Facial Transplantation: Highlighting the Importance of Clinical Vigilance in Donor Selection (2018)

If it be right, do it boldly, if it be wrong leave it undone. —Bernard Gilpin Sir: To date, 40 face transplants have been reported, with encouraging outcomes.1 Donor pool limitations and challenges in aesthetic and immunologic matching contribute to prolonged candidate wait times. However, donor selection is key to success, and all efforts should be made to select the best possible match.2 Through this report, we highlight the importance of heightened clinical vigilance when evaluating face transplant donors. Under institutional review board approval (NCT02158793) in conjunction with the regional organ procurement organization, we evaluated a potential donor after gracious family permission. The donor was 28 years old, cytomegalovirus-negative, Epstein-Barr virus–negative, with drug-induced anoxic brain injury, and met criteria for brain death. ABO compatibility and predetermined matching criteria were met.3 Outside hospital blood cultures had grown yeast (pending speciation), kidney injury was noted on blood work, and no other comorbidities were apparent. The donor was transported to our institution as described previously.3 Vital signs were within normal limits; blood work showed mild leukocytosis, and chest radiography was unremarkable (Fig. 1). Exchange of lines and facial impression were performed, followed by tracheostomy, nasoendoscopy, lavage, and surveillance cultures, which were unremarkable. A three-dimensional craniofacial computed tomographic scan was obtained for virtual surgical planning, followed by angiography. Imaging showed unremarkable sinuses and patent neck vessels. Echocardiography was performed to evaluate for endocarditis in the setting of positive blood cultures and nonsuggestive findings. One day after transfer, an oxygen desaturation episode to 95 percent prompted bronchoscopy, which showed bilateral dark bronchial plaques (Fig. 2). Microscopic examination of bronchoalveolar specimens showed occasional branching septate hyphae suggestive of Aspergillus species. Definitive serologic and culture diagnoses were unavailable because of time limitations before anticipated multivisceral donation. Several hours later, consultation with a senior pathologist led to a high index of suspicion for invasive airway aspergillosis. A few hours before the planned procedure, we aborted and did not proceed with face transplantation because of increased risk of invasive aspergillosis, graft failure, and mortality in our candidate.Fig. 1.: Donor chest radiograph with unremarkable findings.Fig. 2.: Donor bronchoscopic image showing a bronchial mainstem dark plaque.Previous experiences in face transplantation have shown that increased preoperative vigilance can mitigate complications. Donor-to-recipient rosacea transmission has previously resulted in multiple episodes of allograft erythema, initially treated as rejection before definitive management with antibiotics.4 Similarly, an untreated preoperative sinus infection in a face and bilateral upper extremity recipient is thought to have contributed to postoperative pneumonia, shock, and bilateral extremity explantation.4 Moreover, the first uterine allotransplant in the United States was complicated by a fungal graft infection requiring explantation.5 Complications can be unforgiving and teams have an obligation to learn from previous experiences in this emerging field for optimal patient outcomes. This experience has allowed us to appreciate the importance of heightened clinical vigilance in face transplant donor selection, and we have subsequently implemented bronchoscopy as part of the workup. Timing considerations may limit donor evaluations, and discussions with different parties involved become critical in such circumstances. In this case, planning and contingency required thorough discussions between surgical teams, organ procurement organization leadership, and different specialties. We hope our experience can serve as a driver to open reporting of lessons learned in face transplantation for optimal patient outcomes. DISCLOSURE The authors have no financial relationships to disclose in relation to the content of this article. Rami S. Kantar, M.D.Hansjörg Wyss Department of Plastic Surgery Bruce E. Gelb, M.D.Division of Transplant Surgery Alexes Hazen, M.D.Eduardo D. Rodriguez, M.D., D.D.S.Hansjörg Wyss Department of Plastic SurgeryNew York University Langone HealthNew York, N.Y.