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Facial Transplantation for an Irreparable Central and Lower Face Injury: A Modernized Approach to a Classic Challenge

Kantar, Rami S. M.D., M.P.H.; Ceradini, Daniel J. M.D.; Gelb, Bruce E. M.D.; Levine, Jamie P. M.D.; Staffenberg, David A. M.D.; Saadeh, Pierre B. M.D.; Flores, Roberto L. M.D.; Sweeney, Nicole G. N.P.; Bernstein, G. Leslie M.P.A.; Rodriguez, Eduardo D. M.D., D.D.S.

Plastic and Reconstructive Surgery: August 2019 - Volume 144 - Issue 2 - p 264e-283e
doi: 10.1097/PRS.0000000000005885
Reconstructive: Head and Neck: Special Topic
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Background: Facial transplantation introduced a paradigm shift in the reconstruction of extensive facial defects. Although the feasibility of the procedure is well established, new challenges face the field in its second decade.

Methods: The authors’ team has successfully treated patients with extensive thermal and ballistic facial injuries with allotransplantation. The authors further validate facial transplantation as a reconstructive solution for irreparable facial injuries. Following informed consent and institutional review board approval, a partial face and double jaw transplantation was performed in a 25-year-old man who sustained ballistic facial trauma. Extensive team preparations, thorough patient evaluation, preoperative diagnostic imaging, three-dimensional printing technology, intraoperative surgical navigation, and the use of dual induction immunosuppression contributed to the success of the procedure.

Results: The procedure was performed on January 5 and 6, 2018, and lasted nearly 25 hours. The patient underwent hyoid and genioglossus advancement for floor-of-mouth dehiscence, and palate wound dehiscence repair on postoperative day 11. Open reduction and internal fixation of left mandibular nonunion were performed on postoperative day 108. Nearly 1 year postoperatively, the patient demonstrates excellent aesthetic outcomes, intelligible speech, and is tolerating an oral diet. He remains free from acute rejection.

Conclusions: The authors validate facial transplantation as the modern answer to the classic reconstructive challenge imposed by extensive facial defects resulting from ballistic injury. Relying on a multidisciplinary collaborative approach, coupled with innovative emerging technologies and immunosuppression protocols, can overcome significant challenges in facial transplantation and reinforce its position as the highest rung on the reconstructive ladder.

CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

New York, N.Y.

From the Hansjörg Wyss Department of Plastic Surgery and the Transplant Institute, New York University Langone Health.

Received for publication November 16, 2018; accepted February 7, 2019.

This study is registered under the name “Craniomaxillofacial Allotransplantation,” ClinicalTrials.gov identification number NCT02158793 (https://clinicaltrials.gov/ct2/show/NCT02158793).

Disclosure:None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article. Dr. Rodriguez has received speaker honoraria for unrelated activities from DePuy Synthes CMF and KLS Martin. The face transplant was funded by two separate mechanisms, including a Reconstructive Transplantation Research Award (W81XWH-15-2-0036) from the Department of Defense, and institutional support.

A “Hot Topic Video” by Editor-in-Chief Rod J. Rohrich, M.D., accompanies this article. Go to PRSJournal.com and click on “Plastic Surgery Hot Topics” in the “Digital Media” tab to watch.

Supplemental digital content is available for this article. Direct URL citations appear in the text; simply type the URL address into any Web browser to access this content. Clickable links to the material are provided in the HTML text of this article on the Journal’s website (www.PRSJournal.com).

Eduardo D. Rodriguez, M.D., D.D.S., Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, 305 East 33rd Street, New York, N.Y. 10016, eduardo.rodriguez@nyulangone.org, Twitter: @RamiKantar1

Satisfactory outcomes are difficult to achieve through conventional reconstructive approaches following extensive facial injuries.1,2 In 2005, facial transplantation introduced a paradigm shift in craniofacial reconstruction, and offered patients with devastating injuries hope of regaining normal form and function.1,3–7 Our team has successfully treated patients with extensive thermal and ballistic facial injuries with allotransplantation, leading to satisfactory outcomes and overall quality of life.3,4

Relying on fundamental concepts in craniofacial reconstructive surgery, lessons learned from the field and our experience, emerging innovations, and close collaborations with key stakeholders, we validate facial transplantation as a reconstructive solution for irreparable facial injuries.1,3,4,7–20 In this article, we report the successful completion of a partial face and double-jaw transplant in a patient who previously sustained ballistic facial trauma.

