Aesthetic and functional facial transplantation: a classification system and treatment algorithm

Area of Science:

• Plastic Surgery
• Reconstructive Surgery
• Transplantation Surgery

Background:

• Facial vascularized composite allotransplantation (VCFA) is a complex reconstructive procedure with 27 cases reported by July 2013.
• Existing literature and media reports on VCFA were reviewed to inform the development of a standardized approach.
• The need for a practical and surgically applicable classification system and treatment algorithm for facial defects was identified.

Purpose of the Study:

• To develop and present a novel classification system for facial defects.
• To design a treatment algorithm to guide surgical decision-making in facial transplantation.
• To enhance patient selection and improve outcomes for VCFA procedures.

Main Methods:

• A classification system was developed based on craniofacial osteotomies for skeletal defects and aesthetic facial subunits for soft-tissue defects.
• Soft-tissue defects were categorized into three types: oral-nasal (type 1), oronasal-orbital (type 2), and full facial (type 3).
• Bony defects were classified based on involvement: mandibular (M), Le Fort 1 (A), Le Fort 3 (B), and monobloc (C).

Main Results:

• The primary mechanisms of injury leading to facial defects included trauma (n=13), burns (n=8), and congenital deformity (n=3).
• The proposed classification system was applied to analyze defect types, with specific distributions noted for soft-tissue and bony components (e.g., type 1, 1-M, 1-MB, etc.).
• The developed treatment algorithm facilitated vascularized composite allotransplantation addressing both bony and soft-tissue components of the facial defects.

Conclusions:

• Patient selection is critical for the success of VCFA, particularly given the requirement for lifelong immunosuppression.
• The proposed classification system and treatment algorithm offer a structured approach for defining indications for facial transplantation.
• Implementation of this system has the potential to optimize patient selection and enhance outcomes in centers performing facial allotransplantation.