Face Transplantation Research Articles

Face transplantation: A longitudinal histological study focusing on chronic active and mucosal rejection in a series with long-term follow-up

The 2007 Banff working classification of skin-containing Tissue Allograft Pathology addressed only acute T cell-mediated rejection in skin. We report the longitudinal long-term histological follow-up of six face transplant recipients, focusing on chronic and mucosal rejection. We identified three patterns suggestive of chronic rejection (lichen planus-like, vitiligo-like and scleroderma-like). Four patients presented lichen planus-like and vitiligo-like chronic rejection at 52±17months posttransplant with severe concomitant acute T cell-mediated rejection. After lichen planus-like rejection, two patients developed scleroderma-like alterations. Graft vasculopathy with C4d deposits and de novo DSA led to subsequent graft loss in one patient. Chronic active rejection was frequent and similar patterns were noted in mucosae. Concordance between 124 paired skin and mucosal biopsies acute rejection grades was low (κ=0.2, p=.005) but most grade 0/I mucosal rejections were associated with grade 0/I skin rejections. We defined discordant (grade≥II mucosal rejection and grade 0/I skin rejection) (n=55 [70%]) and concordant (grade≥II rejection in both biopsies) groups. Mucosal biopsies of the discordant group displayed lower intra-epithelial GranzymeB/FoxP3 ratios suggesting a less aggressive phenotype (p=.08). The grading system for acute rejection in mucosa may require phenotyping. Whether discordant infiltrates reflect a latent allo-immune reaction leading to chronic rejection remains an open question.

Facial Masculinization from Procedures to Payment: A Review.

As the demand for gender-affirming procedures continues to increase, patients and providers have a greater imperative to understand the current state of facial masculinization. Facial reconstruction for transgender women has been shown to treat gender dysphoria effectively and reduce rates of discrimination and victimization. Although facial masculinization surgery for transgender men is less common, there are multiple surgical and nonsurgical options to supplement the effect of hormone therapy on facial appearance, including but not limited to: receding the hair line, flattening the forehead, expanding the supraorbital ridge, increasing the dorsal nasal projection, squaring the jaw, and augmenting the chin. This review aims to summarize these techniques for providers who wish to inform transgender male patients about their options and discuss them in the context of patient satisfaction and availability of insurance coverage.

Discussion: Is Digital Animation Superior to Text Resources for Facial Transplantation Education? A Randomized Controlled Trial.

Chicago, Ill; and Ann Arbor, Mich. From the Division of Plastic and Reconstructive Surgery, Rush University Medical Center; Department of Oral and Maxillofacial Surgery, Michigan Medicine; and University of Michigan Medical School. Received for publication July 6, 2020; accepted January 14, 2021. Disclosure:The authors have no financial interest to declare in relation to the content of this Discussion or of the associated article. Amir H. Dorafshar, M.D., Division of Plastic and Reconstructive Surgery, Rush University Medical Center, 1725 West Harrison Street, Suite 425, Chicago, Ill. 60612, [email protected], @rushplasticsurgery, @rushplasticsresidency

5: Correlation Of Face Transplant Smile Excursion Measurements With Emotional Evaluation By Artificial Intelligence

