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Semin Plast Surg 2020; 34(04): 245-253
DOI: 10.1055/s-0040-1721760
Review Article

Facial Transplantation: Complications, Outcomes, and Long-Term Management Strategies

Tom Shokri
1   Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
,
Robert Saadi
2   Department of Otolaryngology – Head & Neck Surgery, Penn State Health, Hershey, Pennsylvania
,
Weitao Wang
1   Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
,
Likith Reddy
3   Department of Oral and Maxillofacial Surgery, Texas A&M College of Dentistry, Dallas, Texas
,
Yadranko Ducic
1   Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
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Abstract

Within the past two decades, vascularized facial composite allotransplantation has evolved into a viable option in the reconstructive surgeons' armamentarium for patients with extensive facial disfigurements. As it has expanded the frontiers of microsurgical reconstructive techniques, facial transplantation has come to garner widespread interest within both the medical community and the general public. The procedure has established itself as an amalgamation of the forefronts of reconstructive microsurgery, immunology, and transplantation science. Therein too lies its complexity as multifaceted scientific developments are met with ethical and social issues. Both patients and physicians are faced with the everlasting challenges of immunosuppression regimens and their inherent complications, long-term aesthetic and functional considerations, the role of revision procedures, and the inevitable psychosocial implications. This article reflects on the medical and surgical advancements in facial transplantation surgery and highlights anticipated future challenges. It aims to encourage discussion regarding anticipated barriers to current practice and suggest future directions as we transition into the next phase of facial allograft transplantation.

Keywords

facial transplantation - composite tissue allotransplantation - microvascular surgery - immunosuppression - ethics

Disclosures

The authors have no disclosures.




Publication History

Article published online:
24 December 2020

© 2020. Thieme. All rights reserved.

