11702A_LoRes For Reference MXCSComp Facial Trans J11702A
2015-06-08
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Comprehensive Facial Transplant.
Using Synthes ProPlan CMF,
MatrixMIDFACE and MatrixMANDIBLE
Plating Systems
Case Report
Comprehensive Facial Transplant
Using Synthes ProPlan CMF, MatrixMIDFACE and MatrixMANDIBLE Plating Systems
Patient Profile
A 37 year old male sustained a significant deformity of his
central and lower face as a result of a gun accident fifteen
years prior to the transplant. His maxilla, mandible, teeth, lips
and part of his nose and tongue were lost, leaving him with
limited movement of his mouth.
While his vision was largely unaffected, numerous life-saving
and reconstructive surgeries left his forehead and neck with
considerable scar tissue. His nose was reconstructed using
a skin flap from the forehead, and he received bone grafts
for his mandible and midface. As the soft tissue healed,
he was left with a sunken mouth and flattened nose. He
could not taste and had lost his sense of smell. This young
man endured a very limited life. He wore a baseball cap and
mask to his hospital appointments and otherwise couldn’t
integrate into society.
The patient first came to the University of Maryland Medical
Center in 2005 to discuss reconstructive options with
Dr. Rodriguez. The University of Maryland’s basic and clinical
research program had been investigating the immune
system’s response to vascular composite allograft (VCA)
transplants for over ten years. Their work focused on the
anatomic and immunologic challenges to craniofacial
transplantation and set the groundwork for this surgical
achievement.
The goal for this patient was to restore function and attain
aesthetically pleasing results. Cutting edge surgical practices
and computer-aided planning would be employed to
precisely transplant a matched donor maxilla and mandible
including teeth, a portion of the tongue, facial muscles
and related soft tissue. Facial tissue, nerves and underlying
muscle from the scalp to the base of the neck of the donor
would be used to restore sensory and motor function.
Figures 1 and 2 show the patient prior to the accident and
after numerous reconstructive procedures.
Patient in high school
Figure 1
Results from case reports are not necessarily predictive of results in other cases.
Results in other cases may vary.
Patient presurgical
Figure 2
Synthes Comprehensive Facial Transplant Case Report
Preoperative Planning
Recipient
CT scans of the recipient patient were uploaded to Synthes
ProPlan CMF to create virtual images of the patient’s facial
anatomy. The challenges to reconstruction can be observed
in Figure 3. There is a signifi cant loss of volume of the
midface and previous grafting is evident in both the mandible
and midface.
Through a web-based meeting with a Synthes ProPlan CMF
engineer, the location for osteotomies was determined based
on the bony defects. A Le Fort III osteotomy and a BSSO
were virtually planned (Figures 4–5). Synthes ProPlan CMF
surgical guides for the osteotomies were then designed and
manufactured. Planned placement of the surgical guides for
the nasion, left and right zygomas and mandible are shown
in Figure 6.
Figure 5 Figure 6
Figure 4
Comprehensive Facial Transplant Case Report Synthes 1
Figure 3
Comprehensive Facial Transplant
Donor
Prior to the donor CT scan, interim MMF (maxillary-
mandibular fi xation) was performed to establish Class I
occlusion (Figure 7). The CT scans were uploaded to Synthes
ProPlan CMF and a second web-based planning session was
conducted. Osteotomies for the donor were identifi ed to
match the recipient’s previously planned osteotomies. This
was accomplished by virtually overlaying the donor skull over
the recipient’s (Figures 8–9).
The planning session was also used to confi rm alignment
of bony segments for facial symmetry and to perform
cephalometric analysis. During cephalometric analysis, a
perpendicular line was taken from the Frankfort horizontal
plane (porion to orbitale) through the nasion to check the
menton location (Figures 10–11).
The occlusal plane of the donor was confi rmed to match that
of the recipient post-transplant (Figure 11).
Maxillary position of the donor in normal occlusion was
established and the mandible followed that alignment.
Results from case reports are not necessarily predictive of results in other cases.
Results in other cases may vary.
Figure 11 DonorFigure 10 Recipient
2 Synthes Comprehensive Facial Transplant Case Report
Bone Images Color Key Figures 8–11
Recipient
Donor
Figure 8 Figure 9
Figure 7
Figure 13
Intraoperative Details
The recipient patient’s midface, mandible, and tongue were
dissected while the donor procurement was conducted
simultaneously in an adjacent operating room. Total donor
facial procurement took twelve hours.
Transplant Steps:
1. Skin incision
The skin incision on the recipient began at the hairline
and proceeded inferiorly, while staying anterior to the
ears and down to the level of the neck above the clavicles
(Figure 12).
Bilateral periorbital incisions were performed, preserving
the recipient patient’s eyelids.