Purpose:Examining the outcomes and progression of face transplants has expanded to include the recent advancements in artificial intelligence. This novel methodology has allowed for the objective exploration of emotional expression. To our knowledge, this examined emotional expression has yet to be correlated to the hypothesized functioning of the allograft. We have combined the result of the AI software with a software analyzing smile excursion; demonstrating the progression of the allograft in our face transplant patient. This study helps illuminate the software possibilities for objective measures in transplant progression.Methods:Images were analyzed from our face transplant patient post-operatively at approximately 6-month intervals for four years. The still images for each time interval include both a neutral facial expression and a full-face smile with teeth. The images were taken from video clips of the patient and then analyzed using the FACEgram software (Hadlock & Urban, 2012). The measurements of the smile excursion were standardized based off of the pupil diameter and excursion was measured relative to the neutral expression of each time period. The emotional expression data was acquired using FaceReader AI software from Noldus Information Technology (Wageningen, The Netherlands). The emotional analysis was done on 2 second clips from clinical videos of the patient, the same videos used for the still images. This data was correlated with the smile excursion measurements.Results:The post-operative smile excursion analysis from 6 to 49 months demonstrated a near double in smile excursion from 3.58mm to 6.04mm. The smile excursion data has a squared correlation of 0.705; a strong upward linear trend of excursion. From 6 to 35 months, the happy emotion increased gradually from 0% to 15.8% (49-month data unavailable). Performed correlative analysis showed a positive correlation coefficient of 0.63. This moderate to strong correlation demonstrates the intuitive relationship of happy emotion and lip excursion during full face smiling. The findings also substantiate the AI software’s detection of increasing activity in the lip corner puller action unit from zero to 3/5 intensity over the same period.Conclusion:This study demonstrates the correlation of smile excursion to happy emotional expression in our face transplant patient. The correlation square of the lip excursion shows a trend of increased functioning of the allograft over time; substantiating the AI’s finding. This data provides evidence for the use of artificial intelligence as a measure of transplant strength progression. The conjoined analysis of patient images and videos has supported proof for the ability to analyze transplant healing progression and efficacy in an objective form. Hadlock, T. A., & Urban, L. S. (2012). Toward a Universal, Automated Facial Measurement Tool in Facial Reanimation. Archives of Facial Plastic Surgery,14(4). doi:10.1001/archfacial.2012.111

QS3: The Ideal Match: Optimizing Partial Face Transplants In Terms Of Skin Tone Discrepancies

Background:Partial face composite allotransplantation poses a unique aesthetic challenge. Namely, partial face transplants need to resemble the patient’s native skin. The degree of resemblance considered acceptable is a prominent variable and may depend on the gender and underlying skin tone of the recipient. The primary aim of this study was to investigate the degree of skin tone matching deemed aesthetically tolerable, recipient gender, and recipient skin tone. Two populations were queried: (1) the general public and (2) plastic surgeons. Few studies have investigated this topic from either of these standpoints. A secondary aim was to determine whether participant characteristics such as demographics, skin color, and history of having had facial surgery impacted their perceptions.Methods:This was a cross-sectional investigation of perceptions on skin tone matching. Participants from the general public were recruited through Amazon Mechanical Turk and surgeons were recruited through the American Council of Academic Plastic Surgeons. Participants were queried for aesthetic preferences using frontal face photos from age-standardized models. Skin tones of transplanted segments were varied using the Munsell color scale via Adobe Photoshop (Adobe Inc., San Jose, CA).Results:In total, 550 lay participants from Amazon Mechanical Turk and 21 plastic surgeons provided complete survey responses. On average, plastic surgeons tolerated a lesser degree of skin tone discordance than the lay public: 87% of lay participants and 33% of plastic surgeons believed a change of 4 hues was acceptable (p=0.02). Additionally, all survey respondents tolerated less of a degree of skin tone discrepancy on female faces when compared to male faces (mean difference tolerated: 2 hues for females, 4 hues for males). Participants tended to tolerate less skin tone discrepancy in subjects with similar skin tones as their own (mean difference tolerated: 2 hues for own versus 4 hues for different skin tones, p=0.04).Conclusion:This study highlighted the intensely- subjective nature of aesthetic preferences surrounding skin tone matching on the face, which varied by demographics and between surgeons versus the lay public. Surgeons should ensure that they truly elicit their patients’ preferences, especially given that our results demonstrated a greater tolerance for discrepancies among the lay public compared to plastic surgeons. Procuring a graft for facial allotransplantation is challenging; understanding what level of skin tone discrepancy is tolerable to the recipient can help surgeons improve patient satisfaction and may also lessen time-to-transplant by enlarging the potential donor pool for this type of transplant.

Lights, camera, scalpel: a lookback at 100years of plastic surgery on the silver screen.

