Concomitant Face and Upper Extremity Transplantation

  • Chad R. Gordon
  • Fatih Zor
  • Maria Z. Siemionow


From its first origination involving successful rat hind limb allograft studies using cyclosporine, face and upper extremity transplantation (CTA) has since developed into an exciting and promising subset of reconstructive transplant surgery. Current surgical technique involving CTA has allowed optimal outcomes in patients with massive facial and/or upper extremity defects, however, with its coexisting immunological barrier; obligatory lifelong immunosuppression commits each patient to a daily risk of transplant-related complications with many unanswered questions. Since 1998, nearly 50 hands in 40 patients have been performed around the world at various levels ranging from wrist to shoulder. However, the risk-to-benefit ratio remains controversial in bilateral versus unilateral transplantation and has yet to be answered. A total of ten face transplants have been performed since 2005. Concomitant CTA, which involves a variable combination of allograft subtypes, has been performed in two of the nine face transplant patients. These have included simultaneous bilateral hand transplants and tongue with mandible. Future study is warranted to investigate the potential advantages and disadvantages of using this approach versus a staged manner for reconstruction.


Cortical Reorganization Bilateral Hand Face Transplantation Acute Normovolemic Hemodilution Hand Transplant 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Composite tissue allotransplantation


Cyclosporine A


Extracorporeal phoresis


Intensive care unit


Mycophenolate mofetil


  1. 1.
    Gordon CR, Nazzal J, Lee WPA, Siemionow M, Matthews MS, Hewitt CW. Experimental rat hindlimb to clinical face composite tissue allotransplantation: Historical background and current status. Microsurgery. 2006;26:566-572.PubMedCrossRefGoogle Scholar
  2. 2.
    Siemionow M, Gozel-Ulusal B, Engin Ulusal A, Ozmen S, Izycki D, Zins JE. Functional tolerance following face transplantation in the rat. Transplantation. 2003;75:1607-1609.PubMedCrossRefGoogle Scholar
  3. 3.
    Gozel-Ulusal B, Ulusal AE, Ozmen S, Zins JE, Siemionow MZ. A new composite facial and scalp transplantation model in rats. Plast Reconstr Surg. 2003;112:1302-1311.CrossRefGoogle Scholar
  4. 4.
    Nie C, Yang D, Li N, Liu G, Guo T. Establishing a new orthotopic composite hemiface/calvaria transplantation model in rabbits. Plast Reconstr Surg. 2008;122:410-418.PubMedCrossRefGoogle Scholar
  5. 5.
    Shengwu Z, Qingfeng L, Hao J, et al. Developing a canine model of composite facial/scalp allograft transplantation. Ann Plast Surg. 2007;59:185-194.PubMedCrossRefGoogle Scholar
  6. 6.
    Barth RN, Bluebond-Langner R, Nam A, et al. Facial subunit composite tissue allografts in nonhuman primates: I. Technical and immunosuppressive requirements for prolonged graft survival. Plast Reconstr Surg. 2009;123:493-501.PubMedCrossRefGoogle Scholar
  7. 7.
    Cendales LC, Xu H, Bacher J, Eckhaus MA, Kleiner DE, Kirk AD. Composite tissue allotransplantation: Development of a preclinical model in nonhuman primates. Transplantation. 2005;80:1447-1454.PubMedCrossRefGoogle Scholar
  8. 8.
    Kuo YR, Goto S, Shih HS, et al. Mesenchymal stem cells prolong composite tissue allotransplant survival in a swine model. Transplantation. 2009;87:1769-1777.PubMedCrossRefGoogle Scholar
  9. 9.
    Baccarani A, Follmar KE, Baumeister SP, Marcus JR, Erdmann D, Levin LS. Technical and anatomical considerations of face harvest in face transplantation. Ann Plast Surg. 2006;57:483-488.PubMedCrossRefGoogle Scholar
