Intraoral features and considerations in face transplantation

Abstract

Face transplantation (FT) is a unique and novel addition to the field of reconstructive surgery, which offers new hope to facially disfigured individuals. This review provides an overview of FT, including clinical indications, immunological principles, and functional outcomes, as well as an in‐depth characterization of the intraoral hard and soft tissue findings in the six patients transplanted to date at Brigham and Women's Hospital in Boston, MA, USA. Six FT recipients underwent comprehensive clinical and radiographic evaluation to assess their intraoral status, function, and overall health. The extra‐ and intraoral soft tissue was assessed via quantitative sensory testing. The vitality of the transplanted dental hard tissue was evaluated with clinically available testing methods. Native teeth and prostheses were also assessed. Sensation of transplanted oral mucosa varied based on time elapsed from FT, ranging from minimal at 3 months post‐FT, to nearly complete recovery by approximately 24 months. There was mixed success with the integration of donor teeth (Patients 1, 4 and 6), including associated occlusal discrepancies. Mucosal complications included constriction at the donor/recipient interface (Patients 2 and 5) and solitary episodes of mucosal rejection presenting as lichenoid inflammation (Patients 2 and 4). Face transplantation represents a pivotal moment in the history of reconstructive surgery and transplant medicine, providing new optimism to patients with gross facial deformities. This report highlights the successes of FT, but also the challenges of transplanting hard and soft tissues to restore complex stomatognathic function. Further attention directed toward comprehensive oral rehabilitation in FT will contribute to improved outcomes, with the ultimate goal of restoring and optimizing patient quality of life.

Anesthetic Considerations in Facial Transplantation: Experience at NYU Langone Health and Systematic Review

“…Mouth opening can be limited by burn scar contractures or trauma-related trismus, and obstruction can occur from soft-tissue ptosis. 55 – 59 Many patients present with a tracheostomy in place, whereas others have required tracheostomy pre-, intra-, or even postoperatively. 11 , 17 , 37 , 66 Early tracheostomy can reduce FT operative time and minimizes airway complications.…”

“…Recipients will inevitably return for secondary revisions. 77 , 91 , 92 Although they may present with improved mouth opening and airway volume, 55 , 57 , 58 their extensive histories before FT will continue to require vigilance and proactive pain management strategies, as learned from recipient A’s clinical course. Local anesthetics can be used for revision procedures when possible, and importantly, their use reflects sensory recovery.…”

Maxillofacial Bony Considerations in Facial Transplantation

“…Also, differences in the midface height between the donor and recipient can create tension contributing to poor healing. 26,34,39,40 Next, trismus and TMJ arthralgia can occur secondary to a mismatch in facial width with transfer of a mandible that is wider than the recipient's face. 26 Also, just as a unimaxillary transplant is more likely to lead to malocclusion, it can also have poor articulation between the donor and recipient maxilla and mandible, often leading to restriction in jaw opening and joint arthralgia.…”

Face transplantation for massive mandibular defects: considerations for allograft design and surgical planning

“…Determining the extent of donor bone inclusion is more controversial in the case of patients with defects limited to only the mandible. In such circumstances, some advocate for transplantation of only the affected jaw while others support bimaxillary transplantation [4,11,12] . In 2011, Gordon et al [13,14] introduced through cadaveric studies the concept of "hybrid occlusion", or the occlusal relationship achieved after allotransplanataion between the donor maxilla and recipient's native mandible.…”

“…Singlejaw transplantation resulting in hybrid occlusion has been utilized extensively in clinical cases of face transplantation [11] . Proponents of this technique argue that poor occlusive outcomes may arise with singlejaw as well as with bimaxillary transplantation, but only the more conservative approach accounts for the risk of graft failure by preserving functional recipient anatomy [12,15] . Furthermore, these individuals suggest that occlusion can be improved with subsequent orthognathic and orthodontic interventions [12] .…”