LETTER TO THE EDITOR
MICROSURGERY 35:419–420 (2015)
COMMENT ON: “TWO-STAGE FACE TRANSPLANTATION: A NEW CONCEPT IN VASCULARIZED COMPOSITE ALLOTRANSPLANTATION” Dear Editor,
After reading the excellent article on experimental animal models for face transplant (FT) in two stages by Ramirez et al.,1 we would like to congratulate the authors and comment some details of our personal experience to provide additional relevant clinical information of this procedure in a real clinical scenario. On January 26, 2010, our team carried out the world’s 11th face transplantation.2 One of the main distinctive features of our procedure included the performing of innovative two-stage vascularized composite allotransplantation (VCA) with the following surgical sequence: first, a provisional heterotopic transplantation technique of the allograft to recipient’s thigh area; and second, a final orthotopic transplantation to the neck.3 One surgical team initiated the procedure by preparing the recipient’s femoral vessels to receive the allograft immediately after the initiation of the donor’s allograft removal by other team. After the harvesting, the allograft was immediately transferred to the recipient’s thigh and the provisional anastomoses were performed as follows: end-to-end anastomosis between the left internal jugular vein and the right saphenous vein, and end-toside anastomosis between the left common carotid artery and the right femoral artery. The carotid-jugular system showed a consistent anatomy and diameter for anastomosis to the femoral vessels. When the vascular clamp *Correspondence to: Pedro Infante-Cossio, M.D., Ph.D., D.D.S., Department of Oral and Maxillofacial Surgery, Virgen de Rocio University Hospital, Manuel Siurot Av. 41013 Seville, Spain. E-mail: [email protected] Received 16 November 2014; Accepted 5 December 2014 Published online 17 December 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22367 Ó 2014 Wiley Periodicals, Inc.
was released, the entire facial allograft was fully perfused through the unilateral vascular anastomosis (Fig. 1). After 6 hours, the allograft was successfully transferred to the face once another team had created the face defect and prepared the vessels of the recipient’s neck. No perioperative vascular complications were noticed in the recipient’s thigh area. In our clinical experience, the main advantages of performing two-stage face VCA can be summarized
Figure 1. View of the internal side of the allograft after the provisional heterotopic transplantation to the recipient’s thigh area. Note the microvascular anastomosis between the internal jugular vein and the saphenous vein (black arrow), and between the common carotid artery and the femoral artery (white arrow).
420
Letter to the Editor
as:3,4 1) this technique provided sufficient additional time to create the recipient’s facial defect without compromising allograft ischemia, to perform a thorough hemostatic control of the allograft, especially if it has been harvested from a non-beating heart donor in which a significant hemorrhage is expected, and to select and choose the most suitable recipient vessels and nerves to perform the final microvascular anastomoses; 2) from a logistical point of view, this microsurgical sequence allowed two FT teams could operate simultaneously thanks to the distant location of the thigh from the neck; and 3) in a scenario of multiorgan recovery, this procedure favored transplant teams could achieve a unthreatened donation of vital organs. To date, most FT teams worldwide have conducted a single-stage facial VCA, so this method should be regarded the “standard technique” endorsed by the pioneering successful clinical experiences in the past 9 years.5 However, we agree with the authors that a two-stage face transplantation could be considered a feasible alternative procedure in selected cases. Our clinical experience has shown that a well-planned human FT in two stages can be a reliable and valuable microsurgical option. Nevertheless it still should be contemplated as an experimental procedure to be taken into account only when associated limitations, risks and benefits are respected. The publication of this experimental animal study certainly introduces a new insight in the preclinical research and future potential applications in FT.