2. Identification of arteries and veins
Following the skin retraction, the arteries and veins were
identified and tagged with corresponding color-coded
vessel loops for both the donor and recipient (Figure 13).
– Internal jugular vein (blue) with a thyro-lingual-facial
trunk (green)
– Lingual vein (purple)
– Facial vein (green, above lingual vein)
– External carotid artery (yellow)
– Lingual artery (yellow)
– Facial artery (beige)
– Internal maxillary artery (dark blue)
3. Identification of nerves
Nerves for donor and recipient were identified and
tagged, including the buccal and mandibular branches
of the facial nerve
4. Tongue harvesting
At the donor patient, the tongue was harvested with a
perimeter incision for transplantation to the recipient.
Intraoral buccal mucosa, the hard and soft palate, and
floor of mouth mucosa were included in the dissection.
Figure 12
Comprehensive Facial Transplant Case Report Synthes 3
Comprehensive Facial Transplant
5. Osteotomies
Preoperative planning using Synthes ProPlan CMF iden-
tified the exact location for the bony anatomy cuts. The
planning ensured accurate alignment of the donor bone
on to the recipient defect.
The osteotomies were performed on the recipient using
Synthes ProPlan CMF patient specific surgical guides.
(Figure 14) On the donor patient, cutting guidance was
assisted with intraoperative navigation from the donor
CT scans.
A mandibular bilateral sagittal split osteotomy was
performed at the margins indicated by the guide. Next
the maxillary cuts were made. A LeFort III osteotomy was
performed using Synthes ProPlan CMF surgical guides for
the nasion and left and right zygomas. Removal of the
midface was finalized with an osteotome.
Ischemia time was minimized by harvesting the donor
bone while the tissue was being perfused. After the oste-
otomies were made the accuracy of the cuts was checked
using a sterilizable Synthes ProPlan CMF acrylic bone
model of the recipient defect. (Figure 15) Synthes Electric
Pen Drive System with a pear-shaped burr and medium
burring attachment was used to smooth out any bony
prominences that would create sharp interferences.
Bony anatomy of the donor was temporarily fixated to the
recipient bone model. MatrixMIDFACE plates were
then precontoured and used to provisionally fixate the
facial flap to the model. Model representation Figure 15,
clinical image Figure 16.
6. Transplant of tissue to recipient site
Once the donor bone was prepared, the blood vessels
were ligated and divided. Soft tissue, bone, teeth, the
tongue, and muscles of facial expression were transferred
to the adjacent operating room and overlaid on the recipient.
7. Bone plating
The donor bone was stabilized to the recipient bone with
the precontoured MatrixMIDFACE plates. Two Titanium
Adaption Plates, 8 holes, 0.5 mm thick were used bilater-
ally for stable fixation of the donor left and right maxillas
to the recipient zygomas. A Titanium Y-Plate 1 x 3 holes,
0.5 mm thick provided stable fixation of the donor nasion
to the frontal portion of the recipient (Figure 17).
Figure 14 Figure 15
Figure 16
Figure 17
4 Synthes Comprehensive Facial Transplant Case Report
Results from case reports are not necessarily predictive of results in other cases.
Results in other cases may vary.
8. Reestablishment of blood supply
Following the bone plating at the midface, the blood
supply was reestablished. On the right side, end-to-end
anastomosis of the donor external carotid artery to the
recipient internal maxillary was completed, avoiding the
trunk of the facial and lingual arteries to ensure adequate
vascularity to the tongue.
Next, end-to-end anastomosis of the right donor internal
jugular vein to a branch of the right recipient internal
jugular vein was performed. Anastomosis of the patient
left side followed in a similar manner.
9. Stabilization of mandible
The donor mandible was then fixated to the recipient
mandible bilaterally using four 2.4 mm Titanium
MatrixMANDIBLE screws, self-tapping (Figure 18).
10. Intraoral incision repair
Intraoral repair was performed posterior to the mandibular
molars and continued superiorly to the junction between
the hard palate of the donor, and the soft palate of
the recipient.
The tongue was transplanted circumferentially at the
tongue’s base.
11. Reinnervation
Next, the nerve coaptation was performed. The two
branches of the buccal nerve were connected on either
side of the upper lip and lip commisure. Additionally,
two branches of the marginal mandibular facial nerve
were connected, resulting in a total of four motor nerve
branches reconnected on each side (Figure 19).
12. Completion
The skin was tailored and the soft tissue sutures were
made to close the procedure (Figure 20).
Figure 18
Figure 19
Figure 20
Comprehensive Facial Transplant Case Report Synthes 5
Comprehensive Facial Transplant
Results from case reports are not necessarily predictive of results in other cases.
Results in other cases may vary.
