Handchir Mikrochir Plast Chir 2014; 46(04): 206-213
DOI: 10.1055/s-0034-1385850
Übersichtsarbeit
© Georg Thieme Verlag KG Stuttgart · New York

Fortschritte in der Gesichtstransplantation

Progress in Face Transplantation
M. Kueckelhaus
1   Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, United States
2   Klinik für Plastische Chirurgie und Schwerbrandverletzte, Handchirurgiezentrum, Operatives Referenzzentrum für Gliedmaßentumore, BG Universitätsklinik Bergmannsheil, Bochum
,
M. Lehnhardt
2   Klinik für Plastische Chirurgie und Schwerbrandverletzte, Handchirurgiezentrum, Operatives Referenzzentrum für Gliedmaßentumore, BG Universitätsklinik Bergmannsheil, Bochum
,
S. Fischer
1   Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, United States
,
E. Eriksson
1   Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, United States
,
B. Pomahac
1   Division of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, United States
,
T. Hirsch
2   Klinik für Plastische Chirurgie und Schwerbrandverletzte, Handchirurgiezentrum, Operatives Referenzzentrum für Gliedmaßentumore, BG Universitätsklinik Bergmannsheil, Bochum
› Author Affiliations
Further Information

Publication History

eingereicht 20 March 2014

akzeptiert 09 July 2014

Publication Date:
27 August 2014 (online)

Zusammenfassung

Die Vascularised Composite Allostranspantation (VCA) dient zur Restoration komplexer Defekte. Restoration beschreibt in diesem Zusammenhang die Wiederherstellung von destruiertem Gewebe durch anatomisch identische Strukturen. Bis heute sind weltweit insgesamt bereits über 150 VCAs, davon 31 Gesichtstransplanta­tionen, durchgeführt worden. Die Gesichtstransplantation stellt keine primär lebenserhaltende Maßnahme dar, sondern dient der Verbesserung der Lebensqualität betroffener Patienten. Aufgrund der sich zwingend anschließenden lebenslangen Immunsuppression und den damit verbunden potentiell lebensbedrohlichen Nebenwirkungen ist eine äußerst strenge Indikationsstellung mit individueller Bewertung des Kosten-Nutzen-Verhältnisses essentiell. Sichere Revaskularisation und möglichst vollständige ästhetische und funktionelle Reintegration sind die ultimativen Ziele der Gesichtstransplantation. Aktuell werden, je nach Zentrum, unterschiedliche immunsuppressive Strategien zur Induktions- und Erhaltungstherapie nach Transplantation angewandt. Die Haut bedarf als immunogenste Komponente des Transplantats weiterer Forschung, um mit den Erfolgen der immunsuppressiven Therapie bei transplantierten soliden Organen gleichziehen zu können. Auch die Organpreservation während des Transfers von Spender zu Empfänger stellt ein wichtiges Forschungsgebiet dar. Mit Publikation motivierender funktioneller und ästhetischer Ergebnisse hat sich die zunächst negative Einstellung hinsichtlich dieser nicht überlebensnotwendigen Transplantationen zum Positiven gewandelt. Kontinuierliche Weiterentwicklung chirurgischer Techniken und immunsuppressiver Strategien bilden die Grundlage zur erfolgreichen Etablierung dieses spannenden jungen Verfahrens.

Abstract

Vascularised composite allotransplantation (VCA) is utilised for restoration of complex defects. In this context, restoration describes the replacement of destroyed tissue by identical anatomic structures. Up to date, over 150 VCAs including 31 face transplantations have been performed worldwide. Face transplantation is a life giving, rather than life saving procedure that is intended to significantly improve the patient’s quality of life. Safe revascularisation as well as aesthetic and functional reintegration are the ultimate goals of face transplantation. The necessary lifelong immunosuppression with potentially life-threatening side effects imposes the need for a very strict risk-benefit ratio assessment and currently limits the indications of face transplantation. Different transplant centres use different protocols for induction and maintenance immunosuppression. Skin is the most immunogenic part of the vascularised composite allograft and has been the focus of intensive research efforts in order to replicate the success of immunosuppressive regimens for solid organ transplantation. Organ preservation during transfer from donor to recipient is another important field of research within VCA. The general public’s originally rejecting attitude towards non-lifesaving VCA procedures has changed towards a general acceptance following the publication of promising results after the first cases of face transplantation. Further improvements of surgical techniques and immunosuppressive strategies will be important to drive these young and exciting procedures forward in the future.