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PATIENT AND METHODS

Our face transplant program and team have been described previously.4,15,16 Institutional review board approval was obtained in 2014. Specialized donor consent forms developed in collaboration with the organ procurement organization LiveOnNY were used.4 This article conforms to the principles outlined in the Declaration of Helsinki.

Real-time simulations of the actual procedure were performed in six cadaveric pairs to ensure optimal team performance and objective outcomes evaluation.16,17 Preoperative computerized surgical planning, three-dimensional printing technologies, and intraoperative navigation were all incorporated into the simulation exercises before the clinical face transplant.

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Recipient

The recipient was a cytomegalovirus and Epstein-Barr virus–negative, 25-year-old man who sustained a ballistic facial injury in June of 2016 (Figs. 1 and 2). He underwent multiple procedures for stabilization acutely following injury, including maxillary, mandibular, zygomatic, and right orbital floor open reduction and internal fixation, in addition to bilateral anterolateral thigh and supraclavicular flaps to the central and lower face. He was otherwise healthy and presented to our institution with tissue deficits resulting in lip incompetence, speech and feeding difficulties, exposed hardware, and visual alterations. In preparation for facial transplantation and to improve functional status, the patient underwent percutaneous gastrostomy placement, open tracheostomy, hardware removal, bilateral nasoorbitoethmoid osteotomies, medial canthal tendon repositioning, and bilateral orbital floor reconstruction with alloplastic titanium implants in April of 2017 (Fig. 3). Three-dimensional craniofacial computed tomographic scans and formal head/neck angiographic images were obtained for skeletal and vascular anatomical evaluations (Fig. 4).

Fig. 1.

Fig. 1.

Fig. 2.

Fig. 2.

Fig. 3.

Fig. 3.

Fig. 4.

Fig. 4.

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Donor

The donor was a cytomegalovirus and Epstein-Barr virus–negative 23-year-old man with irreversible anoxic brain injury, and was otherwise healthy.

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Results

On January 4, 2018, the donor family graciously granted permission for face transplant evaluation. The donor met predetermined criteria based on age, sex, height, weight, skin color match, hair color match, dentition, craniofacial dimensions, and overall health. The donor and recipient were ABO identical. The donor human leukocyte antigen profile was typed: A-2, 68; B-35, 44; C-4, 16; DR-4, 7, 53; DQ-2, 8; and DQA1-2, 3. Recipient human leukocyte antigen was typed: A-32, 68; B-44; C-5, 7; DR-9, 15, 53, 51; DQ-6, 9; and DQA1-1, 3. Human leukocyte antigen mismatch was 1, 1, and 2 for A, B, and DR, respectively. Complement-dependent cytotoxicity crossmatch using donor lymphocytes and recipient heat-treated serum was negative for T and B cells. Complement-dependent cytotoxicity crossmatch using donor lymphocytes and recipient heat-untreated serum was negative for T cells and positive for B cells. Flow cytometry demonstrated negative donor T-cell and B-cell crossmatch.

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Face Transplant

An animated overview of the face transplant [see Video, Supplemental Digital Content 1, which demonstrates an animated overview of the face transplant, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/D607 (provided with permission from and copyrights retained by Eduardo D. Rodriguez, M.D., D.D.S.)], a detailed educational video [see Video, Supplemental Digital Content 2, which demonstrates an educational surgical video with intraoperative footage, available in the “Related Videos” section of the full-text article on PRSJournal.com or, for Ovid users, at http://links.lww.com/PRS/D608 (provided with permission from and copyrights retained by Eduardo D. Rodriguez, M.D., D.D.S.)], and interactive three-dimensional surgical plans of the donor and recipient procedures are provided [see Figure, Supplemental Digital Content 3, which shows an educational interactive three-dimensional model of donor and recipient surgical plans, which allows readers to segment recipient and donor craniofacial skeletal and soft-tissue components for a better understanding of the surgical anatomy, available at http://links.lww.com/PRS/D609 (provided with permission from and copyrights retained by Eduardo D. Rodriguez, M.D., D.D.S.)]. Chronologic timelines of recipient and donor procedures are provided (Fig. 5).

