Donor right external carotid artery–to–recipient right external carotid artery anastomosis was performed in an end-to-end fashion. The recipient right facial and lingual artery take-offs from the external carotid artery were preserved. Donor right anterior jugular vein anastomosis to a branch of the recipient right internal jugular vein was performed in end-to-end fashion.
Donor left external carotid artery–to–recipient left external carotid artery anastomosis was performed in end-to-end fashion above the level of the carotid bifurcation. Donor left anterior jugular vein–to–recipient left internal jugular vein anastomosis was performed in end-to-side fashion. Ischemia time was 4 hours 35 minutes. Indocyanine green angiography at the end of the procedure showed adequate allograft vascular perfusion and venous outflow (Fig. 13). [See Figure, Supplemental Digital Content 5, which shows indocyanine green fluorescence angiography delayed image following face transplantation demonstrating adequate allograft venous drainage, http://links.lww.com/PRS/D611. (Provided with permission and copyrights retained by Eduardo D. Rodriguez, M.D., D.D.S.)]
Bilateral facial nerve–sparing superficial parotidectomy dissections proceeding from the preauricular area anteriorly were performed in the recipient. This allowed exposure of the facial nerve and identification using nerve stimulation (Checkpoint Surgical, Cleveland, Ohio). Infraorbital and inferior alveolar sensory nerves were preserved.
Bilateral zygomatic, buccal, and marginal mandibular branch neurorrhaphies were performed in a primary, tension-free, end-to-end fashion, with the addition of fibrin glue sealant. Similarly, infraorbital and inferior alveolar nerve neurorrhaphies were performed bilaterally.
The intraoral palatal, buccal, and floor-of-mouth mucosal tissues were approximated to reestablish oral competence. Special attention was given to repair the mylohyoid and superior strap muscles. The recipient’s new dentition was subsequently placed in a prefabricated, three-dimensionally–printed dental splint, and occlusion was secured using previously placed maxillary and mandibular skeletal anchorage screws (MatrixWAVE MMF System; DePuy Synthes CMF).
Infraorbital dissection through bilateral subciliary incisions allowed accurate realignment of donor and recipient orbicularis muscles. Titanium barbed sutures secured to fixation screws within the internal orbit reestablished normal intercanthal distance. Bilateral lateral portions of the periorbital tissues were then appropriately repositioned along the upper brow. Final soft-tissue redraping and inset were performed with care to align donor and recipient soft tissues (Fig. 14).
Dual induction immunosuppression therapy with antithymocyte globulin and rituximab, triple oral maintenance immunosuppression therapy, and postoperative prophylaxis against opportunistic infections were used as described previously.4 The total procedure time was approximately 25 hours, and the recipient received 17 units of packed red blood cells, 6 units of fresh frozen plasma, and 2 units of platelets.
The patient underwent hyoid and genioglossus advancement for floor-of-mouth dehiscence and palatal wound dehiscence repair on postoperative day 11 (Fig. 15), and open reduction and internal fixation of left mandibular nonunion on postoperative day 108 (Fig. 16). The patient’s most recent clinical images and hospital course are highlighted in Figure 17. The palate and floor of mouth demonstrated adequate healing on postoperative day 284. [See Figure, Supplemental Digital Content 6, which shows palate (above) and floor-of-mouth (below) images on postoperative day 284, showing adequate wound healing, http://links.lww.com/PRS/D612. (Provided with permission from and copyrights retained by Eduardo D. Rodriguez, M.D., D.D.S.)] At the most recent follow-up, the patient demonstrated satisfactory speech intelligibility, and his entire nutritional intake was by mouth. He exhibited difficulty with forming bilabial words and plosives because of incomplete lip puckering. Bilateral facial muscle mild to moderate weakness was noted with smiling and snarling, more on the left side, and eyelid closure was intact bilaterally. Sensation to light touch was intact bilaterally. The tracheostomy was removed on postoperative day 151, and he had no difficulty breathing. He was able to perform activities of daily living independently.
