Faculty Bibliography

Facial transplantation is emerging as a therapeutic option for self-inflicted gunshot wounds. The self-inflicted nature of this injury raises questions about the appropriate role of self-harm in determining patient eligibility. Potential candidates for facial transplantation undergo extensive psychosocial screening. The presence of a self-inflicted gunshot wound warrants special attention to ensure that a patient is prepared to undergo a demanding procedure that poses significant risk, as well as stringent lifelong management. Herein, we explore the ethics of considering mechanism of injury in the patient selection process, referring to the precedent set forth in solid organ transplantation. We also consider the available evidence regarding outcomes of individuals transplanted for self-inflicted mechanisms of injury in both solid organ and facial transplantation. We conclude that while the presence of a self-inflicted gunshot wound is significant in the overall evaluation of the candidate, it does not on its own warrant exclusion from consideration for a facial transplantation.

Since 2005, facial transplantation has emerged as a viable reconstructive option for the most severe defects not amenable to conventional reconstructive techniques, with promising aesthetic and functional outcomes to date. Key facial subunits and midface structures such as the eyelids, lips, and nose are now able to be successfully replaced rather than reconstructed, enabling adequate functional outcomes in even the most extensive defects. However, even in cases of severe facial disfigurement, the decision to proceed with transplantation versus autologous reconstruction remains a source of debate, with no current consensus regarding precise indications and inclusion/exclusion criteria. This report details the case of a candidate referred for face transplantation who ultimately underwent autologous facial reconstruction. Through this representative case, our objective is to clarify the criteria that make a patient a suitable face transplant candidate, as well as to demonstrate the outcomes achievable with a conventional autologous reconstruction, using a methodically planned, multistaged approach.

BACKGROUND:Despite early skepticism, the field of vascularized composite allotransplantation (VCA) has demonstrated feasibility. The ethics of VCA have moved past doubts about the morality of attempting such transplant to how to conduct them ethically. METHODS:Leaders of each program performing and/or evaluating VCA in the United States were invited to participate in a working group to assess the state and future of VCA ethics and policy. Four meetings were held over the course of 1 year to describe key challenges and potential solutions. RESULTS:Working group participants concluded that VCA holds great promise as treatment for patients with particular injuries or deficits, but the field faces unique challenges to adoption as standard of care, which can only be overcome by data sharing and standardization of evaluation and outcome metrics. CONCLUSIONS:Adequate attention must be given to concerns including managing the uniquely intense physician-patient relationship, ethical patient selection, ensuring patients have adequate representation, informing and earning the trust of the public for donation, standardizing metrics for success, and fostering an environment of data sharing. These steps are critical to transitioning VCA from research to standard of care, and to its insurance coverage inclusion.

Facial transplant (FT) is a viable option for patients with severe craniomaxillofacial deformities. Transplant imaging requires coordination between radiologists and surgeons and an understanding of the merits and limitations of imaging modalities. Digital subtraction angiography and CT angiography are critical to mapping vascular anatomy, while volume-rendered CT allows evaluation of osseous defects and landmarks used for surgical cutting guides. This article highlights the components of successful FT imaging at two institutions and in two index cases. A deliberate stepwise approach to performance and interpretation of preoperative FT imaging, which consists of the modalities and protocols described here, is essential to seamless integration of the multidisciplinary FT team. ^©RSNA, 2019 See discussion on this article by Lincoln .

BACKGROUND:Autologous bone grafts remain a standard of care for the reconstruction of large bony defects, but limitations persist. The authors explored the bone regenerative capacity of customized, three-dimensionally printed bioactive ceramic scaffolds with dipyridamole, an adenosine A2A receptor indirect agonist known to enhance bone formation. METHODS:Critical-size bony defects (10-mm height, 10-mm length, full-thickness) were created at the mandibular rami of rabbits (n = 15). Defects were replaced by a custom-to-defect, three-dimensionally printed bioactive ceramic scaffold composed of β-tricalcium phosphate. Scaffolds were uncoated (control), collagen-coated, or immersed in 100 μM dipyridamole. At 8 weeks, animals were euthanized and the rami retrieved. Bone growth was assessed exclusively within scaffold pores, and evaluated by micro-computed tomography/advanced reconstruction software. Micro-computed tomographic quantification was calculated. Nondecalcified histology was performed. A general linear mixed model was performed to compare group means and 95 percent confidence intervals. RESULTS:Qualitative analysis did not show an inflammatory response. The control and collagen groups (12.3 ± 8.3 percent and 6.9 ± 8.3 percent bone occupancy of free space, respectively) had less bone growth, whereas the most bone growth was in the dipyridamole group (26.9 ± 10.7 percent); the difference was statistically significant (dipyridamole versus control, p < 0.03; dipyridamole versus collagen, p < 0.01 ). There was significantly more residual scaffold material for the collagen group relative to the dipyridamole group (p < 0.015), whereas the control group presented intermediate values (nonsignificant relative to both collagen and dipyridamole). Highly cellular and vascularized intramembranous-like bone healing was observed in all groups. CONCLUSION:Dipyridamole significantly increased the three-dimensionally printed bioactive ceramic scaffold's ability to regenerate bone in a thin bone defect environment.

