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Discussion: Management of the Salivary Glands and Facial Nerve in Face Transplantation.

www.PRSJournal.com 1898 I this review article, Frautschi et al. examine the worldwide experience with salivary gland inclusion, salivary-related complications, methods of facial nerve repair, and motor outcomes in face transplant recipients. This article is a welcome addition to the literature on operative refinements and outcomes in vascularized composite allotransplantation. Importantly, this report highlights the difficulties presented by these complex patients and the alarmingly high rate (48 percent) of reported infectious and noninfectious complications related to donor and recipient salivary glands. Given the challenging early postoperative course of facial vascularized composite allograft recipients, this work should serve to inform the care team’s preoperative and postoperative efforts to prevent and safely manage complications thereof. The value of the findings lies in drawing attention to the importance of preoperative planning, identifying modifiable factors, and providing empiric data for the prophylactic use of botulinum toxin in salivary glands for the prevention of postoperative complications. Although the authors were able to pool data from only 25 of the 35 face transplant recipients, they were still able to elucidate meaningful patterns of outcomes for salivary gland exclusion and inclusion, infectious complications, and treatment strategies, along with methods of facial nerve repair and subsequent motor outcomes for this subset of patients. This review builds on prior work describing treatment options and preventive strategies for postoperative sialoceles in face transplant recipients.1 In our group’s published experience with a cohort of five patients, we have used image-guided techniques for diagnostic and therapeutic purposes to guide appropriate antimicrobial therapy and direct administration of botulinum toxin for suspected cases of salivary gland leak.1 We have found that image-guided botulinum toxin injection is effective as a preventive and treatment strategy for salivary gland leak in face transplant recipients. Botulinum toxin is safe and effective in a variety of settings, such as in chronic sialorrhea in children with cerebral palsy,2 in parkinsonian disorders3 and amyotrophic lateral sclerosis,4 and in salivary fistulas following parotidectomy.5 Appropriately, the authors also present common risks observed with the use of botulinum toxin, such as injury/paralysis to surrounding structures and risk for ascending infection, neither of which we observed in our cohort. At our institution, we have moved away from including donor parotid glands for four reasons: (1) to minimize the increased risk of postoperative infected fluid collections related to salivary gland leaks, (2) to eliminate unnecessary bulk to the facial vascularized composite allograft, (3) to avoid the increased operative time that superficial parotidectomy adds to an already complex and lengthy procedure, and (4) to allow for more distal nerve coaptation to facilitate restoration of facial reanimation and to minimize the risk of synkinesis. The authors are correct to include a review of facial nerve coaptation strategies and outcomes in their analysis of salivary gland inclusion and exclusion, given the intimate anatomical relationship with the parotid gland. We agree with the authors that neurorrhaphies in most face transplant recipients are often difficult because of scarring from preexisting trauma and prior reconstructive efforts. Therefore, preparation of the donor