More than a decade since the first face transplantation in 2005, skepticism surrounding technical feasibility has subsided, and the procedure is now adopted as the highest rung on the reconstructive ladder for patients with facial defects not amenable to conventional approaches.22 Efforts in the field have shifted toward refining outcomes, harnessing innovative technologies, and standardizing perioperative processes.5,23,24 This evolving landscape provides teams the opportunity to overcome classic reconstructive challenges imposed by extensive facial injuries, and offers affected patients hope for normal form and function. By relying on lessons learned from the field, our previous experience, emerging innovations, and close collaborations with key stakeholders, we sought to validate facial transplantation as a reconstructive solution for irreparable facial injuries, and describe a modernized approach to the procedure.1,3,4,8–18
Shortage of organ donors remains a significant barrier to solid organ and vascularized composite allotransplantation, with the current transplants performed annually caring for only 10 percent of the demand.25,26 Although major efforts in tissue engineering, xenotransplantation, and expansion of donation after circulatory death offer potential long-term solutions, simpler interventions can alleviate the ongoing deficit.26–28 Collaborations between transplant teams and organ procurement organizations are of the utmost importance and have allowed us to develop a novel donor transfer algorithm for multiorgan and facial allograft procurements.21 Building on our partnership with LiveOnNY, we expanded the donor network’s facial donation service area for our patient to include sister organ procurement organizations, and continue to collaborate closely regarding donor pool expansion opportunities. Moreover, we have shown that simple educational interventions can increase the willingness of the general public to donate facial tissue by almost 20 percent, highlighting the importance of educational initiatives.29
Donor facial restoration following allograft procurement is performed by most teams. Creation of a mask that closely emulates donor facial features preserves the dignity of the donor, and allows families to conduct traditional mourning rituals.34,35 We have previously relied on silicone masks for this purpose, with satisfactory outcomes.3,4 Although traditional silicone masks offer an affordable option for restoration, they rely on invasive donor facial impressions and expertise in anaplastology. More recently, three-dimensional printing was proposed as a simpler alternative to the silicone-based technique.36 To ensure optimal donor facial restoration, we proceeded with testing the three-dimensional printing technique while simultaneously creating a silicone-based mask. The three-dimensionally printed mask was produced from three-dimensional facial images obtained preoperatively and delivered to the operating room before completion of allograft recovery. The three-dimensionally–printed mask achieves striking donor likeness, and offers a less invasive method that minimizes the potential for iatrogenic injury to the allograft. Furthermore, production of the three-dimensionally–printed mask can begin immediately following donor identification and three-dimensional facial imaging, without interfering with other preoperative preparations. These features provide unique opportunities to further streamline facial transplantation, make the donation journey easier for families, and possibly increase willingness for facial donation.
Close postoperative follow-up of face transplant recipients is essential for prompt detection and treatment of complications and rejection. Although there are 11 currently active face transplant centers in the United States, only five have accumulated clinical experience.37 Patients with extensive facial disfigurement will therefore inevitably seek consultations and undergo facial transplantation at geographically distant centers, resulting in significant challenges with postoperative follow-up. Our patient traveled across the United States from the West Coast to the East Coast to undergo facial transplantation, the longest travel distance reported to date. Furthermore, former last-minute procedure cancellation because of donor aspergillus infection, and inclement weather conditions at the time of identification of the donor described here requiring early donor and recipient transfer to our institution, highlight the unpredictable aspects of this endeavor.38,39 Although the experience of our patient offers hope for individuals with extensive facial disfigurement across the nation, the need for adequate preoperative assessment and postoperative follow-up must transcend geographic challenges.37 Similar to the two previous transplants performed by the senior author (E.D.R), multidisciplinary team members traveled frequently to evaluate the patient’s home environment, confirm suitability, and ensure that essential support systems are available.3,4 Collaborations with local providers were also established, and goals of care were thoroughly reviewed.
Recent facial retransplantation introduced a new paradigm in the field and established the feasibility of this option in case of allograft failure.40 Furthermore, the safety of the procedure across a broad age spectrum ranging from 21 to 65 years was recently highlighted in the youngest and oldest face transplant recipients to date.41,42 The face transplant described here marks the forty-fourth procedure reported to date in 43 patients, and supplements the evolving nature of patient selection and care in the field.7,40,42,43 Selecting patients with self-inflicted ballistic injuries is considered by many as controversial. Of the four patients who underwent facial transplantation for self-inflicted gunshot wounds, one patient committed suicide, whereas the remaining three demonstrate good aesthetic and functional outcomes.9,44 It is therefore reasonable to suggest that candidates who are deemed suitable following rigorous preoperative mental health evaluation should be considered for facial transplantation.44 This assessment should be performed within the context of an exhaustive multidisciplinary team, to determine candidate suitability and willingness to comply with treatment.
