The Procurement of Allotransplants for Ballistic Trauma, a Preclinical Study and Two Clinical Cases

Jean-Paul Meningaud¹, Mickael Hivelin¹, Marc-David Benjoar¹, Gaoussou Toure¹, Oana Hermeziu¹, Laurent Lantieri¹.

¹Université Paris 12, Faculté de Médecine, IFR10, Créteil, F-94000, France.

Background: Maxillofacial trauma caused by severe ballistic injuries requires many steps of reconstruction, often with disappointing results. We report on two clinical cases of facial allografts.

Methods:After a preclinical anatomical study of 10 fresh cadavers, we performed allotransplantations of the lower two-thirds of the face in two patients in March and August, 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 tothe other, in the other case.

Results: This cadaveric study confirmed that relying only on the anatomoses between the facial and the maxillary artery for the 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 re-establishment 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 post-operatively. The procurement part of the operation was performed in 7 hours.

Conclusions: 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.