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Craniofacial Principles in Face Transplantation

Caterson, Edward J. MD, PhD*; Diaz-Siso, J. Rodrigo MD*; Shetye, Pradip DDS; Junker, Johan P. E. PhD*; Bueno, Ericka M. PhD*; Soga, Shigeyoshi MD; Rybicki, Frank J. MD, PhD; Pomahac, Bohdan MD*

doi: 10.1097/SCS.0b013e318252d406
Original Articles

Background Face transplantation allows the reconstruction of the previously nonreconstructible injury. Anthropometric landmarks are fixated to corresponding cephalometric landmarks to restore function and appearance, with emphasis on phonation, mastication, and functional upper airway. Currently, only a few face transplantations have been performed worldwide. A portion of these reconstructions involves combinations of hard and soft tissues of the midface.

Methods Craniofacial and orthognathic considerations should be emphasized for functional effect in the planning and execution of face transplants that include both bone and soft tissue elements. These steps are taken to restore normal anatomy by fixating the midface into proper relationship with the skull base. Traditional orthognathic planning, using cephalometric parameters, often involves a line through sella and nasion as a reference for the skull base. Intraoperatively though, without a cephalograph, the sella-nasion plane is not accessible as a reference point.

Results Postoperative analysis of our first face transplant recipient revealed that the Frankfort horizontal plane can alternatively serve as an accessible skull base reference point to guide the positioning of the midface. We have developed a technique to ensure fixation of the midface donor allograft in a proper functional relationship with the skull base, within 1 SD of Bolton normative data.

Conclusions “Reverse craniofacial planning” allows for precise fixation of the hard tissue components of the face transplant in relation to the skull base, as opposed to a “best fit” approach. We believe that this relationship results in the most anatomical restoration of occlusion, speech, and airway function.

From the *Division of Plastic Surgery, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts; †Institute of Reconstructive Plastic Surgery, New York University Medical Center, New York, New York; and ‡Department of Radiology, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts.

Received February 17, 2012.

Accepted for publication February 26, 2012.

Address correspondence and reprint requests to Dr. Edward J. Caterson, Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115; E-mail:

Drs. Caterson and Diaz-Siso contributed equally to this work.

The authors report no conflicts of interest.

© 2012 Mutaz B. Habal, MD