BackgroundThe presentation of medical topics in the cinema can greatly influence the public’s understanding and perception of a medical field, with regard to the doctors and surgeons, medical diagnosis, and treatment and outcome expectations. This study aims to evaluate the representation of plastic surgery in commercial films that include a character with a link to plastic surgery, either as a patient or surgeon.MethodsThe international film databases Internet Movie Database (IMDb), The American Film Institute (AFI), and British Film Institute (BFI) were searched from 1919 to 2019 to identify feature-length films with a link to plastic surgery. Movies were visualized and analyzed to identify themes, and the portrayal of plastic surgery was rated negative or positive, and realistic or unrealistic.ResultsA total of 223 films were identified from 1919 to 2019, produced across 19 countries. Various genres were identified including drama (41), comedy (25), and crime (23). A total of 172 patient characters and 57 surgeon characters were identified as major roles, and a further 102 surgeons as minor roles. Disparities were noted in presentation of surgeons, both in terms of race and gender, with the vast majority of surgeons being white and male. In total only 11 female surgeons were portrayed and only one black surgeon. Thirteen themes emerged: face transplantation, crime, future society, surgeon mental status, body dysmorphic disorder, vanity, anti-aging, race, reconstructive surgery, deformity, scarring, burns, and gender transitioning. The majority of films (146/223) provide an unrealistic view of plastic surgery, painted under a negative light (80/146). Only 20 films provide a positive realistic image (24/77).ConclusionsThere exists a complicated relationship between plastic surgery and its representation on film. Surgical and aesthetic interventions are portrayed unrealistically, with surgeons and patients presented negatively, perpetuating stigma, particularly with regard to cosmetic surgery. Cinema is also characterized by lack of representation of female and non-white surgeons. Recruitment of surgeons as technical advisors would help present a more realistic, representative view, without necessarily sacrificing creativity.Level of evidence: Not ratable.

The four category systematic approach for selecting patients for face transplantation

There is a need for a systematic approach to evaluate patients for potential face transplantation (FT). Ten patients with severe facial defects treated between 1995 and 2017 formed the study group. Data was collected from patient charts and clinical, radiological and laboratory examinations. Facial deficiencies were subdivided into four different categories: anatomical region (10 facial subunits), facial function, aesthetic defect (range 0–9-worst), and impact on health-related quality of life (HRQoL) (15D questionnaire, range 0–1). Immunological status and possible contraindications were also evaluated. Defect aetiology consisted of burns (4), ballistic injury (3), blunt injury (1), blast injury (1), and neurofibromatosis type I (1). All patients had central facial deficiencies and 6 patients had 8 to 10 injured facial subunits. All patients had at least partial loss of facial function. The mean aesthetic disfigurement score was 6.4. The median lowering of 15D score was −0.107. None were significantly sensitized although four patients had relative contraindications and one patient had an absolute contraindication for FT. Three patients with a severe overall facial deficiency were considered as potential FT candidates. We herein propose a comprehensive and systematic tool to evaluate potential candidates for FT. This approach includes assessment of 4 key categories: anatomical regions affected, facial function, aesthetics, and HRQoL.

Representation of Ethics in the Plastic Surgery Literature: A Systematic Review.

A 2009 systematic review demonstrated that ethical discourse was underrepresented in the plastic surgery literature; approximately one in 1000 articles contained ethical discussions. In the decade since, advances in plastic surgery and continued social progress have created new ethical dilemmas. However, it is unclear whether these developments have augmented the representation of ethics in the plastic surgery literature. A review of publications over the past decade can assess whether progress has been made and identify where deficits persist. The authors searched eight bibliographic databases to identify peer-reviewed articles discussing ethical issues in plastic surgery over the past decade. Independent reviewers extracted characteristics and ethical principles from included articles. A total of 7097 articles were identified from the initial search and 531 articles were included for analysis. The principle of autonomy, present in 87.9 percent of articles, had the greatest representation, followed by beneficence (74.4 percent), nonmaleficence (72.3 percent), and justice (51.2 percent). Informed consent and face transplantation were the most prevalent topics discussed. Aesthetic surgery was the subdiscipline of plastic surgery with the greatest ethical discourse, representing 29.8 percent of all included articles. In the past decade, there was approximately a five-fold increase in plastic surgery publications that include ethical discourse, indicating a growing awareness of ethical implications by the plastic surgery community. However, representation of ethical principles remained uneven, and specific subdisciplines of plastic surgery were substantially underrepresented. Plastic surgeons should adopt a more comprehensive approach when framing ethical implications in clinical and research settings.