Although facial transplantation immediately following injury has previously been performed with encouraging outcomes, the optimal time to perform the procedure after injury remains unknown.45 The patient described here underwent facial transplantation 18 months after injury, the shortest interval in the United States. Early transplantation may theoretically achieve earlier social integration and return of facial functions. However, the current prolonged recipient wait times and preference to initially exhaust autologous options make this unlikely to become widespread. It is therefore imperative that teams make all efforts to improve candidates’ daily function and quality of life and perform all necessary preparations while waiting for matching donors. Our patient underwent craniofacial skeletal stabilization and basic soft-tissue coverage immediately following injury. On initial consultation with our team, he was burdened by exposed hardware and modest visual deficits, with acuities of 20/20 in the left eye and 20/50 in the right eye. When autologous reconstruction was deemed inappropriate for optimal outcomes, we proceeded with hardware removal, bilateral nasoorbitoethmoid osteotomies, medial canthal tendon repositioning, and bilateral orbital floor reconstruction with alloplastic titanium implants to improve daily function and restore bilateral 20/20 vision. Tracheostomy and percutaneous gastrostomy were also performed to secure the airway and optimize the patient’s nutritional status before transplantation.
Induction immunosuppression regimens used by face transplant teams are diverse, with antithymocyte globulin being the most commonly used agent for T-lymphocyte depletion.46 We used a combination of antithymocyte globulin and rituximab, a chimeric monoclonal antibody directed against the CD20 protein, leading to mature B-lymphocyte depletion. Although experience with this approach is limited in facial transplantation, there is growing evidence that it may decrease acute rejection in kidney recipients.47–49 Further evidence is necessary to determine the ideal induction regimen; however, use of the described dual approach in the previous face recipient treated at our institution has contributed to a rejection-free postoperative course.4 The patient remains rejection-free up to this date, approximately 3.5 years after facial transplantation.50 Similarly, the patient described here remains rejection-free almost 1 year after transplantation.
Initially developed for intracranial and spinal interventions, computer-assisted surgical navigation in craniomaxillofacial surgery has recently earned wide recognition.51–75 Benefits of the technology include three-dimensional computerized surgical planning and execution, with real-time intraoperative guidance to improve accuracy. Evidence suggests that available surgical navigation systems are comparable, their technical accuracy is within 1 mm, and they lead to an intraoperative precision between 1 and 2 mm.76–80 We have previously described the utility of intraoperative surgical navigation in facial transplantation.3 The use of surgical navigation here allowed accurate fixation of allograft skeletal segments in the recipient. By obtaining a craniofacial computed tomographic scan following recipient defect creation using a mobile intraoperative computed tomography system (Airo), we were able to register and overlay the surgical plan onto the patient skeletal defect for real-time intraoperative image-guided allograft inset.
The estimated costs associated with facial transplantation remain significant, especially when considering the need for lifelong follow-up and immunosuppression. Studies suggest that long-term costs of facial transplantation and autologous reconstruction are comparable.81,82 However, the majority of face transplants have been supported through institutional or research grants rather than third-party coverage, despite the efficacy of the procedure in patients with extensive facial disfigurement who are not amenable to autologous reconstruction. The procedure and perioperative care described here were partially supported by an employer-mediated third-party private insurer. Although third-party coverage remains far from routine in this patient population, we hope that securing coverage for our patient here can generate the necessary momentum to formalize reimbursement mechanisms, and bring facial transplantation one step closer to becoming the standard of care for patients with extensive facial disfigurement, when conventional approaches fail.
In this article, we describe the successful completion of a partial face and double-jaw transplant in a patient with extensive avulsive facial disfigurement following high-energy ballistic trauma. We validate the efficacy of facial transplantation in addressing complex craniomaxillofacial defects, and achieving optimal patient aesthetic and functional outcomes through a modernized approach to the procedure.
The patient provided written consent of the use of his images.
Funding was through a Reconstructive Transplantation Research Award (W81XWH-15-2-0036) and institutional support. The authors would like to acknowledge the donor patient and family for selflessly donating the gift of life, and the recipient patient and family. They would also like to recognize the diligent efforts of LiveOnNY, New York University Langone Health and School of Medicine, LaGuardia Studio–New York University, Materialise, DePuy Synthes CMF, Brainlab, LifeCell, and Checkpoint Surgical. In addition, they would like to acknowledge the outstanding efforts of Margy Maroutsis, Scott J. Farber, M.D., Pradip R. Shetye, D.D.S., Larry E. Brecht, D.D.S., J. Rodrigo Diaz-Siso, M.D., and William J. Rifkin, B.A.
