Reporting Practices on Immunosuppression and Rejection Management in Face Transplantation: A Systematic Review

Abstract

Background Face transplantation is a demanding operation requiring complex planning and expert technical performance. While the documentation of successes of the first transplants is impressive, there are lacunae in reporting of institutional protocols for other critical operation components, namely, immunosuppression, graft surveillance, and management of rejection and graft failure. The purpose of this review is to assess protocol reporting by face transplant teams to determine where we, as a plastic surgery community, can improve. Methods A systematic review of PubMed was conducted to identify literature on face transplants published from November, 2005, starting with the first successful transplant to December, 2018. English-language articles were reviewed for reporting of protocols on antimicrobial prophylaxis, immunosuppression, graft surveillance, and management of rejection and graft failure. Results A total of 44 face transplantation patients were identified. Protocols for antimicrobial prophylaxis, immunosuppressive induction, and maintenance immunosuppression were reported for 61%, 75%, and 73% of patients, respectively. Protocols for graft surveillance and medical management of rejection were reported for 70% of patients in both cases. Surgical salvage strategies to manage graft failure were documented for 43% of patients. Conclusion The current literature on face transplantation does not include consistent reporting on critical aspects of patient care. Medical protocols outlining guidelines for immunosuppression, graft surveillance, and management of rejection and graft failure are the most critical factors determining overall transplant success. However, they are underreported in the literature. Development and communication of standardized protocols is essential to improve patient outcomes and maximize the results of this procedure.

Special Considerations in Face Transplantation: A Systematic Review

“…32 Failure of the allograft can be mitigated with additional surgery and traditional reconstruction, or, as seen in 1 case, a repeat facial allotransplantation from a new donor. 9,11 The salvage procedure commonly involves free flap reconstruction with sites such as the forearm or anterolateral thigh. 5,9 Looking to the future of facial transplantation, the themes that will likely remain constant include the harvest of a distinct allograft for each unique case and the purposeful selection of the treatment team, which will differ from case to case, depending on the inclusion or exclusion of certain anatomy.…”

“…1,6,7 With advancements in immunosuppressive regimens, as well as continued research in the fields of microsurgery and composite tissue allotransplantation, facial transplantation has evolved to be a more plausible plan for treatment, with over 44 cases performed. 8,9 Vascularized composite allotransplantation, however, is extremely complex, with a need for a multi-disciplinary approach; several considerations are necessary in order to achieve a functional and aesthetic result.…”

Software-based Detection of Acute Rejection Changes in Face Transplant

“…This method of testing for rejection could better identify false positives, reduce need for invasive skin biopsies, and standardize rejection management. 24 In summary, it appears that the accurate diagnosis of rejection in FT may include a multimodal approach consisting of tissue biopsy, clinical inspection of allograft supported by quantitative redness detection, and a non-invasive blood biomarker test. Despite promising study results, erythema is a non-specific marker for rejection that can mimic inflammatory, infectious or neoplastic dermatoses.…”

The 2020 Facial Transplantation Update: A 15-Year Compendium

“… 12 Other therapies described include a combination of plasmapheresis, intravenous immunoglobulins, extracorporeal photopheresis, ATGs, eculizumab, and bortezomib. 36 , 40 , 49 Successful management of AR has been proposed as a rationale for the relatively low incidence of CR in FT. Although reports are beginning to emerge, the timeframe for CR remains unknown and expert consensus on CR management and allograft failure has not been established.…”