Is Digital Animation Superior to Text Resources for Facial Transplantation Education? A Randomized Controlled Trial.

Facial transplantation is a complex surgical procedure that requires education of medical professionals, patients, and the general public. The objective of this randomized controlled trial was to compare the educational efficacy of facial transplantation digital animation versus text resources for teaching medical students a complex surgical procedure and its applicable anatomical and surgical principles. Medical student volunteers were recruited and prospectively randomized to an animation or a text group. Students completed preintervention and postintervention assessments of confidence and knowledge of head and neck anatomy and facial transplantation. Student Evaluations of Educational Quality survey assessed student satisfaction with both tools following study crossover. Knowledge assessment was developed using National Board of Medical Examiners guidelines and content validated by four experts. The Cohen d statistic was used to measure the effect size of each intervention. Thirty-six students were assigned randomly to the animation group (n = 19) or the text (n = 17) group. Postintervention analysis demonstrated significantly higher performance scores in the animation group compared to the text group (p = 0.029). The animation group had a larger effect size (Cohen d = 1.96 versus 1.27). Only students in the animation group reported significantly improved confidence in head and neck anatomy after the intervention (p = 0.002). Both groups demonstrated significantly increased postintervention confidence in knowledge of facial transplantation (p < 0.001). Satisfaction scores revealed that students significantly favored the animation resource (p < 0.001). Animation can be an effective tool for facial transplantation education and results in improved student knowledge, confidence, and satisfaction compared to text resources. Facial transplantation can also be used as an educational framework for teaching medical students anatomical and surgical principles.

Face Transplants: An International History.

Face transplants have attracted global media and public attention since the 1990s. The first recipient, Isabelle Dinoire, found herself at the centre of a dramatic episode of surgical innovation after her transplant was announced in November 2005. Subsequently 47 transplants have been conducted worldwide (including two retransplants) up to August 2020, and these have been accompanied by extensive news coverage. Hundreds of papers on the medical, physical, psychological, and ethical implications of the procedure have been published in the scientific literature, disproportionate to the incidence of the procedure. Face transplants have also featured in films, television, and fiction, indicating an appetite for interrogating the social and interpersonal implications of facial difference. However, the history of facial transplantation has largely been unexplored.This article provides the first international history of the global development and implementation of facial transplantation. Using published medical literature, media coverage, and oral history interviews with key participants as source material, it situates the experimental transplant in national, institutional, and professional contexts. It argues that charting the history of face transplants over a 30 year period from initial discussions in 1991 to the present provides a valuable case study through which to consider surgical cultures and discourses of medical innovation in the twenty-first century.

Partial Heterotopic Hindlimb Transplantation Model in Rats.

Vascularized composite allotransplantations (VCA) represent the most advanced reconstruction option for patients without autologous surgical possibilities after a complex tissue defect. Face and hand transplantations have changed disfigured patients' lives, giving them a new aesthetic and functional social organ. Despite promising outcomes, VCA is still underperformed due to life-long immunosuppression comorbidities and infectious complications. The rat is an ideal animal model for in vivo studies investigating immunological pathways and graft rejection mechanisms. Rats are also widely used in novel composite tissue graft preservation techniques, including perfusion and cryopreservation studies. Models used for VCA in rats must be reproducible, reliable, and efficient with low postoperative morbidity and mortality. Heterotopic limb transplantation procedures fulfill these criteria and are easier to perform than orthotopic limb transplants. Mastering rodent microsurgical models requires solid experience in microsurgery and animal care. Herein is reported a reliable and reproducible model of partial heterotopic osteomyocutaneous flap transplantation in rats, the postoperative outcomes, and the means of prevention of potential complications.

Complementary Phenomena: Phantom Hand and Phantom Face.

