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Evidence of Lymphatic Neovascularization and Early Reconstitution of Lymphatics Following Face Transplantation
Michael Sosin, M.D.1, Gerhard S. Mundinger, M.D.1, Cinthia B. Drachenberg, M.D.2, Eduardo D. Rodriguez, M.D., D.D.S.3.
1R Adams Cowley Shock Trauma Center/University of Maryland Medical Center, Baltimore, MD, USA, 2University of Maryland Medical Center, Baltimore, MD, USA, 3New York University Langone Medical Center, New York, NY, USA.

PURPOSE: The purpose of this study is to investigate whether there is lymphatic regeneration following clinical facial transplantation using immunohistology and indocyanine green (ICG) lymphoscintigraphy.
METHODS: Allograft skin biopsies were individually stained Lyve1 lymphatic antibody and CD31 vascular endothelial antibody, and H&E and C4d markers for quality control. Digital images (Aperio Systems, California) were compared in the same histological location in duplicate within each specimen. ICG lymphoscintigraphy was used to determine lymphatic flow.
RESULTS: Forty-two biopsies were evaluated at 15 different time points from post-transplant day 7 to 420. Strong lymphatic regeneration was observed in 52.4% (Figure 1), moderate staining in 14.3%, and weak staining in 33.3% of biopsies. Strong evidence of lymphangiogenesis was present on day 7,10, 44, 79, 269, 402, and 420. Upon 8.5 months postoperatively, ICG lymphoscintigraphy (Figure 2a) revealed initial drainage via distinct lymphatic channels with abrupt dermal splash and lymphostasis at 15 minutes post-injection. Thirty months post-transplant lymphoscintigraphy demonstrated communication of multiple lymphatic channels, between donor and recipient tissue, and distinct drainage into the neck (Figure 2b).
CONCLUSION: There is evidence to suggest that lymphatic regeneration begins following facial transplantation and continues long term.


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