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Full Facial Transplantation: complications, and 6 months clinical outcomes
Bohdan Pomahac, MD, Julian Pribaz, MD, Christian Sampson, MD, Dennis Orgill, MD, PhD, Edward J. Caterson, MD, PhD, Matthew J. Carty, MD, Stephanie Caterson, MD, Yoon Chun, MD, Donald Annino, MD, Ericka M. Bueno, PhD, Jesus R. Diaz-Siso, MD, Elof Eriksson, MD, PhD.
Brigham and Women's Hospital, Boston, MA, USA.

PURPOSE: Three patients with complex pan-facial defects were selected for face transplantation under our IRB-approved protocol. Full face transplantation included the entire facial soft tissues from ear to ear and temporoparietal scalp to neck. Two patients had only nasal bone included in the full facial allograft, while the third patient needed the entire maxilla. Functional facial parts were preserved in all patients, to allow for reconstruction to pre-transplant level. Outcomes of the first 6 post operative months are discussed with a focus on complications, and motor as well as sensory return.
METHODS: All patients had limited nasal breathing, speech, expression and oral competence functions. All donors were gender and skin color and texture-matched. All donors had compatible ABO and negative T and B cell crossmatch. The operations proceeded unremarkably, although Patients 1, 2 and 3, received 24, 2 and 20 units of packed erythrocytes, respectively, to compensate blood losses of 4, 0.5 and 2.5 liters, respectively. The patients recovered initially in the intensive care unit, and later at the surgical floor. Maintenance immunosupression was provided as triple therapy with mycophenolate mofetil (1000 mg bid), tacrolimus (adjusted to blood levels of 10-15 ng/ml) and prednisone (slow taper from 20 mg/day), and was informed by clinical findings and the results of skin biopsies taken periodically and at times of suspected rejection.
RESULTS: The results are summarized in Table 2. Briefly, restoration of facial aesthetics was obtained immediately after the operation. There were significant complications in the post-operative period, most of which were of infectious nature, and all of which were successfully treated. Two patients suffered single episodes of acute rejection which were reversed with pulse steroid therapy. All patients were successfully weaned off steroids within the first 6 postoperative months. Sensory and motor function returns were initially documented at 3 and 6 months postoperative, and continue to improve with time.
CONCLUSION: Facial allotransplantation is a valuable option for treatment of the most severe facial injuries. Surgical and immune suppression related complications are common, but will likely be reduced with growing experience in the future. Approximation of sensory and motor nerves leads to targeted reinnervation, and return of function in 3, and 6 months respectively. Despite changes in appearance, no psychological issues were noted.

Table 2. 6 month outcomes and complications after full facial transplantation in three patients
Patient 1Patient 2Patient 3
Week 1Restoration of olfaction
Discharge from ICU
Pneumonia
Eating, drinking and seeing new face
Discharge from ICU
Pneumonia
Septic shock, acute renal failure
Bilateral allograft ischemia and removal
Week 2Submental and parotid area collections, hematoma, drainage, injection of 10 units of Botox
Fluconazole and amoxicillin clavulanic acid started
Discharge
Discharge
Week 3Allograft lymphadenopathyLow grade fever
Acute rejection treated with methyl prednisolone pulse 500mg/day 3 days
Discharge from ICU
Week 4Unexplained feverHeadachesCraniofacial CT scan
Month 2Elevation of creatinine and dehydration - resolved
Prednisone discontinued
Prednisone discontinued
Unexplained fever
Insulin supplementation
Diarrhea
Acute rejection treated with methyl prednisolone pulse 500mg/day 3 days
Discharge
Month 3Unexplained feverInsulin
Deep vein thrombosis on left leg
Anti-coagulation started with warfarin
Diarrhea
Palatal fistula
Months 4-6Return of sensation in right face up to 5-mm two-point discrimination
Facial movement
Removal of excess skin
Discontinuation of fluconazole and amoxicillin clavulanic acid
Polymicrobial bacteremia
Extraction of two teeth
Elevated creatinine - resolved
Return of sensation in forehead and chin, 5-mm two-point discrimination
Return of gross lip motion
Rosacea/seborrheic dermatitis of facial allograft treated with topical ketoconazole
Clostridium difficile colitis
Prednisone discontinued
Return of sensation, 5-mm two-point discrimination
Return of motor function

Table 1. Peri-operative aspects of the three full face transplantations reported
Patient 1Patient 2Patient 3
Age/Gender25/M30/M57/F
Injury mechanismElectrical burnElectrical burnAnimal attack
Facial defectSoft tissues, eyelids, left eye, nose, lips, teeth, portion of left temporo-parietal scalpSkin over the forehead, cheeks and eyelids, soft tissues of the nose, lipsNose, eyelids, both eyes, maxilla and lips
Immunosuppression inductionMycophenolate mofetil 1g, anti thymocyte globulin 1.5mg/kg, methyl prednisolone 500 mg and taperMycophenolate mofetil 1g, anti thymocyte globulin 1.5mg/kg, methyl prednisolone 500 mg and taperMycophenolate mofetil 1g, anti thymocyte globulin 1.5mg/kg, methyl prednisolone 500 mg and taper
Duration of operation, hours171419
Arterial anastomoses, donor/recipientBilateral: external carotid/external carotidLeft: external carotid/external carotid
Right: facial/facial
Left: Facial/facial
Right: external carotid/external carotid
Venous anastomoses, donor/recipientBilateral: internal jugular/internal jugularLeft: internal jugular/retromandibular
Right: retromandibular/retromandibular
Left: retromandibular/retromandibular
Right: Internal jugular/internal jugular
Facial nerve coaptationLeft: upper and lower division
Right: frontal, zygomatic, buccal and marginal mandibular
Bilateral: buccal and marginal mandibularBilateral: 6 branches including frontal, zygomatic, buccal and marginal mandibular
Sensory nerve coaptationsLeft: mental
Right: supraorbital, infraorbital, mental
Bilateral: supraorbital, infraorbital, mentalBilateral: supraorbital, supratrochlear, mental


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