Jean-Paul Meningaud

Repair of the lower and middle parts of the face by composite tissue allotransplantation in a patient with massive plexiform neurofibroma: a 1-year follow-up study

BACKGROUND The risk to benefit ratio of face transplantation with a composite tissue allograft remains debatable, although this procedure is technically feasible. We report here a 1-year follow-up of a patient who underwent face transplantation with a composite tissue allograft. METHODS On Jan 21, 2007, a 29-year-old man with neurofibromatosis type 1 underwent resection of a massive plexiform neurofibroma diffusely infiltrating the middle and lower part of his face. The main goal was to restore both the cutaneous appearance and function of the face, including, in particular, control of orbicularis oculi and oris muscle contraction. The issues of immunosuppressive therapy, psychological outcome, and social reintergration were addressed, together with the monitoring of graft rejection by biopsies of the skin and mucosa. FINDINGS The initial postoperative course was uncomplicated. Two episodes of clinical rejection occurred on days 28 and 64. The second episode was associated with cytomegalovirus infection. Both episodes resolved favourably, with no further clinical signs of rejection, making the reduction of immunosuppressive treatment possible. A year after surgery, the functional outcome was very good, with successful sensory and motor reinnervation in the transplanted territory. Psychological recovery was excellent, with complete social reintegration. INTERPRETATION This case demonstrates the feasibility of surgically removing a large part of the face and replacing it with a composite tissue allograft. This facial repair procedure, which seems to have a satisfactory risk to benefit ratio, could be offered in rare and selected cases.

Feasibility, reproducibility, risks and benefits of face transplantation: a prospective study of outcomes.

Composite tissue allotransplantations can be indicated when autologous transfers fail to restore human appearance. We report the reproducibility, difficulties, serious adverse events and outcomes of our patients. Five patients were included in a registered clinical research protocol after thorough screenings assessed by an independent expert committee systematically discussing the alternative options. One patient suffered from plexiform neurofibromas, two from third degree burns and two from gunshot injuries. They were included on a national waiting list with a dedicated face procurement procedure. Transplants were harvested from heart beating brain‐dead donors before other tissues and organs. Induction immunosuppressive therapy included antithymocyte globulins, steroids, mycophenolate mophetil and tacrolimus. Maintenance therapy included the last three ones associated with extracorporeal‐photopheresis. Four patients were transplanted with 7‐ to 38‐month follow‐up. One could not due to multiple panel reactive antibodies after 18 months on waiting list. Acute cellular rejections were controlled by conventional treatment. Opportunistic infections affected all patients and lead one patient to die two month after the transplantation. Voluntary facial activity appeared from 3 to 5 month. Face transplantation has been reproducible under conventional immunosuppression. Major improvements in facial aesthetic and function allowed patients to recover social relations and improved their quality of life.

Face transplant graft procurement: a preclinical and clinical study.

Background: Most articles on face composite tissue allotransplantation have considered ethical and immunologic aspects. Few have dealt with the technical aspects of graft procurement. The authors report the technical difficulties involved in procuring a lower face graft for allotransplantation. Methods: After a preclinical study of 20 fresh cadavers, the authors carried out an allotransplantation of the lower two-thirds of the face on a patient in January of 2007. The graft included all the perioral muscles, the facial nerves (VII, V2, and V3) and, for the first time, the parotid glands. Results: The preclinical study and clinical results confirm that complete revascularization of a graft consisting of the lower two-thirds of the face is possible from a single facial pedicle. All dissections were completed within 3 hours. Graft procurement for the clinical study took 4 hours. The authors harvested the soft tissues of the face en bloc to save time and to prevent tissue injury. They restored the donor’s face within approximately 4 hours, using a resin mask colored to resemble the donor’s skin tone. All nerves were easily reattached. Voluntary activity was detected on clinical examination 5 months postoperatively, and electromyography confirmed nerve regrowth, with activity predominantly on the left side. The patient requested local anesthesia for biopsies performed in month 4. Conclusions: Partial facial composite tissue allotransplantation of the lower two-thirds of the face is technically feasible, with a good cosmetic and functional outcome in selected clinical cases. Flaps of this type establish vascular and neurologic connections in a reliable manner and can be procured with a rapid, standardized procedure.

Rhinoplasty: an outcome research.

Background: A bicentric, prospective cohort study was performed to assess the outcome of rhinoplasties from the patient’s perspective. Methods: Fifty-eight patients scheduled for rhinoplasty from two different hospitals (public and private) were examined before and after surgery using the Rhinoplasty Outcomes Evaluation, a specific validated assessment scale. For statistical analysis, paired Student’s t test and the Mann-Whitney test were applied. Student’s t test was used to compare preoperative and postoperative scores. Results: The scores of both the cosmetic and the posttraumatic patients were significantly improved by rhinoplasty (p < 0.0001). There was no significant difference when the authors compared the improvement scores of subgroups ranged by age, sex, primary versus secondary rhinoplasty, time between first consultation and surgery, posttraumatic versus non–posttraumatic patients, and functional versus nonfunctional indications. Conclusions: Whatever the type of initial demand (posttraumatic, cosmetic, or functional), rhinoplasty significantly increased Rhinoplasty Outcomes Evaluation scores. The study design did not allow the authors to determine subgroups of patients more able to obtain an important improvement score.