Results
Accurate alignment of the patient’s bone using Synthes
ProPlan CMF ensured that the height, width, and projection
of the facial anatomy were restored as planned preoperatively.
With the bone as an underlying foundation for the soft tissue
drape, the final outcome resulted in a dramatic improvement
for the recipient patient
By postoperative day six, the patient was able to open and
close his jaws and had some facial movement. He could
also perform ordinary tasks such as shaving and brushing
his teeth. He regained his sense of smell almost immediately
(Figure 21).
At seven months postoperative the patient is successfully
reintegrating into society and can move on with his life. He
has made great improvements through physical and speech
therapy sessions. With hours of practicing his speech and
strengthening his new facial muscles, he has now regained
his speech and can smile and show expression. He is also
able to taste food again and eat mainly by mouth (Figure 22).
The patient will have to take immunosuppressants for the
rest of his life to keep his body from rejecting the donated
face, but the sizeable quantity of vascularized bone marrow
in the donor mandible transplant could mean he may need
less immune suppression over time.
Figure 21
Figure 22
6 Synthes Comprehensive Facial Transplant Case Report
Discussion
A total of 10 cadaveric lab dissections were performed
(20 total cadavers: 10 recipient and 10 donor cadavers) to
ensure successful clinical translation of the surgical procedure
and the preoperative planning protocol. These dissections
were performed with the entire surgical team under strict
time requirements. One of the paired dissections was
performed in adjacent operating rooms with the entire
peri-operative personnel. Lastly, through the generous gift of
another donor family, a research procurement and surgical
rehearsal was previously performed on a patient with
irreversible brain damage.
Grant funding was provided from the Office of Naval
Research (ONR). This grant provided the financial support
of the clinical research face transplant program as well as
10 grant cycles of basic science research support in pre-clinical
vascularized composite allotransplantation models leading up
to and supporting this extensive face transplant. A novel
immunosuppressive protocol was developed from the research
to lower the levels of immunosuppression necessary and
maintain the integrity of the vascularized composite allograft.
The University of Maryland is expanding their facial trans-
plant program to help more patients, including veterans
injured in action.
The generosity of the donor’s family must be recognized.
Five other lives benefited from organs donated for lung,
liver, kidney and heart transplants also performed at the
University of Maryland.
A full scientific manuscript was submitted with further
details of the procedure.
Comprehensive Facial Transplant Case Report Synthes 7
Comprehensive Facial Transplant
Results from case reports are not necessarily predictive of results in other cases.
Results in other cases may vary.
SD900.104 Nasion Guide
SD900.104 Right Zygoma Guide
SD900.104 Left Zygoma Guide
SD900.101 Mandible Guide
SD900.201 Mandible
SD900.234 Skull without Midface
SD900.234 Midface
Acrylic Bone Models
Osteotomy Guides
8 Synthes Comprehensive Facial Transplant Case Report
01.001.580 Electric Pen Drive Set
03.000.303S Saw Blade for Sagittal Saw Attachment
03.000.321S Saw Blade for Reciprocating Saw
Attachment
03.000.071S Egg-Shaped Burr for Burring Speed
Attachment
04.503.377 Titanium MatrixMIDFACE Y-Plate,
1 x 3 holes, 0.7 mm
04.503.373 Titanium MatrixMIDFACE Orbital Rim
Plate,12 holes, 0.7 mm
Titanium MatrixMIDFACE, self-drilling screws
04.503.225 5 mm length
04.503.226 6 mm length
04.503.228 8 mm length
2.4 mm Titanium MatrixMANDIBLE,
self-tapping screws
04.503.442 12 mm length
04.503.444 14 mm length
Implants
Synthes Power Tools
Comprehensive Facial Transplant Case Report Synthes 9
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Fax: (905) 567-3185
© 2013 Synthes, Inc. or its affiliates. All rights reserved. ProPlan CMF and Synthes are trademark of Synthes, Inc. or its affiliates. Printed in U.S.A. 2/13 J11702-A
www.synthes.com
Lead surgeon:
Eduardo D. Rodriguez, M.D., D.D.S.
Chief, Plastic, Reconstructive, and Maxillofacial Surgery
R Adams Crowley Shock Trauma Center
Professor
University of Maryland School of Medicine
Associate Professor
Department of Plastic Surgery
Johns Hopkins School of Medicine
Baltimore, Maryland
Face Transplant Team:
From left to right: Amir Dorafshar, MBChB,
Michael Christy, MD, MA, Eduardo Rodriguez, MD, DDS,
Branko Bojovic, MD, Daniel Borsuk, MD
Photograph Courtesy of Coos Hamburger
Cutting Guides and Planned
Outcome Model Manufactured by:
Distributed by Synthes CMF
Imported by Synthes (Canada) Ltd.
