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Long-term Outcomes After Facial Allotransplantation: Systematic Review of the Literature

BACKGROUND
Facial vascularized composite allotransplantation (fVCA) represents a reconstructive approach that enables superior improvements in functional and esthetic restoration compared to conventional craniomaxillofacial reconstruction. Outcome reports of fVCA are usually limited to short-term follow-up or single-center experiences. We merge scientific literature on reported long-term outcome data to better define the risks and benefits of fVCA.


METHODS
We conducted a systematic review of PubMed/MEDLINE databases in accordance with PRISMA guidelines. English full-text articles providing data on at least 1 unique fVCA patient, with ≥ 3 years follow-up, were included.


RESULTS
The search yielded 1812 articles, of which 28 were ultimately included. We retrieved data on 23 fVCA patients with mean follow-up of 5.3 years. More than half of the patients showed improved quality of life, eating, speech, and motor and sensory function following fVCA. On average, the patients had 1 acute cell-mediated rejection and infectious episode per year. The incidence rates of acute rejection and infectious complications were high within first year posttransplant but declined thereafter. Sixty-five percent of the patients developed at least 1 neoplastic and/or metabolic complication after transplantation. Chronic vascular rejection was confirmed in 2 patients, leading to allograft loss after 8 and 9 years. Two patient deaths occurred 3.5 and 10.5 years after transplant due to suicide and lung cancer, respectively.


CONCLUSIONS
Allograft functionality and improvements in quality of life suggest a positive risk-benefit ratio for fVCA. Recurrent acute rejection episodes, chronic rejection, immunosuppression related complications, and heterogeneity in outcome reporting present ongoing challenges in this field.


CONCLUSIONS:
These aesthetic facial measurements should be taken into consideration during preoperative planning to accommodate patients' cultural backgrounds. Although existing studies adequately characterize attractiveness in European and Asian countries, it remains challenging to evaluate transcultural beauty standards for people of mixed race and people in ethnically diverse countries, where perceptions of attractiveness are shaped both by their own racial features as well as prevailing norms. There is also a paucity of studies examining attractive males, as well as attractive people from non-white and Asian backgrounds. Cephalometric analyses of attractive adults have been performed mostly using 2-dimensional scanning systems or photographs; future analyses should be conducted using 3-dimensional scanning systems now that this technology is available. To better understand the risks and benefits of fVCA, it is imperative to pool data from different medical institutions. The aim of this study is to comprehensively synthesize long-term outcomes after fVCA from the available scientific literature.

METHODS:
Following the PRISMA guidelines, we conducted a systematic review analyzing publications in the PubMed/MEDLINE database. Full-text review articles were included if they provided original data on fVCA with at least 1 outcome measure with 3 or more years of follow-up.

RESULTS:
The literature search retrieved 1,812 articles, from which 28 met the inclusion criteria. Thirty different outcome measures on 23 patients from 6 different medical institutions were identified. The mean follow-up was 5.3 ± 1.9 years and the most common mechanism of injury was ballistic trauma (43.5%), followed by burns (30.4%). After fVCA, 100% of the patients depending on tracheostomy and gastrostomy were decannulated. Compared to pretransplant state, more than 50% of patients had improvements in quality of life (QoL), eating, speech, motor and sensory functions. Overall, the patients had 0.92 acute rejection episodes per 1 transplant year (TY). The treatment response did not correlate with histological grades of rejection, since the adjustment of the maintenance immunosuppression alone resolved 27.1% and 36.2% of all grade 2 and 3 rejection episodes, respectively. Bacterial infections had a higher incidence rate (0.59 events/1 TR) than viral (0.49 events/1 TR) and fungal infections (0.14 events/1 TR). For both acute rejection and infectious episodes, the incidence rates decreased after the first posttransplant year. Transient nephrotoxic episodes (30.4%), dyslipidemia (21.7%), chronic kidney disease (13.0%), hypertension (13.0%), and diabetes mellitus (13.0%) were among the most commonly developed metabolic complications postoperatively. Posttransplant lymphoproliferative disease, lung cancer, and in situ cervix carcinoma presented all equally in 4.3% of the patients. Chronic skin changes (maculopapular lesions, papillary dermal sclerosis, lichenoid aspect) were observed in 30.4% of patients but they did not correlate with decreased allograft function. Chronic vascular rejections were confirmed in 2 patients and led to allograft loss after 8 and 9 years. Two patients died after 9 and 4 years postoperatively due to lung cancer and suicide, respectively. The quantitative outcome measures for which an important number of patients had missing data were mouth opening (82.6%), speech intelligibility test (78.3%), 2-point discrimination (69.6%), hot/cold discrimination (60.9%), monofilament test (56.5%), motor function (electromyography/manual exam) (56.5%), and the QoL (34.8%).

CONCLUSION:
This multicenter compilation of longterm outcomes after fVCA shows an overall favorable postoperative improvement in QoL and allograft functionality. However, the data suggest that, in some cases, the positive outcomes can be compromised by immunosuppressionrelated complications and the threat of chronic rejection. Future outcomes research in fVCA should focus on standardizing the outcome measures between the centers as well as refining the tools for measurement of procedure-specific functional and QoL gains.

Affiliation: Mayo Clinic, Rochester, MN
INTRODUCTION: Massive sacral defect resulting from total sacrectomy presents a reconstructive challenge, 1 and in some cases, the use of vertical or transverse Rectus Abdominis Muscle (RAM) flap may not provide enough soft tissue to reconstruct it. The use of Fleur-de-lys flap technique has been described in cases of autologous breast reconstruction and for thoracic wound defects. 2,3 The aim of this study is to describe the surgical technique of the combination of Transversal Rectus Abdominis Muscle (TRAM) flap with the Vertical Rectus Abdominis Muscle (VRAM) flap, which assumes the form of a "Fleur-de-lys", and to identify the population of patients reconstructed by this technique followed sacral resection.

METHODS:
A retrospective chart review was conducted on patients undergoing oncologic sacral resections followed by Fleur-de-lys myocutaneous flap for soft tissue reconstruction between December 2008 and December 2019. Demographics, clinical and surgical characteristics, postoperative outcomes, and complications were reviewed.

RESULTS:
Two patients underwent Fleur-de-lys myocutaneous flap to sacral reconstruction. A 44-year-old male and a 31-year-old female, both patients presented with a locally advanced sacropelvic chordoma requiring en bloc total sacrectomy and rectal resection. The mean tumor size was 2,139 cm 3 , and the soft tissue defect 13920 cm 3 . Patients underwent pelvic instrumentation with hardware and fibular grafts (1 patient bilateral free fibula flap; the other allograft fibular bone) for spine and pelvic reconstruction followed by pedicled Fleur-de-lys flap. The posterior abdominal wall was reconstructed in 1 patient with Alloderm to avoid bowel herniation. One patient developed a minor abdominal wound dehiscence, managed with dressing change, and wound vac. The other patient presented wound infection and minor dehiscence in the abdominal and sacral requiring surgical debridement with successful healing. The mean hospital stay was 74 days (63-85), and the follow-up was 13 months (7-19). One patient expired after 19 months of the initial surgery.

CONCLUSION:
The Fleur-de-lys myocutaneous flap obliterates massive soft tissue defects resulted from total sacral resections and avoids the need of other flaps with low morbidity associated.