Dr. X Surgeon: Dr. Y Anesthesiologist: Dr. Z Nurse: N Here we elevate the recipient facial flap and dissect the recipient vessels in preparation for microvascular anastomoses.

1. Face Transplantation
Prepared by: Mohammed Eskandar AlmaQaleh
Sana’a University

2. History
M.E.AlmaQaleh2
The development in last few decades & 2ND world war skin resurfacing.
Tom Gibson and Peter Medawar developed the first experimental studies in skin
transplantation and the paradox of foetal and gestation tolerance.
In 1954, Joseph Murray performed the first successful renal transplantation in human.
Gilbert in Ecuador, were doctors performed the first-hand transplantation ever in1964.
In November 2004 Royal College of Surgeons in London released the “Working Party Report
on Face Transplantation.
In 2004 the CCNE (Comité Consultatif National d’Ethique) in France

3. Con…
M.E.AlmaQaleh3
in October 2005, the Ethics Committee of the Cleveland Clinic granted permission for a face
transplantation to Dr. Siemionow’s team perform face transplantation in humans.
Dr. Bernard Devauchelle & Dr.Jean Michel Dubernard performed the world’s first partial
human facetransplantation ( 2005-France)
In April2006, Dr. Shuzhong Guo, at the Xijing Hospitalin Xian (China), performed the world’s
second partial face transplantation.
USA in December 2008 Dr. Maria Siemionow and her team at the Cleveland Clinic performed
face transplantation.
Spanish surgeons in March 2010 performed the first total face transplantation in the world

4. Number of Face Transplantation Around The WORLD
France USA Spain Turkey Belgium China Poland
Face Transplantation
M.E.AlmaQaleh4

5. What is “ Face Transplantation”?
M.E.AlmaQaleh5
Face Transplantation: is a single, complex operation intended to transform severely
deformed features to near normal appearance and function with the use of techniques that
conventional plastic surgery can not match.
Composite Tissue Allograft (CTA): is construct made up skin, muscle, tendon, nerves, bone,
and blood vessels from another human being that potentially can transplanted to an
appropriate recipient.
Face and hand VCA have been included in an independent classification (Gordon type III)

6. CON..
M.E.AlmaQaleh6

7. Experimental Studies
M.E.AlmaQaleh7

8. Experimental Studies
M.E.AlmaQaleh8

9. Experimental Studies
M.E.AlmaQaleh9

10. What are the objectives of “ Face Transplantation”?
M.E.AlmaQaleh10
1. The introduction of a new method of restorative surgery for patients that present with
severe catastrophic face deformities.
2. To obtain optimal outcomes, both functional, psychological and aesthetic.
3. Optimal reconstruction of the face, with complete restoration of the missing anatomy, not
amenable for reconstruction with any other traditional technique(s).
4. To produce the necessary outcomes for the reintegration of the patient into society, family
and work market.

11. Indications of “ Face Transplantation”
M.E.AlmaQaleh11
1. Complete destruction of the eyelids, including the orbital sphincter. (Absolute ind)
2. Complete destruction of the lips, including the oral muscle sphincter.(Absolute ind)
3. Patients affected by face destruction (total or partial) from burns.
Destruction of face sphincters and
severe face scarring are common
problems in burn patients that have an
indication for face VCA

12. Indication of “ Face Transplantation”?
M.E.AlmaQaleh12
Massive third-degree burns to the face
are goodc andidates for face VCA. It
may be considered in the acute phase
for patients with the involvement of
deep
structure

13. Indication of “ Face Transplantation”?
M.E.AlmaQaleh13
4.Posttraumatic face deformities
5. Benign tumors, congenital deformities and other local
extensive malformations Patients affected by burn
squeals present with a broad spectrum of deformity .

