Should We Consider Preparing Patients for Future Face Transplant when Managing Complex Facial Trauma?

With advancements in microsurgical technique and experience, face transplantation is becoming a clinical reality and acceptable procedure. Preparation of the maxillofacial skeleton and initial soft-tissue coverage for face transplant candidates is essential for optimizing the ultimate outcome by providing immediate coverage of vital structures, functionality, and a stable skeletal framework. We present our experience of preparing such a patient who underwent a successful face transplant, with an excellent outcome. A 24-year-old man sustained a self-inflicted ballistic injury to his face. Composite tissue deficits included significant soft-tissue loss in the central lower and midface, comminuted fractures of midface, and large bone gaps of the maxilla and mandible. He underwent open reduction internal fixation of bilateral LeFort III, zygomaticomaxillary complex, and complex maxillary and mandibular fractures with titanium plates and a free anterolateral thigh perforator flap to the midface with concomitant pedicled left supraclavicular artery fasciocutaneous flap to the lower face. He subsequently underwent a second free anterolateral thigh perforator for the exposed mandibular hardware due to partial necrosis of the supraclavicular artery fasciocutaneous flap. The patient achieved stable bone reconstruction and soft-tissue coverage and was discharged home. He was placed on the waiting list for a face transplant by another center in the country and eventually underwent a successful face transplant. We believe that the preparation of the patient with complex craniomaxillofacial trauma for face transplant should be considered when the extent of injury exceeds conventional reconstructive limits. Our approach provides the best opportunity for an optimal face transplant outcome while minimizing flap donor site morbidity.