwhelming postoperative infection. Consequently, combining face transplant with other VCA remains controversial. Another patient died within 2 years of surgery, and this was attributed to compliance issues with immune suppression therapy. The other deaths were documented as secondary to suicide (1) and malignancy (2).1,2. An important point to consider when discussing face transplant surgery is that the recipient does not necessarily take on the facial appearance of the donor. The appearance will be dictated by the nature of the transplant and both donor and recipient features. For example, when the transplant is soft tissue only, the recipients will retain more of their own original appearance. However, where bony reconstruction is also involved, the donor appearance is more likely to be preserved. The site of the facial defect being transplanted is also likely to make a difference, for example, central face versus more peripheral regions.
2. Sosin M, Rodriguez ED. The face transplantation update: 2016. Plast Reconstr Surg 2016;137(6):1841–1850 Between 2005 and 2016, 40 patients underwent facial transplantation surgery worldwide. The most common etiology was trauma which had been the presenting injury in more than 30 patients. The major trauma causes were ballistic (17 cases) and burns (10 cases). Other trauma causes included animal bites and blunt injury. In spite of this, facial transplant is not currently indicted as a primary treatment for major facial trauma, although it could potentially be considered earlier along the treatment pathway rather than subjecting patients to multiple other procedures first. The challenges of undertaking facial transplant surgery in an acute or semi-acute setting are that there are multiple other medical, psychological, and logistical considerations that would need to be addressed and cannot be done without major planning. In general, malignant tumor resection is not a recognized indication for face transplantation. Having a failed free flap reconstruction is not a contraindication to transplant surgery. Many of the face transplant patients had undergone previous free tissue reconstruction and many had undergone more than 10 operations previously.1,2 Although the central face is key to face transplantation, the facial deformity does not need to purely involve the central face, nor does it need to involve the full face. However, it would be expected that the defect was complex, not amenable to conventional reconstruction and that one central facial structure is involved.
There has been debate as to whether blindness should be a contraindication to face transplant surgery. This originally stemmed from hand transplant surgery experience that had shown vision to be important in rehabilitation and not from the concern that a patient would be unable to view the result, although there have been suggestions that the latter is the actual reason. Blind patients have already undergone face transplant and there is no strong reason why a person who is legally blind should not receive a transplant. It would really amount to discrimination if they were unable to have one simply because of blindness. In other areas of plastic surgery, blind patients would not be turned away from procedures considered to be aesthetic such as mastopexy, liposuction, and abdominoplasty. There are a number of universally accepted contraindications to face transplant surgery. These can be subclassified as psychiatric, medical, or psychosocial. Psychiatric contraindications include an active psychiatric disorder, substance abuse, and cognitive and perceptual inability to understand the procedure. Medical contraindications include an active cancer diagnosis or risk of recurrence, immune deficiency (e.g., human immunodeficiency virus-positive status), active infection (e.g., hepatitis), scleroderma, systemic lupus erythematosus, pregnancy, and hypercoagulable disorders. Psychosocial contraindications include a history of poor compliance with medical therapy and a poor social support network.1
procedures score highest. The Cleveland Clinic FACES scoring system was developed as a tool to assist in the preoperative evaluation of a patient’s suitability for face transplantation. It includes five key areas: functional status, aesthetic deficit, medical comorbidities, depth of tissue involvement, and previous surgical procedures. The system has not been formally validated. The functional status component is based on both the Karnofsky and Strauss-Bacon stability scores. The latter assesses aspects of a patient’s social status, including long-term relationships and/or employment. Patients receive a score of 10–60 (not 0–100). A higher score is more favorable for surgery. The analysis tool alone does not represent a complete assessment for the decision-making process. Central defects are weighted more highly than lateral defects (see Table 48.1, Essentials of Plastic Surgery, third edition).
The Karnofsky1 performance score is a commonly used independent assessment tool that grades a patient’s health and functional status using a score of 0–100, where 100 is normal health and function without evidence of disease, and where 0 is dead. Scores in between are given in multiples of 10 and lower scores indicate poorer health and functional status. This system is often used in other areas of plastic surgery such as for head and neck cancer patients when assessing their fitness for surgery. It is important to note that the scoring differs as an independent assessment tool, as compared to when it is incorporated into the FACES scoring system. When used as part of the FACES system, patients can receive between 2 and 9 points depending on the patient’s Karnofsky score/health status. For example, patients will receive 9 points if they have a maximum Karnofsky score of 100 and will receive 2 points if they have a Karnofsky score of 20. This patient scores very badly and a score of this grade suggests that admission to the hospital is indicated (see Table 48.1, Essentials of Plastic Surgery, third edition).
