Bahar Bassiri Gharb

Pathways of sensory recovery after face transplantation.

Background: Severely disfiguring facial injuries have a devastating impact on the patients quality of life. The advent of facial allotransplantation has allowed optimal anatomical reconstruction to be achieved; however, the need for lifelong immunosuppression and unpredictable functional outcomes preclude it from routine acceptance in clinical practice. Evidence from published reports on the first four face transplant recipients indicates improved and accelerated return of sensation to the facial allograft despite suboptimal repair of the sensory nerves. Methods: The authors performed a comparative analysis of the sensory outcomes following face transplantation with the sensory recovery achieved after conventional nerve repair, autologous face and scalp replantation, and vascularized free tissue transfer. Results: Sensory recovery following face transplantation, even when the sensory nerves were not repaired, was comparable to the outcome of microsurgical repair of the peripheral branches of the trigeminal nerve and innervated free flaps. Conclusions: Nearly normal sensory recovery can be expected following facial allotransplantation with or without repair of the sensory nerves. The mechanisms responsible for this surprising outcome include preservation of normal density of the receptors within the facial allograft, regeneration from the recipient bed and allograft margins, transmission of the sensory inputs through afferent fibers contained in the facial nerve, nervi nervorum of the facial nerve, or trigeminofacial communicating rami. Furthermore, immunosuppressive therapy with tacrolimus contributes to the accelerated nerve regeneration. The minimum requirements for quantitative sensory testing and timing of the follow-up assessments are outlined to facilitate comparison of sensory outcomes after face transplantation.

Successes and lessons learned after more than a decade of upper extremity and face transplantation.

Purpose of reviewThis review aims to present the most recent updates on face and upper-extremity allotransplantation. Recent findingsTo date, 27 face and more than 89 upper-extremity allotransplantations have been performed. Both the face and hand transplants restored form, function and patients’ social integration. The complications were comparable with solid organs; however, face transplantation, as well as the combination of face and double hand transplantation, presented with significant morbidity and mortality. Evidence of chronic rejection was confirmed in hand transplants, but it has not been reported yet for facial transplantation. Novel immunosuppressive protocols have allowed a decrease in the number and dosages of traditional immunosuppressants. With increased awareness that following face and hand transplantation, the return of function is more important than anatomical restoration of the missing parts, there has been an important shift in the ethical debate weighing the risks and benefits of face and hand allotransplantation. SummaryEarly results after face and upper extremity transplantation are promising, with 5-year survival rates greater than in solid organ transplants. However, these procedures still need to be closely monitored and the outcome data should be rigorously reported to the central patient registry database to allow continuous surveillance.

The Face as a Sensory Organ

Background: The human face is a highly specialized organ for receiving the sensory information from the environment and for its transmission to the cortex. The advent of facial transplantation has shown that excellent reconstruction of disfiguring defects can be achieved; thus, the expectations are now focused on functional recovery of the transplant. So far, restoration of facial sensation has not received the same attention as the recovery of motor function. Methods: A thorough review of the literature was performed to investigate the current knowledge on the sensory pathways of the human face and their functions to evaluate current methods of sensory assessment and the available data on normal sensation. Results: The presence of Meissner and Ruffini corpuscles, Merkel disks, hair-associated fibers, and intraepidermal free nerve endings was confirmed. Occurrence of extensive cross-communications between trigeminal and facial nerve was substantiated. Two-point discrimination and pressure thresholds represented the most objective measures of facial sensation. Age, sex, and smoker status of the patients were shown to influence normal sensibility values. The most suitable areas for sensory testing based on the tested modality and innervation were inferred. The anatomical course of the nerves and their variations had implications for the harvest of face allografts and repair of the sensory nerves. Conclusions: This review has illustrated the complexity of sensory pathways of the face and their influence on somatic and visceral responses. In view of the discussed data, during facial transplantation, it is important to consider different mechanisms of restoration of facial sensation.

Effectiveness of topical immunosuppressants in prevention and treatment of rejection in face allotransplantation.

