A functional periorbital subunit allograft: Vascular, anatomic, and technical considerations for future subunit facial transplantation

Abstract

Injury to the face can result in the loss of critical specialized structures (the eyelids, lips, ears and nose). Vascularized composite allotransplantation (VCA) allows the surgeon to replace exactly what has been lost. The success of the clinical face transplants suggests the possibility of transplanting specialized units of the face. In this study we explore the neurovascular anatomy and technical specifics for harvest of a functional composite eyelid subunit flap. 12 fresh cadaver heads were studied, each yielding two flaps (N=24). The facial (FA) and superficial temporal arteries (STA) were cannulated and injected with a gelatin/acrylic dye mixture. 6 cadaver heads were evaluated via high-resolution three-dimensional CT scans with contrast. The dye injected into the STA uniformly stained the tissue of the eyelid/periorbital subunit. Injection into the FA resulted in staining of the skin and soft tissues in the medial canthal region and superior eyelid skin in 66% of specimens. CT scan studies confirm our findings with injection into the STA resulting in contrast infiltration of the palpebral arterial arcades in all cases. Injection of the FA resulted in contrast infiltration of the palpebral arterial arcades in 2 of 3 cases. Based this study, a periorbital flap can be based on the STA. Motor innervation of the flap is via the zygomatic and buccal branches of the facial nerve with sensory innervation via the infraorbital, supraorbital and supratrochlear nerves. FA could be used, but its ability to perfuse the entire flap was inconsistent.