Consideration of difficulties and exit strategies in a case of face allotransplantation resulting in failure

Abstract

We describe the first rescue procedure in a case of total face allotransplantation. The recipient was a 54-year-old man with severe disfigurement of the entire face following an accidental gunshot injury 5 years previously. The large defect included the maxilla, mandible, and mid-face. Full face procurement was performed from a multiorgan cadaveric donor and was allotransplanted to the recipient. The post-transplant induction immunosuppressive regimen included ATG combined with tacrolimus, mycophenolate mofetil, and prednisone, while maintenance was provided by the last three of these. Although the early postoperative period was uneventful, squamous cell carcinoma developed in the upper and lower extremities in the fifth postoperative month, and post-transplant lymphoproliferative disorder (PTLD) occurred in the sixth month postoperatively. Malignancies were treated, involving both surgical and medical approaches. The patient developed opportunistic pulmonary and cerebellar aspergillosis. In order to reduce the adverse affects and metabolic and immunological load, the transplanted face was removed and replaced with a free flap. Although the early postoperative period was promising, with the transferred flap surviving totally and all vital signs and general status appearing to be improving, the patient was eventually lost due to complicated infectious and metabolic events. Although this case was unsuccessful, we suggest that the immunological and metabolic load should be reduced as soon as stable medical conditions are established in case of diagnosis of a situation involving a high rate of mortality, such as PTLD and untreatable opportunistic infections. This should include withdrawal of all immunosuppressive drugs and removal of all allotransplanted tissues.

Face allotransplantation for various types of facial disfigurements: A series of five cases

“…Surgical rescue procedures in vascularized composite tissue transplantations are an important issue in case of unexpected events (Ozkan et al, ). In extremity transplantations, the final possible salvage procedure is amputation of the allotransplanted part, which will not result in a worse situation than that pertaining prior to the transplantation procedure.…”

“…In addition to difficulties involving surgical techniques, the most serious handicap is the use of immunosuppressive drugs, which are well known to increase the risk of opportunistic infections, metabolic complications and malignancies. As in all surgical procedures, there must be exit strategies in vascularized composite tissue allotransplantations in case of unfavorable developments (Ozkan et al, ). In the earliest period, experience with solid organ transplantations was employed in order to overcome problems related to the use of immunosuppressive drugs, since there was considerably more experience with these.…”

Anesthetic Considerations in Facial Transplantation: Experience at NYU Langone Health and Systematic Review

“… 2 , 30 , 72 Unfortunately, secondary procedures have also included allograft explantation, providing further insight into strategies for handling adverse outcomes. 13 , 80 …”

Autologous Reconstruction of a Face Transplant Candidate

“…14 Patients receiving facial allografts require mandatory lifelong immunosuppression, which increases their risk of developing infections, renal failure, as well as neoplasms. [15][16][17] Transplant teams must also be ready to address the devastating consequences of allograft rejection and subsequent failure, 18,19 which have resulted in explantation and death. Nevertheless, a recent face retransplantation may offer an alternative for patients with chronic allograft rejection requiring explantation.…”