  10. 10.
    Siemionow M, Unal S, Agaoglu G, Sari A. A cadaver study in preparation for facial allograft transplantation in humans: Part I. What are alternative sources for total facial defect coverage? Plast Reconstr Surg. 2006;117:864-872. Discussion 873-875.PubMedCrossRefGoogle Scholar
  11. 11.
    Siemionow M, Agaoglu G, Unal S. A cadaver study in preparation for facial allograft transplantation in humans: Part II. Mock facial transplantation. Plast Reconstr Surg. 2006;117:876-885. Discussion 886-888.PubMedCrossRefGoogle Scholar
  12. 12.
    Banks ND, Hui-Chou HG, Tripathi S, et al. An anatomical study of external carotid artery vascular territories in face and midface flaps for transplantation. Plast Reconstr Surg. 2009;123:1677-1687.PubMedCrossRefGoogle Scholar
  13. 13.
    Gordon CR, Zor F, Siemionow M. Skin area quantification in preparation for concomitant upper extremity and face transplantation: A cadaver study and literature review. Transplantation 2011 [IN PRESS - Accepted January 15, 2011].Google Scholar
  14. 14.
    Siemionow M, Papay F, Alam D, et al. First U.S. near-total human face transplantation – a paradigm shift for massive facial injuries. Lancet. 2009;374:203-209.PubMedCrossRefGoogle Scholar
  15. 15.
    Lengele BG. Current concepts and future challenges in facial transplantation. Clin Plast Surg. 2009;36:507-521.PubMedCrossRefGoogle Scholar
  16. 16.
    International Registry of Hand and Composite Tissue Transplantation. Hand Registry home website page. Accessed November 28, 2009.
  17. 17.
    Gordon CR, Siemionow M. Requirements for establishing a hand transplant program. Ann Plast Surg. 2009;63:262-273.PubMedCrossRefGoogle Scholar
  18. 18.
    Gordon CR, Siemionow M, Papay F, et al. The world’s experience with facial transplantation: What have we learned thus far? Ann Plast Surg. 2009;63:121-127.CrossRefGoogle Scholar
  19. 19.
    Ravindra KV, Wu S, McKinney M, Xu H, Ildstad ST. Composite tissue allotransplantation: Current challenges. Transplant Proc. 2009;41:3519-3528.PubMedCrossRefGoogle Scholar
  20. 20.
    American Society of Reconstructive Transplantation. Website home page. Accessed November 20, 2009.
  21. 21.
  22. 22.
    Hollenbeck ST, Erdmann D, Levin LS. Current indications for hand and face allotransplantation. Transplant Proc. 2009;41:495-498.PubMedCrossRefGoogle Scholar
  23. 23.
    Gordon CR, Siemionow M, Zins J. Composite tissue allotransplantation: A proposed classification system based on relative complexity. Transplant Proc. 2009;41:481-484.PubMedCrossRefGoogle Scholar
  24. 24.
    Patel SS, Goa KL. Sevoflurane. A review of its pharmacodynamic and pharmacokinetic properties and its clinical use in general anesthesia. Drugs. 1996;51:658-700.PubMedCrossRefGoogle Scholar
  25. 25.
    McDonald DJF. Anesthesia for microvascular surgery: A physiological approach. Br J Anaesth. 1985;57:904-912.CrossRefGoogle Scholar
  26. 26.
    Sigurdsson GH, Banic A, Wheatley AM, Mettler D. Effects of halothane and isoflurane anesthesia on microcirculatory blood flow in musculocutaneous flaps. Br J Anaesth. 1994;73:826-832.PubMedCrossRefGoogle Scholar
  27. 27.
    Hagau N, Longrois D. Anesthesia for free vascularized tissue transfer. Microsurgery. 2009;29:161-167.PubMedCrossRefGoogle Scholar
  28. 28.
    Hynynen M, Eklund P, Rosenberg PH. Anaesthesia for patients undergoing prolonged reconstructive and microvascular plastic surgery. Scand J Plast Reconstr Surg. 1982;16:201-206.PubMedCrossRefGoogle Scholar
  29. 29.