Background/UNASSIGNED:Facial transplantation (FT) experience has grown but success in this innovative and complex field has yet to be defined. The purpose of this study is to determine attitudes regarding the failures in FT and the appropriate management of these failures. Methods/UNASSIGNED:An anonymous, 20-question survey elicited opinions regarding FT failure management. This survey was administered to attendees of 2 FT-focused national meetings. Demographics included sex, age, and personal/institutional FT experience. Attitudes related to FT recipient education, definition of FT failure, and management of complications were gathered. Results/UNASSIGNED:Eighty of 271 attendees completed the survey (29.5%). Respondents were predominantly male (81.3%) and 50 years of age or younger (80.5%). Thirty-eight percentage previously performed an FT and 53.8% were a part of an institution with a vascularized composite allotransplantation (VCA)-related Institutional Review Board (IRB). Respondents almost unanimously agreed it was "absolutely essential" to discuss possibility of FT failure (93.8%), mortality (91.1%), and treatment for chronic rejection (78.8%). However, uncertainty of failure rate existed, with 56.4% citing failure rate as unknown, 25.6% citing <25% and 18.0% citing >25%. 51.2% of those with direct FT experience lacked clear criteria for defining FT success or an institutional protocol for managing chronic rejection. 78.8% believed failed FT patients should be considered for retransplantation, but only about 25% cited functional concerns or esthetic dissatisfaction as appropriate indications. Conclusion/UNASSIGNED:There is a lack of consensus regarding definition of FT failure and rates mortality amongst experts. Even institutions with FT experience lack protocols for managing chronic rejection. Expert consensus and institutional regulations surrounding these issues are warranted.

PURPOSE/OBJECTIVE:Periorbital injuries are common in face transplantation (FT) candidates. It is therefore essential that the ophthalmologist play a central role in the multidisciplinary treatment of these patients. In this study, the authors perform a comprehensive review of all procedures involving periorbital components, provide an update for the ophthalmology community regarding the current state of the field, and present 2 cases. METHODS:A comprehensive review of the literature for all FT procedures including periorbital components was performed. The authors also present 2 patients who received FT including periorbital components for extensive facial disfigurement. One patient sustained high-energy avulsive ballistic injury and underwent a total face, double jaw, and tongue transplant in 2012. The second patient received a total face, eyelids, ears, and skeletal subunits transplant for extensive facial burns in 2015. RESULTS:Literature review demonstrated that 22 (54%) of the 41 patients undergoing FT received allografts containing periorbital components. Only 14 cases (64%) reported on the presence of ocular and periocular complications. The most common complications consisted of lower eyelid ectropion and lagophthalmos, and nearly all required revisional procedures. Both patients presented with significant periorbital scarring and demonstrated good visual acuity and aesthetic outcomes at postoperative follow up between 6 and 28 months. CONCLUSIONS:Face transplantation can address extensive facial and periorbital disfigurement with satisfactory functional and aesthetic outcomes. The majority of FT performed to date have included periorbital components, and postoperative ocular and periocular complications are common. It is critical for ophthalmologists to play a central role in the care of these patients.

BACKGROUND:Mandibular fractures are the most common isolated facial fractures in the United States. Various risk factors have been associated with increased rates of postoperative complications. However, national outcome reports are limited and data are conflicting. Using a national multi-institutional database, the authors sought to analyze 30-day outcomes after mandibular fracture repair and determine risk factors for complications, readmission, and reoperation. METHODS:Retrospective review of the American College of Surgeons National Surgical Quality Improvement database was performed to identify patients undergoing surgical treatment of mandibular fractures between 2010 and 2015 using current procedural terminology codes. Primary outcomes included: wound complications, overall complications, as well as readmission and reoperation rates. Multivariate regression analysis was performed to adjust for confounders. RESULTS:A total of 953 patients were eligible for analysis. Mean patient age was 34.5 years, 84% were males, and 50% were active smokers. Wound complications, overall complications, 30-day reoperation, and readmission occurred in 4.0%, 7.9%, 2.2%, and 33% of patients, respectively. Age was a significant risk factor for 30-day readmission (odds ratio [OR] = 1.06, P = 0.01), reoperation (OR = 1.05, P = 0.01), and overall complications (OR = 1.03, P = 0.02) on multivariate analysis, and smoking was a significant risk factor for 30-day reoperation (OR = 4.86, P = 0.03). CONCLUSION/CONCLUSIONS:The analysis identified age as an independent risk factor for readmission, reoperation, and overall complications. Smokers were also nearly 5 times as likely to undergo additional surgery. This is particularly important given that over half of patients were active smokers, highlighting the importance of perioperative patient education and smoking cessation within this population.