Face Transplantation Research Articles

Ethics of Facial Transplantation: The Effect of Psychological Trauma Associated With Facial Disfigurement on Risk Acceptance and Decision Making.

This study examines and contrasts the effect of risk disclosure on risk acceptance and perceived changes in quality of life (QoL) among individuals with and without facial disfigurement. Psychological distress has been previously shown to alter patients' perception of certain treatments. Due to the grave risks and complications of FT, it is important to understand whether the psychological trauma associated with facial disfigurement alters their perception of FT and its associated risks. Participants with and without facial disfigurement were recruited to complete a questionnaire about their perceived QoL, sense of identity, and willingness to proceed with FT in the context of 3 different hypothetical scenarios involving facial disfiguration. Four hundred nine nonfacially disfigured and 74 facially disfigured participants were included. When both healthy and facially disfigured individuals were presented with the risks and benefits of a FT, they both perceived their QoL to be as low, or significantly lower, than if they had severe facial disfigurement. Furthermore, presenting the risks of FT significantly altered the decision making and risk acceptance of healthy individuals with no facial disfigurement. However, risk disclosure did not affect the decision making among facially disfigured individuals. This study highlights that presenting the complication profile of FT decreases risk acceptance of FT in healthy individuals but has no significant effects on facially disfigured individuals. The psychological impact of facial disfigurement and its influence on accepting the significant risks of FT should be considered and warrants further investigation.

Should We Consider Preparing Patients for Future Face Transplant when Managing Complex Facial Trauma?

Summary:With advancements in microsurgical technique and experience, face transplantation is becoming a clinical reality and acceptable procedure. Preparation of the maxillofacial skeleton and initial soft-tissue coverage for face transplant candidates is essential for optimizing the ultimate outcome by providing immediate coverage of vital structures, functionality, and a stable skeletal framework. We present our experience of preparing such a patient who underwent a successful face transplant, with an excellent outcome. A 24-year-old man sustained a self-inflicted ballistic injury to his face. Composite tissue deficits included significant soft-tissue loss in the central lower and midface, comminuted fractures of midface, and large bone gaps of the maxilla and mandible. He underwent open reduction internal fixation of bilateral LeFort III, zygomaticomaxillary complex, and complex maxillary and mandibular fractures with titanium plates and a free anterolateral thigh perforator flap to the midface with concomitant pedicled left supraclavicular artery fasciocutaneous flap to the lower face. He subsequently underwent a second free anterolateral thigh perforator for the exposed mandibular hardware due to partial necrosis of the supraclavicular artery fasciocutaneous flap. The patient achieved stable bone reconstruction and soft-tissue coverage and was discharged home. He was placed on the waiting list for a face transplant by another center in the country and eventually underwent a successful face transplant. We believe that the preparation of the patient with complex craniomaxillofacial trauma for face transplant should be considered when the extent of injury exceeds conventional reconstructive limits. Our approach provides the best opportunity for an optimal face transplant outcome while minimizing flap donor site morbidity.

Reply re: "Facial Transplantation and Ocular Considerations".

Greenfield, Jason A. B.A.; Kantar, Rami S. M.D., M.P.H.; Rifkin, William J. B.A.; Sosin, Michael M.D.; Diaz-Siso, J. Rodrigo M.D.; Patel, Payal M.D.; Fleming, James C. M.D.; Iliff, Nicholas T. M.D.; Lee, Bradford W. M.D., M.Sc.; Rodriguez, Eduardo D. M.D., D.D.S. Author Information

Vascularized composite allotransplantation in the United States: A retrospective analysis of the Organ Procurement and Transplantation Network data after 5years of the Final Rule.