 
  • Literatur

  • 1 Brown JB, McDowell F. Massive Repairs of Burns with Thick Split-Skin Grafts: Emergency “Dressings” with Homografts. Ann Surg 1942; 115: 658-674
  • 2 Brown JB, McDowell F. Epithelial Healing and the Transplantation of Skin. Ann Surg 1942; 115: 1166-1181
  • 3 Tobin GR, Breidenbach 3rd WC, Ildstad ST et al. The history of human composite tissue allotransplantation. Transplant Proc 2009; 41: 466-471
  • 4 Harrison JH, Merrill JP, Murray JE. Renal homotransplantation in identical twins. Surg Forum 1956; 6: 432-436
  • 5 Murray JE, Merrill JP, Dammin GJ et al. Study on transplantation immunity after total body irradiation: clinical and experimental investigation. Surgery 1960; 48: 272-284
  • 6 Merrill JP, Murray JE, Takacs FJ et al. Successful transplantation of kidney from a human cadaver. JAMA 1963; 185: 347-353
  • 7 Gilbert R. Transplant is successful with a cadaver forearm. Med Trib Med News 1964 1964; 5: 20
  • 8 Gilbert R. Hand transplanted from cadaver is reamputated. Med Trib Med News 1964 1964; 5: 23
  • 9 Dubernard JM, Owen E, Herzberg G et al. Human hand allograft: report on first 6 months. Lancet 1999; 353: 1315-1320
  • 10 Dubernard JM, Owen E, Herzberg G et al. The first transplantation of a hand in humans. Early results. Chirurgie 1999; 124: 358-365 discussion 365–367
  • 11 Devauchelle B, Badet L, Lengele B et al. First human face allograft: early report. Lancet 2006; 368: 203-209
  • 12 Murphy BD, Zuker RM, Borschel GH. Vascularized composite allotransplantation: An update on medical and surgical progress and remaining challenges. J Plast Reconstr Aesthet Surg 2013;
  • 13 Sarhane KA, Tuffaha SH, Broyles JM et al. A Critical Analysis of Rejection in Vascularized Composite Allotransplantation: Clinical, Cellular and Molecular Aspects, Current Challenges, and Novel Concepts. Front Immunol 2013; 4: 406
  • 14 Haxby JV, Hoffman EA, Gobbini MI. Human neural systems for face recognition and social communication. Biol Psychiatry 2002; 51: 59-67
  • 15 Pomahac B, Pribaz J. Facial composite tissue allograft. J Craniofac Surg 2012; 23: 265-267
  • 16 Dubernard JM, Lengele B, Morelon E et al. Outcomes 18 months after the first human partial face transplantation. N Engl J Med 2007; 357: 2451-2460
  • 17 Groenewoud AF, Thorogood J. A preliminary report of the HTK randomized multicenter study comparing kidney graft preservation with HTK and EuroCollins solutions. HTK Study Group. Transpl Int 1992; 5 (Suppl. 01) S429-S432
  • 18 Cavallari A, Cillo U, Nardo B et al. A multicenter pilot prospective study comparing Celsior and University of Wisconsin preserving solutions for use in liver transplantation. Liver Transpl 2003; 9: 814-821
  • 19 Michel P, Vial R, Rodriguez C et al. A comparative study of the most widely used solutions for cardiac graft preservation during hypothermia. J Heart Lung Transplant 2002; 21: 1030-1039
  • 20 Pomahac B, Pribaz JJ, Bueno EM et al. Novel surgical technique for full face transplantation. Plast Reconstr Surg 2012; 130: 549-555
  • 21 Pomahac B, Lengele B, Ridgway EB et al. Vascular considerations in composite midfacial allotransplantation. Plast Reconstr Surg 2010; 125: 517-522
  • 22 Meningaud JP, Benjoar MD, Hivelin M et al. Procurement of total human face graft for allotransplantation: a preclinical study and the first clinical case. Plast Reconstr Surg 2010; 126: 1181-1190
  • 23 Houseman ND, Taylor GI, Pan WR. The angiosomes of the head and neck: anatomic study and clinical applications. Plast Reconstr Surg 2000; 105: 2287-2313
  • 24 Alizai AM, Trobe JD, Thompson BG et al. Ocular ischemic syndrome after occlusion of both external carotid arteries. J Neuroophthalmol 2005; 25: 268-272
  • 25 Geibprasert S, Pongpech S, Armstrong D et al. Dangerous extracranial-intracranial anastomoses and supply to the cranial nerves: vessels the neurointerventionalist needs to know. AJNR Am J Neuroradiol 2009; 30: 1459-1468
  • 26 Pomahac B, Pribaz J, Eriksson E et al. Restoration of facial form and function after severe disfigurement from burn injury by a composite facial allograft. Am J Transplant 2011; 11: 386-393
  • 27 Jabaley ME, Wallace WH, Heckler FR. Internal topography of major nerves of the forearm and hand: a current view. J Hand Surg Am 1980; 5: 1-18
  • 28 Piza-Katzer H, Balogh B, Muzika-Herczeg E et al. Secondary end-to-end repair of extensive facial nerve defects: surgical technique and postoperative functional results. Head Neck 2004; 26: 770-777
  • 29 Ustuner ET, Zdichavsky M, Ren X et al. Long-term composite tissue allograft survival in a porcine model with cyclosporine/mycophenolate mofetil therapy. Transplantation 1998; 66: 1581-1587
