Face Transplantation for Granulomatosis With Polyangiitis (Wegener Granulomatosis): Technical Considerations, Immunological Aspects, and 3-Year Posttransplant Outcome. Issue 3 (March 2019)

• Record Type: Journal Article
• Authors: Hashem, Ahmed M.; Djohan, Risal; Bernard, Steven; Hendrickson, Mark; Schwarz, Graham; Gharb, Bahar B.; Rampazzo, Antonio; Hoffman, Gary S.; Doumit, Gaby; Bergfeld, Wilma; Zins, James E.; Siemionow, Maria; Papay, Francis; Gastman, Brian
• Is Part Of: Annals of plastic surgery. Volume 82:Issue 3(2019)
• Publication Date: 2019-03
• Subjects: face transplantation -- vascularized composite allotransplantation -- Wegener granulomatosis -- granulomatosis with polyangiitis (Wegener) -- transplantation -- facial reconstruction -- head and neck reconstruction; Surgery, Plastic -- Periodicals; 617.95205
• DOI: 10.1097/SAP.0000000000001735
• Languages: English
• ISSNs: 0148-7043

Abstract

Abstract : Background: We report new data for a rare face transplant performed 3 years ago. Granulomatosis with polyangiitis (GPA) (Wegener) is a severe autoimmune necrotizing vasculitis and parenchymal inflammatory disease that can affect any organ including those of the craniofacial region. Skin involvement manifests as malignant pyoderma. This account (1) highlights the technical details of face transplantation for this unique indication, (2) reports the 3-year posttransplant outcome, and (3) describes relevant immunological aspects. Methods: A Le Fort III near-total face and near-total scalp transplant was performed after extensive trauma and subsequent bone and soft tissue infection in a patient with GPA. Incisions were planned along facial aesthetic subunits. The vascular pedicle comprised the facial and superficial temporal arteries bilaterally. The functioning left eye was preserved and fitted into the donor tissues. Results: The procedure took 21 hours, and transfusion was limited to 4 units of packed red cells. Early medical and surgical complications were successfully treated. At 3 years, acceptable aesthetic outcome was achieved with adequate color match and scalp hair growth. The patient has recovered light touch, temperature, and 2-point discrimination and has evidence of symmetric cheek elevation albeit with limited eyelid and frontalis function. GPA relapse did not occur. Four acute rejections were fully reversed. Conclusions: This case represents a new underlying disease (trauma + GPA) leading to face transplantation and a unique clinical scenario where allografting was indicated for potentially life-threatening and sight-preserving reasons and not for mere functional and aesthetic concerns. Despite complexity, 3-year clinical outcome is encouraging, and the patient is no longer at risk for dural exposure, meningitis, and related morbidity.