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Background: A critical barrier to successful limb replantation and allotransplantation is the maximum allowable limb ischemia time of 4 to 6 hours. The current gold standard is to preserve amputated limbs on an ice slurry. Experimental machine perfusion has yielded promising results as an alternative. In particular, hypothermic acellular perfusion has enabled preservation of amputated limbs for up to 12 hours thus far., Methods: Amputated forelimbs of Yorkshire pigs were preserved on static cold storage at 4°C for 4 hours (static cold storage group) or perfused at 8°C for 24 hours (perfusion group) with oxygenated modified STEEN Solution perfusate before replantation. Animals were followed up for 7 days after replantation., Results: Eight animals underwent replantation (cold storage group, n = 4; perfusion group, n = 4). Seventy-five and 100 percent of animals in the static cold storage and perfusion groups survived for 7 days, respectively. Glycogen and adenosine triphosphate remained stable throughout perfusion. Heart and respiratory rate after replantation were increased in the static cold storage group. There was increased damage in muscle biopsy specimens obtained from animals in the static cold storage group after 7 days when compared with those from animals in the perfusion group., Conclusions: Hypothermic acellular ex vivo perfusion of limbs for up to 24 hours enables tissue preservation comparable to that obtained with conventional static cold storage for 4 hours and may reduce muscle damage and systemic reactions on limb replantation. Translation to human limbs may help improve limb replantation and allotransplantation outcomes.

Background: Trismus can be a challenging consequence of ballistic trauma to the face, and has rarely been described in the setting of face transplantation. Almost half of all current face transplant recipients in the world received transplantation to restore form and function after a ballistic injury. Here we report our experience and challenges with long standing trismus after face transplantation., Methods: We reviewed the medical records of our face transplant recipients whose indication was ballistic injury. We focused our review on trismus and assessed the pre-, peri- and postoperative planning, surgery and functional outcomes., Results: Two patients received partial face transplantation, including the midface for ballistic trauma. Both patients suffered from impaired mouth opening, speech intelligibility, and oral competence. Severe scarring of the temporomandibular joint (TMJ) required intraoperative release in both patients, and additional total condylectomy on the left side 6 months posttransplant for 1 patient. Posttransplant, both patients achieved an improvement in mouth opening; however, there was persistent trismus. One year after transplantation, range of motion of the jaw had improved for both patients. Independent oral food intake was possible 1 year after surgery, although spillage of liquids and mixed consistency solids persisted. Speech intelligibility testing showed impairments in the immediate postoperative period, with improvement to over 85% for both patients at 1 year posttransplant., Conclusions: Ballistic trauma to the face and subsequent reconstructive measures can cause significant scarring and covert injuries to structures such as the TMJ, resulting in long standing trismus. Meticulous individual planning prior to interventions such as face transplantation must take these into account. We encourage intraoperative evaluation of these structures as well as peri- and postoperative treatment when necessary. Due to the nature of the primary injury, functional outcomes after face transplantation in these patients may differ substantially from those of other indications.

Background: Current knowledge of the impact of facial vascularized composite allograft (VCA) procurement on the transplantation outcomes of the concomitantly recovered solid organs is limited to isolated case reports and short-term results. Here we report on a nationwide analysis of facial allograft donor surgery experience and long-term outcomes of the concomitantly recovered solid organs and their recipients., Methods: There were 10 facial VCA procurements in organ donors between December 2008 and October 2014. We identified the population of subjects who received solid organs from these 10 donors using the Scientific Registry of Transplant Recipients. We retrospectively reviewed operative characteristics, intraoperative parameters, and postoperative outcomes., Results: Six of 10 donor surgeries were performed at outside institutions, all on brain-dead donors. Mean operative duration for facial VCA recovery was 6.9 hours (range, 4-13.25 hours). A total of 36 solid organs were recovered and transplanted into 35 recipients. Survival rates for kidney and liver recipients were 100% and 90% at a median follow-up of 33 and 27.5 months, respectively (range, 6-72 months). Graft survival rates for kidneys and livers were 15 of 16 (94%) and 9 of 10 (90%), respectively. Recipient and graft survival rates for hearts and lungs were 75% (n = 4) and 100% (n = 3) at mean follow-up time of 14.75 and 16 months, respectively. A liver recipient died at 22 months from unknown causes and a heart recipient died of leukemia at 10 months., Conclusions: Facial VCA procurement does not appear to adversely affect the outcomes of transplant recipients of concomitantly recovered solid organ allografts.

Background: Facial allotransplantation provides a unique opportunity to restore facial form and function in severely disfigured patients. Using a single unilateral facial artery for vascularization can significantly reduce surgical duration and thus facilitate the practice of face transplantation., Methods: A 33-year-old man with a history of high-energy ballistic trauma received a facial allograft comprising the lower two-thirds of the face, including maxilla and mandible. Vascular anastomoses involved one unilateral facial artery and two veins. Vascularization patterns, airway volume, and facial functions were assessed before and 1 year after transplantation. In addition, immunosuppressive therapy and rejection episodes were recorded., Results: One year after transplantation, the facial allograft is well perfused and gradually improving in function. Unilateral facial artery anastomosis remains patent and collateralization with the contralateral side is taking place through collaterals of the submental arteries. Bony perfusion of the maxilla and mandible is provided periosteally. Bilateral venous outflow is evident. Airway volume is significantly increased compared with before transplantation, and gastrostomy and tracheostomy tubes have been securely removed. The recipient has gained the abilities to smell, speak, feel, and grimace 1 year after transplantation. Steroids were successfully weaned after 9 months, leaving the patient on dual immunosuppressive therapy with tacrolimus and mycophenolate mofetil. Two rejection episodes occurred, of which one was treated by steroid pulse and the other by adjusting the maintenance therapy., Conclusions: In this patient, a facial allograft comprising the lower two-thirds of the face including the maxilla and mandible is sufficiently perfused by one unilateral facial artery. Bilateral venous outflow, however, seems to be necessary. Facial allotransplantation can significantly and securely improve facial form and function., Clinical Question/level of Evidence: Therapeutic, V.