On July 3, 2014, the Organ Procurement and Transplantation Network (OPTN) began overseeing vascularized composite allotransplantation/allografts (VCA) in the United States. For the past 6years, centers performing VCAs have been requested to submit data into a biometric repository, in parallel with systems used by solid organ transplant centers. Currently, 62 VCAs are reported in the entire OPTN database, with 36 of these transplants reported as performed after VCA was added to the OPTN Final Rule. Of these 36 recipients, 16 received uterus transplants, most of which (11) occurred from living donors. Ten patients received hand transplants and 6 received face transplants. Two patients received abdominal wall transplants, 1 patient received a scalp transplant, and 1 patient received a penile transplant. The present manuscript represents the query of a nationalized database for VCA type, immunosuppression treatment, and clinical outcomes for VCAs. This manuscript provides a report of the current VCA data reported to the OPTN after the Final Rule.

Indications for and Outcomes of Endoscopic Sinus Surgery and Other Rhinologic Surgery After Facial Transplant

This case series study seeks to identify and describe rhinologic procedures after facial transplants to assess the clinical and radiologic indications for intervention as well as the outcomes after intervention.

4364 Ethicists’ Viewpoints on Face Transplant: A survey study to guide clinical practice

OBJECTIVES/GOALS: Face transplant can offer functional and aesthetic restoration to patients who have exhausted reconstructive options. Ethical issues in face transplant still abound, including that of patient selection. The goal of this study was to assess ethicists’ viewpoints on face transplant. METHODS/STUDY POPULATION: A large-scale online survey of attendees of the International Conference on Clinical Ethics Consultation (N = 401) was performed to assess ethicists’ opinions on issues in face transplant. Questions were asked regarding the risk-benefit ratio of immunosuppression, permissibility of face transplant for more recipient subpopulations (including children and blind patients), donor-recipient age, gender, and ethnicity mismatches, and ethics committee make-up. RESULTS/ANTICIPATED RESULTS: Among 84 respondents, 84% agreed it is permissible to perform a face transplant on an adult with no medical contraindications. The majority of respondents agreed that it is permissible to perform a face transplant on a child or blind recipient. An issue of continued concern was risk of immunosuppression. Respondents had a high threshold of permissibility for ethnic mismatches between donor and recipient, and 43% reported it is permissible to have a gender mismatch. A 10 year age difference between donor and recipient was the most commonly accepted. Questions regarding the ideal composition of a face transplant ethics committee demonstrated consensus on the roles that should be represented. DISCUSSION/SIGNIFICANCE OF IMPACT: This study provides insight into ethicists’ viewpoints on face transplant, which demonstrates a high level of permissibility towards the procedure. This may be due to the early success of face transplants and the shifting ethical issues in the field to practical aspects of the procedure. This research also provides guidance to programs regarding questions of donor and recipient selection, ethics committee composition, and offers insight into strengthening the ethical framework of the field.

Full Facial Allotransplantation Including the Temporomandibular Joints: A Radiologic and Anatomical Cadaveric Study.

Facial allotransplantation including the temporomandibular joints may improve the functional outcomes in face transplant candidates who have lost or damaged this joint. Linear and angular measurements were taken in 100 dry skulls and mandibles and in 100 three-dimensionally-reconstructed facial computed tomographic scans to determine the variability of the temporomandibular joint, glenoid fossa, and mandible. A vascular study was performed in six fresh cadaveric heads, followed by harvest of the face allograft in three heads. Next, four heads were used for mock transplantation (two donors and two recipients). The full facial allograft included four different segments: a Le Fort III, a mandibular tooth-bearing, and two condyle and temporomandibular joint-bearing segments. Statistical analysis was performed using SAS software. In only one-third of the skulls, the condylar shape was symmetric between right and left sides. There was a wide variability in the condylar coronal (range, 14.3 to 23.62 mm) and sagittal dimensions (range, 5.64 to 10.96 mm), medial intercondylar distance (range, 66.55 to 89.91 mm), and intercondylar angles (range, 85.27 to 166.94 degrees). This high variability persisted after stratification by sex, ethnicity, and age. The temporomandibular joint was harvested based on the branches of the superficial temporal and maxillary arteries. The design of the allograft allowed fixation of the two condyle and temporomandibular joint-bearing segments to the recipient skull base, preserving the articular disk-condyle-fossa relationship, and differences were adjusted at the bilateral sagittal split osteotomy sites. Procurement and transplantation of a temporomandibular joint-containing total face allograft is technically feasible in a cadaveric model.

