Computerized Approach to Facial Transplantation: Evolution and Application in 3 Consecutive Face Transplants

Abstract

Background:Face transplant (FT) candidates present with unique anatomic and functional defects unsuitable for autologous reconstruction, making the accurate design and transplantation of patient-specific allografts particularly challenging. In this case series, we present our computerized surgical planning (CSP) protocol for FT.Methods:CSP, computer-aided design and manufacturing, intraoperative navigation, and intraoperative computerized tomography have been successfully incorporated into a comprehensive protocol. Three consecutive FTs were performed. CSP and postoperative results were compared using computerized tomography–derived cephalometric measurements, and the literature was reviewed.Results:Two full and 1 partial FT were successfully performed using the CSP protocol. CSP facilitated the execution of FT with minor angular and translational cephalometric variations on immediate postoperative imaging. Our evolving experience was accompanied by a decreased reliance on cadaveric simulation, from 10 mock transplants and a research procurement before the senior author’s first clinical FT (2012) to 6 mock transplants and no research procurement before the third FT (2018). Operative time was significantly reduced from 36 to 25 hours, as was the need for major orthognathic surgical revision. This reflects the learning curve and variable case complexity, but it is also representative of improved planning and execution, complemented by the systematic incorporation of CSP into FT.Conclusions:A CSP protocol allows for refinement of operative flow, technique, and outcomes in partial and full FT. Standards for functional and esthetic outcomes are bound to evolve with the field’s growth, and computerized planning and execution offer a reproducible approach to FT through objective quality assurance.

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.…”

“…Five pathologies or types of traumas are essentially associated with face transplants: ballistic traumas, neurofibromatosis, animal bites, burns, and certain sequelae of cancer [ 10 , 11 , 12 , 13 , 14 , 15 , 16 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 ].…”

Face Transplant: Current Update and First Canadian Experience

“…1). [1][2][3][4][5][6][7] Although the technical feasibility of this procedure is well established, experience with facial vascularized composite allotransplantation remains in its infancy. The need for lifelong immunosuppression, its adverse effects, and its potential for chronic rejection have limited the procedure to only the most severe injuries.…”

The 2020 Facial Transplantation Update: A 15-Year Compendium

“… 14 , 33 The application of computerized surgical planning (CSP) and computer-aided design and manufacturing (CAD/CAM) of patient-specific devices has been instrumental to allow FT teams to adopt a customized approach to various clinical scenarios and achieve superior functional and aesthetic outcomes, including optimized operative flow and cephalometric and occlusal relationships after transplantation. 34 At least 8 other FT teams have relied on various forms of three-dimensional (3D) imaging and CAD/CAM for preparation and execution of their FTs. 1 , 13 , 15 , 28 , 35 , 36 Nonetheless, CSP should serve as a guide for FT surgeons, rather than dictate intraoperative decision-making; deviating from the computerized plan may be necessary in real time.…”

“… 37 To date, 2 clinical FTs have utilized ISN as an adjunct to CSP, allowing intraoperative guidance of LeFort III osteotomies in the first patient and image-guided allograft inset and fixation in the second patient. 34 Mixed reality (MR) technology has recently been proposed as a complementary option for use in FT planning and intraoperative visualization. 38 In addition to the perceived benefits of MR, including enhanced visualization and easier maintenance of sterility, costs and surgical planning time have been cited as advantages of the holographic model over CSP and CAD/CAM.…”