Full Face Transplantation: 12-Month Outcomes

Full face transplantation restores, rather than reconstructs, the most severe facial defects. Three patients with complex pan-facial defects were deemed eligible for face transplantation under our IRB-approved protocol in late 2010 and early 2011. All patients had limited nasal breathing, speech, expression, and oral competence function. Outcomes of the first 9 postoperative months are discussed with a focus on complications.

All donors were gender, skin color and skin texture-matched. All donors had compatible ABO and negative T and B cell crossmatch. Full face transplantation included the entire facial soft tissues from ear to ear and temporoparietal scalp to neck. In two patients, the nasal bone was the only osseous component included in the full facial allograft; the third patient required the entire maxilla. Functional facial structures were preserved in all patients, to allow for functional reconstruction to the pre-transplant level. 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 monitored by clinical findings and the results of skin biopsies taken periodically and at times of suspected rejection.

Restoration of facial aesthetics was obtained immediately after the operation. There were significant complications in the post-operative period, most of which were of an 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.

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. Nonetheless, knowledge of complications commonly associated with facial allotransplantation will help surgical teams prevent and prepare for these events. Furthermore, data from these early surgical experiences will improve the informed consent process and allow for better patient education.