Heterotopic Transplantation of Allogeneic Vertical Rectus Abdominis Myocutaneous Flaps in Miniature Swine

BackgroundVascularized composite tissue allotransplantation (VCA) opens new possibilities for reconstruction of complex tissue defects, including upper extremity and facial transplantation. The main challenges in VCA transplantation are the side effects of long-term immunosuppression and chronic graft rejection. Translational preclinical animal models are crucial for VCA research to improve clinical outcomes and to study underlying immunologic mechanisms. Herein, we describe a novel, large animal, non–bone-bearing VCA model in inbred, swine leukocyte antigen–typed miniature swine. MethodsTransplantation of vertical rectus abdominis myocutaneous (VRAM) flaps was performed between fully swine leukocyte antigen–mismatched miniature swine. The flaps were transferred to the posterolateral aspect of the neck of recipients and anastomosed to the common carotid artery and internal jugular vein. Different immunosuppressive drug regimens were used. Clinical graft evaluation was performed daily, and punch biopsies were taken for histology. ResultsTen VRAM transplants were performed. The mean ischemia time was 89.4 min (SD ± 47), mean pedicle length 7.5 cm (SD ± 2), mean venous diameter 2.5 mm (SD ± 0.4), and mean arterial diameter 2.2 mm (SD ± 0.3). Follow-up demonstrated good correlation between clinical appearance and progression of graft rejection confirmed by histologic assessment. Complications were intraoperative cardiac arrest in one recipient and one flap loss due to venous compromise. ConclusionsVRAM transplantation in miniature swine is an appropriate preclinical VCA model, with the advantage of good clinical and histologic correlation during the course of rejection, as well as easy access to the graft. The availability of inbred, haplotyped animals allows studies across different major histocompatibility complex barriers in a non–bone-bearing VCA.

Validation of Animal Models for Facial Transplantation Research

BackgroundThe development of consistent animal experimental models is important for continued research on specific biological and immunologic aspects of vascularized composite allografts. It is also important for the translation of immune regulation and tolerance induction strategies and treatment ideas from bench to bedside. The purpose of our study is to provide an outline of the use of animal models in simulated facial transplant surgery and to investigate the feasibility of animal model use. MethodsThe animals underwent hemifacial flap transplant surgery. The flaps were placed on the external carotid artery and external jugular vein of the donor animal. Twenty-one procedures were performed in 4 different animals (6 rats, 5 rabbits, 6 dogs, 4 pigs). Two experienced plastic surgeons and 5 students performed allotransplant. ResultsAll 4 models were suitable for facial allotransplant with different anatomic characteristics. Average feasibility scores were 4.8 for pigs, 3.6 for rabbits, 3.2 for dogs, and 3.4 for rats. Evaluations concluded that pigs were the most practical and realistic models for facial allotransplant training. Other models achieved validation thresholds. ConclusionsThis study is the first comparative validation assessment of animal models used in facial allotransplant. It supports the use of pig models for surgical skills training. Pigs were the preferred simulation models, while rats, rabbits, and dogs were considered inferior models for transplant simulation.

Establishing Photographic Standards for Facial Transplantation: A Systematic Review of the Literature.

