The Posterior Tibial Artery Flap as a Sentinel Flap in Face Transplant

Abstract

Facial vascularized composite tissue procurement has unique logistical challenges and requires immense coordination with the solid organ procurement teams.[1] One aspect of the procedure is the procurement of a sentinel flap. Sentinel flaps are utilized in some centers for remote-site rejection monitoring in facial vascularized composite tissue allotransplantation, thus minimizing biopsies of the facial graft. Routine biopsies are performed on the sentinel flap and the facial allograft is biopsied only when the histopathology of the graft demonstrates a Grade I rejection or higher.[2] Harvesting the sentinel flap is an added challenge, especially since it is ideal to harvest prior to aorta cross-clamp to minimize ischemia time and prevent thrombus. Reported flaps used as sentinel flaps are the radial forearm flap, which have generally been inset into the groin of the recipient.[3] However, the radial forearm flap harvest places the procuring surgeon in the midst of the solid organ procurement teams, thus potentially complicating solid organ harvesting. We present our experience with the use of the posterior tibial artery flap as a sentinel flap in facial vascularized composite tissue allotransplantation. This flap is an ideal donor sentinel flap due to its location far from both the face transplant and solid organ procurement teams, its reliable vascular pedicle, and its ease of harvest.[4] We demonstrate the first utilization of this flap and believe that the use of this flap could maximize the ability for solid organ transplant teams to simultaneously perform solid organ harvesting while the sentinel flap is being raised, thus enabling a more streamlined process and better coordination in composite tissue allotransplantation.