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  • References

  • 1 Hettiaratchy S, Butler PE. Face transplantation--fantasy or the future?. Lancet 2002; 360 (9326): 5-6
    CrossrefPubMedGoogle Scholar
  • 2 Morris PJ, Bradley JA, Doyal L. et al. Facial transplantation: a working party report from the Royal College of Surgeons of England. Transplantation 2004; 77 (03) 330-338
    CrossrefPubMedGoogle Scholar
  • 3 Siemionow M, Ozmen S, Demir Y. Prospects for facial allograft transplantation in humans. Plast Reconstr Surg 2004; 113 (05) 1421-1428
    CrossrefPubMedGoogle Scholar
  • 4 Wiggins OP, Barker JH, Martinez S. et al. On the ethics of facial transplantation research. Am J Bioeth 2004; 4 (03) 1-12
    CrossrefPubMedGoogle Scholar
  • 5 Shanmugarajah K, Hettiaratchy S, Butler PE. Facial transplantation. Curr Opin Otolaryngol Head Neck Surg 2012; 20 (04) 291-297
    CrossrefPubMedGoogle Scholar
  • 6 Dubernard JM, Lengelé B, Morelon E. et al. Outcomes 18 months after the first human partial face transplantation. N Engl J Med 2007; 357 (24) 2451-2460
    CrossrefPubMedGoogle Scholar
  • 7 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 (9639): 639-645
    CrossrefPubMedGoogle Scholar
  • 8 Siemionow M, Ozturk C. An update on facial transplantation cases performed between 2005 and 2010. Plast Reconstr Surg 2011; 128 (06) 707e-720e
    CrossrefPubMedGoogle Scholar
  • 9 Siemionow MZ, Papay F, Djohan R. et al. First U.S. near-total human face transplantation: a paradigm shift for massive complex injuries. Plast Reconstr Surg 2010; 125 (01) 111-122
    CrossrefPubMedGoogle Scholar
  • 10 Pomahac B, Pribaz J, Eriksson E. et al. Three patients with full facial transplantation. N Engl J Med 2012; 366 (08) 715-722
    CrossrefPubMedGoogle Scholar
  • 11 Shanmugarajah K, Hettiaratchy S, Clarke A, Butler PE. Clinical outcomes of facial transplantation: a review. Int J Surg 2011; 9 (08) 600-607
    CrossrefPubMedGoogle Scholar
  • 12 Siemionow M, Ozturk C. Face transplantation: outcomes, concerns, controversies, and future directions. J Craniofac Surg 2012; 23 (01) 254-259
    CrossrefPubMedGoogle Scholar
  • 13 Sosin M, Ceradini DJ, Levine JP. et al. Total face, eyelids, ears, scalp, and skeletal subunit transplant: a reconstructive solution for the full face and total scalp burn. Plast Reconstr Surg 2016; 138 (01) 205-219
    CrossrefPubMedGoogle Scholar
  • 14 Tasigiorgos S, Kollar B, Krezdorn N, Bueno EM, Tullius SG, Pomahac B. Face transplantation-current status and future developments. Transpl Int 2018; 31 (07) 677-688
    CrossrefPubMedGoogle Scholar
  • 15 Fischer S, Kueckelhaus M, Pauzenberger R, Bueno EM, Pomahac B. Functional outcomes of face transplantation. Am J Transplant 2015; 15 (01) 220-233
    CrossrefPubMedGoogle Scholar
  • 16 Siemionow M. The decade of face transplant outcomes. J Mater Sci Mater Med 2017; 28 (05) 64
    CrossrefPubMedGoogle Scholar
  • 17 Giatsidis G, Sinha I, Pomahac B. Reflections on a decade of face transplantation. Ann Surg 2017; 265 (04) 841-846
    CrossrefPubMedGoogle Scholar
  • 18 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 (02) 367-378
    CrossrefPubMedGoogle Scholar
  • 19 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 (02) 386-393
    CrossrefPubMedGoogle Scholar
  • 20 Guo S, Han Y, Zhang X. et al. Human facial allotransplantation: a 2-year follow-up study. Lancet 2008; 372 (9639): 631-638
    CrossrefPubMedGoogle Scholar
  • 21 Barret JP, Gavaldà J, Bueno J. et al. Full face transplant: the first case report. Ann Surg 2011; 254 (02) 252-256
    CrossrefPubMedGoogle Scholar
  • 22 Pomahac B, Pribaz JJ, Bueno EM. et al. Novel surgical technique for full face transplantation. Plast Reconstr Surg 2012; 130 (03) 549-555
    CrossrefPubMedGoogle Scholar
  • 23 Dorafshar AH, Bojovic B, Christy MR. et al. Total face, double jaw, and tongue transplantation: an evolutionary concept. Plast Reconstr Surg 2013; 131 (02) 241-251
    CrossrefPubMedGoogle Scholar
  • 24 Khalifian S, Brazio PS, Mohan R. et al. Facial transplantation: the first 9 years. Lancet 2014; 384 (9960): 2153-2163
    CrossrefPubMedGoogle Scholar
  • 25 Devauchelle B, Badet L, Lengelé B. et al. First human face allograft: early report. Lancet 2006; 368 (9531): 203-209
