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Face Transplantation: on the Verge of Becoming Clinical Routine?

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Face Transplantation: on the Verge of Becoming Clinical Routine? Hindawi Publishing Corporation BioMed Research International Volume 2014, Article ID 907272, 9 pages http://dx.doi.org/10.1155/2014/907272 Review Article Face Transplantation: On the Verge of Becoming Clinical Routine? Ralf Smeets, Carsten Rendenbach, Moritz Birkelbach, Ahmed Al-Dam, Alexander Gröbe, Henning Hanken, and Max Heiland Department of Oral and Maxillofacial Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany Correspondence should be addressed to Ralf Smeets; [email protected] Received 11 December 2013; Revised 15 February 2014; Accepted 21 May 2014; Published 9 June 2014 Academic Editor: Andrea Ferri Copyright © 2014 Ralf Smeets et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Introduction. Face transplantation (FT) is an innovative achievement of modern reconstructive surgery and is on the verge of becoming a common surgical opportunity. This review article was compiled to provide an update on this surgical field, especially regarding clinical outcomes, benefits, and complications implied. Methods. We performed an extensive research on all English- language Medline articles, case reports, and reviews published online until September 15, 2013. Used search terms were “face transplantation,” “face transplant,” “facial transplantation,” “facial transplant,” “face allograft,” and “facial allograft.” Results.Todate 27 FTs have been performed worldwide. 19 of these cases have been published in the Medline database. Long-term follow-up reports of FT cases are rare. Three deaths associated with the procedure have occurred to date. The clinical outcomes of FT are satisfying. Reinnervation of sensation has been faster than motor recovery. Extensive functional improvements have been observed. Due to strict immunosuppression protocols, no case of hyperacute or chronic rejection and no graft-versus-host disease have occurred to date. Conclusions. As studies on long-term outcomes are missing, particularly regarding immunosuppression-related complications, FT will stay experimental for the next years. Nevertheless, for a small group of patients, FT already is a feasible reconstructive option. 1. Introduction been held since 2002 [1–6], face transplantation (FT) has become this viable alternative. The reconstruction of acquired facial defects and deformity FTispartofthevascularizedcompositetissueallo- resulting from trauma, burns, and tumor resection has always transplantation (VCA) concept referring to all nonorgan been a great challenge for surgeons as the head and neck transplants and combining bone, tendons, muscles, nerves, region provides complex anatomy and essential functions vessels, and skin. It couples the principles of microsurgical decisively contributing to each patient’s quality of life. Sur- reconstruction with those of human organ transplantation [7] gical intervention should ideally result in both functionally andhastherebyopenednewpossibilitiesinthereconstruc- and aesthetically satisfying results not last because the face tion of severely disfigured patients [8]. Since the first FT was contributes to each patient’s identity formation and as this successfully performed in 2005 [9] at least 26 procedures fol- part of the body is always exposed, thus providing the basis lowed in 7 countries and this new surgical field seems to mark for social interaction. transition from an experimental status to a common standard As conventional surgical procedures such as local or free procedure. However, as severe complications including the flap transfers do not comply with these requirements in cases decease of three patients have been observed and as there are of extensive damage or loss of greater parts of the face involv- only few data regarding long-term follow-up, a new debate ing multiple tissues, innovative therapeutic strategies had to has been raised [10]. be developed. Despite the fact that intensive discussions on This review article was compiled to provide an extensive dreaded and substantiated advantages and disadvantages had overview and update on the world’s experience with facial 2 BioMed Research International Table 1: Inclusion and exclusion criteria of the literature research. Database searches, number of hits Inclusion criteria Exclusion criteria Initial search Pubmed/Medline: 192 ✓ ✓ English-language papers Cadaver study EMBase: 278 ✓ Human study ✓ Anatomical study ✓ Case reports ✓ Experimental study −83: duplicates ✓ Original articles ✓ Brief communications ✓ Review articles ✓ Letters and comments Title and abstract 194 research articles transplantation. The main outcome of the study was to