Enhancing Face Transplant Outcomes: Fundamental Principles of Facial Allograft Revision

Abstract

Facial transplantation (FT) has become a feasible reconstructive solution for patients with devastating facial injuries. Secondary revisions to optimize functional and aesthetic outcomes are to be expected, yet the optimal timing and approach remain to be determined. The purpose of this study was to analyze all facial allograft revisions reported to date, including the senior author's experience with 3 FTs.

Methods: A literature review was performed, with 2 reviewers independently conducting title and abstract screening, followed by a full-text review. All articles mentioning FT revision surgeries were evaluated. The medical records of the senior author's 3 FT recipients were additionally reviewed.

Results: Initially, 721 articles were captured and 37 were included in the final analysis. Thirty-two FTs were reported to have involved posttransplant allograft revisions, with FT recipients undergoing a mean of 4.8 ± 4.6 revision procedures. The mean duration between FT and the first revision procedure was 149 ± 179 days. A wide spectrum of revisions was identified and categorized as involving the soft tissues, craniofacial skeleton, dentition, oronasal cavity, salivary glands, facial nerve, or ocular region. In the senior author's experience, when indicated, posttransplant occlusal changes and integrity of the donor-recipient intraoral interface were successfully addressed with secondary procedures without allograft compromise or loss.

Conclusions: The worldwide experience shows that secondary procedures are nearly ubiquitous after FT and can be safely performed at various timepoints. The authors thereby establish 5 distinct categories of facial allograft revisions and define 7 critical principles to optimize posttransplant procedures.

Fig. 1.

Article selection process.

Fig. 2.

Immediate posttransplant result. Excess soft tissue envelope was deliberately included with the facial allograft to account for a postoperative edema and to allow for a tension-free closure. Printed with permission from and copyrights retained by Eduardo D. Rodriguez, MD, DDS.

Fig. 3.

Soft tissue revisions–allograft resuspension. After facial transplantation, patient 2 experienced upper facial and brow ptosis (A), which required 2 separate brow lifts, on POD 241 and 1291. B, Photograph of the patient 1 week after his second brow lift. Printed with permission from and copyrights retained by Eduardo D. Rodriguez, MD, DDS.

Fig. 4.

Patient 3 underwent orthodontic treatment with elastics, starting on posttransplant day 11 for class II malocclusion with an open bite that developed posttransplantation. A, The photograph was taken after 1 month into the treatment. B, Normal allograft occlusion was restored after 10 months of orthodontic treatment. C, The patient at 2 years after transplantation, with mild anterior open bite. Printed with permission from and copyrights retained by Eduardo D. Rodriguez, MD, DDS.

Fig. 5.

Posttransplant photographs. Patient 1 developed class III malocclusion after facial transplantation. A, The recipient is shown before correction with Le Fort III advancement. Intraoperatively, the midface was disimpacted and advanced to restore class I occlusion. Normal occlusion was restored, as seen 11 months (B) and 5 years after craniofacial revision (C). Printed with permission from and copyrights retained by Eduardo D. Rodriguez, MD, DDS.

Fig. 6.

Oronasal cavity revisions. At his latest follow-up appointment (2 years posttransplant), patient 3 continues to demonstrate satisfactory repair, with an intact palate (A) and floor of the mouth (B). Printed with permission from and copyrights retained by Eduardo D. Rodriguez, MD, DDS.

Fig. 7.

Ocular revisions. After facial transplantation, patient 3 required ocular revisions for bilateral medial telecanthus and lower eyelid retraction (A). On POD 108, he underwent bilateral medial canthoplasties with lower eyelid tissue rearrangement. Due to persistent left telecanthus and eyelid malposition, he returned to the operating room on POD 248 for medial canthoplasty and tissue rearrangement. B, The photograph shows results 1 month after the last ocular revision, showing correction of telecanthus and eyelid positions. Printed with permission from and copyrights retained by Eduardo D. Rodriguez, MD, DDS.

Fig. 8.

Face transplants performed by the senior author. Photographs of patient 1 (A and D), patient 2 (B and E), and patient 3 (C and F) before facial transplantation (A–C) and after facial transplantation and all revisional procedures (D–F). The senior author’s experience with these 3 face transplant recipients demonstrates the safety and satisfactory long-term outcomes of facial allograft secondary revisions. Printed with permission from and copyrights retained by Eduardo D. Rodriguez, MD, DDS.