After tissue or limb loss, the development of sensation and perception of the lost or deafferent tissue is defined as a phantom phenomenon. We investigated the presence of phantom phenomena in individuals who underwent a full face transplant as well as those who had a hand transplant. Specifically, we investigated sensory perception of the face on the fingers and sensory perception of the fingers on the face in three full face and four hand transplant patients. In all seven individuals, we used a brush to separately stimulate the right and left sides of the face or the palmar and dorsal faces of the hand. We then asked the individuals if they felt a sensation of touch on any other part of their body and, if so, to describe their perceptions. Changes in the regions of the primary sensory cortex representing the hand and face were defined using fMRI obtained via tactile sensory stimulation of the clinical examination areas. Two of the full face transplant patients reported sensory perceptions such as a prominent sensation of touch on their faces during sensory stimulation of their fingers. Three of the hand transplant patients reported sensory perceptions, which we referred to as finger patches, during sensory stimulation of the face area. In fMRI, overlaps were observed in the cortical hand and face representation areas. We consider the phantom hand and phantom face phenomena we observed to be complementary due to the neighborhood of the representations of the hand and face in the somatosensory cortex.

Facial Transplantation: Principles and Evolving Concepts.

After studying this article, the participant should be able to: 1. Appreciate the evolution and increasing complexity of transplanted facial allografts over the past two decades. 2. Discuss indications and contraindications for facial transplantation, and donor and recipient selection criteria and considerations. 3. Discuss logistical, immunologic, and cost considerations in facial transplantation, in addition to emerging technologies used. 4. Understand surgical approaches and anatomical and technical nuances of the procedure. 5. Describe aesthetic, functional, and psychosocial outcomes of facial transplantation reported to date. This CME article highlights principles and evolving concepts in facial transplantation. The field has witnessed significant advances over the past two decades, with more than 40 face transplants reported to date. The procedure now occupies the highest rung on the reconstructive ladder for patients with extensive facial disfigurement who are not amenable to autologous reconstructive approaches, in pursuit of optimal functional and aesthetic outcomes. Indications, contraindications, and donor and recipient considerations for the procedure are discussed. The authors also review logistical, immunologic, and cost considerations of facial transplantation. Surgical approaches to allograft procurement and transplantation, in addition to technical and anatomical nuances of the procedure, are provided. Finally, the authors review aesthetic, functional, and psychosocial outcomes that have been reported to date.

The 2020 Facial Transplantation Update: A 15-Year Compendium.

SummaryOver the past 15 years, landmark achievements have established facial transplantation (FT) as a feasible reconstructive option for otherwise irreparable craniofacial defects. However, as the field matures and long-term outcomes begin to emerge, FT teams around the world are now facing new challenges. Data for this review were identified by searches of the PubMed/MEDLINE database from inception through August 2020. All English-language articles pertaining to FT were included. Significant advances in candidate selection, technology, operative technique, posttransplant care, and immunosuppressive management have contributed to the tremendous expansion of the field, culminating in the execution in the past 3 years of 2 facial re-transplantations, and most recently the world’s first successful combined face and double hand transplant in August 2020. Despite these achievements, the allograft donor pool remains limited, with long wait times, requiring surgical experimentation with cross-sex FT. Immunosuppressive management has improved, but significant adverse events continue to be reported. Most recently, the COVID-19 pandemic has placed an unprecedented strain on the healthcare system, with various implications for the practice of reconstructive transplantation. In this article, we provide the most comprehensive and up-to-date FT review, highlighting fundamental lessons learned and recent advancements, while looking toward the challenges ahead. Over the past 15 years, extensive multidisciplinary efforts have been instrumental to the establishment of FT as a feasible reconstructive option. As novel challenges are beginning to emerge, continued collaborative and multispecialty research efforts are needed to further this field.

Agarose composite hydrogel and PVA sacrificial materials for bioprinting large-scale, personalized face-like with nutrient networks

Large, deep, complex, and severe tissue defects and deformities of the face are the problems encountered in clinical practice. Autologous tissue reconstruction or allograft face transplantation has been adopted but has problems such as blood supply difficulties, collateral damage, immune rejection, and ethical disputes. 3D bioprinting enables personalized tissue regeneration. However, simple hydrogels are prone to collapse during printing, are limited in size, and have poor shape and structure. The present study used three polysaccharide hydrogel composites of nanocellulose, agarose, and sodium alginate with seeded cells as bioinks and polyvinyl alcohol (PVA) as sacrificial material to construct the structures that did not collapse (characteristic parts, such as lips and nose). The nutrient network gradually formed a blood vessel-like structure. The hydrogels prepared using these three polysaccharides have great potential in the construction of personalized, complex, and vascularized tissue-engineered anatomical faces and provide a new strategy for autologous full face reconstruction.

