The authors present the results of a facial Composite Tissue Allotransplantation with 12 months follow up on a a 29 yo patient with plexiform neurofibroma. The patient was operated by several plastic surgeons with no success (over 35 operations). We decided to go to this process after several anatomical and technical studies. These studies completed with ethical and immunological reviews by several expert committees resulted in an IRB approval in October 2005. Several expert committees directed by the French national agencies made the necessity of several modifications. The patient was on waiting list since August 2006. He was carefully reviewed by psychologist and psychiatrist and give inform consent.  

The surgery took place on Sunday 21 January 2007. The excision of all neurofibroma resulted in extreme blood loss.  The excision included all soft tissue under zygomatic arch on both side down to the neck and laterally to the ears. Facial nerve was dissected at its origin in the stylo mastoid foramen. The lower branches of the facial nerve were sacrificed as going into the tumour. The harvest of the face was done by another team in another hospital of the great Paris area on a brain dead donor.  The face was harvested on beating heart before the other organs. End to end anastomosis was performed on external carotid and thyrolingofacial trunk on one side which allowed complete revascularisation of the entire flap. We then performed nerve anastomosis beginning on left facial nerve end to side on facial trunk followed by both sub orbitaries nerves along with mucosa closure and finishing with end to end anastomosis on facial nerve on right side. At last vascular anastomosis was done on both vein and arteries on right side.. 

For the donor: the French law is based on “supposed consent”. In this case we ask specific consent of the family for harvesting the face. The restoration of the body was done by doing first a mold of the face with alginate. A solid mask was done during the harvest and could be put on the defect so that the other team could harvest other organ after total repair of the face.

For the immunosuppression we used a protocol with anti lymphocyte serum for 10 days started at the time of anastomosis, Tacrolimus MMF and Steroids as in other CTA or kidney transplants. The biopsies at day 28 showed a moderate infiltration of lymphocyte grade 1 which necessitated corticosteroid therapy. The concomitant moderate inflammation then quickly resolved. The biopsies at day 42 did not show any more lymphocyte infiltration at the level of mucous membranes. At day 60 the patient sustained antiviral-resistant cytomegalovirus (CMV) , leading to ganciclovir but not to cidofovir resistance and we identified a new DNA polymerase mutation, this was associated with acuted rejection which was resolutive after CMV infection treatment.  Biopsies since that episode do not show any sign of rejection.

Active movement started to appear at 6 months and the patient required locale anesthesia at four month

From a psychological point of view the patient saw his new face 10 days after the intervention and seems to perfectly accept the new aspect. His general state is excellent. He is able to carry alone not only the routine activites of dayly living (gestures, dress, toilet & food) but can go to departement store and has started a new job. He and comes every month for routine examination and still follow active therapy for improvement of facial movement.

Conclusion

Face transplant has move from ethical debate to surgical reality.  However, as in other organ transplant this procedure carries high risks and needs longtime follow-up to evaluate the risks and benefits of such procedure even if our first data shows that, beside the feasibility, functional and psychological results go behind our initial expectation.