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A Novel Surgical Approach to Facial Transplantation: A Synthesis of Computer-Assisted Techniques and Fundamental Craniofacial Principles
Emile N. Brown, M.D., Amir H. Dorafshar, MBChB, Branko Bojovic, M.D., Michael R. Christy, M.D., Daniel E. Borsuk, M.D., M.B.A, Philip S. Brazio, M.D., Eduardo D. Rodriguez, M.D., D.D.S..
R Adams Cowley Shock Trauma Center, Baltimore, MD, USA.

PURPOSE: As we move from transplantation of partial facial segments composed of soft tissue alone to transplantation of full faces including underlying bone, the need to adhere to fundamental craniofacial principles, especially the maintenance of dental occlusion, becomes increasingly important. Additionally, as facial transplant procedures become more complex, there is an escalating need for techniques to improve surgical precision and efficiency. The evolving technologies of computer-assisted planning and intraoperative navigation may lead to shorter operating times and more precise skeletal fixation.
METHODS: Mock face transplants were performed in 18 cadavers (9 donor-recipient pairs). The allograft (Fig. A) consisted of all facial and anterior neck skin, mimetic muscles, multiple sensory and motor nerve branches, the anterior tongue and segments of the maxilla via a Le Fort III type osteotomy and mandible via bilateral sagittal split osteotomies (BSSO’s). The bilateral lingual and facial arteries, as well as bilateral external jugular and thyrolinguofacial veins served as vascular pedicles. Computed tomography (CT) scans of the cadaveric heads were obtained prior to dissection and virtual surgical planning software was used to plan the osteotomies (Fig. B). During the mock face transplant, a surgical navigation system was employed to ensure accurate execution of the planned osteotomies. Postoperative CT scans were obtained to confirm accurate skeletal fixation.
RESULTS: All mock transplants were completed in less than 10.5 hours. The combination of preoperative computer-assisted planning and intraoperative guidance consistently produced a donor allograft that could be easily fixated to the prepared recipient. Proper occlusion was maintained and no more than minimal burring of the Le Fort III osteotomy sites was necessary. Postoperative CT scans confirmed accurate skeletal fixation. By preserving the lingual arteries, a viable tongue segment could be included in the allograft. There were sufficient pedicle lengths for all anticipated vascular anastomoses and neurorrhaphies, as well as adequate soft tissue for coverage of the entire recipient defect. The overall aesthetic results were excellent.
CONCLUSION: Although preservation of dental occlusion has posed a consistent challenge in prior face transplants, we have applied our experience with craniofacial trauma to allow us to consistently transfer facial allografts with maintenance of proper occlusion. Preoperative computer-based planning and intraoperative navigation ensured a good match between the recipient and donor facial skeletons and allowed very precise osteotomies, greatly reducing the need for intraoperative adjustments and manipulation. The use of BSSO’s allowed straightforward adjustment of the mandible to “fit” the maxilla, as is done in a traditional orthognathic procedure. This full facial allograft represents one of the most extensive ever described, consisting of all facial skin and a significant portion of the tongue and facial skeleton. It is intended to represent a typical trauma pattern that we have observed in many victims of facial ballistic injuries, as well as in our wounded warriors. Variations on this basic design could provide reconstruction for a number of patients we have encountered.


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