14. Indication of “ Face Transplantation”?
M.E.AlmaQaleh14
GUNSHOOT
Complex congenital deformities Type I neurofibromatosis, vascular
malformation

15. Contraindications of “ Face Transplantation”
M.E.AlmaQaleh15
1. Evidence of tumour malignancy
2. Negative report from psychiatric/psychological evaluation (active
psychiatric disorders, severe personality disorders and known and
reported non-compliance to treatments, among others)
3. Medical conditions that affect systems and/or organs (especially those
that may be affected by immunosuppression drugs)

16. Co$t
M.E.AlmaQaleh16
The face transplant patient underwent 23 conventional
reconstructive procedures before undergoing face
transplantation. The costs of conventional reconstruction and face
transplantation were $353,480 and
$349,959, respectively

17. Functional Anatomy
M.E.AlmaQaleh17
The bases of vascularized composite tissue allotransplantation rely on general principles of
plastic and reconstructive surgery and on modern reconstructive microsurgery
Complete knowledge of anatomy of blood vessels and nerves and other
anatomical units in the face and neck region is fundamental for the success of face
transplantation

18. Functional Anatomy
M.E.AlmaQaleh18
Arterial Anatomy
Carotid Artery :
- External C.A
- Internal C.A

19. Functional Anatomy
M.E.AlmaQaleh19
Venous Anatomy
Carotid Artery
-Facial Vein
-External Jugular Vein
-Internal Jugular Vein
-Cephalic Vein

20. Functional Anatomy
M.E.AlmaQaleh20
Nervous Anatomy
- Trigeminal .N
- Facial .N

21. Types of Face Transplants
M.E.AlmaQaleh21
According to Quantity of Tissue that Transplanted
- Partial transplantation: parts of the face are
transplanted either as subunits or units. One or
many face units are included in the
transplant.
-
Total/full transplantation: the whole face is
transplanted as a graft, similarly to solid organ
transplantation.
Lengele’s classification: depending on the type of tissues and areas that are transplanted.
- It classified to 5 types each type subdivided to two types A & B in which type A transplants include
soft tissues only, whereas type B transplants include different amounts of face
bones.

22. Lengele’s Classification
M.E.AlmaQaleh22
A-Type I Face Transplant (Lower Central):
Includes the inferior third of the face(the nose, lips and chin area).
-Vascularization depends on both face arteries.
-Main motor branches include buccal, mandibular and zygomatic face nerves.
-The mental and infraorbital nerves provide sensation.
- Type B transplants may include the mandible and maxilla
- This was the world’s first face transplantation ever, performed on November
2005 in Amiens, France (Dr. Devauchelle and team).

23. Lengele’s Classification
M.E.AlmaQaleh23
B-Type II Face Transplant (Mid Central):
Includes The nose, upper lip, cheeks and mimic muscles It may
include also the inferior part of the face.
-The maxilla and parts of the mandible are bones included in a type II
B face transplant.
- Vascularization is obtained by the face pedicles, and it should
include the infraorbital nerve and the zygomatic and buccal rami of
the face nerve.

24. Lengele’s Classification
M.E.AlmaQaleh24
C-Type III Face Transplant (Upper Face)
 Includes the forehead, eyelids and root of the nose and
mimic muscles.
 Bone is not transplanted in this type of transplant.
However, depending on the requirements of the
recipient, parts of the nose and/or zygoma may be
included

25. Lengele’s Classification
M.E.AlmaQaleh25
D-Type IV Face Transplant
 The skin and fat tissue of the face is transplanted. It
constitutes a true resurfacing procedure of the entire
face.
 This VCA graft is especially designed for burned
patients.
 It does restore sensation, and all three trigeminal
branches are included in
the allograft.
 Vascularisation is obtained by face and temporal
vessels harvested separately or in continuity with the
external carotid artery

26. Lengele’s Classification
M.E.AlmaQaleh26
E-Type V Face Transplant ((Full Face Transplant)
 Type V transplants are full/total-face transplants includes all of
the former (skin, fat, mimic muscles, nose, eyelids, lips, mucosa,
etc.). Type B transplants would include the mandible, maxilla,
zygomas and the
nose.
 It contains all expression muscles, face motor branches and all
three segmental branches of the trigeminal nerve, and it is
vascularized by the face and temporal arches.
 The world’s first full- face transplant was performed in Barcelona
(Dr. Barret and team) in March 2010