1. Khalifian S, Brazio PS, Mohan R, et al. Facial transplantation: The first 9 years. Lancet 2014;384:2153–2163.
2. Pribaz JJ, Caterson EJ. Evolution and limitations of conventional autologous reconstruction of the head and neck. J Craniofac Surg. 2013;24:99–107.
3. Dorafshar AH, Bojovic B, Christy MR, et al. Total face, double jaw, and tongue transplantation: An evolutionary concept. Plast Reconstr Surg. 2013;131:241–251.
4. Sosin M, Ceradini DJ, Levine JP, et al. Total face, eyelids, ears, scalp, and skeletal subunit transplant: A reconstructive solution for the full face and total scalp burn. Plast Reconstr Surg. 2016;138:205–219.
5. Fischer S, Kueckelhaus M, Pauzenberger R, Bueno EM, Pomahac B. Functional outcomes of face transplantation. Am J Transplant. 2015;15:220–233.
6. Gordon CR, Siemionow M, Papay F, et al. The world’s experience with facial transplantation: What have we learned thus far? Ann Plast Surg. 2009;63:572–578.
7. Rifkin WJ, David JA, Plana NM, et al. Achievements and challenges in facial transplantation. Ann Surg. 2018;268:260–270.
8. Sosin M, Rodriguez ED. The face transplantation update: 2016. Plast Reconstr Surg. 2016;137:1841–1850.
9. Lantieri L, Grimbert P, Ortonne N, et al. Face transplant: Long-term follow-up and results of a prospective open study. Lancet 2016;388:1398–1407.
10. Morelon E, Petruzzo P, Kanitakis J, et al. Face transplantation: Partial graft loss of the first case 10 years later. Am J Transplant. 2017;17:1935–1940.
11. Dubernard JM, Devauchelle B. Face transplantation. Lancet 2008;372:603–604.
12. Kanitakis J, Petruzzo P, Badet L, et al. Chronic rejection in human vascularized composite allotransplantation (hand and face recipients): An update. Transplantation 2016;100:2053–2061.
13. Diaz-Siso JR, Parker M, Bueno EM, et al. Facial allotransplantation: A 3-year follow-up report. J Plast Reconstr Aesthet Surg. 2013;66:1458–1463.
14. Pomahac B, Pribaz J, Eriksson E, et al. Three patients with full facial transplantation. N Engl J Med. 2012;366:715–722.
15. Sosin M, Ceradini DJ, Hazen A, et al. Total face, eyelids, ears, scalp, and skeletal subunit transplant research procurement: A translational simulation model. Plast Reconstr Surg. 2016;137:845e–854e.
16. Sosin M, Ceradini DJ, Hazen A, et al. Total face, eyelids, ears, scalp, and skeletal subunit transplant cadaver simulation: The culmination of aesthetic, craniofacial, and microsurgery principles. Plast Reconstr Surg. 2016;137:1569–1581.
17. Brown EN, Dorafshar AH, Bojovic B, et al. Total face, double jaw, and tongue transplant simulation: A cadaveric study using computer-assisted techniques. Plast Reconstr Surg. 2012;130:815–823.
18. Bojovic B, Dorafshar AH, Brown EN, et al. Total face, double jaw, and tongue transplant research procurement: An educational model. Plast Reconstr Surg. 2012;130:824–834.
19. Fisher M, Dorafshar A, Bojovic B, Manson PN, Rodriguez ED. The evolution of critical concepts in aesthetic craniofacial microsurgical reconstruction. Plast Reconstr Surg. 2012;130:389–398.
20. Mohan R, Borsuk DE, Dorafshar AH, et al. Aesthetic and functional facial transplantation: A classification system and treatment algorithm. Plast Reconstr Surg. 2014;133:386–397.
21. Diaz-Siso JR, Plana NM, Schleich B, Irving H, Gelb BE, Rodriguez ED. Novel donor transfer algorithm for multiorgan and facial allograft procurement. Am J Transplant. 2017;17:2496–2497.