Background The use of topical immunosuppressants has been anecdotally reported for the treatment of rejection in vascularized composite allotransplantation. The aim of this study was to evaluate the effectiveness of topical tacrolimus and clobetasol in the prevention and treatment of rejection. Methods Seventy-six hemiface allotransplants, between ACI (RT1a) donors and Lewis (RT1l) recipients, were performed in 11 groups and treated with topical tacrolimus or clobetasol, or in combination with systemic cyclosporine A and anti–&agr;&bgr;–T-cell receptor antibody for 1 week. Topical treatment increased the survival of the allograft in all groups. Results Best outcomes were obtained in the groups treated with systemic therapy and topical tacrolimus. Expression of proinflammatory cytokines interleukin 2, interferon &ggr;, tumor necrosis factor &agr;, and transforming growth factor &bgr; correlated with clinical signs of rejection and the final outcomes. Clobetasol application was associated with a marked depletion of lymphocytic populations, and dermal and epidermal atrophy. Conclusions Both topical tacrolimus and clobetasol were effective in treating episodes of acute rejection, and the best outcomes were achieved when their application was initiated after systemic immunosuppression. Topical tacrolimus proved to be a preferable adjunct agent to the systemic therapy by preventing both the local and systemic complications.

Pediatric vascularized composite allotransplantation.

BackgroundVascularized composite allotransplantation (VCA) has experienced a growing acceptance, which has led to a debate centered on extending the indications of the procedure to include pediatric patients. The aim of this article was to discuss such indications based on the evidence in pediatric solid organ transplantation, reconstructive surgery in children, and VCA in adult patients. MethodsPapers published on the outcomes of pediatric solid organ transplantation, growth after replantation of extremities, vascularized autologous tissue transfer, craniofacial surgery, orthognathic procedures, facial fractures, and outcomes after repair of peripheral nerves in children were reviewed. ResultsAlthough the outcomes of solid organ transplantation in children have improved, the transplanted organs continue to have a limited lifespan. Long-term immunosuppressive therapy exposes the patients to an increased lifetime risk of infections, diabetes, hypertension, dyslipidemia, cardiovascular disease, and malignancy. Growth impairment and learning disabilities are other relevant drawbacks, which affect the pediatric recipients. Nonadherence to medication is a common cause of graft dysfunction and loss among the adolescent transplant recipients. Rejection episodes, hospitalizations, and medication adverse effects contribute negatively to the quality of life of the patients. Although normal growth after limb transplantation could be expected, pediatric facial transplant recipients may present with arrest of growth of transplanted midfacial skeleton. ConclusionsConsidering the non–life-threatening nature of the conditions that lead to eligibility for VCA, it is suggested that it is premature to extend the indications of VCA to include pediatric patients under the currently available immunosuppressive protocols.

Microsurgical Anatomy of the Terminal Hypoglossal Nerve Relevant for Neurostimulation in Obstructive Sleep Apnea.

Neurostimulation of the hypoglossal nerve has shown promising results in the treatment of obstructive sleep apnea. This anatomic study describes the detailed topography of the hypoglossal nerves motor points as a premise for super‐selective neurostimulation in order to optimize results and minimize the risk of complications related to main nerve trunk manipulation.

Long-term outcomes of total knee arthroplasty following soft-tissue defect reconstruction with muscle and fasciocutaneous flaps

Background: Insufficient soft-tissue coverage following total knee arthroplasty jeopardizes prosthesis retention and may lead to significant complications. The aim of this study was to evaluate the natural history of total knee arthroplasty following flap reconstruction of soft-tissue defects. Methods: A retrospective review of patients treated with flaps after failed total knee arthroplasty between 1998 and 2013 was conducted. Patients with preexisting soft-tissue defects who required reactive flap reconstruction were included in group 1. Patients with no preexisting soft-tissue defects, but with extensive débridement during revision total knee arthroplasty requiring immediate proactive flap coverage, were included in group 2. Results: Fifty-eight patients in group 1 were treated with 86 flaps, and 15 patients in group 2 were treated with 17 flaps. Mean length of follow-up was 67.0 and 54.7 months, respectively (p = 0.21). Flap-related complications and number of subsequent flap revisions were comparable in both groups. Patients in group 1 had a higher rate of implant reinfection (58 percent versus 27 percent; p < 0.05), amputations (25 percent versus 0 percent; p < 0.05), and subsequent prosthesis revisions (2.2 versus 0.9; p < 0.05). Functional joint was preserved in 54 percent and 80 percent of cases, respectively. Mean gain in range of motion and quality of life were significantly better in group 2 (p < 0.05). Conclusions: Early proactive soft-tissue coverage of total-knee arthroplasty is critical to long-term success. In cases where reactive treatment is required, significantly worse outcomes and a high rate of complications should be expected. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Establishing the Feasibility of Face Transplantation in Granulomatosis With Polyangiitis.

