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Renukaradhya, S., and Rao:

Face transplant: A revolutionary approach and role of dentist

Tanya Nandkeoliar1, Kaushik Ranjan Deb2

1Department of Periodontology, Dental College, Regional Institute of Medical Sciences, Autonomous Institute Under Ministry of Health and Family Welfare, Government of India, Imphal, Manipur, India; 2Dental College, Regional Institute of Medical Sciences, Autonomous Institute Under Ministry of Health and Family Welfare, Government of India, Imphal, Manipur, India

Correspondence: Dr. Kaushik Ranjan Deb, Dental College, Regional Institute of Medical Sciences, Autonomous Institute Under Ministry of Health and Family Welfare, Government of India, Imphal, Manipur, India. E-mail: kaushikranjandeb1994@gmail.com
Received: 07 July 2018;
Accepted: 18 August 2018
doi: 10.15713/ins.jcri.228

Abstract

Face transplant forms a part of vascularized composite tissue allotransplantation (transfer of organs or tissue from one individual to another), which is the basis of modern microsurgery and reconstructive plastic surgery. A face transplant is a medical procedure to replace all or part of a person’s face using tissue from a cadaver. Face transplantation can include skin from the face, neck and/or scalp, lips and tongue, muscles used for facial movement and expression, and nerves to animate as well as to provide sensation. Supportive bony structures can also be included. Oral surgeons play a major role in alignment of teeth, reconstruction of midface, maxilla, mandible including teeth, and tongue. It gives better esthetics and functional results including increase in the opening of mouth, chewing, and breathing. The new computer-assisted planning and execution system aims to make it less likely to misalign the new set of bones, jaws, and prevent other reconstructive abnormalities. In spite of risks and rejection, face transplant gives a better appearance, i.e., gives a new life to the patient and improves his social status and lifestyle.

Keywords Face transplant and dentistry, face transplant, vascularized composite tissue allotransplantation


Introduction

One’s face is often considered their identity which represents the ancestry, ethnicity, and self-perception.[1] In today’s esthetic driven society where smile and facial attractiveness represents one’s happiness, mental state, and success, it is very difficult to attain normal and socially acceptable facial architecture after gross disfigurement.[2] Face transplant is a revolutionary procedure by which we can achieve so successfully.

The movie Face-Off starring John Travolta and Nicolas Cage is a classic example of how spectacular face transplant could be.

History

The world’s first partial face transplant was done in November 2005 by a group of French surgeons lead by prof. Jean Michel Dubernard on a 38-year-old Isabella Dinoire after being bitten by a dog.[3,4]

First, full-face transplant was done in 2010 by a team led by Dr. Barret on Óscar who lost his facial structure by accident and injury.[5]

Face Transplant: A Revolutionary Approach and Role of Dentist

Principle

Face transplant forms a part of vascularized composite tissue allotransplantation (transfer of organs or tissue from one individual to another), which is the basis of modern microsurgery and reconstructive plastic surgery.[6] The first clinical use of this principle was done in 1998 with the first successful human hand transplant.[7] After 7 years of this, the first human face transplant was performed in Amiens, France.[3]

Types

Partial facial transplantation

It consists of nose, lips, and amounts of chin and cheek. It requires sensory and motor nerve anastomoses as it includes skin, mucosa, and muscle. The dynamic and static facial slings are used to restore the functional movements if motor anastomoses failed.[8]

Full-face transplant

It consists of whole face transfer from donor to recipient. If it fails, then the following treatment modalities are used:

  1. Autologous skin graft application.

  2. Artificial skin such as dermal substitute and Integra application followed by skin graft.

  3. Repeat the face transplant procedure, but it has unfavorable prognosis because of prior sensitization.

In the future, full-face transplant will also include nose, ears, and eyelids transplant according to patient’s needs.[8]

Table 1 shows classification of facial transplantation allografts.[9,10]

Table 1: Classification of facial transplantation allografts

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Indication

Patients having disfigured face by means of:

  • Accidents/traumatic injury, burn.

  • Birth defects/congenital defects.

  • Malignant disease.

  • Facial structures lost due to infection which are untreatable with conventional surgical technique.

Table 2 shows determining patient eligibility.[11]

Table 2: Determining patient eligibility

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Table 3 shows finding a match (DONOR).[11]

Table 3: Finding a match (DONOR)

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Appearance after full-face transplant

Prediction of appearance after full-face transplant is challenging. Various studies which used computer modeling suggest that recipient face resembles a “third face” which neither looks like recipient pre-injury nor the donor, but it takes the characteristics skeleton structure of recipient and soft tissues of donor. The new subcutaneous tissues and skin move better than the pre-transplant grafted face.[8]

Informed consent[12]

The patient should understand the following contents before undergoing face transplantation.