Synkinesis refers to unwanted involuntary contractions that occur during voluntary muscle activation in another area of the face. It can occur secondary to aberrant regeneration after injury with resultant innervation of nonnative muscle groups. When undertaking face transplant surgery, coaptation of the motor nerve closer to the target muscle may help reduce subsequent synkinesis. Sensory reinnervation of nerve coaptation occurs earlier than motor reinnervation. Because of the vascular networks within the head and neck, bilateral vascular anastomoses are not normally required. Unilateral anastomoses of the internal jugular and external carotid (or one of its branches such as the facial artery) are typically used. Immune suppression is started preoperatively to reduce the risk of acute rejection. This may be achieved with a depleting agent such as antithymocyte globulin (a monoclonal antibody) or alemtuzumab (a polyclonal antibody). These are known as depleting agents as they reduce the number of lymphocytes. During harvest from the donor, face procurement may be halted if the donor becomes unstable to allow solid organ procurement. Once facial tissue procurement is complete the donor is fitted with a silicone prosthesis to cover the facial defect created.
The priority for face transplantation is to reestablish vascularity in the first instance by performing the arterial anastomosis with the facial artery or other most suitable branch of the external carotid system and performing the venous anastomosis with the internal jugular vein or one of its main tributaries. In many situations with free tissue transfer, obtaining bony stability is considered the primary task such that the vascular anastomoses can be performed with bony stability obtained. For example, in head and neck reconstruction following tumor extirpation where the neomandible is screwed into place, or in lower limb trauma after fracture reduction and application of hardware to long bone fractures. This is traditionally the case for replantation cases too especially those involving the digits. However, minimizing ischemia time is particularly vital for the successful outcome in composite free tissue transfers because tissues such as muscle do not tolerate extended ischemia times well. Once vascularity and bony stability are established, the remaining structures can be repaired from deep to superficial.
To date, every face transplant patient with follow-up of more than 1 year has recorded at least one episode of acute graft rejection. These episodes were clinically apparent as erythema, edema with nodules, or papules and were treated satisfactorily by adjustment of immune suppression therapy. Microvascular graft failures have been low (4%) which is consistent with expected autologous free tissue transfer failure rates. There have been five deaths reported in the most recent follow-up data set. Significant infection rates have been low. Common localized infections include viral or fungal subtypes such as cytomegalovirus (CMV), herpes, and candida. These are generally well treated with medications such as acyclovir or fluconazole, respectively. One of the benefits of face transplant is improved social reintegration and this has been promising in face transplants undertaken so far.1–3
Panel reactive antibodies are used to determine whether a patient has specific human leukocyte antigen antibodies.1 A sample of a patient’s blood is tested against the lymphocytes of 100 blood donors. The number of donors to which the patient has a reaction is expressed as a percentage (0–100%). A high percentage indicates that a patient has a high risk of acute rejection and may have to wait an extended time for a suitable donor. It does not reflect chronic rejection status or the blood type of the patient. All patients will require antithymocyte globulin preoperatively as part of the depleting agent process, and all patients will have a typical triple therapy maintenance regimen which will include steroids, tacrolimus, and mycophenolate mofetil.
The Banff classification is used to grade rejection in vascular composite tissue grafts such as face and hand transplants. When evidence of rejection is evident in the skin, small biopsy samples are obtained for analysis.1,2 The grading system is as follows: • Grade 0: No rejection • Grade I: Mild rejection, seen as mild perivascular infiltrate (lymphocytic) • Grade II: Moderate rejection, seen as moderate to dense perivascular inflammation that can include • Grade III: Severe rejection, seen as dense inflammation with epidermal involvement, epithelial apoptosis/necrosis • Grade IV: Necrotizing rejection, seen as necrosis of epidermis and/or other skin elements This patient has evidence of a grade II reaction and may require alterations of the immunosuppressive regimen. Of historic interest, the Banff conference was first held in Banff, Alberta, Canada in 1991. It is an international meeting to discuss transplant pathology. The twelfth meeting was held in Brazil in 2013.
true? Patients undergoing face transplantation will need to take lifelong immunosuppressive therapy. Typical maintenance therapy for patients undergoing face transplant surgery is triple therapy including corticosteroids, tacrolimus, and mycophenolate mofetil. Steroids such as cortisol tend to have generalized immunosuppressant effects with anti-inflammatory properties. Calcineurin inhibitors such as tacrolimus prevent interleukin (IL)-2-dependent activation of lymphocytes. Mycophenolate mofetil is an antiproliferative agent. First-line management of acute rejection is to increase maintenance immunosuppression and ensure close observation of the patient. Second-line management involves steroid boluses, with or without increased doses of maintenance immunosuppressants or topical agents (e.g., clobetasol). Third-line management involves using induction therapy agents. Agents given as induction therapy can be classified as depleting or nondepleting agents. Depleting agents decrease lymphocyte numbers and include polyclonal antithymocyte globulin and alemtuzumab, which is a monoclonal antibody directed against CD52 (a cell surface marker present on mature lymphocytes). Nondepleting agents do not decrease lymphocyte counts but prevent T-cell activation via the IL-2-dependent pathway (monoclonal anti-IL-2 receptor antibodies). Chronic rejection was initially thought to be less for face transplant and other vascularized composite autograft (VCA) patients than solid organ recipients, but as more data is collected, it appears that chronic rejection is a factor in VCA transfer. PART IV Breast