Composite tissue allotransplantations can be indicated when autologous transfers fail to restore human appearance. We report the reproducibility, difficulties, serious adverse events and outcomes of our patients. Five patients were included in a registered clinical research protocol after thorough screenings assessed by an independent expert committee systematically discussing the alternative options. One patient suffered from plexiform neurofibromas, two from third degree burns and two from gunshot injuries.They were included on a national waiting list with a dedicated face procurement procedure. Transplants were harvested from heart beating brain-dead donors before other tissues and organs. Induction immunosuppressive therapy included antithymocyte globulins, steroids, mycophenolate mophetil and tacrolimus. Maintenance therapy included the last three ones associated with extracorporeal-photopheresis. Four patients were transplanted with 7-to 38-month followup. One could not due to multiple panel reactive antibodies after 18 months on waiting list. Acute cellular rejections were controlled by conventional treatment. Opportunistic infections affected all patients and lead one patient to die two month after the transplantation. Voluntary facial activity appeared from 3 to 5 month. Face transplantation has been reproducible under conventional immunosuppression. Major improvements in facial aesthetic and function allowed patients to recover social relations and improved their quality of life.

The face-grafting techniques are innovative and highly complex, requiring well-defined organization of all the teams involved. Subsequent to the first report in France in 2005, there have been 17 facial allograft transplantations performed worldwide. We describe anaesthesia and postoperative management, and the problems encountered, during the course of seven facial composite tissue grafts performed between 2007 and 2011 in our hospital. The reasons for transplantation were ballistic trauma in four patients, extensive neurofibromatosis in two patients, and severe burns in one patient. Anaesthesia for this long procedure involves advanced planning for airway management, vascular access, technique of anaesthesia, and fluid management. Preparation and grafting phases were highly haemorrhagic (>one blood volume), requiring massive transfusion. Median (range) volumes given for packed red cell (PRC) and fresh-frozen plasma (FFP) were 64.2 ml kg(-1) (35.5-227.5) and 46.2 ml kg(-1) (6.3-173.7), respectively. Blood loss quantification was difficult because of diffuse bleeding to the drapes. The management of patients with neurofibromatosis or burns involving the whole face was more difficult and haemorrhagic than the patients with lower face transplantation. Average surgical duration was 19.1 h (15-28 h). Postoperative severe graft oedema was present in most patients. Most patients encountered complications in ICU, such as renal insufficiency, acute respiratory distress syndrome, and jugular thrombosis. Opportunistic bacterial infections were a feature during the postoperative period in these highly immunosuppressed patients.