Background:Photography provides a means for objective assessment and dissemination of clinical information. The American Society of Plastic Surgeons (ASPS) and Plastic Surgery Foundation (PSF) published photography guidelines in 2006 to optimize its clinical use. However, photographic documentation of outcomes in facial transplantation (FT) continues to lack standardization. We therefore appraised the current state of FT photography in the peer-reviewed literature.Methods:A PubMed search was conducted from July 2005 to July 2019. Studies containing photographs of partial or full FT recipients were included. Non-English language articles, cadaveric and animal studies, technique papers, and case reports were excluded. Data were extracted from 91 articles. Adherence rates were calculated to determine whether published FT photographs followed ASPS/PSF guidelines. Proposed photographic standards particular to FT were then formulated to guide standardization of practice.Results:Only 28.6% (26/91) of articles adhered to the photographic conventions of preparation, positioning, and views. Of 162 patient appearances in the 91 articles, 95% (154/162) met the criteria for preparation, 98.8% (160/162) met the criteria for positioning, but only 24.7% (40/162) met the criteria for views.Conclusions:Photographic documentation of FT outcomes in the peer-reviewed literature is limited, with inconsistent adherence to ASPS/PSF guidelines. There is substantial deficiency in provision of alternative views, with the majority of publications only depicting the frontal view. FT photography standards should specifically incorporate alternative views, proper lighting and framing, and elimination of distractions, and accommodate for remote patient self-photography. This will promote a transparent and consistent longitudinal evaluation of the surgical results.

What's next in facial transplants?

What's next in facial transplants?

Abstract 50: Occlusal & Dental Outcomes Following Facial Allotransplantation

Purpose: Most of the literature surrounding face transplantation focuses on immunology, function, and psychology. Dental and orthognathic outcomes remain persistently underreported. This study sought to review the worldwide face transplant experience, and for the first time, evaluate dental, orthognathic, and skeletal outcomes. Methods: All composite allografts containing maxilla and/or mandible with alveolus were examined, and dental and orthognathic complications recorded. Clinical photographs, radiographs, and/or CT scans from the literature were analyzed using Angle’s Classification, cephalometrics, and facial profile angles. The most recent orthognathic outcomes of our three facial transplant patients are also presented. Results: The worldwide experience consists of 45 face transplantations; 25 patients received allografts containing maxilla or mandible, and 16 (64%) involved double-jaw. All documented patients had at least one dental/occlusal complication: TMJ ankylosis (9/25, 36%), dental caries and extractions (32%), palatal fistula (28%), Angle class II malocclusion (24%), class III (12%), open bite (20%), maxillary rotation (8%), skeletal non-union (8%), hardware infection (4%); 28% of patients underwent revision surgeries involving Lefort I, III, or mandibular osteotomies. Imaging conducive to Angle, cephalometric, or facial profile angle analysis was available in 100% (7) of reported maxilla, and 63% (10) of double jaw transplants. The majority of maxilla-only transplants had insufficient teeth, while soft tissue profile was most commonly class II. Double jaws were equally Angle class I, II, or III, but mostly class I or class III with regard to facial angle profile. All of our patients have received maxilla and/or mandible, and all have required dental extractions. Angle classification, cephalometrics, and facial profile angles vary across our patients, while class III soft tissue facial profile appears to predominate. Conclusion: Dental and orthognathic complications remain extremely common but underreported after facial allotransplantation involving either single or double jaw composites. In fact, every documented face transplant has at least one occlusal or skeletal defect. The risk of malocclusion increases with simultaneous transplantation of maxilla and mandible, and often necessitates revision surgery in this unique population. Craniofacial principles and advanced surgical planning should be utilized to achieve facial balance. Additionally, we must standardize the way in which face transplant patients are presented in the literature.

Hemi-tongue Allograft Transplantation in Dogs.

