Current principles of facial allotransplantation: the Brigham and Women's Hospital Experience

Abstract

Background: Facial allotransplantation is a revolutionary operation that has at last introduced the possibility of nearly normal facial restoration to patients afflicted by the most severe cases of facial disfigurement.

Methods: The facial transplantation team at Brigham and Women's Hospital evaluated more than 20 patients as potential face transplant recipients; of these, six became face transplant candidates and underwent full screening procedures. The team performed facial allotransplantations in four of these patients between April of 2009 and May of 2011. This is the largest clinical volume of facial transplant recipients in the United States to date.

Results: The authors have learned important lessons from each of these four unique cases and from the more than 20 patients that they have evaluated as potential face transplant recipients. The authors have translated lessons learned through direct experience into a set of fundamental surgical principles of the operation.

Conclusions: The authors' surgical principles emphasize safety, technical feasibility, preservation of functional facial units, and return of motor and sensory function. This article describes each of these principles along with their rationale and, in some instances, illustrates their application.

Figure 1

(A) A full facial transplantation candidate at the time of initial evaluation. (B) Orbital islands of skin were maintained to provide for lining behind planned ocular prostheses. Periorbital skin was maintained to substitute missing intraoral lining.

Figure 1

(A) A full facial transplantation candidate at the time of initial evaluation. (B) Orbital islands of skin were maintained to provide for lining behind planned ocular prostheses. Periorbital skin was maintained to substitute missing intraoral lining.

Figure 2

* From Housemann ND et al. The Angiosomes of the Head and Neck: Anatomic Study and Clinical Applications, Plastic Reconst Surg 2000 (105):2287–2313. The angiosome territories of the facial artery (2) are shown in frontal and profile view. The angiosome territories of the: internal maxillary (1), facial (2), ophthalmic and internal carotid (3), superficial temporal (4), posterior auricular (5), occipital (6), transverse cervical (7), deep cervical (8), inferior thyroid (9) and superior thyroid (10) arteries are depicted in frontal and lateral views. Based on these angiosomes, it was thought that in order to perfuse a full facial flap including portions of the lateral cheek, ears, scalp and forehead, multiple arteries had to be anastomosed on each side. We demonstrated that single anastomosis of facial artery (2) on each side is sufficient to perform a full facial flap containing full cheeks, forehead, and partial scalp. * will be reprinted with permission.

Figure 2

* From Housemann ND et al. The Angiosomes of the Head and Neck: Anatomic Study and Clinical Applications, Plastic Reconst Surg 2000 (105):2287–2313. The angiosome territories of the facial artery (2) are shown in frontal and profile view. The angiosome territories of the: internal maxillary (1), facial (2), ophthalmic and internal carotid (3), superficial temporal (4), posterior auricular (5), occipital (6), transverse cervical (7), deep cervical (8), inferior thyroid (9) and superior thyroid (10) arteries are depicted in frontal and lateral views. Based on these angiosomes, it was thought that in order to perfuse a full facial flap including portions of the lateral cheek, ears, scalp and forehead, multiple arteries had to be anastomosed on each side. We demonstrated that single anastomosis of facial artery (2) on each side is sufficient to perform a full facial flap containing full cheeks, forehead, and partial scalp. * will be reprinted with permission.

Figure 3

This patient suffered high voltage burn injuries to the face 11 years prior. Extensive conventional reconstruction yielded the results observed in (A). Note that the patient is wearing a prosthetic nose. Oral competence could not be restored. The facial muscles of the forehead, cheeks, and eyelids were functional and therefore preserved. The allograft face was placed over the functioning facial bed, and only nerves that provide function to the lips were reconnected, yielding the results observed in (B), where 4 months after the transplant operation the patient is capable of facial expression, limited by receding swelling.

Figure 3

This patient suffered high voltage burn injuries to the face 11 years prior. Extensive conventional reconstruction yielded the results observed in (A). Note that the patient is wearing a prosthetic nose. Oral competence could not be restored. The facial muscles of the forehead, cheeks, and eyelids were functional and therefore preserved. The allograft face was placed over the functioning facial bed, and only nerves that provide function to the lips were reconnected, yielding the results observed in (B), where 4 months after the transplant operation the patient is capable of facial expression, limited by receding swelling.