Multi-Organ and Complex Full Facial Segment Procurement from a Brain Dead Donor

Abstract

The procurement of facial vascularized composite allografts (VCA) is complicated by highly variable recipient defects, in contrast to more standardized recovery of solid organ and hand VCA. In donors undergoing facial VCA recovery, coordination with multi-organ recovery is essential to preserve functional outcomes of solid organ allografts. Methods: We performed coordinated procurement of a full facial VCA with abdominal organ recovery for transplantation from a brain dead donor. The facial VCA included all facial skin, mimetic muscles, multiple sensory and motor nerve branches, the anterior tongue and segments of the maxilla and mandible. Abdominal organ recovery included liver and kidneys. Close monitoring of arterial blood gases, urine output, transfusion requirements, and key steps of facial VCA dissection guided timing of abdominal organ recovery. Results: Recovery of the facial VCA required ˜10.5 hours, with tracheostomy and silicone mask impression performed prior to procurement. Transfusion of 9 units packed red blood cells, 6 units fresh frozen plasma, 1 pooled unit platelets, and 7 L crystalloid were required to maintain stable hemodynamics (MAP 70.1±8.4mmHg) and adequate urine output (0.7 mL/kg/Hr). Donor coagulopathy increased transfusion requirements and the majority of blood loss occurred after mid-face dissection and the initiation of abdominal organ recovery. Oxygenation (192-254 mmHg) and blood pH (7.30-7.35) were normal throughout recovery. Abdominal organ recovery was initiated 6.5 hours into the procedure and prior to performing facial VCA osteotomies; abdominal and facial recovery teams were able to operate concurrently thereafter. After heparinization, the facial VCA was explanted for backtable flushing with University of Wisconsin solution. Abdominal organ recovery immediately followed without complication and good recipient graft function. Conclusions: Facial VCA procurement entails additional blood loss and substantial extension of donor recovery operations. Close monitoring of the donor allows for delayed solid-organ recovery after facial skeletal dissection and potential greatest blood loss. Coordinated care between anesthesia, solid-organ, and facial VCA teams allows for procurement of a complicated facial VCA while preserving solid organ outcomes.