The 2020 Facial Transplantation Update: A 15-Year Compendium

Abstract

Summary Over the past 15 years, landmark achievements have established facial transplantation (FT) as a feasible reconstructive option for otherwise irreparable craniofacial defects. However, as the field matures and long-term outcomes begin to emerge, FT teams around the world are now facing new challenges. Data for this review were identified by searches of the PubMed/MEDLINE database from inception through August 2020. All English-language articles pertaining to FT were included. Significant advances in candidate selection, technology, operative technique, posttransplant care, and immunosuppressive management have contributed to the tremendous expansion of the field, culminating in the execution in the past 3 years of 2 facial re-transplantations, and most recently the world’s first successful combined face and double hand transplant in August 2020. Despite these achievements, the allograft donor pool remains limited, with long wait times, requiring surgical experimentation with cross-sex FT. Immunosuppressive management has improved, but significant adverse events continue to be reported. Most recently, the COVID-19 pandemic has placed an unprecedented strain on the healthcare system, with various implications for the practice of reconstructive transplantation. In this article, we provide the most comprehensive and up-to-date FT review, highlighting fundamental lessons learned and recent advancements, while looking toward the challenges ahead. Over the past 15 years, extensive multidisciplinary efforts have been instrumental to the establishment of FT as a feasible reconstructive option. As novel challenges are beginning to emerge, continued collaborative and multispecialty research efforts are needed to further this field.

Face Transplant: Indications, Outcomes, and Ethical Issues—Where Do We Stand?

“…Data obtained from the 19 included articles and additional interesting papers [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 ] were organized and are reported in the following paragraphs.…”

“…Conventional techniques can treat most facial injuries: the destruction of the nose, jaws, cheeks, etc. However, beyond a certain stage of severity, some loss of substance cannot be functionally or aesthetically repaired [ 2 , 3 , 4 , 5 , 6 , 21 ]. At the current stage of our knowledge, it is not possible to repair orbicularis muscles (lips and eyelids) when they are totally destroyed.…”

“…More than elsewhere, improvisation may expose the patient to massive hemorrhage and death. Recipient vessels (external carotid artery and venous trunks) and recipient nerves (trunks of the facial nerves and branches of the trigeminal nerves) are identified and prepared [ 2 , 3 , 4 , 5 , 6 , 7 , 21 ]. This step is difficult when patients have been operated on multiple times or when it comes to burns.…”

“…Specifically, the flora colonizing the donor’s oral and respiratory mucosa, peripheral ganglia, and lymph nodes is transferred during the procedure and predisposes recipients to donor-derived infections. Furthermore, immunosuppressive therapy increases the recipient’s risk of opportunistic infections [ 3 ]. The flora most frequently found in nasal cavities is represented by Corynebacteriaceae, Propionibacteriaceae, and Staphylococcus, while Prevotella, Streptococcus, Veillonella, and Neisseria genera are more commonly found in oral spaces.…”

“…Progress has been made and multiple successful procedures have been conducted all over the world, and new refined techniques have been developed. Over the past two decades, 48 FT procedures have been carried out in 46 patients (2 documented retransplantations) [ 2 , 3 ]. However, the annual rate of accidents leading to complex facial trauma is still extremely high [ 4 ].…”