Central importance of emotional and quality-of-life outcomes in the public's perception of face transplantation.

Face transplantation is a surgical innovation to manage people with severely interrupted facial function and form. How the public perceive face transplantation and its potential implications for the recipient, donor, and society is unclear. The aim of this study was to understand the public perception of face transplantation, including when it is appropriate, what information is required to feel adequately informed, and which factors influence a person's willingness to donate their face. This was a nationwide survey of participants representative of the GB public. A quantitative analysis was performed. Free-text qualitative responses were coded with thematic content analysis and a narrative analysis was constructed. The survey included 2122 participants. Face transplantation was considered worth the potential risks if it improved an individual's quality of life, gave them a 'normal life', and/or increased their confidence and social interaction. Respondents were worried about the impact face transplantation might have on donor families, especially recipient families adapting to the identity of the donor. Respondents most concerned about the concept of face transplantation were aged at least 55 years (χ2(4) = 38.9, P < 0.001), women (χ2(1) = 19.8, P < 0.001) , and Indian/Asian (χ2(4) = 11.9, P = 0.016). The public perceive emotional and psychological outcomes as equally as important as, or more important than, surgical outcomes when determining the appropriateness of face transplantation. Future research should focus on measuring and describing emotional and psychological outcomes after face transplantation.

‘That is the skin of my brother’: alterity, hybridity and media representations of facial transplantation

In this paper, I explore the 2012 face transplant performed on US recipient Richard Norris and how it was represented by the media as a ‘makeover story’. Informed by press...

Maxillofacial Bony Considerations in Facial Transplantation.

Alloplastic facial transplantation has become a new rung on the proverbial reconstructive ladder for severe facial wounds in the past couple of decades. Since the first transfer including bony components in 2006, numerous facial allotransplantations across many countries have been successfully performed, many incorporating multiple bony elements of the face. There are many unique considerations to facial transplantation of bone, however, beyond the considerations of simple soft tissue transfer. Herein, we review the current literature and considerations specific to bony facial transplantation focusing on the pertinent surgical anatomy, preoperative planning needs, intraoperative harvest and inset considerations, and postoperative protocols.

Facial Transplantation: A Dilemma of the Four Basic Medical Ethics Principles.

Facial Transplantation: A Dilemma of the Four Basic Medical Ethics Principles.

Successful Treatment of Life-Threatening COVID-19 Infection in a Face Transplant Recipient.

Recent literature suggests that severe COVID-19 is associated with an exaggerated immune response during viral infection, resulting in cytokine storm. Although elevated plasma interleukin 6 (IL-6) has been reported in severe COVID-19 infections, and treatment with anti–IL-6 (tocilizumab) has demonstrated promising outcomes both domestically and abroad, reports remain limited and therapeutic regimens vary considerably. Furthermore, research pertaining to transplant recipients, COVID-19 infection, and anti–IL-6 therapy remains underdeveloped. Herein, we report the successful treatment of the only reported facial vascularized composite allograft (VCA) recipient who contracted severe COVID-19 and the first reported VCA recipient with COVID-19 infection that received anti–IL-6 immunotherapy resulting in an excellent recovery despite his multiple preexisting and COVID-19–related comorbidities—adult respiratory distress syndrome, acute renal failure requiring hemodialysis, and concomitant sepsis due to extensive drug-resistant bacterial pneumonia upon presentation. To date, he has not demonstrated any anti-IL-6 drug-related adverse effects. This preliminary report also suggests that our immunosuppressed VCA patients can indeed demonstrate a robust cytokine response during COVID-19 infection and may also respond favorably to emerging anticytokine immune therapies. We hope that our experience proves helpful to other centers that might encounter critically ill VCA recipients in the ongoing COVID-19 pandemic and in the years to follow.