First human facial re-transplantation after graft failure and irreversible necrosis

1. At 30 months post-procedure, facial retransplantation using vascularized composite allotransplantation demonstrated good motor and sensory function.

2. At 2-years post-procedure, the patient was able to perform activities of daily living unassisted and return to part-time work.

Evidence Rating Level: 4 (Below Average)

Study Rundown: In 2010, a 35 year-old male patient underwent a total facial transplantation due to a severe plexiform neurofibroma. After an initial success, this procedure ultimately failed 6 years later due to rising plasma levels of HLA-B51 (donor-specific antibody) and progressive fibrosis of the graft. Over the subsequent 2 years, extensive necrosis developed, and the facial graft had to be removed. This case report chronicles the retransplantation of a second human face for this patient using vascularized composite allotransplantation (VCA). On January 15, 2018, a second facial allograft was found from a brain-dead donor, matching the recipient for blood group and testing negative for cytomegalovirus, Epstein-Barr virus and toxoplasmosis. Although there were eight HLA mismatches present, the clinical team decided to proceed, as the patient could no longer survive without a transplantation. Although the procedure involved massive blood loss, the patient survived and the retransplantation was successfully performed. Postoperatively, the patient followed an intensive regime of immunosuppression. An extensive psychological support system was provided both before and after surgery to help with the transition. Regular biopsies of VCA skin and mucosa were performed in an effort to catch subclinical episodes of acute rejection before they progressed. After an extensive stay in the intensive care unit and plastic surgery ward, the patient was discharged from hospital 1 year post-procedure. Although the patient suffered from episodes of anxiety and discouragement, assessment for post-traumatic stress disorder and a major depressive episode was negative. Despite the presence of bilateral facial sensation at 30 months post-op, there remained complete right-sided facial palsy. However, the patient reported regaining a reasonable quality of life and was able to return to work part-time.

Click to read the study in The Lancet

Relevant Reading: Vascularized composite allotransplantation: medical complications

In-Depth [case series]:  This case report is a 30 month follow-up of the first in-human facial retransplantation using VCA. After finding a suitable donor, the facial graft was harvested simultaneously while the recipient was prepared for transplantation. A novel oxygen carrier (HEMO2life; Hemarina, Morlaix, France) was added to the heparinized storage solution of the graft to minimize ischemia-reperfusion injury. The surgical procedure involved massive blood loss, with a total of 32 units of packed red blood cells, 30 units of fresh frozen plasma and nine concentrated suspensions of blood platelets transfused. The duration of recipient preparation and retransplantation were 9 and 5 hours, respectively. A desensitization protocol was initiated to reduce the chance of acute allograft rejection when the patient was stable, involving numerous doses of intravenous antithymocyte globulins, methylprednisolone, anti-CD20 monoclonal antibodies, anti-B-cell activating factor monoclonal antibodies, 17 sessions of plasma exchange, immunoglobulins and eculizumab. The patient also received extensive psychiatric support to reduce the psychological trauma of a second facial transplantation. Additionally, an immunosuppression maintenance regime was maintained for the entirety of the 30 month follow-up period, which included tacrolimus, mycophenolate mofetil and corticosteroids. Finally, the patient had routine biopsies of the retransplanted skin and mucosa on post-op day 2, then weekly, and finally at months 6, 9, 10, 14, 21 and 23 after the procedure. This was done to monitor for any subclinical events of acute graft rejection. The patient remained in hospital a total of 1 year post-op, during which he developed several infections, including norovirus, cytomegalovirus esophagitis and aspiration pneumonia. He was eventually discharged, but continued to have anxiety regarding his procedure and health status. He was given ongoing support and follow-up, and was gradually weaned from benzodiazepines and sertraline by 24 months post-op. At 30 months post-procedure, the patient reports a restored quality of life. He has regained facial sensation, and some motor function, yet complete right-sided facial palsy remains. He is able to perform activities of daily living unassisted, work part-time, and no other complications have been reported so far. He continues to be followed regularly by the transplantation team.

Image: PD

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