Identity

Patient will most likely generate a third face which will not look like recipient pre-injury. This may develop identity issues with the patient.

Immunosuppressant drugs

Patients have to take immunosuppressant drugs lifelong. Inability to do so would result in rejection of graft. There will be significant side effects of those drugs such as infective and neoplastic and CVS complications, though monitoring is essential for rest of the life.

Rejection

Complete graft loss may occur followed by rejection which can be treated with altering medicine or it may require further surgery. Rejection of graft may worsen patient’s appearance.

Psychosocial issues

Psychological acceptance of the third face may take time. Psychological relationship between post operative third face and pre-injurious face is still under study.

Surgical issues

Face transplant has similar risk and mortality as any other free flap surgery. Technical failure has been reported to about 4%.

Functional recovery

Functional recovery is variable and unpredictable and may take years.

Media interest

As it is a modern and revolutionary procedure, media interest is most likely high.

Surgical Procedure[13,14]

  1. Surgical team: It is a multidisciplinary approach. Experts from reconstructive surgery such as plastic and oral and maxillofacial surgery, orthodontic, psychiatry, otolaryngology, infectious disease, social work, nursing, nutrition, physiotherapy, ophthalmology, and pain medicine should work together to provide the best possible care for patients.

  2. Selection of donor and recipient: Criteria for selection of donor and recipient are discussed earlier. Harvesting the facial flap and vessels from a brain-dead donor are the first steps of transplant procedure.

  3. Tracheostomy is performed simultaneously in both recipient and donor patients.[15] Further, skin incision is begun at the hairline and proceeding inferiorly while staying anterior to the ears and down to the level of clavicles, bilateral periorbital incision is performed preserving the recipient patient’s eyelids.

  4. Following the skin retraction, the vessels and nerves are identified and tagged with corresponding color-coded vessels loops.

  5. At the donor patient, the tongue is harvested with perimeter incision for transplantation to the recipient.

  6. Ostectomy is performed on the recipient using synthase proplan CMF patient-specific surgical guide and a cutting guidance is assisted on the donor patient with the use of intraoperative navigation.

  7. Removal of midface and mandible is finalized with an osteotome. The accuracy of cuts is checked using a sterilizable synthase proplan CMF bone model of recipient defect and fine adjustment is made using a bur.

  8. Bone, teeth, tongue, soft tissues, muscles of facial expression, etc., are transferred and followed by bone plating. The blood supply is reestablished and nerve coaptation is performed using microsurgery.

  9. Finally, soft tissue sutures are placed to close the procedure. Accurate alignment of patients bone using synthase proplan CMF ensures that the height, width, and projection of facial anatomy are restored as planned preoperatively.

An Artificial Prosthesis to Reconstruct Donor Defects Following Facial Transplantation

The donor face reconstruction postoperatively must be emphasized. It is recommended that a donor’s body must be restored to a pleasant appearance following organ harvesting.[16] The face provides person’s identity and familial characteristics, thus making it a unique identifier. The failure to recognize a ones face leads to a bereavement reaction. Grieving by the donor’s family members is done when brain death has been confirmed within the confines of the intensive care unit instead of immediately post harvesting. Therefore, there is optimum benefit to the transplant recovery team when the donor’s facial features are reconstructed. The appearance of the donor’s face and the development of a suitable facial prosthesis rank highly in surveys of health professionals involved in transplantation. In spite of discussion on altered identity, it has been suggested by recent public engagement exercises that identity issues are not likely to reduce access to donor faces.[17]

Materials and Methods

Stage 1

Primary impression is taken with alginate impression material in intensive care unit before transfer to the OT which is done within 30 min.

Stage 2

Impression is then transferred to the laboratory where replica is made using plaster of Paris which is also done within 30 min.

Stage 3

The facial plaster of Paris is replicated using silicon putty material by applying it over the plaster cast. It is removed from the cast once set and inserted into the plaster of Paris set within a prefabricated steel box. Further, when setting is complete, two layers of soft adhesive red dental carding wax are applied. This would reproduce the thickness of skin and the subcutaneous tissues required (approximately 5 mm).

Plaster of Paris is poured into this wax-coated molding box. After filling, a lid is placed so as to stop the plaster from shrinking, and the box left to set for approximately 30 min. This will help to produce the second cast for retention of the underlying characteristics of the face to the maximum.

Stage 4

This is the final stage and it involves the mixing of a prosthetic colorant with silicone elastomer to obtain the required skin tone. A silicone “sandwich” is created by pouring silicone elastomer into the molding box and placing the second cast on top. This will set in 1 h approximately.