Background: One of the major challenges in traumatic amputation is the need to keep ischemia time brief (4 to 6 hours) to avoid ischemic damage and enable successful replantation. The current inability to meet this challenge often leads to traumatic limb loss, which has a considerable detrimental impact on the quality of life of patients., Methods: The authors' team built a portable extracorporeal membrane oxygenator device for the perfusion of amputated extremities with oxygenated acellular solution under controlled parameters. The authors amputated forelimbs of Yorkshire pigs, perfused them ex vivo with acellular Perfadex solution for 12 hours at 10°C in their device, and subsequently replanted them into the host animal. The authors used limbs stored on ice slurry for 4 hours before replantation as their control group., Results: Clinical observation and histopathologic evaluation both demonstrated that there was less morbidity and less tissue damage to the cells during preservation and after replantation in the perfusion group compared with the standard of care. Significant differences in blood markers of muscle damage and tissue cytokine levels underscored these findings., Conclusions: The authors demonstrated the feasibility and superiority of ex vivo hypothermic oxygenated machine perfusion for preservation of amputated limbs over conventional static cold storage and herewith a substantial extension of the allowable ischemia time for replantation after traumatic amputation. This approach could also be applied to the field of transplantation, expanding the potential pool of viable donor vascularized composite allografts.

Background: Face transplantation has emerged as a clinical reality for the restoration of complex facial defects. Critical to the advancement of the burgeoning field of reconstructive transplantation is the quality of the methods used to measure and report the impact of face transplantation on quality of life., Methods: A systematic search using PubMed and EMBASE was conducted for all studies matching the a priori inclusion criteria from 2005 through 2015. Bibliographies of included studies were also reviewed. Two authors (M.A.A and H.K) independently performed screening of titles., Results: The authors identified 17 articles reporting on quality-of-life outcomes among 14 face transplant recipients. Combinations of objective and subjective measures were used to assess quality of life. Instruments used to assess quality of life after face transplantation included over 25 different instruments. Four centers, comprising eight patients, have reported using prospective, systematic data with validated instruments. Overall, there is reported improvement in quality of life after face transplantation. Heterogeneity and a paucity of data between articles preclude a quantitative analysis., Conclusions: Anecdotal and subjective reports of improvements in quality of life after face transplantation constitute the majority of reported outcomes in the English peer-reviewed literature. Improved efforts in methods and standardization of collection and reporting of quality-of-life data after face transplantation are needed to better appreciate the impact of face transplantation on quality of life and justify lifelong immunosuppression and its attendant risks and morbidity.

Background: Face transplantation has emerged as a viable option for certain patients in the treatment of devastating facial injuries. However, as with autologous free tissue transfer, the need for secondary revisions in face transplantation also exists. The authors' group has quantified the number of revision operations in their cohort and has assessed the rationale, safety, and outcomes of posttransplantation revisions., Methods: A retrospective analysis of prospectively collected data of the authors' seven face transplants was performed from April of 2009 to July of 2015. The patients' medical records, preoperative facial defects, and all operative reports (index and secondary revisions) were critically reviewed., Results: The average number of revision procedures was 2.6 per patient (range, zero to five procedures). The median time interval from face transplantation to revision surgery was 5 months (range, 1 to 10 months). Most interventions consisted of debulking of the allograft, superficial musculoaponeurotic system plication and suspension, and local tissue rearrangement. There were no major infections, allograft skin flap loss, or necrosis. One patient suffered a postoperative complication after autologous fat grafting in the form of acute rejection that resolved with pulse steroids., Conclusions: Secondary revisions after face transplantation are necessary components of care, as they are after most conventional free tissue transfers. Secondary revisions after face transplantation at the authors' institution have addressed both aesthetic and functional reconstructive needs, and these procedures have proven to be safe in the context of maintenance immunosuppression. Patient and procedure selection along with timing are essential to ensure patient safety, optimal function, and aesthetic outcomes., Clinical Question/level of Evidence: Therapeutic, V.

Background: Face transplantation has been shown to improve the functional and aesthetic deficits of facially disfigured individuals. Given promising short-term results, it is important to examine whether face transplantation centers are effectively reaching the targeted facial disfigurement population. The authors' center reviewed their face transplantation contacts to assess patient recruitment and outreach performance., Methods: The authors performed a retrospective review of their face transplantation contacts from the time of their institutional review board protocol approval (February of 2008) to October of 2015. They investigated the relationship between referral pattern (i.e., physician versus self) with the contact's demographic characteristics (i.e., age, sex, race, mechanism of injury, and geographic location) and clinical trial status., Results: There were a total of 72 face transplantation contacts. The average age of the contacts was 38 years, and the majority were men [n = 41 (56.9 percent)]. Most were white (n = 33), and the most prevalent mechanism of injury was burns (46.4 percent). The majority of the contacts resided within the United States (n = 47), with most from the Northeastern United States (n = 21). Of the 72 contacts, 35 (48.6 percent) were physician referrals and 37 (51.4 percent) were self-referrals. Physician referrals have led to the most screened and transplanted contacts in their center, whereas self-referral often led to immediate exclusion., Conclusions: The authors show the diversity of patient characteristics and referral patterns in their clinical trial. Furthermore, they describe the relationship of characteristics to outcomes in their cohort and identify areas of improvement, such as patient and physician education. Lastly, they are reminded of the potential impact on the burn community.