  • 30 Petruzzo P, Badet L, Gazarian A et al. Bilateral hand transplantation: six years after the first case. Am J Transplant 2006; 6: 1718-1724
  • 31 Lantieri L, Meningaud JP, Grimbert P et al. Repair of the lower and middle parts of the face by composite tissue allotransplantation in a patient with massive plexiform neurofibroma: a 1-year follow-up study. Lancet 2008; 372: 639-645
  • 32 Siemionow M, Papay F, Alam D et al. Near-total human face transplantation for a severely disfigured patient in the USA. Lancet 2009; 374: 203-209
  • 33 Barret JP, Gavalda J, Bueno J et al. Full face transplant: the first case report. Ann Surg 2011; 254: 252-256
  • 34 Pomahac B, Pribaz J, Eriksson E et al. Three patients with full facial transplantation. N Engl J Med 2012; 366: 715-722
  • 35 Breidenbach WC, Gonzales NR, Kaufman CL et al. Outcomes of the first 2 American hand transplants at 8 and 6 years posttransplant. J Hand Surg Am 2008; 33: 1039-1047
  • 36 Guo S, Han Y, Zhang X et al. Human facial allotransplantation: a 2-year follow-up study. Lancet 2008; 372: 631-638
  • 37 Hu W, Lu J, Zhang L et al. A preliminary report of penile transplantation. Eur Urol 2006; 50: 851-853
  • 38 Jones JW, Gruber SA, Barker JH et al. Successful hand transplantation. One-year follow-up. Louisville Hand Transplant Team. N Engl J Med 2000; 343: 468-473
  • 39 Delaere P, Vranckx J, Verleden G et al. Tracheal allotransplantation after withdrawal of immunosuppressive therapy. N Engl J Med 2010; 362: 138-145
  • 40 Hautz T, Brandacher G, Zelger B et al. Immunologic aspects and rejection in solid organ versus reconstructive transplantation. Transplant Proc 2010; 42: 3347-3353
  • 41 Lantieri L, Hivelin M, Audard V et al. Feasibility, reproducibility, risks and benefits of face transplantation: a prospective study of outcomes. Am J Transplant 2011; 11: 367-378
  • 42 Petruzzo P, Testelin S, Kanitakis J et al. First human face transplanta­tion: 5 years outcomes. Transplantation 2012; 93: 236-240
  • 43 Andreu G, Leon A, Heshmati F et al. Extracorporeal photochemotherapy: evaluation of two techniques and use in connective tissue disorders. Transfus Sci 1994; 15: 443-454
  • 44 Ciancio G, Miller J, Garcia-Morales RO et al. Six-year clinical effect of donor bone marrow infusions in renal transplant patients. Transplantation 2001; 71: 827-835
  • 45 Gorantla VS, Brandacher G, Schneeberger S et al. Favoring the risk-benefit balance for upper extremity transplantation – the Pittsburgh Protocol. Hand Clin 2011; 27: 511-520 ix-x
  • 46 Gorantla VS, Schneeberger S, Brandacher G et al. T regulatory cells and transplantation tolerance. Transplant Rev (Orlando) 2010; 24: 147-159
  • 47 Bejarano PA, Levi D, Nassiri M et al. The Pathology of full-thickness cadaver skin transplant for large abdominal defects: a proposed grading system for skin allograft acute rejection. Am J Surg Pathol 2004; 28: 670-675
  • 48 Cendales LC, Kirk AD, Moresi JM et al. Composite tissue allotransplantation: classification of clinical acute skin rejection. Transplantation 2006; 81: 418-422
  • 49 Kanitakis J, Petruzzo P, Jullien D et al. Pathological score for the evaluation of allograft rejection in human hand (composite tissue) allotransplantation. Eur J Dermatol 2005; 15: 235-238
  • 50 Schneeberger S, Kreczy A, Brandacher G et al. Steroid- and ATG-resistant rejection after double forearm transplantation responds to Campath-1H. Am J Transplant 2004; 4: 1372-1374
  • 51 Cendales LC, Kanitakis J, Schneeberger S et al. The Banff 2007 working classification of skin-containing composite tissue allograft pathology. Am J Transplant 2008; 8: 1396-1400
  • 52 Diaz-Siso JR, Bueno EM, Sisk GC et al. Vascularized composite tissue allotransplantation – state of the art. Clin Transplant 2013; 27: 330-337
  • 53 Knoll BM, Hammond SP, Koo S et al. Infections following facial composite tissue allotransplantation – single center experience and review of the literature. Am J Transplant 2013; 13: 770-779
  • 54 Sehgal VN, Srivastava G, Dogra S. Tacrolimus in dermatology-pharmacokinetics, mechanism of action, drug interactions, dosages, and side effects: part I. Skinmed 2008; 7: 27-30
  • 55 Schneeberger S, Ninkovic M, Piza-Katzer H et al. Status 5 years after bilateral hand transplantation. Am J Transplant 2006; 6: 834-841
  • 56 Kiwanuka H, Bueno EM, Diaz-Siso JR et al. Evolution of ethical debate on face transplantation. Plast Reconstr Surg 2013; 132: 1558-1568
  • 57 Kaufman CL, Ouseph R, Blair B et al. Graft vasculopathy in clinical hand transplantation. Am J Transplant 2012; 12: 1004-1016