Facial Vascularized Composite Allotransplantation Research Articles

Complex facial reconstruction by vascularized composite allotransplantation: The first Belgian case

Complex injuries to the central part of the face are difficult to reconstruct with the current plastic surgery methods. The ultimate one-staged approach to restore anatomy and vital facial functions is to perform a vascularized composite allotransplantation (VCA). A 54-year-old man suffered from a high-energy ballistic injury, resulting in a large central facial defect. A temporary reconstruction was performed with a free plicated anterolateral thigh (ALT) flap. Considering the goal to optimally restore facial function and aesthetics, VCA was considered as an option for facial reconstruction. A multidisciplinary team approach, digital planning, and cadaver sessions preceded the transplantation. A digitally planned facial VCA was performed involving the bilateral maxillae, the hard palate, a part of the left mandible, and the soft tissues of the lower two-thirds of the face. Due to meticulous preparations, minimal adjustments were necessary to achieve good fitting in the recipient. At week 17, a grade 4 rejection was successfully treated; sensory and motor recovery was noted to occur from the fourth postoperative month. Several serious infectious and medical problems have occurred until 15-months postoperatively; following that, the clinical situation has remained stable. Two years postoperatively, the patient and his family are very satisfied with the overall outcome and social reintegration in the community is successful. The first face transplant in Belgium (#19 worldwide) was successful because of a meticulous 3-year preparation by a large multidisciplinary team. In our experience, preparatory cadaver dissections and three-dimensional (3D) computed tomographic (CT) modeling were valuable tools for an optimal intraoperative course and good alignment of the bony structures. Continuous long-term multidisciplinary follow-up is mandatory for surveillance of the complications associated with the immunosuppressive regime and for functional assessment of the graft.

Evolving Concepts of Skin and Mucosal Biopsy in Facial Vascularized Composite Allotransplantation

Facial vascularized composite allotransplantation has ushered in a new era in treating complex facial injuries that cannot be reconstructed using traditional techniques. Multiple teams have reported their experiences in monitoring for allograft rejection using skin and mucosal biopsies. The association of biopsy findings and clinical observations are poorly understood and are continuously being redefined. We review the world’s experience in monitoring skin and mucosal histological findings in facial transplantation, review acute rejection, antibody-mediated rejection, chronic rejection, and describe our institutional experience in the monitoring and management of facial allograft histology.

Regulatory T Cells Are Not Predictive of Outcomes in a Nonhuman Primate Model of Vascularized Composite Allotransplantation

T regulatory cells (Tregs) have been associated with prolonged allograft survival and tolerance across a wide variety of species and organ types. We used our nonhuman primate model of facial vascularized composite allotransplantation (VCA) to study the association of Tregs with graft outcomes. We quantified Tregs in peripheral blood and allograft biopsies from nonhuman primates after heterotopic partial facial segment allotransplantation from major histocompatibility complex class I-mismatched donors using flow cytometry and immunohistochemistry. Immunosuppression consisted of tacrolimus and mycophenolate mofetil without induction or depletional therapies. Circulating and graft skin Treg values were compared with graft outcomes and with histologic grade from concurrent biopsies. Treg proportion in peripheral blood ranged from 0.156% to 9.00% with a mean of 3.34%±0.22%. FoxP3 staining was observed in 3 of 29 graft biopsies. Median circulating Treg value did not predict time to Banff grade II rejection (hazard ratio, 0.9; confidence interval, 0.4-2.2) or graft loss (hazard ratio, 0.5; confidence interval, 0.01-5.3). Animals that experienced rejection did not have significantly different peripheral blood or graft skin Treg values from those that did not. Biopsy specimens with grade I or II rejection were more likely to contain Tregs (25% vs. 0%; P=0.044) despite no difference in concurrent circulating Tregs (3.56% vs. 3.36%; P=0.704). These findings in a clinically relevant model suggest that Tregs may have limited prognostic value with standard immunosuppressive protocols used in VCA. Further studies are necessary to determine the specific role of Tregs in VCA and any role of Treg monitoring in clinical practice.

Facial Vascularized Composite Tissue Allotransplantation

Reconstruction of severe composite defects of the face is challenging for reconstructive surgeons. Despite several reconstructive techniques, the functional and aesthetic results of these patients are not acceptable. As a major organ, face, has an utmost importance in daily life. The specific characteristics of face require not a reconstruction, but a replace with same tissue. With the evolution of vascularized composite tissue allotransplantation, successful reconstruction of these defects became into reality. However, this new reconstructive option brings its new problems with it. Today, we are witnesses of evolution of reconstructive surgery to restorative surgery. In this article, this evolution is summarized.

Immunobiology of Face Transplantation

Fourteen face transplants have been performed worldwide since the procedure was successfully introduced in 2005. Vascularized composite tissue allotransplantation may now be considered a viable option for the repair of complex craniofacial defects, for which the results of autologus reconstruction remain suboptimal. However, the benefits must be balanced against the risks inherent in major surgery and the adverse effects of lifelong immunosuppression. In this article, we review the current practice and areas of controversy in facial vascularized composite tissue allotransplantation with particular respect to the unique immunobiology of this procedure. We also describe promising recent advances in immunotherapy and tolerance induction strategies that may soon reach clinical application.

Gestures with objects: Sensorimotor schemes or symbols?

Complex injuries to the central part of the face are difficult to reconstruct with the current plastic surgery methods. The ultimate one-staged approach to restore anatomy and vital facial functions is to perform a vascularized composite allotransplantation (VCA).A 54-year-old man suffered from a high-energy ballistic injury, resulting in a large central facial defect. A temporary reconstruction was performed with a free plicated anterolateral thigh (ALT) flap. Considering the goal to optimally restore facial function and aesthetics, VCA was considered as an option for facial reconstruction. A multidisciplinary team approach, digital planning, and cadaver sessions preceded the transplantation.A digitally planned facial VCA was performed involving the bilateral maxillae, the hard palate, a part of the left mandible, and the soft tissues of the lower two-thirds of the face. Due to meticulous preparations, minimal adjustments were necessary to achieve good fitting in the recipient. At week 17, a grade 4 rejection was successfully treated; sensory and motor recovery was noted to occur from the fourth postoperative month. Several serious infectious and medical problems have occurred until 15-months postoperatively; following that, the clinical situation has remained stable. Two years postoperatively, the patient and his family are very satisfied with the overall outcome and social reintegration in the community is successful.The first face transplant in Belgium (#19 worldwide) was successful because of a meticulous 3-year preparation by a large multidisciplinary team. In our experience, preparatory cadaver dissections and three-dimensional (3D) computed tomographic (CT) modeling were valuable tools for an optimal intraoperative course and good alignment of the bony structures. Continuous long-term multidisciplinary follow-up is mandatory for surveillance of the complications associated with the immunosuppressive regime and for functional assessment of the graft.