Depression, anxiety and quality of life: outcome 9 months after facial cosmetic surgery

OBJECTIVE The request for cosmetic surgery is of a psychological nature. Very few studies have quantitatively assessed whether or not this psychological need was actually satisfied, and more precisely, which psychic components were satisfied. MATERIAL AND METHODS This is a multicentric, prospective cohort study. One hundred and three patients scheduled for facial cosmetic surgery from three different hospitals were examined before and after surgery using four assessment scales validated using European populations. The Montgomery and Asberg depression rating scale (MADRS) measured the existence and intensity of depression, the self-assessment test of thoughts in social interaction (SISST) measured the positive or inhibitory thoughts in the context of social relationships, and the European quality of life 5 dimensions (EQ-5D) (generic test) measured the quality of life. In addition, a semi-directive interview was specially created by our team. For statistical analysis, ANOVA and Students t test were applied. RESULTS Twenty-four patients were lost to follow-up. Although the initial MADRS index was high (p<0.05), it did not change after surgery (p>0.1). SISST+ (positive thoughts): the social anxiety of the individual examined was significantly greater than that of the control group (p<0.005) and improved after surgery (p<0.01). The SISST- (inhibitory thoughts) did not change (p>0.1). The EQ-5D visual analogue scale (VAS) did not reveal any difference (p>0.1) while the descriptive EQ-5D demonstrated over-representation of anxiety/depression (p<0.01), and an improvement of this (p<0.05) postoperatively. The mean subjective satisfaction index was 8.1 (scale of 1-10) without sharing any influence of the complications suffered (65% of the patients made self-assessments). CONCLUSION The best indications for facial cosmetic surgery seem to be a lack of self-confidence associated with a desire for social interaction, and a request focused on a specific physical feature. The results presented add documentary confirmation to the impression shared by the majority of cosmetic surgeons. However, it was also confirmed that cosmetic surgery is not limited to its technical components, but remains a medical act which must consider the overall effect on the whole patient.

The procurement of allotransplants for ballistic trauma: a preclinical study and a report of two clinical cases.

Background: Maxillofacial trauma caused by severe ballistic injuries requires many steps of reconstruction and is often associated with disappointing results. The authors report on two clinical cases of facial allografting. Methods: After a preclinical anatomical study of 10 fresh cadavers, the authors performed allotransplantation of the lower two-thirds of the face in two patients in March and August of 2009. The grafts included all perioral muscles, facial nerves, parotid glands, the anterior region of the maxilla, and part of the mandible. The mandibular osteotomy included only the chin in one case, and the mandibular arch from one angle to the other in the second case. Results: The cadaveric study confirmed that relying only on the anastomoses between the facial and the maxillary artery for vascularization of the posterior part of the maxilla was unsafe. Periosteal vascularization seemed essential. The clinical results confirmed that complete revascularization from a single facial pedicle was possible: the first end-to-end arterial anastomosis to the left external carotid artery was sufficient for full perioperative revascularization of the flap and immediate reestablishment of bilateral venous flow. The facial appearance of both recipients improved gradually, with the development of changes in expression and the appearance of nasolabial folds. Preoperatively placed gastrostomies and tracheostomies were able to be removed in both patients within 6 weeks postoperatively. The procurement part of the operation was performed in 7 hours. Conclusion: Partial facial composite tissue allotransplantation of the lower two-thirds of the face along with parts of the maxilla and mandible (chin or entire-toothed mandible) is technically feasible, with a good cosmetic and functional outcome in typical cases of attempted suicide with rifles.

Cinegammography and 3-D emission tomoscintigraphy for evaluation of revascularized mandibular bone grafts: a preliminary report

The following reports a study conducted to investigate a scintigraphic monitoring procedure for bone free flap in mandibular reconstruction. This procedure is based on the one hand, on vascular and bone cinegammography, and on the other hand, on vascular and bone 3-D tomoscintigraphy. We used a prospective cohort study design. All patients who underwent free flap mandibular reconstruction from April 1993 to April 1998 in the Salpêtrière University Hospital, France (20 cases) have been evaluated in relation to this scintigraphic procedure. Vascular and bone scintigraphy were performed within the second week after surgery during 2 consecutive days. All images were read by one author (J.- Y. B.), who did not know the skin status of the flap. The results were compared with the viability of revascularized bone grafts as evaluated by the skin status and Greenberg classification based on bone radiographs three months after reconstruction. Vascular cinegammography seems to be closely related to anastomosis patency. Bone cinegammography gives appreciable information on bone viability. 3-D vascular tomoscintigraphy remains difficult to interpret. 3-D bone tomoscintigraphy gives precise information on the viability of the different segments of the bone flap. These results suggest that vascular and bone 3-D tomoscintigraphy coupled with cinegammography have an excellent prognostic value. In the event of partial failure it can give information on the location of the impaired patency and on the osseous fragment which has lost any viability.