Even in its simplest form (involving soft tissue resurfacing), a donor facial graft will invariably result in the loss of superficial facial characteristics such as eyebrows. Pre-operative harvesting of hair or addition of artificial hair to the prosthesis could be the alternatives. In addition, generic masks of all genders and facial types are also available to this donor-specific method of face transplant for the fabrication of the donor’s prosthesis. These are constructed in case unforeseen constraints prevent the immediate fabrication of a donor-specific prosthesis.

Role of dentist

Pre-operative

Analysis of mandible, maxilla, and occlusion provides better esthetics and functional results to the patient postoperatively.

Intraoperative

Oral surgeons play a major role in the reconstruction of midface, alignment of teeth, mandible, and maxilla including tongue and teeth, BSSO of mandible, osteotomy of maxilla, bone plating, and suturing. Reconstruction of donor’s face is performed by the prosthodontics (as discussed earlier).

The new computer-assisted planning and execution system and synthase proplan CMF patient-specific surgical guide make it less likely to misalign the new set of jaws, bones, and also prevent various other reconstructive abnormalities.

Post-operative

Post-operative management of pain, mouth opening, lip closure, minor orofacial reconstruction and occlusion, and surgery can be better managed by a dentist.

Medication[18]

For the prevention of rejection of graft, the patient should take various medications such as corticosteroid and cyclosporine. These would suppress the immune system. The drug levels are monitored in the blood so as to prevent any side effect. It is extremely critical for all the transplant patients to take all the prescribed drugs and to follow-up regularly. In addition, antibacterial, antiviral, and painkillers are required to be taken.

Risks and discomforts[19]

General risks for transplantation

  • Risks and side effects of drugs.

  • Mood swings following transplant surgery.

Risks for Facial transplant[18,20]

  • Psychiatric support must be proved to the patients before and after partial facial transplantation.

  • Rejection.

  • Identity issues.

Risks of taking transplant drugs for a lifetime[18]

  • Infections.

  • Diabetes.

  • Cancer.

  • Kidney failure.

The benefits of facial transplantation[20]

Improved functionality

The physical functionality of the human face can be restored by face transplant surgery including the ability to breathe, swallow, speak, smile, and show other emotions.

Rehabilitation of appearance

Restoration of a near-normal facial appearance can be achieved by face transplantation. This can help patients in regard gaining the confidence to return to their former lifestyles including social activities and jobs.

Pain reduction and discomfort

Two major reasons why face transplant surgery should lead to less pain and discomfort. First, face transplant is not involving many surgeries and many recoveries unlike conventional surgeries. Second, it is not involved other surgical sites for autologous graft unlike conventional surgeries.

Table 4 shows Compilation of published face transplant cases, most recent outcomes and complications.[21-29]

Table 4: Compilation of published face transplant cases, most recent outcomes and complications

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CONCLUSION

Facial transplantation is a life-changing procedure, whereas organ transfer is life-saving. The modern drug therapy and advance surgical technique have the potential to broaden up its clinical application and success rate which provides an esthetic appearance and gives a new life to the patient by improving his lifestyle and social status.

References

1.  Chenggang Y, Yan H, Xudong Z, Binglun L, Hui Z, Xianjie M, et al. Some issues in facial transplantation. Am J Transplant 2008;8:2169-72.

2.  Theodorakopoulou E, Meghji S, Pafitanis G, Mason KA. A review of the world's published face transplant cases:Ethical perspectives. Scars Burn Heal 2017;3:2059513117694402.

3.  Doctors perform first partial face transplant. msnbc.com;2018 [18]. Available From:http://www.nbcnews.com/id/10265941/ns/health-health_care/t/doctors-perform-first-partial-face-transplant/#.WuWX24hubIU [Last cited on 2016 Apr 20].

4.  Devauchelle B, Badet L, LengeléB, Morelon E, Testelin S, Michallet M, et al. First human face allograft:Early report. Lancet 2006;368:203-9.

5.  Face Transplants. Documenting Reality;2018[18]. Available from:https://www.documentingreality.com/forum/f149/face-transplants-150380/. [Last cited on 2017 Jan 20].

6.  Unal S, Agaoglu G, Zins J, Siemionow M. New surgical approach in facial transplantation extends survival of allograft recipients. Ann Plast Surg 2005;55:297-303.

7.  Dubernard JM, Owen E, Herzberg G, Lanzetta M, Martin X, Kapila H, et al. Human hand allograft:Report on first 6 months. Lancet 1999;353:1315-20.