    Agich GJ, Siemionow M. Facing the ethical questions in facial transplantation. Am J Bioeth. 2004;4:25-27.PubMedGoogle Scholar
  30. 30.
    Gordon CR, Siemionow M, Coffman K, et al. The Cleveland Clinic FACES score: A preliminary assessment tool for identifying the optimal face transplant candidate. J Craniofac Surg. 2009;20:1969-1974.PubMedCrossRefGoogle Scholar
  31. 31.
    Murray JE. “The establishment of composite tissue allotransplantation as a clinical reality”. In: Hewitt CW, Lee WPA, Gordon CR, eds. Transplantation of Composite Tissue Allografts. New York: Springer; 2008:3-12.CrossRefGoogle Scholar
  32. 32.
    Siemionow M, Papay F, Djohan R, et al. First U.S. near-total human face transplantation – a paradigm shift for massive complex injuries. Plast Reconstr Surg. 2010;125:111-122.PubMedGoogle Scholar
  33. 33.
    Gander B, Brown CS, Vasilic D, et al. Composite tissue allotransplantation of the hand and face: A new frontier in transplant and reconstructive surgery. Transpl Int. 2006;19:868-880.PubMedCrossRefGoogle Scholar
  34. 34.
    Giraux P, Sirigu A, Schneider F, Dubernard JM. Cortical reorganization in motor cortex after graft of both hands. Nat Neurosci. 2001;4:1-2.CrossRefGoogle Scholar
  35. 35.
    Faggin BM, Nguyen KT, Nicoelis MA. Immediate and simultaneous sensory reorganization at cortical and subcortical levels of the somatosensory system. Proc Natl Acad Sci. 1997;94:9428-9433.PubMedCrossRefGoogle Scholar
  36. 36.
    Pleger B, Dinse HR, Ragert P, et al. Shifts in cortical representations predict human discrimination improvement. Proc Natl Acad Sci. 2001;98:12255-12260.PubMedCrossRefGoogle Scholar
  37. 37.
    Farnè A, Roy AC, Giraux P, Dubernard JM, Sirigu A. Face or hand, not both: perceptual correlates of reafferentation in a former amputee. Curr Biol. 2002;12:1342-1346.PubMedCrossRefGoogle Scholar
  38. 38.
    Mathes DW, Kumar N, Ploplys E. A survey of North American burn and plastic surgeons on their current attitudes toward facial transplantation. J Am Coll Surg. 2009;208:1051-1058.PubMedCrossRefGoogle Scholar
  39. 39.
    Mathes DW, Schlenker R, Ploplys E, Vedder N. A survey of North American hand surgeons on their current attitudes toward hand transplantation. J Hand Surg Am. 2009;34:808-814.PubMedCrossRefGoogle Scholar
  40. 40.
    Chinese face transplant Li Guoxing dies.”,27574,24829166-23109,00.html. Website Accessed June 19, 2009.
  41. 41.
    Breidenbach W, Kadiyala R, Buell J, Blair B, Kaufman C. Update on the American Hand Transplant Experience: Five Hand Transplants Performed in Louisville. Oral presentation, American Transplant Congress; June 2, 2009; Boston, MA.Google Scholar
  42. 42.
    Unadkat JV, Horibe EK, Schneeberger S, Solari M, McLean K, Gorantla V, Lee WPA. Chronic rejection in experimental composite tissue allotransplantation: First evidence. American Society of Reconstructive Microsurgery, Annual Meeting; January 2008; Beverly Hills, CA.Google Scholar
  43. 43.
    Alam DS, Papay F, Djohan R, et al. The technical and anatomical aspects of the world’s first near-total human face and maxilla transplant. Arch Facial Plast Surg. 2009;11:369-377.PubMedCrossRefGoogle Scholar
  44. 44.
    Schneeberger S, Ninkovic M, Margreiter R. Hand transplantation: the innsbruck experience. In: Hewitt CW, Lee WPA, Gordon CR, eds. Transplantation of Composite Tissue Allografts. New York: Springer; 2008:234-250.CrossRefGoogle Scholar

Copyright information

© Springer London 2011

Authors and Affiliations

  1. 1.Department of Plastic SurgeryCleveland ClinicClevelandUSA

Personalised recommendations