Face transplantation for massive mandibular defects: considerations for allograft design and surgical planning

Abstract

Modern face transplant techniques have advanced to allow for the transfer of vascularized skeletal components in addition to overlying soft tissue. This represents significant opportunity for individuals with mandibular defects that are not amenable to traditional reconstruction. Care must be taken when planning and executing transplants with these complex grafts, as satisfactory functional and aesthetic outcomes rely on achieving proper spatial relationships between the mandible, skull base, and midface. Which donor skeletal elements are included in the allograft and how they are harvested are important considerations in this planning and are associated with controversy. To optimize outcomes in the reconstruction of single-jaw defects, some advocate for transplantation of only the affected jaw while others support bimaxillary transplantation. Clinical evidence in this debate is not conclusive at this time. In current practice, including donor dentoalveolar anatomy by utilizing a bilateral sagittal split osteotomy of the mandible is favored to optimize outcomes such as dental occlusion. It has been suggested that harvesting the mandible at the level of the condyle or even the temporal bone may also be possible and may improve temporomandibular joint-related outcomes. Despite encouraging preclinical evidence, these strategies remain controversial. After allograft design, successful mandibular reconstruction with face transplantation relies on surgical precision in the donor and recipient procedures. Computerized surgical planning, computer-aided design and manufacturing, and intraoperative navigation are technologies currently in use to mitigate operative complexity. Results in both cadaveric and clinical face transplantations suggest these technologies are reliable and beneficial, although some room for improvement remains.

Keywords

Face transplantation / mandibular reconstruction / allograft design / bimaxillary transplantation / temporomandibular joint reconstruction / computerized surgical planning / computer-aided design and manufacturing / intraoperative navigation

References

[1] Fischer S,Krezdorn N,Kueckelhaus M.First lower two-thirds osteomyocutaneous facial allograft perfused by a unilateral facial artery: outcomes and vascularization at 1 year after transplantation..Plast Reconstr Surg2017;139:1175e-83e

[2] Pomahac B,Diaz-Siso JR,Talbot SG.Face transplantation..Curr Probl Surg2011;48:293-357

[3] Infante-Cossio P,Gomez-Cia T,Garcia-Perla-Garcia A.Current role in facial allograft transplantation: what have we learned?.Plast Aesthet Res2016;3:211-8

[4] Ramly EP,Diaz-Siso JR,Shetye PR.Outcomes after tooth-bearing maxillomandibular facial transplantation: insights and lessons learned..J Oral Maxillofac Surg2019;77:2085-103

[5] Rifkin WJ,Plana NM,Diaz-Siso JR.Achievements and challenges in facial transplantation..Ann Surg2018;268:260-70

[6] Cavadas PC,Thione A.Surgical aspects of a lower face, mandible, and tongue allotransplantation..J Reconstr Microsurg2012;28:43-7

[7] Plana NM,Diaz-Siso JR,Rodriguez ED.Dental considerations and the role of prosthodontics and maxillofacial prosthetics in facial transplantation..J Am Dent Assoc2018;149:90-9

[8] Brown EN,Bojovic B,Borsuk DE.Total face, double jaw, and tongue transplant simulation: a cadaveric study using computer-assisted techniques..Plast Reconstr Surg2012;130:815-23

[9] Dorafshar AH,Mundinger GS,Brown EN.Found in space: computer-assisted orthognathic alignment of a total face allograft in six degrees of freedom..J Oral Maxillofac Surg2014;72:1788-800

[10] Mohan R,Dorafshar AH,Bojovic B.Aesthetic and functional facial transplantation: a classification system and treatment algorithm..Plast Reconstr Surg2014;133:386-97

[11] Khalifian S,Mohan R,Brandacher G.Facial transplantation: the first 9 years..Lancet2014;384:2153-63

[12] Wall A,Pomahac B.Intraoral features and considerations in face transplantation..Oral Dis2016;22:93-103

[13] Gordon CR,Peacock ZS,Yaremchuk MJ.Le Fort-based maxillofacial transplantation: current state of the art and a refined technique using orthognathic applications..J Craniofac Surg2012;23:81-7

[14] Gordon CR,Peacock ZS,Zins JE.Osteocutaneous maxillofacial allotransplantation: lessons learned from a novel cadaver study applying orthognathic principles and practice..Plast Reconstr Surg2011;128:465e-79e

[15] Pomahac B,Sisk GC.Current principles of facial allotransplantation: the Brigham and Women’s Hospital Experience..Plast Reconstr Surg2013;131:1069-76 PMCID:PMC4374342

[16] Khavanin N,Lee DY,Dorafshar AH.Anatomic considerations for temporomandibular joint vascularized composite allotransplantation..J Craniofac Surg2018;29:871-7

[17] Lantieri L,Audard V,Meningaud JP.Feasibility, reproducibility, risks and benefits of face transplantation: a prospective study of outcomes..Am J Transplant2011;11:367-78

[18] Dorafshar A,Christy M,Iliff N.Total face, double jaw, and tongue transplantation: an evolutionary concept..Plast Reconstr Surg2013;131:241-51

[19] Krezdorn N,Perry B,Tasigiorgos S.Trismus in face transplantation following ballistic trauma..J Craniofac Surg2018;29:843-7

[20] Aycart MA,Kueckelhaus M,Bueno EM.A retrospective analysis of secondary revisions after face transplantation: assessment of outcomes, safety, and feasibility..Plast Reconstr Surg2016;138:690e-701e

[21] Jacobs JMS,Levine JP,Weimer K.Best face forward: virtual modeling and custom device fabrication to optimize craniofacial vascularized composite allotransplantation..Plast Reconstr Surg2013;131:64-70

[22] Bell RB.Computer planning and intraoperative navigation in cranio-maxillofacial surgery..Oral Maxillofac Surg Clin North Am2010;22:135-56

[23] Caterson EJ,Shetye P,Bueno EM.Craniofacial principles in face transplantation..J Craniofac Surg2012;23:1234-8

[24] Rudman K,Rhee J.Computer-assisted innovations in craniofacial surgery..Facial Plast Surg2011;27:358-65

[25] Kim Y,Kim YO.Virtual reality and augmented reality in plastic surgery: a review..Arch Plast Surg2017;44:179-87 PMCID:PMC5447526

[26] Wong K,Xavier BA.Applications of augmented reality in otolaryngology: a systematic review..Otolaryngol Head Neck Surg2018;159:956-67

[27] Sosin M,Hazen A,Staffenberg DA.Total face, eyelids, ears, scalp, and skeletal subunit transplant cadaver simulation: the culmination of aesthetic, craniofacial, and microsurgery principles..Plast Reconstr Surg2016;137:1569-81

[28] Sosin M,Levine JP,Staffenberg DA.Total face, eyelids, ears, scalp, and skeletal subunit transplant: a reconstructive solution for the full face and total scalp burn..Plast Reconstr Surg2016;138:205-19