27. Teamwork
M.E.AlmaQaleh27
Facial
Transplant
patient
Surgeon
Physiatrist
Psychologist
Nursing
Nutritionist
Case
management/
Social work
Respiratory
Therapist
Occupational
Therapist
Physical
Therapist
Speech-
Language
Pathologist

28. Steps of Procedure
at Glance
Sana’a University

29. Total Face
Double Jaw
&
Tongue
Transplantation
Maryland Medical Center
19th & 20th of March 2012

30. Recipient History & Physical Exam
M.E.AlmaQaleh30
 The patient is a 37 years old male who
sustained to gunshot in 1997.
 He had undergone greater than 20
reconstructive procedure since 1997 including
multiple free tissue transfer.
 After 15 years of living behind surgical mask
he consented to proceed with a face
transplant.
 After Institutional review board (IRB) approval
a donor
with match facial color, age, ABO, HLA & viral
status was identified on march 17 2012

31. Recipient Pre-OP CT Angiography
M.E.AlmaQaleh31
 It is obtained to define the vascular
anatomy of recipient face & to help guide
the surgical plan.
 The vascular study verified & isolated right
lingual arterial supply to the tongue, the
right external carotid artery confirmed
common trunk to facial & lingual arteries,
therefore the arterial an anastomosis
designed to be performed at location that
would spare supply to the tongue.

32. Recipient Surgical Markings
M.E.AlmaQaleh32
 Markings were designed to include all the
disfigured scars & traumatized tissues.
 Markings begin at the pre-tricky of
forehead & continued along pre-auricular
crease extending down the neck to
encompass all scarred tissue.
 The upper eyelids are marked to include
the eyelid skin to ensure tension free
closure & injury to corneal blank

33. Donor Pre-Dissection Fluorescence Vascular Angiography
M.E.AlmaQaleh33
 Green dye is infused into the
donor prior to dissection of
flap to establish the base line
of perfusion

34. Donor Surgical Markings, Facial Flap Elevation & Vessels Dissection
M.E.AlmaQaleh34
 The markings are outlined
from the sternal notch at the
base of the neck & along the
pre-auricular crease & then
includes the anterior portion
of the scalp via the coronal
incision.
 The initial incision begins at
the sternal notch and
proceeds laterally until
arriving the posterior margin
of external collateral mastoid
muscle
 The upper margin of neck incision begins inferior to the ear lobule &
continues to join the clavicular incision.

35. Donor Surgical Markings, Facial Flap Elevation & Vessels Dissection
M.E.AlmaQaleh35
 Using fine tip needle cautery
the neck flap is elevated in
the sum-platesma plane.
 All sensory nerves including
regular nerve are spared
when possible.
 Self-retracting hooks are used
to retract the
sternocleidomastoid muscle
laterally to allowing access to
the major neck vessels
 The I.J.V & branches &the common carotid artery & its bifurcation are
circumferentially exposed.

36. Donor Surgical Markings, Facial Flap Elevation & Vessels Dissection
M.E.AlmaQaleh36
 The hypoglossal nerve is
reflected to expose the
lingual and facial trunks of the
external carotid artery as well
as the internal maxillary
artery.
 The lingual artery dissection
proceeds in an entry grid
manner until arriving at the
anterior 1l3 of the tongue via
the floor of the mouth
 The I.J.V & branches &the common carotid artery & its bifurcation are
circumferentially exposed.

37. Donor:Facial Nerve Dissection
M.E.AlmaQaleh37
 The approach to the facial
nerve is similar in both
patients.
 A skin flap is elevated in
subcutaneous plane &
continues deep to the parotid
masseteric fascia as nerve
exist to gland.
 Special attention is made to
identify the upper middle and
lower division of facial nerve
 Intra-operarive alternating current nerve stimulation is used to help
identify all branches of facial nerve.
 Notice: The elevation of the upper lip & depression lower lip with nerve stimulation.

