Maxillary and Mandibular Healing after Facial Allotransplantation

Abstract

PURPOSE: Facial transplantation has emerged as a viable option in treating devastating facial injuries. Despite the high healing rate of Le Fort I-II-III and bilateral sagittal split osteotomies (BSSO) in non-transplant patients (with reported non-union rates of 1.6% and 2.6%, respectively),[1,2] previous studies have reported nonunion between the allograft and the recipient’s bone at the area of maxillary and mandibular osteotomies. [3,4] This suboptimal bone healing remains unexplained and is still yet to be investigated. In this study, we present three patients that received facial transplantation at our institution with a focus on the healing of the mandibular and maxillary osteotomies after osteocutaneous face transplantation. METHOD: A retrospective chart review was conducted of facial allotransplantation patients at the Cleveland Clinic from December 2008 to inception. Demographics such as age, date of birth, and sex were recorded. Additional variables included procedures, revisions, reoperations, medications, and bone stability and healing. Computed tomography (CT) images assessed alignment of skeletal components, bony union quality, and stability of fixation. RESULTS: Three patients receiving facial allotransplantation at our institution were included in our study: two had Le Fort III segment transplantation, and one had transplantation of both a Le Fort III segment and mandibular BSSO. The Le Fort III segment in all three patients exhibited mobility and fibrous union at the Le Fort III osteotomy on CT. In contrast, the BSSO healed uneventfully after transplantation and revision surgery, with bony union confirmed by both CT and histology of the fixation area between the donor and recipient mandible bilaterally. No patients with midfacial fibrous union required revision of the nonunion as they were clinically asymptomatic. CONCLUSION: Le Fort osteotomies demonstrated inferior healing in patients undergoing facial transplantation compared to Le Fort osteotomies in patients treated for malocclusion. Interestingly, the mandible healed uneventfully after facial transplantation, likely due to the amount of rich cancellous bone in the mandible. This similarly reflects bone healing rates in patients undergoing mandibular surgery for correction of malocclusion or hand transplantation at the level of the humerus, radius, and ulna. Nonunion of the midface does not require revision unless the patient is clinically symptomatic. REFERENCES: 1. Imholz B, Richter M, Dojcinovic I, and Hugentobler M, Non-union of the maxilla: a rare complication after Le Fort I osteotomy. Revue de stomatologie et de chirurgie maxillo-faciale. 2010; 111(5-6): p. 270-275. 2. Chin M and Toth BA, Le Fort III advancement with gradual distraction using internal devices. Plast Reconstr Surg. 1997; 100(4): p. 819-30; discussion 831-2. 3. Lantieri L, Grimbert P, Ortonne N, et al., Face transplant: long-term follow-up and results of a prospective open study. Lancet. 2016; 388(10052): p. 1398-1407. 4. Goutard M, Lellouch AG, Dussol B, and Lantieri LA, Facial Trauma 8 years after a Face Transplantation. Plast Reconstr Surg Glob Open. 2021; 9(5): p. e3575.