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World J Transplant. Dec 24, 2016; 6(4): 646-649
Published online Dec 24, 2016. doi: 10.5500/wjt.v6.i4.646
Face transplantation: Anesthetic challenges
Aparna Dalal
Aparna Dalal, Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
Author contributions: Dalal A authored the paper.
Conflict-of-interest statement: The author has not received any financial support for this review article, nor has any conflicts of interest to disclose.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Aparna Dalal, MD, Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, 1428 Madison Ave, New York, NY 10029, United States. dalalanesthesia@gmail.com
Telephone: +1-216-2722545 Fax: +1-646-6853610
Received: February 14, 2016
Peer-review started: February 14, 2016
First decision: March 25, 2016
Revised: August 22, 2016
Accepted: October 17, 2016
Article in press: October 19, 2016
Published online: December 24, 2016
Processing time: 142 Days and 7.2 Hours
Abstract

Face transplantation is a complex vascular composite allotransplantation (VCA) surgery. It involves multiple types of tissue, such as bone, muscles, blood vessels, nerves to be transferred from the donor to the recipient as one unit. VCAs were added to the definition of organs covered by the Organ Procurement and Transplantation Network Final Rule and National Organ Transplant Act. Prior to harvest of the face from the donor, a tracheostomy is usually performed. The osteotomies and dissection of the midface bony skeleton may involve severe hemorrhagic blood loss often requiring transfusion of blood products. A silicon face mask created from the facial impression is used to reconstruct the face and preserve the donor’s dignity. The recipient airway management most commonly used is primary intubation of an existing tracheostoma with a flexometallic endotracheal tube. The recipient surgery usually averages to 19-20 h. Since the face is a very vascular organ, there is usually massive bleeding, both in the dissection phase as well as in the reperfusion phase. Prior to reperfusion, often, after one sided anastomosis of the graft, the contralateral side is allowed to bleed to get rid of the preservation solution and other additives. Intraoperative product replacement should be guided by laboratory values and point of care testing for coagulation and hemostasis. In face transplantation, bolus doses of pressors or pressor infusions have been used intraoperatively in several patients to manage hypotension. This article reviews the anesthetic considerations for management for face transplantation, and some of the perioperative challenges faced.

Keywords: Face transplantation; Vascular composite allotransplantation; Organ harvest; Facial reconstruction

Core tip: Face transplantation is a complex vascular composite allotransplantation surgery. During donor harvest, osteotomies and dissection of the midface bony skeleton may involve severe hemorrhagic blood loss often requiring transfusion of blood products. A silicon face mask created from the facial impression is used to reconstruct the face and preserve the donor’s dignity. The recipient surgery usually averages to 19-20 h. Since the face is a very vascular organ, there is usually massive bleeding, both in the dissection phase as well as in the reperfusion phase, requiring use of pressors. This article reviews the anesthetic considerations for management for face transplantation, and some of the perioperative challenges faced.