38. Donor Peri-Orbital Dessection
M.E.AlmaQaleh38
 A lower eyelid subcilary incision is made on a
dissection proceeds deep to the orbicularis oculi
muscle.
 The dissection meets the level of the facial
nerve dissection at the zygomatic major muscle
 Once the muscularcutaneous flap is elevated the
dissection is proceeds to the orbital foor medial
and lateral walls
 An osteomy is made at the orbital floor to
visualize the infra-orbital nerve & keratinin
runner is used to liberate the nerve from its
foramen
 The nerve is dissected as proximal as possible before
transection.
 The upper eyelid dissection is performed in similar fashion until arriving the super orbital rim.

39. Coronal Flap Dessection
M.E.AlmaQaleh39
 In the recipient the coronal flap elevation
proceeds in the subcutaneous plane While in
the donor it proceeds in subgalio subfrontalis
plane until joinog the peri orbital dissection at
the level of super orbital rim.
 The super orbital nerve are visualized and
transected to allow for facile collection with
donor nerves

40. Mandibular bilateral sagittal split osteotomies
M.E.AlmaQaleh40
 Skeletal osteotomies are
begun with the mandible.
 A standard sagittal split
osteotomies perform via
an intra-oral & extra-oral
approach to allow access
to the I.A.N which is
transected in a manner to
preserve maximal length

41. Le Fort III Midface Osteotomy
M.E.AlmaQaleh41
 Once the intra0operative navigations are
completed the mid face Lefort III osteotomy
is performed with reciprocating saw.
 The midline osteotomy is joined with
zygomatic or frontal, orbital & terrigal
maxillary osteotomies in a similar fashion.
 A curved male scissors is used to complete
the division septum in the nasal mucosa.
 Vascularity is grossly inspected while
maintaining by pedicle perfusion Here we complete the dissection of facial soft tissues, the double jaws & the tongue.

42. Donor: Skeletal Tailoring & Plate Bending to Recipient
Stereolithographic Model
M.E.AlmaQaleh42
 When soft tissues & bony dissection are
completed the donor bones are tailored
and temporally fixed to stereolithographic
model of the recipient facial defect plates.
 Plates are manually molded & used to fixate
the facial flap to the model
Here we complete the dissection of facial soft tissues, the double jaws & the tongue.

43. Donor Post-Dissection Fluorescence Vascular Angiography
M.E.AlmaQaleh43
 The imaging confirms the
complete perfusion of the
facial flap & tongue as well as
the deep mucosal surfaces

44. Recipient: Facial Flap Elevation & Vessels Dissection
M.E.AlmaQaleh44
 The recipient facial flap
elevation & vessels dissection
occurs concurrent to that of
the donor.
 Vessel dissection proceeds in
a similar fashion.
 Care is taken to preserve the
lingual facial arterial trunk on
the right side of the neck and
facial artery on the left side.

45. Recipient: Facial Nerve Dissection
M.E.AlmaQaleh45
 The nerves are dissected as
previously described in donor
and the recipient nerve
branches are divided as close
to their muscles targets as
possible and labeled with
sutures ligatures.
 Innervation to the muscles of
the upper division is spared
on the recipient to preserve
normal eyelid function

46. Recipient Periorbital Dissection
M.E.AlmaQaleh46
 The periorbital incisions are made through the
skin only at the level of the supraorbital &
infraorbital rims.
 The periorbital dissection is performed in a
subcutaneous plane to the orbicularis oculi &
and underlying structures are preserved in an
effort to avoid impairment of the corneal blink

47. Preparation of Donor Flap Transplant
M.E.AlmaQaleh47
 Once vascular perfusion is confirmed the donor
pedicles are divided and transferred to the
back table.
 University of Wisconsin solution is flushed into
the vessels and the tissue is cooled in a bath of
ice.
 The face is examined and vascular pedicles are
tailored and prepared for transplant.
 In order to preserve dignity of the donor &
respect the donor family a professional
rendered silicon mask is completed affixed to
the open wound .