identify the peculiarities and commonalities of all reported −155: not meeting inclusion criteria FT cases until 2013, with special regard to the clinical outcome and complications implied. Specific aims of this paper were to analyze preoperative, surgical, and logistic aspects as well Full text 36 research articles astheclinicalandpsychologicaloutcomeofallFTcasesin dependence of these surgical considerations. In particular we addressed the question of whether the kind of performed +2: media reports nerve repair had an influence on the time span until sensor recovery reoccurred. Further the study aimed to analyze the immunological protocols that were used. Final set 38 references 2. Material and Methods Figure 1: Flow diagram of the inclusion process. In order to generate this retrospective review article on thecurrentstatusandclinicaloutcomesoffacialtransplan- tation, we first performed an extensive literature research measures were donor and recipient age difference in means, on Medline (http://ncbi.nih.gov/Pubmed)andonEMBase surgical duration on average, follow-up period on average, (http://elsevier.com/online-tools/embase). Search terms used and sensory and motor recovery in months in dependence included face transplantation, face transplant, facial transplan- on the kind of performed nerve repair. No additional analyses tation, facial transplant, face allograft, and facial allograft pub- were performed. lished online until September 15, 2013. Only English-language articles on humans with an abstract provided were listed. This initial research generated 192 articles on Medline and 3. Results and Discussion 278 articles on EMBase. First of all, duplicates were removed. All entries were then screened by two authors for relevance 3.1. Main Characteristics. As far as reported 27 face trans- according to our predefined inclusion and exclusion criteria plantations have been performed to date in France (n = (Table 1). Only articles containing information of at least 9), the United States of America (n = 7), Turkey (n =5), one FT recipient or FT procedure regarding indications, Spain (n =3),China(n =1),Belgium(n = 1), and Poland harvesting procedure, microsurgical aspects, clinical and psy- (n = 1). 19 of these cases have been published on Medline. chological outcomes, and therapeutic or immunosuppressive Based on the number of cases, most experience exists at the strategies were included in the compilation of our review. University Hospital Henri Mondor, Creteil,´ France (Lantieri Only case reports, original articles, and review articles were et al.), and at Brigham and Women’s Hospital, Boston, USA taken into consideration. According to our inclusion and (Pomahac et al.). Tables 2, 3, 4 and 5 provideanoverview exclusion criteria, finally 36 articles were included in the com- on the main characteristics of all procedures. The average pilation of our review [8, 9, 11–44]. Additionally information age of the recipients was 34.6 ± 10.0 years, ranging from was gathered from scientific meeting presentations and from 19 to 59 years. The average age of the donors was 39.7 ± media reports, especially those concerning the latest cases 13.0 years (19 to 65 years). Age disparity between donor and with a follow-up period of less than one year. The concept of recipient varied from 1 year to 36 years. Eight recipients our literature search is provided in Figure 1. were more than 10 years younger than their corresponding In order to create an overview on the differences and donor. The recipient male-to-female ratio was 21 : 5. To date peculiarities of the single FT cases, all articles were sys- there are 3 deaths associated with the procedure, representing tematically screened for the outcome of interests listed in 11.1% of all recipients. One patient died 27 months after Tables 2, 3, 4(a, b), and 5. Data extraction of each article surgery because of a lack of compliance considering the was performed by two of the primary authors. Each article immunosuppressive therapy [10]. The second case of death wasanalyzedtwiceanduncertaintiesandtheriskofbias has occurred in the third French recipient due to prolonged of individual articles were addressed by discussion with the anoxic cardiac arrest following multidrug-resistant infections seniorauthors.RelevantdatawasfinallylistedinanExcel and consequent graft necrosis [11]. The third patient deceased table for comparison and measurements. Principal summary in July 2013 after suffering from recurrent cancer [45]. BioMed Research International 3 Table 2: Main characteristics of the first 27 face transplantations. Number Year City & team leader R sex, age D age Indication Type SD (h) FUP (y) 1 11/2005 Devauchelle F, 38 46 Animal attack Partial 15 7.8 Amiens, France myocutaneous ∗ 204/2006
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