22. Devauchelle B, Badet L, Lengelé B, et al. First human face allograft: Early report. Lancet 2006;368:203–209.
23. Suchyta M, Mardini S. Innovations and future directions in head and neck microsurgical reconstruction. Clin Plast Surg. 2017;44:325–344.
24. Kantar RS, Rifkin WJ, Diaz-Siso JR, Bernstein GL, Rodriguez ED. Quality improvement in facial transplantation: Standard approach for novel procedures. Plast Reconstr Surg Global Open 2018;6:e1653.
25. Diaz-Siso JR, Rodriguez ED. Facial transplantation: Knowledge arrives, questions remain. Lancet 2016;388:1355–1356.
26. Manyalich M, Nelson H, Delmonico FL. The need and opportunity for donation after circulatory death worldwide. Curr Opin Organ Transplant. 2018;23:136–141.
27. Gao G, Huang Y, Schilling AF, Hubbell K, Cui X. Organ bioprinting: Are we there yet? Adv Healthc Mater. 2018;7: doi: 10.1002/adhm.201701018.
28. Meier RPH, Muller YD, Balaphas A, et al. Xenotransplantation: Back to the future? Transpl Int. 2018;31:465–477.
29. Plana NM, Kimberly LL, Parent B, et al. The public face of transplantation: The potential of education to expand the face donor pool. Plast Reconstr Surg. 2018;141:176–185.
30. Bassiri Gharb B, Frautschi RS, Halasa BC, et al. Watershed areas in face transplantation. Plast Reconstr Surg. 2017;139:711–721.
31. Cotofana S, Steinke H, Schlattau A, et al. The anatomy of the facial vein: Implications for plastic, reconstructive, and aesthetic procedures. Plast Reconstr Surg. 2017;139:1346–1353.
32. Bondaz M, Ricard AS, Majoufre-Lefebvre C, Caix P, Laurentjoye M. Facial vein variation: Implication for facial transplantation. Plast Reconstr Surg Glob Open 2014;2:e183.
33. Gupta V, Tuli A, Choudhry R, Agarwal S, Mangal A. Facial vein draining into external jugular vein in humans: Its variations, phylogenetic retention and clinical relevance. Surg Radiol Anat. 2003;25:36–41.
34. Petit F, Paraskevas A, Lantieri L. A surgeons’ perspective on the ethics of face transplantation. Am J Bioeth. 2004;4:14–16; discussion W23–W31.
35. Grant GT, Liacouras P, Santiago GF, et al. Restoration of the donor face after facial allotransplantation: Digital manufacturing techniques. Ann Plast Surg. 2014;72:720–724.
36. Mäkitie AA, Salmi M, Lindford A, Tuomi J, Lassus P. Three-dimensional printing for restoration of the donor face: A new digital technique tested and used in the first facial allotransplantation patient in Finland. J Plast Reconstr Aesthet Surg. 2016;69:1648–1652.
37. Rifkin WJ, Manjunath A, Kimberly LL, et al. Long-distance care of face transplant recipients in the United States. J Plast Reconstr Aesthet Surg. 2018;71:1383–1391.
38. Kantar RS, Gelb BE, Hazen A, Rodriguez ED. Facial transplantation: Highlighting the importance of clinical vigilance in donor selection. Plast Reconstr Surg. 2018;142:611e–612e.
39. Blinder A, Mazzei P, Bidgood J. ‘Bomb cyclone’: Snow and bitter cold blast the Northeast. The New York Times. January 4, 2018.
40. Garrel-Jaffrelot T. Frenchman is first in world to get 2 full face transplants. The New York Times. April 19, 2018.
41. Connors J. How a transplanted face transformed Katie Stubblefield’s life. Natl Geogr Mag. August 14, 2018.
42. Rosenberg E. His face was severely damaged on a hunt: Now he’s the world’s oldest face transplant recipient. The Washington Post. September 14, 2018.
43. Lindford AJ, Mäkisalo H, Jalanko H, et al. The Helsinki approach to face transplantation. J Plast Reconstr Aesthet Surg. 2019;72:173–180.
44. Kiwanuka H, Aycart MA, Gitlin DF, et al. The role of face transplantation in the self-inflicted gunshot wound. J Plast Reconstr Aesthet Surg. 2016;69:1636–1647.
45. Maciejewski A, Krakowczyk Ł, Szymczyk C, et al. The first immediate face transplant in the world. Ann Surg. 2016;263:e36–e39.