48. Le Fort III Skeletal Fixation of Donor to Recipient
M.E.AlmaQaleh48
 Once the recipient defect is
established and hemostasis is
confirmed a donor face is removed
from the cooling solution and
transferred to patient.
 Bony fixation is done by using a Y
plate at the nasal frontal suture and
by stabilizing donors zygomatic of
the recipient with two palates on
either side.

49. Microvascular Anastomoses
M.E.AlmaQaleh49
 Once the midface is stabilized the vascular pedicle
is tailored to limit vessel redundancy and to help
prevent kinking.
 The left donor external carotid arteries
anastomosed to the left recipient external carotid
end to end.
 The left donor internal jugular vein is anastomose
end to side to recipient left internal jugular vein
 Upon completion of the left vessel anastomosis
the facial allograft is clinically inspected.
 Please note the progressive reperfusion of lower
lip and face crossing the midline
 Following initial confirmation of perfusion the
right donor external carotid arteries
 anastomosed to the recipient right internal maxillary artery end to end.
 Avoiding the trunk of facial and lingual artery to ensure adequate vascularity to the
native recipient tongue
 The right internal jugular vein is anastomosis end to end to abranch of the right
recipient internal jugular vein

50. Post-Reperfusion Fluorescence Vascular angiography of Facial Transplant
M.E.AlmaQaleh50
The imaging confirms the complete reperfusion of facial flap & tongue as well as a deep surfaces following
transplant

51. Mandibular Skeletal Fixation
M.E.AlmaQaleh51
 The maxillary & mandibular
dentition are temporarily
stabilized with inter-maxillary
fixation.
 The donor mandibular bodies are
stabilized to the recipient
mandibular bodies by cortical
screws on each side.
 The skeletal & dental occlusion is
verified & compared to the
planned post-operative occlusion.

52. Intra-Oral & Tongue Insetting
M.E.AlmaQaleh52
 The tongue and
intraoral soft tissue
are tailored and re-
approximated to
ensure watertight
closure using re-
absorbable suture
in an interrupted
horizontal
mattress fashion

53. Nerve Cooptation
M.E.AlmaQaleh53
 The nerves of facial animation
properly matched their
corresponding functional motor unit
branches by identifying the color-
coded suture ligature.
 Three donor motor nerve grass or
interpose when needed.
 The nerves are co-opted with simple
interrupted suture and fibrin glue.

54. Pre-Orbital Re-draping
M.E.AlmaQaleh54
 The periorbital soft tissues are
tailored and primarily closed.
 Medial and lateral canthal
backscisoors performed

55. Final Soft Tissue Insetting
M.E.AlmaQaleh55
 The vascular pedicles
are verified one last
time before tailoring
and re-draping of the
neck, check & scalp
tissue .

56. Summary of Skeletal Transplant
M.E.AlmaQaleh56
 Through confirmation with pre-operative
virtual surgical plan and intraoperative
navigation the donor osteotomies were
designed and performed to remove the
maxilla, zygoma, nose & mandible.
 The recipient osteotomies were designed and
performed to remove all of the non-native
bone & to recreate the hard tissue defect.
 Post-operative CT scans confirm the proper
anatomic restoration of the recipient midface
& lower face.
 Occlusal relationship &facial width projection
& height matched to pre-operative plan

57. M.E.AlmaQaleh57

58. M.E.AlmaQaleh58

59. M.E.AlmaQaleh59

60. M.E.AlmaQaleh60

61. M.E.AlmaQaleh61

62. M.E.AlmaQaleh62

63. References
M.E.AlmaQaleh63
Maryland
Medical
Center
19th & 20th of
March 2012

64. M.E.AlmaQaleh64