Search

In 2005, the first facial vascularized composite allotransplant was performed in France. In May 2018, our team at Maisonneuve-Rosemont Hospital, Montreal, Quebec, had the privilege to participate in the first facial transplant in Canada. Interdisciplinary collaboration, coordination, and communication formed the cornerstone of this medical undertaking and, ultimately, its success. This report details the anesthetic and organizational considerations of our experience.

Summary: Facial vascularized composite allotransplantation has emerged as a groundbreaking reconstructive solution for patients with severely disfiguring facial injuries. The authors report on the first Canadian face transplant. A 64-year-old man sustained a gunshot wound, which resulted in extensive midface bony and soft-tissue damage involving the lower two-thirds of the face. In May of 2018, he underwent a face transplant consisting of Le Fort III and bilateral sagittal split osteotomies in addition to skin from the lower two-thirds of the face and neck. Virtual surgical planning was used to fabricate osteotomy guides and stereolithographic models. Microsurgical anastomoses of the facial (three branches) and infraorbital nerves were performed bilaterally. At 18-month follow-up, the aesthetic outcome was excellent. Partial restoration of light touch sensation had been observed over the majority of the allograft. Although significantly affected, animation, speech, mastication, and deglutition were continuously improving with intensive therapy. Nevertheless, the patient was now tracheostomy and gastrostomy free. Despite these limitations, he reported a high degree of satisfaction with the procedure and had reintegrated into the community. Four grade I episodes of acute rejection with evidence of endotheliitis were successfully treated. Postoperative complications were mainly infectious, including mucormycosis of the left thigh, treated with surgical resection and antifungal therapy. Undoubtedly, immunosuppression represents the greatest obstacle in the field and limits the indications for facial vascularized composite allotransplantation. Continuous long-term follow-up is mandatory for surveillance of immunosuppression-related complications and functional assessment of the graft., Competing Interests: Disclosure:The authors have no conflicts of interest to declare. A research grant was donated by Johnson & Johnson., (Copyright © 2021 by the American Society of Plastic Surgeons.)

Background: Histologic criteria for diagnosing acute rejection in vascularized composite tissue allograft (VCA) have been established by the Banff 2007 Working Classification of Skin-Containing Composite Tissue Allograft, but the role of early vascular lesions in graft rejection warrants additional analysis., Methods: We performed a retrospective study of 34 skin biopsies performed over 430 d for rejection surveillance, in Canada's first face allotransplant recipient. Three observers reviewed all biopsies to assess the nature and intensity of the inflammatory skin infiltrate. A complete histological and immunohistochemical review of the vascular components was performed with a focus on lymphocytic vasculitis, intravascular fibrin, vessel caliber, extent of injury, C4d positivity, and inflammatory cell phenotyping. We then correlated these data points to clinical and immunosuppression parameters., Results: Acute vascular damage in biopsies that would be classified as mild acute rejection correlates with troughs in immunosuppression and subsides when immunosuppressive tacrolimus doses are increased. Grade 0 Banff rejection and Grade I without lymphocytic vasculitis were almost indistinguishable, whereas Grade I with lymphocytic vasculitis was an easy and reproducible histologic finding., Conclusions: Our results highlight the possible relevance of vascular injury in the context of VCA, as its presence might underlie a more aggressive form of immune rejection. If these findings are validated in other VCA patients, vascular injury in mild rejection might warrant a different clinical approach.