    CrossrefPubMedGoogle Scholar
  • 26 Nordin M, Hagbarth KE. Mechanoreceptive units in the human infra-orbital nerve. Acta Physiol Scand 1989; 135 (02) 149-161
    CrossrefPubMedGoogle Scholar
  • 27 Hwang K, Hwang JH, Cho HJ, Kim DJ, Chung IH. Horizontal branch of the supraorbital nerve and temporal branch of the facial nerve. J Craniofac Surg 2005; 16 (04) 647-649 , discussion 650
    CrossrefPubMedGoogle Scholar
  • 28 Shankland II WE. The trigeminal nerve. Part III: the maxillary division. Cranio 2001; 19 (02) 78-83
    CrossrefPubMedGoogle Scholar
  • 29 Siemionow M, Gharb BB, Rampazzo A. The face as a sensory organ. Plast Reconstr Surg 2011; 127 (02) 652-662
    CrossrefPubMedGoogle Scholar
  • 30 Canan S, Asim OM, Okan B, Ozek C, Alper M. Anatomic variations of the infraorbital foramen. Ann Plast Surg 1999; 43 (06) 613-617
    CrossrefPubMedGoogle Scholar
  • 31 Aziz SR, Marchena JM, Puran A. Anatomic characteristics of the infraorbital foramen: a cadaver study. J Oral Maxillofac Surg 2000; 58 (09) 992-996
    CrossrefPubMedGoogle Scholar
  • 32 Hu KS, Kwak HH, Song WC. et al. Branching patterns of the infraorbital nerve and topography within the infraorbital space. J Craniofac Surg 2006; 17 (06) 1111-1115
    CrossrefPubMedGoogle Scholar
  • 33 Hwang K, Nam YS, Choi HG, Han SH, Hwang SH. Cutaneous innervation of lower eyelid. J Craniofac Surg 2008; 19 (06) 1675-1677
    CrossrefPubMedGoogle Scholar
  • 34 Singhal D, Pribaz JJ, Pomahac B. The Brigham and Women's Hospital face transplant program: a look back. Plast Reconstr Surg 2012; 129 (01) 81e-88e
    CrossrefPubMedGoogle Scholar
  • 35 Rifkin WJ, David JA, Plana NM. et al. Achievements and challenges in facial transplantation. Ann Surg 2018; 268 (02) 260-270
    CrossrefPubMedGoogle Scholar
  • 36 Kirkey S. Canada's First Face Transplant. Accessed July 8, 2020 at: https://nationalpost.com/feature/canadas-first-face-transplant
    PubMedGoogle Scholar
  • 37 Gordon CR, Siemionow M, Papay F. et al. The world's experience with facial transplantation: what have we learned thus far?. Ann Plast Surg 2009; 63 (05) 572-578
    CrossrefPubMedGoogle Scholar
  • 38 Sosin M, Mundinger GS, Dorafshar AH. et al. Eyelid transplantation: lessons from a total face transplant and the importance of blink. Plast Reconstr Surg 2015; 135 (01) 167e-175e
    CrossrefPubMedGoogle Scholar
  • 39 Ozkan O, Ozkan O, Ubur M, Hadimioglu N, Cengiz M, Afsar I. Face allotransplantation for various types of facial disfigurements: a series of five cases. Microsurgery 2018; 38 (08) 834-843
    CrossrefPubMedGoogle Scholar
  • 40 Aycart MA, Alhefzi M, Kueckelhaus M. et al. A retrospective analysis of secondary revisions after face transplantation: assessment of outcomes, safety, and feasibility. Plast Reconstr Surg 2016; 138 (04) 690e-701e
    CrossrefPubMedGoogle Scholar
  • 41 Greenfield JA, Kantar RS, Rifkin WJ. et al. Ocular considerations in face transplantation: report of 2 cases and review of the literature. Ophthal Plast Reconstr Surg 2019; 35 (03) 218-226
    CrossrefPubMedGoogle Scholar
  • 42 Grigos MI, LeBlanc É, Rifkin WJ. et al. Total eyelid transplantation in a face transplant: analysis of postoperative periorbital function. J Surg Res 2020; 245: 420-425
    CrossrefPubMedGoogle Scholar
  • 43 Sosin M, Rodriguez ED. The face transplantation update: 2016. Plast Reconstr Surg 2016; 137 (06) 1841-1850
    CrossrefPubMedGoogle Scholar
  • 44 Woman Receives Total Face Transplant at Cleveland Clinic. Accessed July 9, 2020 at: https://health.clevelandclinic.org/woman-receives-total-face-transplant-at-cleveland-clinic/
    PubMedGoogle Scholar
  • 45 Lassus P, Lindford A, Vuola J. et al. The Helsinki face transplantation: surgical aspects and 1-year outcome. J Plast Reconstr Aesthet Surg 2018; 71 (02) 132-139
    CrossrefPubMedGoogle Scholar
  • 46 Caterson EJ, Diaz-Siso JR, Shetye P. et al. Craniofacial principles in face transplantation. J Craniofac Surg 2012; 23 (05) 1234-1238
    CrossrefPubMedGoogle Scholar
  • 47 Dorafshar AH, Brazio PS, Mundinger GS, Mohan R, Brown EN, Rodriguez ED. Found in space: computer-assisted orthognathic alignment of a total face allograft in six degrees of freedom. J Oral Maxillofac Surg 2014; 72 (09) 1788-1800