Indocyanine green applications in plastic surgery: A review of the literature

INTRODUCTION Use of indocyanine green (ICG) near-infrared fluorescence as a dye to assess tissue vascularization is now well standardized. The aim of this literature review was to review and resume the most recent recommendations for ICG use in its plastic surgery applications. METHODS A systematic literature review was performed using Medline, EMBASE, and PubMed databases to obtain the latest recommendations for ICG in plastic surgery. Inclusion criteria were all articles written in English language that evaluated pre-, intra-, or postoperative ICG applications in surgical procedures usually performed by plastic surgeons. Case reports, reviews, meta-analyses, and experimental studies on animals or cadavers were excluded after title and abstract screening. RESULTS Of the 1389 article titles retrieved, 41 full-text articles met the inclusion criteria. ICG applications in plastic surgery were ICG lymphangiography used in sentinel lymph node mapping for breast cancer and melanoma and in microsurgery for the staging and treatment of secondary chronic lymphedema. The latest updates of ICG angiography in assessing free flaps, pedicled flaps, or large skin paddles were also retrieved. CONCLUSIONS Large prospective studies suggest that ICG lymphography could be used as a single tracer to reliably perform sentinel lymph node biopsy. In the case of cutaneous melanoma, ICG lymphography increases node detection sensitivity and accuracy in conjunction with lymphoscintigraphy. In chronic lymphedema, it is useful for pre- and postoperative staging and intraoperative anatomical location of lymphatic pathways when lymphovenous bypass is indicated. ICG angiography is used intraoperatively to assess free flap anastomosis and design skin paddles and postoperatively to monitor buried flaps. In pedicled perforator flaps or for large skin paddles, intraoperative ICG angiography is strongly correlated with postoperative outcomes. LEVEL OF EVIDENCE 3.

Ethical questions raised by the first allotransplantations of the face: A survey of French surgeons

INTRODUCTION More than any other allograft, the allotransplantation of the face has a symbolic character, which raises a large number of questions. The objective of this article is to make an analysis through a survey carried out among French surgeons. METHODS A file of 909 e-mail addresses of surgeons was created so as to send out a questionnaire regarding 10 ethical issues. RESULTS Beyond the technical prowess, the surgeons ethical reflection initially focused on the notion of consent to donation and care. They attached equal importance to all ethical questions. They spontaneously raised the issue of over-mediatization of these first transplants and the place of the transplant surgeons and their patients in the medical information. CONCLUSION Over two thirds of the surgeons attached importance to ethical issues regarding the donor and recipient of a facial allograft. Some of the principal questions facing facial transplantation is of an ethical nature as it is an unprecedented procedure that is challenged by the axiom to first do no harm and the need of modern medicine to limit risk to as close to zero as possible. For the non-specialist, accepting psychologically the face of another individual appears to be a real issue. Contrary to that, the main demand expressed by the facial transplant recipients appears to be related to facial functions rather than appearance.

Epidemiology and classification of dog bite injuries to the face: A prospective study of 108 patients

BACKGROUND Dog bites are considered to be septic injuries, and their location on the face, with its highly symbolic topography and important social functions, is particularly pertinent. In addition to specific medical aspects, such as their psychological impact, they are also of relevance in terms of child protection measures. In light of the far-reaching importance of this subject, we were prompted to carry out a prospective study, over 13 years, to identify risk factors. Our results highlight specific risk factors, and they may hence assist with the implementation of concrete primary prevention measures against dog bites. METHODS An information sheet was prepared and filled out during the intake of patients who had been bitten on the face. Data analysis was performed using Epi Info Version 6.04dfr software to find a correlation between the factors studied and the dog bite to the face. RESULTS Dog bites to the face represented 0.83% of the emergency admissions to our service. A considerable majority of these involved children, with 68.5% of patients <16 years of age, and 33.3% of patients aged between 2 and 5 years. The wounds were multiple and of variable severity. The type of dog involved was frequently a German Shepherd. Strikingly, 91.3% of bites had occurred in a single-parent environment. CONCLUSIONS Our study has determined that the fundamental factors that increase the probability of a dog bite to the face are as follows: the child being 2-5 years old, a single-parent context, and involvement of a German Shepherd-type dog.