Microsurgery DOI 10.1002/micr
PEDRO INFANTE-COSSIO, M.D., Ph.D., D.D.S.* Department of Oral and Maxillofacial Surgery Virgen Del Rocio University Hospital Seville, Spain DOMINGO SICILIA-CASTRO, M.D., Ph.D. AND TOMAS GOMEZ-CIA, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Virgen Del Rocio University Hospital Seville, Spain
REFERENCES 1. Ramirez AE, Lao WW, Wang Y-L, Cheng H-Y, Wei F-C. Two-stage face transplantation: A new concept in vascularized composite allotransplantation. Microsurgery 2015;35:218–226. 2. Gomez-Cia T, Sicilia-Castro D, Infante-Cossio P, Barrera-Pulido F, Gacto-Sanchez P, Lagares-Borrego A, Narros-Gimenez R, GarciaPerla A, Hernandez-Guisado JM, Gonzalez-Padilla JD. Second human facial allotransplantation to restore a severe defect following radical resection of bilateral massive plexiform neurofibromas. Plast Reconstr Surg 2011;127:995–996. 3. Sicilia-Castro D, Gomez-Cia T, Infante-Cossio P, Gacto-Sanchez P, Barrera-Pulido F, Lagares-Borrego A, Narros-Gimenez R, GarciaPerla A, Hernandez-Guisado JM, Gonzalez-Padilla JD. Reconstruction of a severe facial defect by allotransplantation in neurofibromatosis type 1: A case report. Transplant Proc 2011;43:2831–2837. 4. Gomez-Cia T, Infante-Cossio P, Sicilia-Castro D, Gacto-Sanchez P, Gonzalez-Padilla JD. Sequence of multiorgan procurement involving face allograft. Am J Transplant 2011;11:2261. 5. Infante-Cossio P, Barrera-Pulido F, Gomez-Cia T, Sicilia-Castro D, Garcia-Perla-Garcia A, Gacto-Sanchez P, Hernandez-Guisado JM, Lagares-Borrego A, Narros-Gimenez R, Gonzalez-Padilla JD. Facial transplantation: A concise update. Med Oral Patol Oral Cir Bucal 2013;18:e263–271.
MICROSURGERY 35:419–420 (2015)
COMMENT ON: “TWO-STAGE FACE TRANSPLANTATION: A NEW CONCEPT IN VASCULARIZED COMPOSITE ALLOTRANSPLANTATION” Dear Editor,
After reading the excellent article on experimental animal models for face transplant (FT) in two stages by Ramirez et al.,1 we would like to congratulate the authors and comment some details of our personal experience to provide additional relevant clinical information of this procedure in a real clinical scenario. On January 26, 2010, our team carried out the world’s 11th face transplantation.2 One of the main distinctive features of our procedure included the performing of innovative two-stage vascularized composite allotransplantation (VCA) with the following surgical sequence: first, a provisional heterotopic transplantation technique of the allograft to recipient’s thigh area; and second, a final orthotopic transplantation to the neck.3 One surgical team initiated the procedure by preparing the recipient’s femoral vessels to receive the allograft immediately after the initiation of the donor’s allograft removal by other team. After the harvesting, the allograft was immediately transferred to the recipient’s thigh and the provisional anastomoses were performed as follows: end-to-end anastomosis between the left internal jugular vein and the right saphenous vein, and end-toside anastomosis between the left common carotid artery and the right femoral artery. The carotid-jugular system showed a consistent anatomy and diameter for anastomosis to the femoral vessels. When the vascular clamp *Correspondence to: Pedro Infante-Cossio, M.D., Ph.D., D.D.S., Department of Oral and Maxillofacial Surgery, Virgen de Rocio University Hospital, Manuel Siurot Av. 41013 Seville, Spain. E-mail: [email protected] Received 16 November 2014; Accepted 5 December 2014 Published online 17 December 2014 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22367 Ó 2014 Wiley Periodicals, Inc.
was released, the entire facial allograft was fully perfused through the unilateral vascular anastomosis (Fig. 1). After 6 hours, the allograft was successfully transferred to the face once another team had created the face defect and prepared the vessels of the recipient’s neck. No perioperative vascular complications were noticed in the recipient’s thigh area. In our clinical experience, the main advantages of performing two-stage face VCA can be summarized
Figure 1. View of the internal side of the allograft after the provisional heterotopic transplantation to the recipient’s thigh area. Note the microvascular anastomosis between the internal jugular vein and the saphenous vein (black arrow), and between the common carotid artery and the femoral artery (white arrow).