Background:When complete recovery of tongue function following tumor excision is desired, reestablishment of the complex movements of the tongue is necessary. However, currently available methods for recovery of tongue function, such as flap surgery or prosthesis insertion, are inadequate. In the current study, we investigated the effects of transplantations of tongue allografts.Methods:Hemi-tongue allotransplantation procedures were performed with 8 pairs of sex-blind and unrelated beagle dogs. In each donor, the right side of the tongue, including the lingual and hypoglossal nerves, extrinsic muscles of the tongue, mucous membrane of the oral floor, lingual artery, and vein were exposed. A vascularized transplantation method was used with manual anastomosis of the blood vessels and nerves.Results:Survival of the grafted tongue was only noted in 1 dog that died 5 days after transplantation. We suspected that the death was due to nutritional deficiency or dehydration, rather than hyperacute rejection of the transplant or technical failure of the microsurgical anastomosis. The grafted tongue was partially connected to the side of the recipient tongue, and lymphocyte infiltration was observed in this dog.Conclusions:Postoperative management is difficult in dogs. Even if tongue allograft including nerves and extrinsic muscles is performed, it seems to take a long time before the tongue recovers its functions. Furthermore, expansive tongue allograft was too invasive a treatment for animals. If we want to adapt this procedure to humans, the first trial in a human will be done without animal experiments, as was the case with face transplantations.

Face transplants as surgical acts and psychosocial processes

Face transplants as surgical acts and psychosocial processes

Mixed Reality and 3D Printed Models for Planning and Execution of Face Transplantation.

The aim of this study was to evaluate a novel holographic craniofacial surgical planning application and its implementation throughout the planning and operative stages of facial transplantation by performing a critical analysis of comparative utility, cost, and limitations of MR and 3D printing. Face transplantation is a highly complex form of craniofacial reconstruction requiring significant planning, knowledge of patient-specific spatial relationships, and time-sensitive decision making. Computer-aided 3D modeling has improved efficiency and outcomes of complex craniofacial reconstruction by enabling virtual surgical planning and 3D printed model generation. MR technology can enhance surgical planning, improve visualization, and allow manipulation of virtual craniofacial biomodels within the operative field. Accounting for the time-sensitive nature of face transplantation, a unique, highly coordinated workflow for image acquisition and processing was designed to facilitate rapid holographic rendering and 3D printing. During recent face transplantation, both holographic and 3D printed models were utilized, and the time and cost of fabrication were compared. Holographic models required less time and cost for fabrication. They provided both comprehensive visualization of 3D spatial relationships and novel means to perform VSP and virtual face transplantation by interacting with and manipulating patient-specific, anatomic holograms. Time efficiency, low-cost biomodel production, provision of unlimited preoperative surgical rehearsal, and potential for intraoperative surgical guidance makes holographic VSP and MR highly promising technology for use in complex craniofacial surgery.

Vascularized Composite Allotransplantation 2.0: The Future Is Now.

Landmark achievements have shaped the modern history of vascularized composite allotransplantation. From the first clinically successful hand transplant in 1998 to the first face transplant in 2005, the field has expanded to include larynx, abdominal wall, uterus, penis, and lower extremity transplantation. In the field’s third decade, clinicians are faced with unprecedented challenges and opportunities. Long-term outcome data are scarce but encouraging overall. Forty-six face transplants have been performed, with allograft and recipient survival reaching 10 years in the first reported face transplant.1 Another recipient underwent successful facial retransplantation for chronic rejection 8 years after his initial face transplant.2 Uterine transplantation has expanded rapidly, with over 60 transplants performed and live births from both living- and dead-donor allografts. Over 120 hand transplants have been performed, with one recipient’s survival exceeding 20 years with a functional allograft.3 However, little is known about patients who have lost their transplanted allografts, and the role of retransplantation, targeted muscle reinnervation, and myoelectric prosthetics remains to be explored. Cross-sex extremity transplantation has been reported, expanding donor-recipient matching possibilities. Two attempts at combined face and hand transplantation, a quadruple limb transplant, and a triple limb transplant have resulted in allograft loss or recipient death.4 Nonetheless, a cautious diversification in procedural scope remains on the horizon, highlighting the field’s evolving complexity. With operative feasibility no longer in question, new priorities include technical refinement, pharmacologic innovation, and systems-based interventions. Functional and aesthetic quality standards have improved along with operative time, hospital stay, recovery, and rehabilitation. A deeper understanding of complications and timing of secondary revisions has also emerged.5 Translational research efforts focus on nerve regeneration and cortical reintegration, the safety and efficacy of immunosuppression, and the pursuit of immunologic tolerance, and sustainable improvement in quality of life is redirecting clinical focus toward patient-reported outcome research. Finally, coordinated efforts are needed to ensure the financial and logistical viability of vascularized composite allotransplantation within modern health care systems. The steady increase in the number of procedures and vascularized composite allotransplantation centers with varying levels of experience calls for the establishment of clinical standards, quality benchmarks, and appropriate reimbursement schemes. Guideline development, structured data sharing, and thoughtful regulation should be embraced to promote patient safety and well-being if the field is to cement its viability. Although advances in immunology, tissue engineering, and xenotransplantation may eventually redefine the field’s boundaries, clinical transplantation today continues to be limited by its donor pool despite engagement efforts by organ procurement organizations. Media coverage has been extensive but varying in quality, and members of the general public lack access to relevant, reliable, and understandable information. As vascularized composite allotransplantation recipients reintegrate into their communities and new potential candidates seek care, educating the medical workforce is just as crucial. Many training programs, national associations, and published journals have taken the lead in educating the next generation of leaders in comprehensive plastic and reconstructive care. The field has outgrown its experimental origins and is steadily joining the clinical mainstream. The climb is steep, but vascularized composite allotransplantation is an immunologic breakthrough away from formally joining the reconstructive elevator. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No funding was received for this work.

