Vascular Considerations in Composite Midfacial Allotransplantation

Background: Advances in microsurgery and immunosuppression have allowed for facial reconstruction at a qualitatively new level with facial composite tissue allografts. Although donor tissue recovery is unique for each patient, transplantation of the maxilla and overlying soft tissues will be a frequent indication. Vascularity of the maxilla and palate, supplied by facial arteries alone, has been a concern. Based on cadaver dissections and a clinical case, vascular considerations for transplantation of the entire midface are discussed. Methods: To prepare for central facial transplantation in an identified patient, a preclinical dissection was completed on four cadavers. In April of 2009, an extended midfacial allotransplantation was performed. The flap included the entire group of facial mimetic muscles with overlying skin, sensory and motor nerves, nose, upper lip, maxilla, teeth, and hard palate. Results: The preclinical study identified key anatomical structures for inclusion in the composite tissue allograft. Moreover, dissections showed that the facial and angular blood vessels were connected to branches of the maxillary vessels through an anastomotic network organized around the periosteum and bony canals of the midfacial skeleton. Transplantation of a central face allograft including the maxilla and palate was anticipated to be feasible. A technically successful clinical case was completed. Conclusions: Anatomical and clinical observations elucidated several technical points related to composite tissue transplantation of the midface. Careful graft harvest, appropriate selection of donor and recipient vessels, complete allograft revascularization, and restoration of sensory and motor function are critical to making face transplant surgery safe and functional.