Granulomatosis with polyangiitis (GPA; formerly Wegeners granulomatosis) is a rare vasculitis that commonly starts in the craniofacial region. We report a case that was masked by prior facial trauma and associated with pyoderma gangrenosum (PG). Disease progression and aggressive debridements led to severe facial tissue loss. The decision to perform a face transplant was controversial because of the risk of disease relapse on the facial allograft. We reviewed renal transplant outcomes in GPA for possible relevance. A PubMed search retrieved 29 studies. Patient and graft survival, relapse, morbidity, mortality, rejection and immunosuppression were assessed. Ten‐year patient survival and graft survival were 84.4% and 72.6%, respectively. GPA relapse occurred in 31.5%, and upper airway/ocular relapse occurred in 17.8% (resolved in 76.9%). Mortality was 12.3%. Acute and chronic rejection rates were 14.9% and 6.8%, respectively. Traditional posttransplant immunosuppression was effective. Our review suggests that GPA renal transplant outcomes are comparable to general renal transplant cohorts. Furthermore, transplanted GPA patients exhibit lower disease relapse secondary to lifelong immunosuppression. This supported our decision to perform a face transplant in this patient, which has been successful up to the present time (1‐year posttransplantation). Untreated GPA and PG are potential causes of worse surgical outcomes in the craniofacial region.

Vascularized axillary lymph node transfer: A novel model in the rat.

Vascularized lymph node transfer (VLNT) is a promising microvascular free flap technique for the surgical treatment of lymphedema. To date, few experimental animal models for VLNT have been described and the viability of lymph nodes after the transfer tested. We aimed to evaluate the feasibility of axillary VLNT in the rat. Lymph node containing flaps were harvested from the axillary region in 10 Lewis rats based on the axillary vessels. Flaps were transferred to the ipsilateral groin and end‐to‐side microanastomosis was performed to the femoral vessels using 10‐0 sutures. Indocyanine green (ICG) angiography was used to confirm flap perfusion. On postoperative day 7, flaps were elevated to assess their structure and vessel patency. Hematoxylin and eosin staining was used to confirm the presence and survival of lymph nodes. All animals tolerated the procedure well. Immediate post‐procedure ICG angiography confirmed flap perfusion. No signs of ischemia or necrosis were observed in donor extremities. At postoperative day 7, all flaps remained viable with patent vascular pedicles. Gross examination and histology confirmed the presence of 3.6 ± 0.5 lymph nodes in each flap without any signs of necrosis. This study showed that the transfer of axillary lymph nodes based on the axillary vessels is feasible. The flap can be used without the need for donor animals and it contains a consistent number of lymph nodes. This reliable VLNT can be further utilized in studies involving lymphedema, transplantation, and induction of immunologic tolerance.

Surgical Management of Mandibular Intraosseous Schwannomas.

Abstract Intraosseous schwannomas of the mandible are rare tumors that usually arise from peripheral nerve sheaths of the main trunk or branches of the inferior alveolar nerve (IAN). A systematic review of the English literature through PubMed was conducted from 1945 to 2016. Forty-nine patients of mandibular intraosseous schwannomas were identified. The most common location of the tumor was the posterior mandible (61.2%). There were 28 patients in whom the tumor involved the IAN (57.1%). The most commonly performed procedures included enucleation through a mucoperiosteal flap and a bone window (73%), curettage (10%), segmental mandibulectomy (10%), and sagittal split ramus osteotomy (6%). The recurrence rate was 6%: all 3 recurrent patients occurred in the posterior area. The authors report a 72-year-old female with a schwannoma of the IAN which was removed through a sagittal split of the mandible, although there was a bony defect of the external cortex after biopsy of the lesion. The nerve was reconstructed with a sural nerve graft. Due to the slow growing nature and encapsulation of schwannomas, surgical resection seems the best treatment with optimal functional outcomes and low recurrence rate even with a minimally invasive approach. Sagittal split ramus osteotomy and segmental mandibulectomy are reserved to large or posterior lesions to aid with radical resection or improve exposure and reconstruction.