Facial Transplantation: Principles and Evolving Concepts

Abstract

Learning Objectives: After studying this article, the participant should be able to: 1. Appreciate the evolution and increasing complexity of transplanted facial allografts over the past two decades. 2. Discuss indications and contraindications for facial transplantation, and donor and recipient selection criteria and considerations. 3. Discuss logistical, immunologic, and cost considerations in facial transplantation, in addition to emerging technologies used. 4. Understand surgical approaches and anatomical and technical nuances of the procedure. 5. Describe aesthetic, functional, and psychosocial outcomes of facial transplantation reported to date. Summary: This CME article highlights principles and evolving concepts in facial transplantation. The field has witnessed significant advances over the past two decades, with more than 40 face transplants reported to date. The procedure now occupies the highest rung on the reconstructive ladder for patients with extensive facial disfigurement who are not amenable to autologous reconstructive approaches, in pursuit of optimal functional and aesthetic outcomes. Indications, contraindications, and donor and recipient considerations for the procedure are discussed. The authors also review logistical, immunologic, and cost considerations of facial transplantation. Surgical approaches to allograft procurement and transplantation, in addition to technical and anatomical nuances of the procedure, are provided. Finally, the authors review aesthetic, functional, and psychosocial outcomes that have been reported to date.

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.…”

“…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 ].…”

Recipient Selection Criteria for Facial Transplantation

“…Support for offering FT as treatment for SIWs 39,42,43,56,61,79,87,100 was in part because SIWs can sometimes be accidental rather than related to SI. In addition, there were programs that did not consider any past SI an exclusion criterion 3,9,42,87,97 . Their policies required patients to have no current SI and to pass the routine psychosocial screening before proceeding with FT.…”

“…1,2 Since then, 48 FTs have been performed to date, including 2 retransplantations and one successful combined FT and bilateral hand transplant. [3][4][5] The procedure is in high demand, with an estimated 32-58 of every 100,000 people in the United States potentially benefiting from FT. 6 However, the nascency of FT requires a cautious approach and more exploration before it becomes readily available to this patient population. As the number of FTs continues to rise, so do the opportunities to identify which determinants of clinical success need further understanding.…”