Video 1.

Video 1.

Video 2.

Video 2.

Fig. 5.

Fig. 5.

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Donor Procedure

Preparation

On January 4, 2018, the donor was transported to our institution as described previously.21 Tracheostomy, exchange of lines, placement of titanium skeletal anchorage screws, and dental impressions were then performed.

A three-dimensional craniofacial computed tomographic scan was obtained for computerized surgical planning (Fig. 6). Scan data were subsequently uploaded to the surgical planning software (ProPlan CMF; Materialise, Inc., Leuven, Belgium) (see Figure, Supplemental Digital Content 3, http://links.lww.com/PRS/D609). Donor skeletal osteotomies were designed to match the planned recipient osteotomies. Computerized modeling and superimposition of the donor and recipient skeletal segments were then performed (Fig. 7). Once the surgical plan was approved, early cutting-guide design and three-dimensionally–printed fabrication were initiated, allowing timely sterilization and delivery to the operating room.

Fig. 6.

Fig. 6.

Fig. 7.

Fig. 7.

Computed tomographic angiography followed by formal angiography of the head/neck demonstrated significant vascular variants, with bilateral facial venous systems draining predominantly into the anterior jugular veins, with minor anastomoses to the external jugular veins and none to the internal jugular systems (Fig. 8). Facial impressions using alginate molding reinforced with plaster and three-dimensional facial images using the Spider three-dimensional scanner (Artec, Inc., Santa Clara, Calif.) were obtained.

Fig. 8.

Fig. 8.

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Allograft Procurement

On January 5, 2018, the donor was brought to the operating room for simultaneous recovery of facial and solid organ allografts. The planned osteotomies were comparable to those performed by the senior author (E.D.R) in a previous face transplantation.3,17,18

Markings along the nasal radix, subciliary lines, preauricular creases extending to the neck, and clavicles toward the sternal notch above the tracheostomy were outlined. The initial incision proceeded from the sternal notch above the tracheostomy laterally to the posterior border of the sternocleidomastoid muscle. The subplatysmal flap was elevated and the anterior and external jugular veins were circumferentially dissected. Retrograde dissection allowed identification of the internal jugular vein and common carotid artery. The facial vein draining into the anterior jugular vein and the facial artery originating from the external carotid artery were identified and preserved.

Facial nerve dissection was performed as described previously, with special attention to identify the zygomatic, buccal, and marginal mandibular branches using intraoperative nerve stimulation.15,18 Dissection proceeded with a nasal radix incision, which allowed elevation of the nasal flap inferiorly and subperiosteal dissection until reaching the medial orbital walls. Subciliary and temporal forehead incisions allowed dissection in the plane deep to the orbicularis oculi muscle until reaching the inferior orbital rim and zygoma. Intraorally, an incision was extended from the retromolar trigone to the floor of the mouth, along the mucosal borders of the mandibular ramus, and superiorly to the posterior soft palate, with special attention to preserve allograft buccal and palatal mucosae. Sensory nerves including infraorbital and inferior alveolar nerves were identified and preserved.

Thorough dissection allowed placement of the cutting guides as planned (Fig. 7) and completion of the bilateral mandibular sagittal split and Le Fort III osteotomies. Final divisions of the nasal septum and mucosal elements were performed, allowing elevation of the entire allograft based on its vascular blood supply off the bilateral external carotid arteries and anterior jugular veins. The maxillary segment was tailored to a stereolithographic model of the planned recipient skeletal defect.

Before division of the vascular pedicles, indocyanine green fluorescence angiography was used to confirm facial allograft perfusion (LifeCell SPY Elite Imaging System; LifeCell Corp., Branchburg, N.J.) (Fig. 9). Appropriate perfusion to the palate and posterior aspect of the allograft was also ensured. [See Figure, Supplemental Digital Content 4, which shows facial allograft indocyanine green fluorescence angiography following dissection completion and before release from the vascular pedicles showing adequate perfusion and blood supply to the posterior aspect of the allograft including sinuses, http://links.lww.com/PRS/D610. (Provided with permission from and copyrights retained by Eduardo D. Rodriguez, M.D., D.D.S.)] Following division of the vascular pedicles, the allograft was maintained in maxillomandibular fixation, transferred to the back table in an ice-water bath, and flushed with 3 liters of University of Wisconsin solution. Solid organ recovery was also performed successfully.