    CrossrefPubMedGoogle Scholar
  • 48 Gordon CR, Susarla SM, Peacock ZS, Kaban LB, Yaremchuk MJ. Le Fort-based maxillofacial transplantation: current state of the art and a refined technique using orthognathic applications. J Craniofac Surg 2012; 23 (01) 81-87
    CrossrefPubMedGoogle Scholar
  • 49 Gordon CR, Susarla SM, Peacock ZS. et al. Osteocutaneous maxillofacial allotransplantation: lessons learned from a novel cadaver study applying orthognathic principles and practice. Plast Reconstr Surg 2011; 128 (05) 465e-479e
    CrossrefPubMedGoogle Scholar
  • 50 Blondeel P. Facial transplantation—the Gent, Belgium clinical experience. Presented at the State of the Art: Facial Reconstruction & Transplantation, Baltimore, MD, May 17–19, 2013
    PubMedGoogle Scholar
  • 51 Jacobs JMS, Dec W, Levine JP. et al. Best face forward: virtual modeling and custom device fabrication to optimize craniofacial vascularized composite allotransplantation. Plast Reconstr Surg 2013; 131 (01) 64-70
    CrossrefPubMedGoogle Scholar
  • 52 Wall A, Bueno E, Pomahac B, Treister N. Intraoral features and considerations in face transplantation. Oral Dis 2016; 22 (02) 93-103
    CrossrefPubMedGoogle Scholar
  • 53 Ramly EP, Kantar RS, Diaz-Siso JR, Alfonso AR, Shetye PR, Rodriguez ED. Outcomes after tooth-bearing maxillomandibular facial transplantation: insights and lessons learned. J Oral Maxillofac Surg 2019; 77 (10) 2085-2103
    CrossrefPubMedGoogle Scholar
  • 54 Brown EN, Dorafshar AH, Bojovic B. et al. Total face, double jaw, and tongue transplant simulation: a cadaveric study using computer-assisted techniques. Plast Reconstr Surg 2012; 130 (04) 815-823
    CrossrefPubMedGoogle Scholar
  • 55 Fischer S, Lian CG, Kueckelhaus M. et al. Acute rejection in vascularized composite allotransplantation. Curr Opin Organ Transplant 2014; 19 (06) 531-544
    CrossrefPubMedGoogle Scholar
  • 56 Cavadas PC, Ibáñez J, Thione A. Surgical aspects of a lower face, mandible, and tongue allotransplantation. J Reconstr Microsurg 2012; 28 (01) 43-47
    Article in Thieme ConnectPubMedGoogle Scholar
  • 57 Madani H, Hettiaratchy S, Clarke A, Butler PEM. Immunosuppression in an emerging field of plastic reconstructive surgery: composite tissue allotransplantation. J Plast Reconstr Aesthet Surg 2008; 61 (03) 245-249
    CrossrefPubMedGoogle Scholar
  • 58 Diaz-Siso JR, Bueno EM, Sisk GC, Marty FM, Pomahac B, Tullius SG. Vascularized composite tissue allotransplantation--state of the art. Clin Transplant 2013; 27 (03) 330-337
    CrossrefPubMedGoogle Scholar
  • 59 Lantieri L, Grimbert P, Ortonne N. et al. Face transplant: long-term follow-up and results of a prospective open study. Lancet 2016; 388 (10052): 1398-1407
    CrossrefPubMedGoogle Scholar
  • 60 Diaz-Siso JR, Fischer S, Sisk GC. et al. Initial experience of dual maintenance immunosuppression with steroid withdrawal in vascular composite tissue allotransplantation. Am J Transplant 2015; 15 (05) 1421-1431
    CrossrefPubMedGoogle Scholar
  • 61 Schneeberger S, Gorantla VS, Brandacher G. et al. Upper-extremity transplantation using a cell-based protocol to minimize immunosuppression. Ann Surg 2013; 257 (02) 345-351
    CrossrefPubMedGoogle Scholar
  • 62 Petruzzo P, Testelin S, Kanitakis J. et al. First human face transplantation: 5 years outcomes. Transplantation 2012; 93 (02) 236-240
    CrossrefPubMedGoogle Scholar
  • 63 Krezdorn N, Murakami N, Pomahac B, Riella LV. Immunological characteristics of a patient with belatacept-resistant acute rejection after face transplantation. Am J Transplant 2016; 16 (11) 3305-3307
    CrossrefPubMedGoogle Scholar
  • 64 Theodorakopoulous E, Meghji S, Pafitanis G. et al. A review of the world's published face transplant cases: ethical perspectives. Scars Burns Heal 2017; 3: 1-10
    PubMedGoogle Scholar
  • 65 Dharnidharka VR, Lamb KE, Gregg JA, Meier-Kriesche HU. Associations between EBV serostatus and organ transplant type in PTLD risk: an analysis of the SRTR National Registry Data in the United States. Am J Transplant 2012; 12 (04) 976-983
    CrossrefPubMedGoogle Scholar
  • 66 Hussein K, Rath B, Ludewig B, Kreipe H, Jonigk D. Clinico-pathological characteristics of different types of immunodeficiency-associated smooth muscle tumours. Eur J Cancer 2014; 50 (14) 2417-2424