420
Letter to the Editor
as:3,4 1) this technique provided sufficient additional time to create the recipient’s facial defect without compromising allograft ischemia, to perform a thorough hemostatic control of the allograft, especially if it has been harvested from a non-beating heart donor in which a significant hemorrhage is expected, and to select and choose the most suitable recipient vessels and nerves to perform the final microvascular anastomoses; 2) from a logistical point of view, this microsurgical sequence allowed two FT teams could operate simultaneously thanks to the distant location of the thigh from the neck; and 3) in a scenario of multiorgan recovery, this procedure favored transplant teams could achieve a unthreatened donation of vital organs. To date, most FT teams worldwide have conducted a single-stage facial VCA, so this method should be regarded the “standard technique” endorsed by the pioneering successful clinical experiences in the past 9 years.5 However, we agree with the authors that a two-stage face transplantation could be considered a feasible alternative procedure in selected cases. Our clinical experience has shown that a well-planned human FT in two stages can be a reliable and valuable microsurgical option. Nevertheless it still should be contemplated as an experimental procedure to be taken into account only when associated limitations, risks and benefits are respected. The publication of this experimental animal study certainly introduces a new insight in the preclinical research and future potential applications in FT.
Microsurgery DOI 10.1002/micr
PEDRO INFANTE-COSSIO, M.D., Ph.D., D.D.S.* Department of Oral and Maxillofacial Surgery Virgen Del Rocio University Hospital Seville, Spain DOMINGO SICILIA-CASTRO, M.D., Ph.D. AND TOMAS GOMEZ-CIA, M.D., Ph.D. Department of Plastic and Reconstructive Surgery Virgen Del Rocio University Hospital Seville, Spain
REFERENCES 1. Ramirez AE, Lao WW, Wang Y-L, Cheng H-Y, Wei F-C. Two-stage face transplantation: A new concept in vascularized composite allotransplantation. Microsurgery 2015;35:218–226. 2. Gomez-Cia T, Sicilia-Castro D, Infante-Cossio P, Barrera-Pulido F, Gacto-Sanchez P, Lagares-Borrego A, Narros-Gimenez R, GarciaPerla A, Hernandez-Guisado JM, Gonzalez-Padilla JD. Second human facial allotransplantation to restore a severe defect following radical resection of bilateral massive plexiform neurofibromas. Plast Reconstr Surg 2011;127:995–996. 3. Sicilia-Castro D, Gomez-Cia T, Infante-Cossio P, Gacto-Sanchez P, Barrera-Pulido F, Lagares-Borrego A, Narros-Gimenez R, GarciaPerla A, Hernandez-Guisado JM, Gonzalez-Padilla JD. Reconstruction of a severe facial defect by allotransplantation in neurofibromatosis type 1: A case report. Transplant Proc 2011;43:2831–2837. 4. Gomez-Cia T, Infante-Cossio P, Sicilia-Castro D, Gacto-Sanchez P, Gonzalez-Padilla JD. Sequence of multiorgan procurement involving face allograft. Am J Transplant 2011;11:2261. 5. Infante-Cossio P, Barrera-Pulido F, Gomez-Cia T, Sicilia-Castro D, Garcia-Perla-Garcia A, Gacto-Sanchez P, Hernandez-Guisado JM, Lagares-Borrego A, Narros-Gimenez R, Gonzalez-Padilla JD. Facial transplantation: A concise update. Med Oral Patol Oral Cir Bucal 2013;18:e263–271.
