Secondary Revisions after Facial Transplantation: Optimizing Functional and Aesthetic Outcomes

Background: Facial transplantation has emerged as a viable option in treating devastating facial injuries.^1-3 The benefits of near normal restoration of multiple functional and aesthetic units in previously non-reconstructable defects have been reported in the literature and media.^1,2 However, as with autologous free tissue transfer, the need for secondary refinements in facial transplantation also exists.^3,4 Here we present our cohort of patients after facial transplantation, their respective defects, and surgical revisions.

Patients and Methods: Our institutional review board approved protocol for facial allotransplantation includes a provision for retrospective chart review. A total of seven face transplants have been performed at our institution from April 2009 to October 2014. This is the largest clinical volume of facial transplant recipients in the world. The patients’ histories, pre-operative facial defects and all operative reports were critically reviewed.  

Results: Four patients have undergone full face transplants and four (1 full, 3 partial) have received an osteomyocutaneous allograft at our institution. Five of the seven face transplant recipients have undergone at least one revisional procedure to address functional and/or aesthetic concerns. The time interval from index surgery to revisional surgery ranged from 1 – 10 months (mean: 5.4 months). The mean number of revisional procedures was 3.2 per patient. The mean follow-up time from latest revision ranged from 5-47 months (mean: 20.4 months). Most interventions have consisted of debulking of soft tissues, SMAS plication and suspension, and local tissue rearrangement. Complications from revision surgery were limited and consisted of persistent contour abnormalities. There were no major infections, hematomas, skin flap loss or necrosis, and most importantly, there were no allograft losses. One patient suffered a post-operative complication after fat grafting in the form of acute rejection that resolved with pulse steroids.   

Conclusions: Secondary refinements after facial transplantation may become standard of care as they are now after conventional free tissue transfer.⁴ Secondary refinements after facial transplantation at our institution have addressed both aesthetic and functional aspects and have proven to be safe and introduce minimal complications in the context of dual maintenance immunosuppression. Patient and procedure selection along with timing are paramount to ensure patient safety and optimal functional and aesthetic outcomes.