Computerized Approach to Facial Transplantation: Evolution and Application in 3 Consecutive Face Transplants

Abstract

Face transplant (FT) candidates present with unique anatomic and functional defects unsuitable for autologous reconstruction, making the accurate design and transplantation of patient-specific allografts particularly challenging. In this case series, we present our computerized surgical planning (CSP) protocol for FT.

Methods: CSP, computer-aided design and manufacturing, intraoperative navigation, and intraoperative computerized tomography have been successfully incorporated into a comprehensive protocol. Three consecutive FTs were performed. CSP and postoperative results were compared using computerized tomography-derived cephalometric measurements, and the literature was reviewed.

Results: Two full and 1 partial FT were successfully performed using the CSP protocol. CSP facilitated the execution of FT with minor angular and translational cephalometric variations on immediate postoperative imaging. Our evolving experience was accompanied by a decreased reliance on cadaveric simulation, from 10 mock transplants and a research procurement before the senior author's first clinical FT (2012) to 6 mock transplants and no research procurement before the third FT (2018). Operative time was significantly reduced from 36 to 25 hours, as was the need for major orthognathic surgical revision. This reflects the learning curve and variable case complexity, but it is also representative of improved planning and execution, complemented by the systematic incorporation of CSP into FT.

Conclusions: A CSP protocol allows for refinement of operative flow, technique, and outcomes in partial and full FT. Standards for functional and esthetic outcomes are bound to evolve with the field's growth, and computerized planning and execution offer a reproducible approach to FT through objective quality assurance.

Fig. 1.

CSP protocol for face transplantation. Certain elements of the protocol may be modified based on the specific clinical scenario. Printed with permission and copyrights retained by E.D.R.

Fig. 2.

Computed tomographic imaging of patient 1 before (A, frontal view, B, lateral view) vs. after face transplantation (C, lateral view). Printed with permission and copyrights retained by E.D.R.

Fig. 3.

CSP for patient 1. A, Lateral view, CSP before transplantation. B, Initial postoperative CT scan results. F-OP angle indicates Frankfort–occlusal plane angle; SNA, sella-nasion-A; SNB, sella-nasion-B. Printed with permission and copyrights retained by E.D.R.

Fig. 4.

Patient 1 before (A) and 4 years and 2 months (B) following total face, double jaw, and tongue transplantation. Printed with permission and copyrights retained by E.D.R.

Fig. 5.

Computerized surgical planning for patient 2. A, Donor planned osteotomies and customized cutting guides. B, Recipient planned osteotomies and customized cutting guides. C, Postoperative 3D computed tomographic imaging for patient 2 on postoperative day 32, showing the nasal, mandibular, and bilateral zygomatic skeletal subunits included in the allograft. Printed with permission and copyrights retained by E.D.R.

Fig. 6.

Patient 2 before (A) and 2 years (B) following total face, eyelids, ears, scalp, and skeletal subunit transplantation. Printed with permission and copyrights retained by E.D.R.

Fig. 7.

Computerized surgical plan for patient 3. A, Donor planned osteotomies and customized cutting guides. B, Recipient planned osteotomies and customized cutting guides. C, Postoperative CT imaging result. Printed with permission and copyrights retained by E.D.R.

Fig. 8.

Patient 3. Representative heat map analysis of planned vs. actual positions of allograft skeletal segments in the recipient. Spectrum ranges from green (smallest difference) to red (largest difference). Printed with permission and copyrights retained by E.D.R.

Fig. 9.

Patient 3 before (A) and 9 months (B) following partial face and double jaw transplantation. Printed with permission and copyrights retained by E.D.R.