Summary of Facial Transplantation: Surgical and Postoperative Care

## Introduction Facial transplant surgery is a complex reconstructive procedure that restores form and function to patients with severe facial defects. This material covers surgical preparation, harvesting and recipient preparation, vascular and nerve anastomosis, bone fixation, soft-tissue handling, and postoperative considerations. The goal is to present the procedure step by step for a not-attending student with clear explanations, practical examples, and concise definitions. > Definition: Facial transplant surgery — a multidisciplinary surgical procedure that replaces missing or damaged facial tissues with donor facial tissues to restore anatomy and function. ## Overview of the Procedure Breaking the procedure into stages helps understanding and clinical planning: 1. Donor preparation and harvest 2. Graft preservation and transport 3. Recipient preparation and debridement 4. Vascular and nerve anastomoses 5. Bone fixation and soft-tissue inset 6. Closure and postoperative care Each stage has technical nuances that affect outcome, ischemia time, functional recovery, and cosmetic result. ## 1. Donor preparation and harvest ### Key steps - Perform tracheotomy on donor and create a face mold so the donor can be restored after harvest. - Harvest while donor is heart-beating when possible to minimize warm ischemia and facilitate identification of small vessels. - Use coronal or sagittal scalp incisions depending on whether the scalp is needed. - Identify and dissect external carotid arteries, thyrolingofacial trunks, external jugular veins, and relevant arterial branches (facial, posterior auricular, superficial temporal). > Definition: Thyrolingofacial trunk — a neck arterial trunk that may supply facial soft tissues and is commonly used for venous/arterial anastomosis in facial harvest. ### Practical tips - Leave maxilla and mandible attached to soft tissue when planning bony harvest to preserve vascularity. - Secure lacrimal duct catheters and any fragile neurovascular branches before placing the graft in cold storage. Did you know that harvesting the face while the heart is beating reduces warm ischemia and helps identify small bleeding branches that could be missed on a non-beating donor? ## 2. Graft preservation and transport - Immediately after harvest, wash graft with heparinized saline and place in organ preservation solution on ice. - Use a standard icebox with preservation fluid; take care to secure catheters and mark important branches. - Before donor release to the family, reconstruct appearance with a pre-made resin mask. Fun fact: Cold preservation reduces metabolic demand of muscle and skin and helps preserve neuromuscular function during transfer. ## 3. Recipient preparation and debridement ### Goals - Remove scarred and nonviable tissue while preserving viable muscle and cosmetic units. - Prepare vascular pedicles in the neck: external carotid artery, thyrolingofacial trunk, external jugular veins. - Perform a superficial parotidectomy to expose and mobilize facial nerve branches when motor nerve repair is planned. > Definition: Cosmetic unit — anatomic regions of the face (forehead, nose, cheeks, lips, chin) used to plan incisions and graft inset to avoid patchwork appearance. ### Practical example - For lower face reconstruction after ballistic trauma, remove the entire lower-face unit (several cm below mandibular angle) to allow inset of a matching donor lower-face unit, improving cosmetic continuity. ## 4. Vascular anastomoses ### Principles - Perform end-to-end arterial anastomosis typically on the external carotid artery. - Perform venous anastomoses on thyrolingofacial trunks and external jugular veins when available. - If superficial veins are absent (e.g., severe burns), consider end-to-side anastomosis between the thyrolingofacial trunk and the external jugular to create a long pedicle for reliable drainage. ### Sequence and rationale - Complete one side arterial and venous anastomo