Face Allotransplantation for treatment of a high voltage midfacial injury
Bohdan Pomahac, Sr., M.D., Julian Pribaz, M.D., Donald Annino, M.D., Dennis P. Orgill, M.D., Ph.D., Christian Sampson, M.D., Elof Eriksson, M.D., Ph.D., Stephanie Caterson, M.D., Yoon Chun, M.D..
Brigham and Women's Hospital, Boston, MA, USA.
Composite facial tissue allotransplantation has gained acceptance as a treatment for the most severe facial deformities in an appropriate recipient. Early transplants have focused on soft tissue, but many injuries amenable to facial transplantation will require maxillary and/or mandibular transplantation.
: IRB approved the protocol and recipient. Facial tissue allotransplantation was performed from a 60 years donor to 59 years old recipient of compatible ABO type and negative cross-match. The donor and recipient were matched for age, sex and skin type. The donor himself had recently received heart transplantation but sustained an irreversible stroke resulting in brain death. The recipient had sustained high voltage electrical injury to his midface 4 years prior to the transplantation. Three teams worked simultaneously on preparation of the recipient, dissection of the donor and recovery of the radial forearm fasciocutaneous functional and monitoring sentinel flap. Recovery of the allograft face was performed on a heart-beating donor. The bony part of the allograft included the entire maxilla to the level of lateral infraorbital rims, root of the nose at the glabella, hard palate including donor teeth, and was separated at the level of the perpendicular pterygoid processes of the sphenoid bone while preserving the nasal septum, conchas, and walls of the maxillary sinuses. The soft tissues included bilaterally the entire group of facial mimetic muscles with overlying skin, the facial, buccal, and infraorbital nerves, the nose and the upper lip including the commissures and small parts of lower lip. Bleeding during the osteotomy was minimal due to carotid control cephalad to harvested vessel transection.
Vascular anastomosis was performed between external carotid arteries on the left side, and facial arteries on the right with accompanying veins. Neurorraphies were performed of both sensory and motor nerves. These included bilateral buccal and infra-orbital nerves to provide sensation both in the buccal mucosa and on the surface of the cheeks. Five facial nerve branches on the right and six facial nerve branches on the left were performed to facilitate motor function return.
Total ischemia time was 1 h 15 min. Radial forearm fasciocutaneous flap was used for release of the contracted 1st web space on the recipient’s right hand with the goal of using it for monitoring biopsies as well.
The operation took over 17 hours using 3 teams. At least two rejection episodes were successfully managed with steroids. Post-operative complications included 2 episodes of minor infections, and slowly resolving diabetes mellitus requiring insulin administration. At 6 months, the patient partially recovered sensation in his cheeks, and started moving oral commissures.
Transplantation of midface including the entire maxilla and overlying soft tissues is technically feasible. Early post-operative results are encouraging in both superior esthetic as well as functional outcomes as compared to conventional means of reconstruction. Further follow-up will help better define functional outcomes and future complications.