Fig. 9.

Fig. 9.

Both silicone (Smooth-On, Inc., Easton, Pa.) and three-dimensionally–printed masks (LaGuardia Studio, New York, N.Y.) were prepared for donor facial restoration (Fig. 10). The silicone mask was generated from the preoperative facial impressions. The three-dimensional mask was created from the preoperative facial three-dimensional images, and fixed into place over the donor facial defect after allograft procurement.

Fig. 10.

Fig. 10.

Donor transfusions included 7 units of packed red blood cells, 3 units of fresh frozen plasma, and 1 unit of platelets. Allograft dissection time was approximately 10 hours.

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Recipient Procedure

Recipient facial preparation was performed simultaneously in an adjacent operating room. Common and external carotid arteries, internal and external jugular veins, and their branches including facial branches were dissected circumferentially, and all remaining hardware was removed. Bilateral zygomatic, buccal, and marginal mandibular branches of the facial nerve, and sensory nerves including infraorbital and inferior alveolar nerves, were preserved and transected distally. The Stenson duct was identified and preserved. Le Fort III and bilateral sagittal split osteotomies were performed based on the preoperative surgical plan (Fig. 7).

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Skeletal Fixation

Intraoperative navigation was used to confirm skeletal segment position (Airo; Brainlab, Inc., Chicago, Ill.) (Fig. 11). Rigid fixation of the allograft was completed at the zygomatic bodies using 0.7-mm miniplates, and bilateral mandibular fixation was performed using bicortical 1.85-mm positional lag screws (MatrixORTHOGNATHIC Plating System; DePuy Synthes CMF, West Chester, Pa.) (Fig. 12).

Fig. 11.

Fig. 11.

Fig. 12.

Fig. 12.

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Microvascular Anastomoses

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.)]

Fig. 13.

Fig. 13.

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Nerve Coaptations

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.

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Intraoral Reconstruction

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).

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Medial Canthal Reconstruction and Soft-Tissue Redraping

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).

Fig. 14.

Fig. 14.

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Immunosuppression

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.

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Complications, Revisions, and Outcomes

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.

Fig. 15.

Fig. 15.

Fig. 16.

Fig. 16.

Fig. 17.

Fig. 17.

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Discussion

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

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Donor Pool

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

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Donor Vascular Anatomy

The donor facial artery and vein are critical for allograft perfusion.30 Although the facial artery is known to demonstrate wide anatomical variation, the facial vein usually follows a more predictable course, beginning in the inner canthal area, and ultimately draining into the internal jugular vein.31 Anatomical studies have demonstrated facial vein variation rates ranging from 0.3 to 9 percent, with the majority consisting of drainage into the external jugular vein.32,33 To our knowledge, the donor venous anatomy described here constitutes the first report of bilateral facial venous drainage into the anterior jugular veins. More importantly, this was confirmed only following formal head and neck angiography. Although anatomical variations of the facial vein are uncommon, our experience highlights the importance of accurate preoperative delineation of the donor vasculature to ensure allograft procurement success, and prevent iatrogenic vascular injuries with their potential devastating consequences.

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Donor Facial Restoration

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.

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Long-Distance Patient Care

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.

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Patient Selection

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.

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Comprehensive Patient Care

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.

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Induction Immunosuppression

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.

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Surgical Navigation

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.

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Cost Considerations

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.

Thirteen years after the first face transplant, rhetorical pourquoi pas’s are answered, the efficacy of the procedure in craniofacial reconstruction is widely substantiated, and hope for patients with devastating facial injuries is rejuvenated more than ever. By relying on lessons learned from the field, our previous experience, mobilizing state-of-the-art emerging technologies, collaborative relationships, and translating research innovations into clinical practice, we validate facial transplantation as a solution to the classic reconstructive challenge imposed by extensive ballistic facial injuries and describe a modernized approach to the procedure. With these issues in mind, international collaborations and transparent reporting of outcomes among face transplant teams are imperative more than ever to address the inherent challenges facing the field, most notably the side effects of lifelong immunosuppression and crippling donor shortages.

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CONCLUSIONS

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.

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PATIENT CONSENT

The patient provided written consent of the use of his images.

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ACKNOWLEDGMENTS

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.

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