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Watershed Areas in Face Transplantation

Bassiri Gharb, Bahar M.D., Ph.D.; Frautschi, Russell S. B.S.; Halasa, Brianna C.; Doumit, Gaby D. M.D., M.Sc.; Djohan, Risal S. M.D.; Bernard, Steven L. M.D.; Gastman, Brian R. M.D.; Siemionow, Maria Z. M.D., Ph.D., D.Sc.; Papay, Francis A. M.D.; Rampazzo, Antonio M.D., Ph.D.

Plastic and Reconstructive Surgery: March 2017 - Volume 139 - Issue 3 - p 711–721
doi: 10.1097/PRS.0000000000003130
Reconstructive: Head and Neck: Original Articles

Background: The maxillary artery has traditionally been considered the main blood supply of the facial skeleton. However, the deep and concealed location makes the harvest of facial allografts based on this artery challenging, giving preference to the facial artery. There is growing evidence that the junction between the hard and soft palate may represent a watershed area in facial artery–based allografts. The aim of this study was to review the occurrence of partial allograft necrosis and modify the available craniofacial techniques, allowing for a reliable harvest of maxillary artery–based facial allografts.

Methods: PubMed/MEDLINE databases were searched for articles presenting allograft perfusion details and the occurrence of partial flap necrosis. Next, 25 fresh cadaver heads were used: eight allografts were harvested by means of a traditional Le Fort III approach, in six the maxillary artery was injected with latex, in three cadaver heads lead oxide gel was injected in the maxillary artery, and eight full facial allografts were harvested through a modified approach.

Results: Seven patients developed palatal fistulas or palatal necrosis (41 percent) when allograft was perfused through the facial artery. The traditional Le Fort III approach demonstrated consistent injury to maxillary artery/branches. The modified approach allowed for preservation of the maxillary artery under direct vision.

Conclusions: Current facial transplantation outcomes indicate that facial artery–based allografts containing Le Fort III bony components can experience compromised palate perfusion. The described modified Le Fort III approach allowed safe dissection of the maxillary artery, preserving the arterial blood supply to the facial skeleton.


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Cleveland, Ohio; and Chicago, Ill.

From the Department of Plastic Surgery, Cleveland Clinic; and the Department of Orthopaedics, University of Illinois.

Received for publication March 15, 2016; accepted July 11, 2016.

Presented at the 12th Annual Meeting of the International Hand and Composite Tissue Allotransplantation Society, in Philadelphia, Pennsylvania, April 16 through 18, 2015; the American Society for Reconstructive Microsurgery Annual Meeting, in Paradise Island, Bahamas, January 24 through 27, 2015; and recipient of the Kawamoto Award for the best paper at the 71st Annual Meeting of the American Cleft Palate-Craniofacial Association, in Indianapolis, Indiana, March 28 through 29, 2014.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

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Antonio Rampazzo, M.D., Ph.D., Department of Plastic Surgery, Cleveland Clinic, 9500 Euclid Avenue, Desk A6-522, Cleveland, Ohio 44195,

©2017American Society of Plastic Surgeons