Restoration of Facial Form and Function After Severe Disfigurement from Burn Injury by a Composite Facial Allograft

Abstract

Composite facial allotransplantation is emerging as a treatment option for severe facial disfigurements. The technical feasibility of facial transplantation has been demonstrated, and the initial clinical outcomes have been encouraging. We report an excellent functional and anatomical restoration 1 year after face transplantation. A 59-year-old male with severe disfigurement from electrical burn injury was treated with a facial allograft composed of bone and soft tissues to restore midfacial form and function. An initial potent antirejection treatment was tapered to minimal dose of immunosuppression. There were no surgical complications. The patient demonstrated facial redness during the initial postoperative months. One acute rejection episode was reversed with a brief methylprednisolone bolus treatment. Pathological analysis and the donor's medical history suggested that rosacea transferred from the donor caused the erythema, successfully treated with topical metronidazol. Significant restoration of nasal breathing, speech, feeding, sensation and animation was achieved. The patient was highly satisfied with the esthetic result, and regained much of his capacity for normal social life. Composite facial allotransplantation, along with minimal and well-tolerated immunosuppression, was successfully utilized to restore facial form and function in a patient with severe disfigurement of the midface.

Functional Outcomes of Face Transplantation

“…In addition to the burden of disfigurement leading to social isolation, patients who experience severe facial trauma often lose their ability to communicate through words or expressions, eat without substantial accommodations such as straws or pureed food, and/or breathe without assistance, among others (1). All of these limitations are often accompanied by a state of full mental capacity, making facial injuries one of the most difficult disabilities conceivable.…”

“…The search terms were ''facial graft,'' ''facial transplantation,'' and ''facial allotransplant''; the time frame was between January 2000 and March 2014. Articles were in English language and contained at least one case report of FT. We identified 28 articles fulfilling these criteria (1,4,5,.…”

Facial transplantation: the first 9 years

“…Chronic renal insuffi ciency has been reported in two patients, 14,19 one of whom had to be switched from calcineurin inhibitor to sirolimus at 11 months for chronic renal insuffi ciency, which resolved after treatment for thrombotic microangiopathy that followed treatment conversion. 19 New-onset diabetes developed in two recipients 23,34 (one of whom received prolonged high-dose tacrolimus treatment). A third patient needed to be given insulin.…”

“…36 Rosacea developed in one graft and mimicked acute rejection until successful treatment with topical metronidazole. 34,43 Rejection episodes have generally been readily reversible with pulse dose corticosteroids, augmented in some cases by topical drugs (steroids 17,36 and tacrolimus 17 ). Other treatments have included increasing the tacrolimus target trough level, 23 topical drugs alone, 34 and observation 12 for grade 1 rejection; addition of topical drugs for grade 2 rejection; and addition of plasmapheresis, eculizumab, bortezomib, 42 and induction drugs such as anti-thymocyte globulin 12 and alemtuzumab 42 for grade 3 rejection.…”

Three Patients with Full Facial Transplantation

“…1 Since 2005, a total of 18 patients have received transplants with promising results. [2][3][4][5][6][7] Most facial transplantations have been designed to restore partial-face defects; fullface transplantations include the forehead, eyelids, nose, lips, chin, and cheeks, 8,9 with or without underlying bone. Full-face transplantation has been considered nearly impossible because of the complexity of the blood supply as well as ethical, psychological, and social implications.…”