46. Kueckelhaus M, Fischer S, Seyda M, et al. Vascularized composite allotransplantation: Current standards and novel approaches to prevent acute rejection and chronic allograft deterioration. Transpl Int. 2016;29:655–662.
47. van den Hoogen MW, Kamburova EG, Baas MC, et al. Rituximab as induction therapy after renal transplantation: A randomized, double-blind, placebo-controlled study of efficacy and safety. Am J Transplant. 2015;15:407–416.
48. Tydén G, Genberg H, Tollemar J, et al. A randomized, doubleblind, placebo-controlled, study of single-dose rituximab as induction in renal transplantation. Transplantation 2009;87:1325–1329.
49. Yin H, Wan H, Hu XP, et al. Rituximab induction therapy in highly sensitized kidney transplant recipients. Chin Med J (Engl.) 2011;124:1928–1932.
50. Gelb BE, Diaz-Siso JR, Plana NM, et al. Absence of rejection in a facial allograft recipient with a positive flow crossmatch 24 months after induction with rabbit anti-thymocyte globulin and anti-CD20 monoclonal antibody. Case Rep Transplant. 2018;2018:7691072.
51. Zhang JS, Qu L, Wang Q, et al. Intraoperative visualisation of functional structures facilitates safe frameless stereotactic biopsy in the motor eloquent regions of the brain. Br J Neurosurg. 2018;32:472–390.
52. Mohyeldin A, Elder JB. Stereotactic biopsy platforms with intraoperative imaging guidance. Neurosurg Clin N Am. 2017;28:465–475.
53. Siasios ID, Pollina J, Khan A, Dimopoulos VG. Percutaneous screw placement in the lumbar spine with a modified guidance technique based on 3D CT navigation system. J Spine Surg. 2017;3:657–665.
54. Du JP, Fan Y, Wu QN, Wang DH, Zhang J, Hao DJ. Accuracy of pedicle screw insertion among 3 image-guided navigation systems: Systematic review and meta-analysis. World Neurosurg. 2018;109:24–30.
55. He Y, Zhang Y, An JG, Gong X, Feng ZQ, Guo CB. Zygomatic surface marker-assisted surgical navigation: A new computer-assisted navigation method for accurate treatment of delayed zygomatic fractures. J Oral Maxillofac Surg. 2013;71:2101–2114.
56. Andrews BT, Surek CC, Tanna N, Bradley JP. Utilization of computed tomography image-guided navigation in orbit fracture repair. Laryngoscope 2013;123:1389–1393.
57. Cai EZ, Koh YP, Hing EC, et al. Computer-assisted navigational surgery improves outcomes in orbital reconstructive surgery. J Craniofac Surg. 2012;23:1567–1573.
58. Zhang S, Gui H, Lin Y, Shen G, Xu B. Navigation-guided correction of midfacial post-traumatic deformities (Shanghai experience with 40 cases). J Oral Maxillofac Surg. 2012;70:1426–1433.
59. Markiewicz MR, Dierks EJ, Potter BE, Bell RB. Reliability of intraoperative navigation in restoring normal orbital dimensions. J Oral Maxillofac Surg. 2011;69:2833–2840.
60. Markiewicz MR, Dierks EJ, Bell RB. Does intraoperative navigation restore orbital dimensions in traumatic and post-ablative defects? J Craniomaxillofac Surg. 2012;40:142–148.
61. Scolozzi P, Terzic A. “Mirroring” computational planning, navigation guidance system, and intraoperative mobile C-arm cone-beam computed tomography with flat-panel detector: A new rationale in primary and secondary treatment of midfacial fractures? J Oral Maxillofac Surg. 2011;69:1697–1707.
62. Yu H, Shen G, Wang X, Zhang S. Navigation-guided reduction and orbital floor reconstruction in the treatment of zygomatic-orbital-maxillary complex fractures. J Oral Maxillofac Surg. 2010;68:28–34.
63. Yu H, Shen SG, Wang X, Zhang L, Zhang S. The indication and application of computer-assisted navigation in oral and maxillofacial surgery: Shanghai’s experience based on 104 cases. J Craniomaxillofac Surg. 2013;41:770–774.
64. Novelli G, Tonellini G, Mazzoleni F, Bozzetti A, Sozzi D. Virtual surgery simulation in orbital wall reconstruction: Integration of surgical navigation and stereolithographic models. J Craniomaxillofac Surg. 2014;42:2025–2034.
