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Trismus in Face Transplantation Following Ballistic Trauma

Krezdorn, Nicco MD*,†; Alhefzi, Muayyad MD*,‡; Perry, Bridget§; Aycart, Mario A. MD*; Tasigiorgos, Sotirios MD*; Bueno, Ericka M. PhD*; Green, Jordan R. PhD§; Pribaz, Julian J. MD||; Pomahac, Bohdan MD*; Caterson, Edward J. MD, PhD*

Journal of Craniofacial Surgery: June 2018 - Volume 29 - Issue 4 - p 843–847
doi: 10.1097/SCS.0000000000004271
Original Articles

Background: Trismus can be a challenging consequence of ballistic trauma to the face, and has rarely been described in the setting of face transplantation. Almost half of all current face transplant recipients in the world received transplantation to restore form and function after a ballistic injury. Here we report our experience and challenges with long standing trismus after face transplantation.

Methods: We reviewed the medical records of our face transplant recipients whose indication was ballistic injury. We focused our review on trismus and assessed the pre-, peri- and postoperative planning, surgery and functional outcomes.

Results: Two patients received partial face transplantation, including the midface for ballistic trauma. Both patients suffered from impaired mouth opening, speech intelligibility, and oral competence. Severe scarring of the temporomandibular joint (TMJ) required intraoperative release in both patients, and additional total condylectomy on the left side 6 months posttransplant for 1 patient. Posttransplant, both patients achieved an improvement in mouth opening; however, there was persistent trismus. One year after transplantation, range of motion of the jaw had improved for both patients. Independent oral food intake was possible 1 year after surgery, although spillage of liquids and mixed consistency solids persisted. Speech intelligibility testing showed impairments in the immediate postoperative period, with improvement to over 85% for both patients at 1 year posttransplant.

Conclusions: Ballistic trauma to the face and subsequent reconstructive measures can cause significant scarring and covert injuries to structures such as the TMJ, resulting in long standing trismus. Meticulous individual planning prior to interventions such as face transplantation must take these into account. We encourage intraoperative evaluation of these structures as well as peri- and postoperative treatment when necessary. Due to the nature of the primary injury, functional outcomes after face transplantation in these patients may differ substantially from those of other indications.

*Department of Surgery, Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA

Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, Hannover, Germany

Division of Plastic Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada

§Speech and Feeding Disorders Lab, MGH Institute of Health Professions, Charlestown, MA

||Department of Plastic Surgery, University of South Florida, Tampa, FL.

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

Received 7 July, 2017

Accepted 6 October, 2017

Drs Pomahac, Krezdorn and Bueno receive partial salary support from a research contract with the United States Department of Defense (#W911QY-09-C-0216). Opinions, interpretations, conclusions and recommendations are those of the author and are not necessarily endorsed by the United States Department of Defense.

The authors report no funding and conflicts of interest.

© 2018 by Mutaz B. Habal, MD.