8.  Morris P, Bradley A, Doyal L, Earley M, Hagen P, Milling M, et al. Face transplantation:A review of the technical, immunological, psychological and clinical issues with recommendations for good practice. Transplantation 2007;83:109-28.

9.  Barret JP, GavaldàJ, Bueno J, Nuvials X, Pont T, Masnou N, et al. Full face transplant:The first case report. Ann Surg 2011;254:252-6.

10.  Lengelé BG. Current concepts and future challenges in facial transplantation. Clin Plast Surg 2009;36:507-21.

11.  Face Transplant Patient Eligibility - Brigham and Women's Hospital;2018 [18]. Available from:https://www.brighamandwomens.org/surgery/plastic-surgery/restorative-surgery/patient-eligibility-facial-transplant. [Last cited on 2016 Jun 20].

12.  Renshaw A, Clarke A, Diver AJ, Ashcroft RE, Butler PE. Informed consent for facial transplantation. Transpl Int 2006;19:861-7.

13.  Petit F, Paraskevas A, Minns AB, Lee WP, Lantieri LA. Face transplantation:Where do we stand?. Plast Reconstr Surg 2004;113:1429-33.

14.  Comprehensive Facial Transplant Video;2018 [18]. Available from:https://www.youtube.com/watch?v=kh4l-CztDG0. [Last cited on 2001 Feb 21].

15.  Roche NA, Vermeersch HF, Stillaert FB, Peters KT, De Cubber J, Van Lierde K, et al. Complex facial reconstruction by vascularized composite allotransplantation:The first belgian case. J Plast Reconstr Aesthet Surg 2015;68:362-71.

16.  Robertson JA. Face transplants:Enriching the debate. Am J Bioeth 2004;4:32-3.

17.  Clarke A, Simmons J, White P, Withey S, Butler P. Attitudes to face transplantation:Results of a public engagement exercise at the Royal Society Summer Science Exhibition. J Burn Care Res 2006;27:394-8.

18.  Face Transplant Patient Guide-Brigham and Women's Hospital;2018[18]. Available from:https://www.brighamandwomens.org/Departments_and_Services/surgery/services/PlasticSurg/Reconstructive/FaceTransplantSurgery/pdf/FaceTransplantPatientGuide.pdf. [Last cited on 2016 Feb 20].

19.  Pomahac MB, Surgery P, Surgery R, Hospital B. Bohdan Pomahac, MD-Brigham and Women's Hospital;2018 [18]. Avaiable from:https://www.physiciandirectory.brighamandwomens.org/details/1250/bohdan-pomahac-plastic_surgery-restorative_surgery-bos. [Last cited on 2017 Jun 20].

20.  Face Transplant Benefits and Risks - Brigham and Women's Hospital.;2018 [18]. Available from:https://www.brighamandwomens.org/surgery/plastic-surgery/restorative-surgery/benefits-and-risks-facial-transplant. [Last cited on 2016 Apr 20].

21.  Infante-Cossio P, Barrera-Pulido F, Gomez-Cia T, Sicilia-Castro D, Garcia-Perla-Garcia A, Gacto-Sanchez P, et al. Facial transplantation:A concise update. Med Oral Patol Oral Cir Bucal 2013;18:e263-71.

22.  Sosin M, Rodriguez ED. The face transplantation update:2016. Plast Reconstr Surg 2016;137:1841-50.

23.  Lantieri L, Grimbert P, Ortonne N, Suberbielle C, Bories D, Gil-Vernet S, et al. Face transplant:Long-term follow-up and results of a prospective open study. Lancet 2016;388:1398-407.

24.  Garrett GL, Beegun I, D'Souza A. Facial transplantation:Historical developments and future directions. J Laryngol Otol 2015;129:206-11.

25.  Gordon CR, Siemionow M, Papay F, Pryor L, Gatherwright J, Kodish E, et al. The world's experience with facial transplantation:What have we learned thus far?. Ann Plast Surg 2009;63:572-8.

26.  Khalifian S, Brazio PS, Mohan R, Shaffer C, Brandacher G, Barth RN, et al. Facial transplantation:The first 9 years. Lancet 2014;384:2153-63.

27.  Shanmugarajah K, Hettiaratchy S, Clarke A, Butler PE. Clinical outcomes of facial transplantation:A review. Int J Surg 2011;9:600-7.

28.  Roche NA, Blondeel PN, Van Lierde KM, Vermeersch HF. Facial transplantation:History and update. Acta Chir Belg 2015;115:99-103.

29.  Pomahac B, Pribaz J, Eriksson E, Bueno EM, Diaz-Siso JR, Rybicki FJ, et al. Three patients with full facial transplantation. N Engl J Med 2012;366:715-22.