Accelerated chronic skin changes without allograft vasculopathy: A 10-year outcome report after face transplantation

BackgroundLong-term outcomes after face transplantation are rarely reported in the scientific literature. Here we present outcome data of a partial face allograft recipient 10 years after transplantation. MethodsMedical records were reviewed for functional and psychosocial outcomes as well as complications. Histopathologic analyses of autopsy tissues and characterization of skin immune cells were performed. ResultsThe patient retained long-term motor and sensory function, though with a noticeable drop in sensory function after year 5. Social reintegration of the patient was marked by reconnection with his family and participation in public social activities. Immunosuppressive therapy consisted of tacrolimus (target levels 6–8 ng/mL after the first year), mycophenolate, and prednisone, while steroids were completely weaned between years 1 and 7. One acute cellular rejection episode of grade II or higher occurred on average per year and led to chronic skin changes (papillary dermal sclerosis with superficial hyalinization, epidermal thinning with loss of rete ridges, perieccrine fibrosis), but the allograft vessels, muscles, adipose tissue, and bone were spared. Allograft skin was characterized by increased number of CD4+ TNF-α/IL17A producing T-cells as compared with native skin. Long-term kidney function was maintained at 60 mL/min estimated glomerular filtration rate. Unfortunately, the preexisting hepatitis C virus infection with liver cirrhosis was resistant to 3 treatments with new direct-acting antivirals and eventually hepatocellular carcinoma developed, causing the patient’s death 10 years after transplantation. ConclusionThis report suggests that face transplants can maintain their function for at least 10 years. Chronic skin changes can occur independently of allograft vasculopathy.

Is Vascularized Composite Allograft Transplantation Experimental or an Accepted Surgical Procedure: Results from a National Survey.

More than 85 patients have received over 100 hand/arm transplants and more than 35 patients have received full or partial face transplants at institutions around the world. Given over two decades of experience in the field and in the light of successful outcomes with up to 17 years follow up time, should we still consider vascularized composite allograft (VCA) as a research/clinical investigation? We present the results of a nationwide electronic survey whose intent was to gather institutional bias with regard to this question. An 11 question survey that was developed by VCA advisory committee of American Society of Transplantation was sent to all identified Internal Review Board chairs or directors in the United States. We received a total of 54 responses (25.3%) to the survey. The majority (78%) of responses came from either the chairperson, director, or someone who is administratively responsible for an IRB. Though certainly not an exhaustive investigation into each institution's preference, we present a representative sampling. The results of which favor VCA as an accepted clinical procedure given the appropriate setting. Further research is needed to fully ascertain practices at each individual institution.

