A Single Center's Experience with Donation of Facial Allografts for Transplantation

Abstract

Purpose: Face transplantation offers superior functional and aesthetic outcomes when compared with conventional reconstruction. Optimizing criteria to match donors and recipients will improve outcomes. However, there is limited available literature regarding donor procurement and matching. Methods: The Brigham and Women's Hospital describes its experience with facial allograft donation for 7 face transplants performed between 2009 and 2014. Important considerations include donors' type of death, allograft ischemia time, demographics, immunologic compatibility, serology, and donor facial restoration. Results: Brain-dead, heart-beating donors were preferred because their hemodynamic stability facilitated procurement logistics. The maximum allograft ischemia time allowed by our team was 4 hours. Donor and recipient should be matched in appearance by having the same gender, similar age, and comparable skin tone/texture. Immunologic compatibility requires ABO compatibility, suitable HLA typing, and negative crossmatch. Donor serology for infectious diseases, especially cytomegalovirus (CMV) and Epstein-Barr virus (EBV), is important because of implications of post-transplant immunosuppression. High-risk CMV and EBV matches (donor-positive/ recipientnegative) should be avoided when possible. Facial restoration with a prosthetic mask was performed to preserve the donor's dignity. Conclusions: Although every face transplant recipient has unique needs, the authors hope that sharing their institution's experience with facial allograft donor characteristics will help other face transplant centers and guide future regulation of facial composite allograft donation.

Donor and Recipient Matching in Facial Vascularized Composite Allotransplantation: A Closer Look at the Donor Pool

“…Although donation after cardiac death is theoretically possible in vascularized composite allotransplantation, extended (warm) ischemia time (especially in the case of uncontrolled donation after circulatory death) and significantly more complicated donor and recipient team coordination must be considered. 6,24,25 In this context, the majority of donors (93 percent) were not available to our center because of distance, travel time, and thus unacceptable ischemia time. To increase the geographic radius of potential vascularized composite allotransplant donors and to diminish longer ischemia time, new strategies for ex situ tissue preservation are paramount, and this donor pool may be of relevance in the future.…”

“…In summary, many factors may also complicate identifying a match (e.g., high panel reactive antibodies, cytomegalovirus for some centers). 2,6 In our experience, approximately 50 percent of all families that are approached regarding vascularized composite allotransplant donation of their dead family member decline and "opt out" of the donation process. This can lead to prolonged wait times for recipients.…”

“…3–5 In addition, visible (physical appearance) compatibility criteria bear great relevance for facial vascularized composite allotransplant donor-recipient matching. 6 Some donor exclusion criteria such as sex, skin color, blood type, and body mass index are recipient specific. To date, little is known about the relative distribution of these matching criteria among potential facial vascularized composite allotransplant donors and how these may affect actual wait times.…”

“…The sheer number of compatibility criteria restricts the pool of potential donors. 6 Thus, a recipient can wait months to years for a transplant. In selected cases, wait times may become unacceptable, and with an increase in vascularized composite allotransplant listings, the gap between vascularized composite allotransplant availability and demand may widen in the future.…”