Sequence of Multiorgan Procurement Involving Face Allograft

Abstract

To the Editor: We gratefully congratulate Bueno et al. for their comprehensive review of technical details of facial allograft procurement in the scenario of multiorgan recovery (1Bueno J Barret JP Serracanta J et al.Logistics and strategy of multiorgan procurement involving total face allograft.Am J Transplant. 2011; 11: 1091-1097Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar). We agree with their proposed sequence of organ dissection and multiorgan procurement when different surgical teams are involved. However, we would like to share some considerations arising from our own experience to provide relevant information to other teams contemplating facial allograft in a similar scenario. On January 26, 2010, we performed a case of successful partial facial graft procurement from an 18-year-old male (2Gomez-Cia T Sicilia-Castro D Infante-Cossio P et al.Second human facial allotransplantation to restore a severe defect following radical resection of bilateral massive plexiform neurofibromas.Plast Reconstr Surg. 2011; 127: 995-996Crossref PubMed Scopus (37) Google Scholar). The cause of brain death was a traffic accident. Initially, with the patient with orotracheal intubation in the intensive care unit, we took a mold of the donor’s face to produce a resin mask for the subsequent restoration of the face. The endotracheal tube connector was temporarily disconnected from ventilator for separation of the mold and then reconnected. Immediately after the donor was brought to the operating room (OR) to perform a simultaneous multiorgan recovery of heart, lungs, liver, intestine, kidneys and face graft. Sixteen surgeons participated in the donor procedure: two heart surgeons, two lung surgeons, three intestine surgeons, two liver surgeons, two urologists, two plastic surgeons, two oral and maxillofacial surgeons and one plastic resident. Our strategy for donor organ recovery consisted of four steps: (i) dissection of organs with intact donor circulation in brain death, (ii) cannulation and in situ cooling of different organs with simultaneous exanguination, (iii) removal of heart, lungs, intestine and liver and (iv) consequent discontinuation of donor life support, followed by face and kidneys removal. The recovery of the facial graft lasted 4 h and 15 min. The graft procured included an osteomyocutaneous allograft of the lower two thirds of the face including an osseous chin segment. The allograft was immediately transferred to an adjacent OR. Total ischemia time from donor’s cardiac death to re-perfusion in recipient’s vessels was 5 h. To date, allografts harvested from a heart-beating donor have been reported in France and USA (3Devauchelle B Badet L Lengelé B et al.First human face allograft: Early report.Lancet. 2006; 368: 203-209Abstract Full Text Full Text PDF PubMed Scopus (482) Google Scholar,4Siemionow M Papay F Alam D et al.Near-total human face transplantation for a severely disfigured patient in the USA.Lancet. 2009; 374: 203-209Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar) whereas only one has been partially described as obtained from a cadaveric donor in China (5Guo S Han Y Zhang X et al.Human facial allotransplantation: A 2-year follow-up study.Lancet. 2008; 372: 631-638Abstract Full Text Full Text PDF PubMed Scopus (206) Google Scholar). In case of multiorgan recovery most face transplantation teams have worldwide procured the “face in first place.” This method could be considered as a “standard technique” since pioneering clinical case experiences in the past 5 years have established the feasibility of recovering facial allografts from the carotid-jugular system without compromising the remaining solid organs in heart-beating donors. Bueno et al. (1Bueno J Barret JP Serracanta J et al.Logistics and strategy of multiorgan procurement involving total face allograft.Am J Transplant. 2011; 11: 1091-1097Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar) have demonstrated the feasibility of total face allograft procurement simultaneous to solid organs in close cooperation with transplant teams. They performed approximately half of the graft dissection prior to solid organ recovery and the remainder just after cardiac death. In multiorgan procurement, a critical point is to minimize blood loss to allow safe donation of vital organs. Our sequence of harvesting the face allograft starting shortly after the recovery of the thoracic and abdominal organs has also demonstrated to be a reliable alternative procedure to others previously described. The authors of this manuscript have no conflicts of interest to disclose as described by the American Journal of Transplantation.