Face transplantation for massive mandibular defects: considerations for allograft design and surgical planning

Modern face transplant techniques have advanced to allow for the transfer of vascularized skeletal components in addition to overlying soft tissue. This represents significant opportunity for individuals with mandibular defects that are not amenable to traditional reconstruction. Care must be taken when planning and executing transplants with these complex grafts, as satisfactory functional and aesthetic outcomes rely on achieving proper spatial relationships between the mandible, skull base, and midface. Which donor skeletal elements are included in the allograft and how they are harvested are important considerations in this planning and are associated with controversy. To optimize outcomes in the reconstruction of single-jaw defects, some advocate for transplantation of only the affected jaw while others support bimaxillary transplantation. Clinical evidence in this debate is not conclusive at this time. In current practice, including donor dentoalveolar anatomy by utilizing a bilateral sagittal split osteotomy of the mandible is favored to optimize outcomes such as dental occlusion. It has been suggested that harvesting the mandible at the level of the condyle or even the temporal bone may also be possible and may improve temporomandibular joint-related outcomes. Despite encouraging preclinical evidence, these strategies remain controversial. After allograft design, successful mandibular reconstruction with face transplantation relies on surgical precision in the donor and recipient procedures. Computerized surgical planning, computer-aided design and manufacturing, and intraoperative navigation are technologies currently in use to mitigate operative complexity. Results in both cadaveric and clinical face transplantations suggest these technologies are reliable and beneficial, although some room for improvement remains.

Recognizing Emotional Expression as an Outcome Measure After Face Transplant

Limited quantitative data exist on the restoration of nonverbal communication via facial emotional expression after face transplant. Objective and noninvasive methods for measuring outcomes and tracking rehabilitation after face transplant are lacking. To measure emotional expression as an indicator of functional outcomes and rehabilitation after face transplant via objective, noninvasive, and nonobtrusive software-based video analysis. This single-center case-control study analyzed videos with commercially available video analysis software capable of detecting emotional expression. The study participants were 6 patients who underwent face transplant at Brigham and Women's Hospital between April 2009 and March 2014. They were matched by age, race/ethnicity, culture, and sex to 6 healthy controls with no prior facial surgical procedures. Participants were asked to perform either emotional expressions (direct evaluation) or standardized facial movements (indirect evaluation). Videos were obtained in a clinical setting, except for direct evaluation videos of 3 patients that were recorded at the patients' residences. Data analysis was performed from June 2018 to November 2018. The possibility of detecting the emotional expressions of happiness, sadness, anger, fear, surprise, and disgust was evaluated using intensity score values between 0 and 1, representing expressions that are absent or fully present, respectively. Six patients underwent face transplant (4 men; mean [SD] age, 42 [14] years). Four underwent full face transplants, and 2 underwent partial face transplants of the middle and lower two-thirds of the face. In healthy controls, happiness was the only emotion reliably recognized in both indirect (mean [SD] intensity score, 0.92 [0.05]) and direct (mean [SD] intensity score, 0.91 [0.04]) evaluation. Indirect evaluation showed that expression of happiness significantly improved 1 year after transplant (0.04 point per year; 95% CI, 0.02 to 0.06 point per year; P = .002). Expression of happiness was restored to a mean of 43% (range, 14% to 75%) of that of healthy controls after face transplant. The expression of sadness showed a significant change only during the first year after transplant (-0.53 point per year; 95% CI, -0.82 to -0.24 point per year; P = .005). All other emotions were detectable with no significant change after transplant. Nearly all emotions were detectable in long-term direct evaluation of 3 patients, with expression of happiness restored to a mean of 26% (range, 5% to 59%) of that of healthy controls. Partial restoration of facial emotional expression is possible after face transplant. Video analysis software may provide useful clinical information and aid rehabilitation after face transplant.