    CrossrefPubMedGoogle Scholar
  • 67 Kueckelhaus M, Turk M, Kumamaru KK. et al. Transformation of face transplants: volumetric and morphologic graft changes resemble aging after facial allotransplantation. Am J Transplant 2016; 16 (03) 968-978
    CrossrefPubMedGoogle Scholar
  • 68 Grulich AE, Vajdic CM. The epidemiology of cancers in human immunodeficiency virus infection and after organ transplantation. Semin Oncol 2015; 42 (02) 247-257
    CrossrefPubMedGoogle Scholar
  • 69 Krezdorn N, Lian CG, Wells M. et al. Chronic rejection of human face allografts. Am J Transplant 2019; 19 (04) 1168-1177
    CrossrefPubMedGoogle Scholar
  • 70 Renshaw A, Clarke A, Diver AJ, Ashcroft RE, Butler PE. Informed consent for facial transplantation. Transpl Int 2006; 19 (11) 861-867
    CrossrefPubMedGoogle Scholar
  • 71 Brown CS, Gander B, Cunningham M. et al. Ethical considerations in face transplantation. Int J Surg 2007; 5 (05) 353-364
    CrossrefPubMedGoogle Scholar
  • 72 Coffman KL, Siemionow MZ. Ethics of facial transplantation revisited. Curr Opin Organ Transplant 2014; 19 (02) 181-187
    CrossrefPubMedGoogle Scholar
  • 73 Liu X, Langsdon S, Holloway W. et al. The ethics of facial allotransplantation: a systematic review. Plast Reconstr Surg Glob Open 2019; 7 (10) e2425
    CrossrefPubMedGoogle Scholar
  • 74 Kiwanuka H, Bueno EM, Diaz-Siso JR, Sisk GC, Lehmann LS, Pomahac B. Evolution of ethical debate on face transplantation. Plast Reconstr Surg 2013; 132 (06) 1558-1568
    CrossrefPubMedGoogle Scholar
  • 75 Paradis C, Siemionow M, Papay F. et al. Ethical considerations in the first American face transplant. Plast Reconstr Surg 2010; 126 (03) 896-901
    CrossrefPubMedGoogle Scholar
  • 76 Marchac A, Kuschner T, Paris J, Picard A, Vazquez MP, Lantieri L. Ethical issues in pediatric face transplantation: should we perform face transplantation in children?. Plast Reconstr Surg 2016; 138 (02) 449-454
    CrossrefPubMedGoogle Scholar
  • 77 Flynn J, Shaul RZ, Hanson MD, Borschel GH, Zuker R. Pediatric facial transplantation: ethical considerations. Plast Surg (Oakv) 2014; 22 (02) 67-69
    CrossrefPubMedGoogle Scholar
  • 78 Suchyta MA, Sharp R, Amer H, Bradley E, Mardini S. Ethicists' opinions regarding the permissibility of face transplant. Plast Reconstr Surg 2019; 144 (01) 212-224
    CrossrefPubMedGoogle Scholar
  • 79 Hull AM, Lowe T, Devlin M, Finlay P, Koppel D, Stewart AM. Psychological consequences of maxillofacial trauma: a preliminary study. Br J Oral Maxillofac Surg 2003; 41 (05) 317-322
    CrossrefPubMedGoogle Scholar
  • 80 Furr LA, Wiggins O, Cunningham M. et al. Psychosocial implications of disfigurement and the future of human face transplantation. Plast Reconstr Surg 2007; 120 (02) 559-565
    CrossrefPubMedGoogle Scholar
  • 81 Coffman KL. Psychiatric evaluation of the face transplant candidate. Curr Opin Organ Transplant 2015; 20 (02) 222-228
    CrossrefPubMedGoogle Scholar
  • 82 Kiwanuka H, Aycart MA, Gitlin DF. et al. The role of face transplantation in the self-inflicted gunshot wound. J Plast Reconstr Aesthet Surg 2016; 69 (12) 1636-1647
    CrossrefPubMedGoogle Scholar
  • 83 Maldonado JR, Sher Y, Lolak S. et al. The Stanford Integrated Psychosocial Assessment for Transplantation: a prospective study of medical and psychosocial outcomes. Psychosom Med 2015; 77 (09) 1018-1030
    CrossrefPubMedGoogle Scholar
  • 84 Aycart MA, Kiwanuka H, Krezdorn N. et al. Quality of life after face transplantation: outcomes, assessment tools, and future directions. Plast Reconstr Surg 2017; 139 (01) 194-203
    CrossrefPubMedGoogle Scholar
  • 85 Cogliandro A, Barone M, Salzillo R, Persichetti P. Quality of life after face transplantation: outcomes, assessment tools, and future directions. Plast Reconstr Surg 2017; 140 (05) 757e
    CrossrefPubMedGoogle Scholar
  • 86 Oser ML, Nizzi MC, Zinser JL. et al. Quality of life and psychosocial functioning 2 years following facial transplantation. Psychosomatics 2018; 59 (06) 591-600
    CrossrefPubMedGoogle Scholar
  • 87 FitzGibbon GM. The commandments of Gillies. Br J Plast Surg 1968; 21 (03) 226-239
    CrossrefPubMedGoogle Scholar