Title: Mock Facial Transplantation A Cadaver Study In Preparation For
Facial Allograft Transplantation In Humans – Part II
Authors: Maria Siemionow, MD, PhD, Galip Agaoglu, MD, Sakir Unal, MD
In preparation for facial allograft transplantation in humans we have
performed series of cadaver dissections to estimate feasibility and
timing of facial flap harvest, integrity of vascular territories and
applicability of conventional flaps to cover total facial defect (1).
As a continuation of this first report, in this study we have
performed a mock facial transplantation by harvesting a total
facial/scalp flap in one group of cadavers and transferring the flap
to the recipient cadavers, where facial skin was excised as a
“monoblock” full-thickness skin graft creating a full facial defect.
Method: A total of 10 fresh human cadavers were dissected. Seven of
the cadavers were female and three were male. The average age of
cadavers was 64 years (range, 51 to 91 years). In eight cadavers the
total facial-scalp flap including external ear component was elevated
in the same fashion as we have described before (1), whereas in two
cadavers the facial skin was harvested as a “monoblock” fullthickness graft to mimic skin graft removal in the potential
allograft recipients.
In the donor, we have measured: 1- the time of facial-scalp flap
harvesting, 2- the length of the arterial pedicles (external carotid
artery), 3- venous pedicles (facial and external jugular veins) and
4- sensory nerves (supraorbital, infraorbital, mental, and great
auricular), which were included in the facial flaps.
In the recipient, we have evaluated: 1- the time of facial skin
harvest in the form of “monoblock” full-thickness skin graft, 2- the
time and sequences of donor facial flap inset, 3- anchoring regions
for the inset of the donor facial flaps against the gravitational
forces, 4- the sequences of sensory nerve coaptation and vascular
pedicle anastomoses.
Results: In the Donor Cadaver the mean harvesting time of the total
facial/scalp flap harvest was 235.62±21.94minutes. The mean length of
the supraorbital, infraorbital, mental and great auricular nerves was
1.5±0.15, 2.46±0.25, 3.02±0.31 and 6.11±0.42cm, respectively. The
mean length of the external carotid artery, facial and external
jugular veins was 5±0.32, 3.15±0.32 and 5.78±0.5cm, respectively.
In the Recipient Cadaver the mean harvesting time of facial skin as a
“monoblock” full-thickness graft was 47.5±3.53minutes. The mean time
for the preparation of the arterial and venous pedicles and sensory
nerves for the future anastomoses and coaptation was 30±0minutes. The
mean time for the facial flap anchoring was 22.5±3.53minutes. The
total mean time of facial mock transplantation without vessels and
nerves repair was 320±7.07minutes (5hours and 20minutes) (Table 1).
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The sequences of the mock facial transplantation are presented in
Table 2.
Conclusion: Based on anatomical dissections in this cadaver study, we
have estimated the time and sequence of the facial flap harvest and
inset to mimic the clinical scenario of facial transplantation
procedure.
Based on our experience and cadaver studies we suggest that during
first attempts of facial transplantation it would be appropriate to
perform transplantation of the facial skin only without other facial
components such as muscles or bones.
We are convinced that successful facial skin allograft
transplantation would be feasible and would open a new reconstructive
option for the severely burned and disfigured patients. Once the
problem of life-long immunosuppression will be solved, facial
transplantation could be introduced into the armamentarium of
reconstructive procedures in the plastic surgery.
Table 1. Total time needed for preparation of the Recipient’s Defect
and inset of the Donor facial flap to the Recipient
Surgical procedure
Facial skin graft harvesting in the
Recipient (min)
Preparation of the arterial and venous
pedicles and nerves for anastomoses
and repair (min)
Inset of the Donor facial flap into
the recipient (min)
Facial flap harvesting time from the
Donor Cadavers No 7 and 10 to the
Recipient Cadavers 8 and 9,
respectively (min)
Total time for mock facial
transplantation (min)
Cadaver
No 8
Cadaver
No 9
Mean
Time
(min)
47.5±3.5
3
30±0
50
45
30
30
25
20
22.5±3.5
3
210
230
220±14.1
4
315
325
320±7.07
Table 2. Mock Facial Transplantation Procedure–Sequence Of Procedures
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1- Transfer of the Donor facial flap into the
Recipient’s facial defect
2- Coaptaion of the supraorbital, infraorbital and
mental nerves
3- Anchoring of the flap at the region of the
mandibular and zygomatic ligaments
4- Anchoring of the flap to the pre-auricular region,
mastoid fascia and temporal fascia
5- Anchoring of the flap to the frontal bones
6- Closure of the upper and lower gingivobuccal
incisions
7- Closure of the upper and lower conjunctival
incisions
8- Anastomoses of the external carotid arteries
between the donor and recipient
9- Anastomoses of the facial veins between the donor
and recipient
10- Coaptation of the great auricular nerves
11- Anastomoses of the external jugular veins between
the donor and recipient
12- Closure of the skin incisions
REFERENCES
1- Siemionow M., Unal S., Agaoglu G., Sari A. What are alternative
sources for total facial defect coverage? A cadaver study in
preparation for facial allograft transplantation in humans –
part I. Plast. Reconstr. Surg (In press)
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