65. Bly RA, Chang SH, Cudejkova M, Liu JJ, Moe KS. Computer-guided orbital reconstruction to improve outcomes. JAMA Facial Plast Surg. 2013;15:113–120.
66. Li Z, Yang RT, Li ZB. Applications of computer-assisted navigation for the minimally invasive reduction of isolated zygomatic arch fractures. J Oral Maxillofac Surg. 2015;73:1778–1789.
67. Zinser MJ, Mischkowski RA, Dreiseidler T, Thamm OC, Rothamel D, Zöller JE. Computer-assisted orthognathic surgery: Waferless maxillary positioning, versatility, and accuracy of an image-guided visualisation display. Br J Oral Maxillofac Surg. 2013;51:827–833.
68. Sun Y, Luebbers HT, Agbaje JO, Lambrichts I, Politis C. The accuracy of image-guided navigation for maxillary positioning in bimaxillary surgery. J Craniofac Surg. 2014;25:1095–1099.
69. Mazzoni S, Badiali G, Lancellotti L, Babbi L, Bianchi A, Marchetti C. Simulation-guided navigation: A new approach to improve intraoperative three-dimensional reproducibility during orthognathic surgery. J Craniofac Surg. 2010;21:1698–1705.
70. Yu H, Wang X, Zhang S, Zhang L, Xin P, Shen SG. Navigation-guided en bloc resection and defect reconstruction of craniomaxillary bony tumours. Int J Oral Maxillofac Surg. 2013;42:1409–1413.
71. Wang X, Lin Y, Yu H, et al. Image-guided navigation in optimizing surgical management of craniomaxillofacial fibrous dysplasia. J Craniofac Surg. 2011;22:1552–1556.
72. Feichtinger M, Pau M, Zemann W, Aigner RM, Kärcher H. Intraoperative control of resection margins in advanced head and neck cancer using a 3D-navigation system based on PET/CT image fusion. J Craniomaxillofac Surg. 2010;38:589–594.
73. Zhang WB, Mao C, Liu XJ, Guo CB, Yu GY, Peng X. Outcomes of orbital floor reconstruction after extensive maxillectomy using the computer-assisted fabricated individual titanium mesh technique. J Oral Maxillofac Surg. 2015;73:2065.e1–2065.15.
74. Guo R, Guo YX, Feng Z, Guo CB. Application of a computer-aided navigation technique in surgery for recurrent malignant infratemporal fossa tumors. J Craniofac Surg. 2015;26:e126–e132.
75. Azarmehr I, Stokbro K, Bell RB, Thygesen T. Surgical navigation: A systematic review of indications, treatments, and outcomes in oral and maxillofacial surgery. J Oral Maxillofac Surg. 2017;75:1987–2005.
76. Strong EB, Rafii A, Holhweg-Majert B, Fuller SC, Metzger MC. Comparison of 3 optical navigation systems for computer-aided maxillofacial surgery. Arch Otolaryngol Head Neck Surg. 2008;134:1080–1084.
77. Franchini M, Mannucci PM. Efficacy and safety of a recombinant factor VIII produced from a human cell line (simoctocog alfa). Expert Opin Drug Saf. 2017;16:405–410.
78. Marmulla R, Hilbert M, Niederdellmann H. Inherent precision of mechanical, infrared and laser-guided navigation systems for computer-assisted surgery. J Craniomaxillofac Surg. 1997;25:192–197.
79. Wanschitz F, Birkfellner W, Watzinger F, et al. Evaluation of accuracy of computer-aided intraoperative positioning of endosseous oral implants in the edentulous mandible. Clin Oral Implants Res. 2002;13:59–64.
80. Chiu WK, Luk WK, Cheung LK. Three-dimensional accuracy of implant placement in a computer-assisted navigation system. Int J Oral Maxillofac Implants 2006;21:465–470.
81. Nguyen LL, Naunheim MR, Hevelone ND, et al. Cost analysis of conventional face reconstruction versus face transplantation for large tissue defects. Plast Reconstr Surg. 2015;135:260–267.
82. Siemionow M, Gatherwright J, Djohan R, Papay F. Cost analysis of conventional facial reconstruction procedures followed by face transplantation. Am J Transplant. 2011;11:379–385.