4 key issues in facial allotransplantation
By Maria Frisch

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Facial allotransplantation has transformed the future of patients with severe facial disfigurement by allowing for nearly normal facial restoration. Since 2005, at least 21 facial allotransplantations have been performed worldwide, with an estimated 90 percent overall success rate — two of the 21 patients died. This article summarizes four key issues regarding this procedure.
  1. Procedure time-constraints. This procedure is subject to a four-hour time constraint. Thus, time-saving measures must be used. One such time-saving measure is presented here: Instead of anastomosing a full facial clap to multiple arteries, adequate perfusion is possible through single arterial anastomosis on each side of the face, saving valuable procedure time. This is done through use of preoperative imaging (computed tomographic angiography and magnetic resonance angiography) of the unique vascular anatomy of each patient.

  2. Lifelong immunosuppression. Lifelong immunosuppression (medication) and follow-up (to reduce side effects of immunosuppression and to examine functional status of allograft) is a necessary evil to maintain the allograft. This may present a financial challenge for some patients. Thus, plans and provisions should be made. This may include obtaining lifelong coverage authorization from a patient's insurance. Acute rejection during the first year is common, but may be adequately managed within an inpatient setting by administering methylprednisolone boluses followed by a steroid taper. Immunosuppression-associated side effects that have been reported in previous cases include malignancy, drug toxicity and opportunistic infections. Future research should seek solutions to reduce the burden of immunosuppression.

  3. Reintegration of functionality. The speed of most sensory and motor recovery depends on axonal regrowth of the recipient's nerve past the coaptation site. Thus, neurorrhaphies should be performed as close to the adjacent target muscles as the anatomy allows, by minimizing the length of the donor portion of the nerves and/or maximizing the length of the recipient portion of the nerves. Many advocate for attempting neurorrhaphies in every instance when nerve stumps are present and healthy. In other cases, nerve grafts may be used to bridge distances. If nerves are not present and usable, and nerve grafting is not possible, then nerve transfers may be used. Sensory nerve recovery typically occurs 3-8 months after transplantation. Motor recovery is slower, occurring 6-18 months after transplantation.

  4. Aesthetics and psychological response. Aesthetics are most often the result of preserved functional units and unscarred facial skin. This is generally accomplished through resurfacing. There have been no psychological complications reported, resulting from changes in facial identity. Measurable improvements in depression, body image, quality of life and social reintegration have been reported. Quantitative evaluation of psychological outcomes in each patient is strongly encouraged.
Face transplant interventions are still in their infancy and much is yet to be learned, underscoring the importance of informed consent and review of all options. The next several years will hopefully reveal knowledge and improved outcomes.

Maria Frisch is a healthcare consultant and clinical research scientist. She received her medical training from St. George's Medical School and graduate training in public health from the University of Minnesota.


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