Since 2005, more than 45 facial transplants (FTs) have been performed worldwide with encouraging outcomes in motor and sensory function and psychosocial health.1 Most patients who have undergone FTs have significant midface deformity, including destruction of the nostrils, turbinates, and septum requiring maxilla-containing allografts to provide bony facial structure.2
Literature on endoscopic sinus surgery (ESS) and other rhinologic procedures in the FT recipient population is scarce. Given the unique physiologic and immunologic effects of FT, additional study of sinus disease in this population is essential to establish best practices for management of sinonasal issues in FT recipients. This population is at high risk for life-threatening graft rejection, and acute and chronic infections are often complex to treat in this patient population. The aim of this study was to identify and describe rhinologic procedures after FT to assess the clinical and radiologic indications for intervention as well as the outcomes after intervention in this patient cohort.
A case series was retrospectively compiled of patients who underwent FT at our institution with a minimum follow-up of 12 months. This study falls under 2 protocols approved by the Partners Institutional Review Board: 2008P000550, which included written consent as a prospective trial of patients undergoing FT including long-term follow-up, and 2019P000047, which was approved for additional retrospective review of ESS and other rhinologic and otolaryngologic procedures after FT. Patient data were reviewed for all sinonasal operations performed, including ESS and rhinologic operative notes, sinonasal/facial imaging, and clinic notes. Indications and details of each operative intervention, functional outcomes, and complications were extracted. Craniofacial computed tomography and magnetic resonance imaging were analyzed using the Lund-Mackay scoring system preoperatively and postoperatively by 2 independent reviewers (A.Y. and A.Z.M.). Inconsistency was resolved by a senior author (R.W.B.). Analysis was completed with Stata SE, version 15.1 (StataCorp).
Between April 2009 and January 2019, a total of 8 patients underwent FT at our institution. Mean (SD) age at the date of FT was 43.1 (13.8) years (range, 25-59 years); 75% (6 of 8) were men. Mean (SD) follow-up time was 80.5 (32.9) months (range, 19-124 months). More detailed demographic information on the patient cohort has been previously published by our working group.1 None of the FT recipients had a history of chronic rhinosinusitis (CRS), asthma, or aspirin/nonsteroidal anti-inflammatory drug sensitivity prior to FT. The facial allograft donor histories with regard to CRS or sinonasal symptoms are unknown.
Six of 8 FT recipients underwent rhinologic procedures (Table). Three patients received full or partial facial allografts that included the maxillary sinus for the restoration of sinonasal structure for severe ballistic injury or animal attack. All of these patients underwent sinonasal surgery for CRS post-FT. These procedures included septoplasty, maxillary antrostomy, ethmoidectomy, dacryocystorhinostomy, release of nasal adhesions, and nasal scar debridement (Figure). Overlapping or misaligned donor and recipient septum was addressed in 1 patient. Recipients of allografts not containing the maxillary sinus did not require ESS but did require endoscopic rhinologic resection of nasal synechia and/or septoplasty for nasal obstruction. Patients reported subjective symptom improvement after ESS. However, the mean (SD) Lund-Mackay scores remained stable postoperatively (preoperative, 9.8 [2.4]; postoperative, 8.2 [2.5]).
To our knowledge, this is the first study to report the indications and outcomes of ESS and rhinologic procedures following FT in the largest single-center cohort of FT recipients worldwide. Indications for post-FT rhinologic surgery relate to the type of facial allograft. Recipients of facial allografts containing maxilla and maxillary sinus were at higher risk for having post-FT rhinologic pathology. Challenges with aligning the sinus ostia and donor and recipient septum contributed to some of the burden of sinonasal disease in FT recipients.3,4 Endoscopic sinus surgery and other rhinologic interventions achieved symptom relief in FT recipients with CRS. Additional factors, such as immunosuppression and mucosal involvement5,6 during acute rejection, might additionally contribute to impaired mucociliary clearance of the maxillary sinus and require further study.
Accepted for Publication: March 23, 2020.
Corresponding Author: Regan W. Bergmark, MD, Center for Surgery and Public Health, Brigham and Women’s Hospital, Department of Otolaryngology–Head and Neck Surgery, Harvard Medical School, 45 Francis St, Boston, MA 02114 (rbergmark@bwh.harvard.edu).
Published Online: June 11, 2020. doi:10.1001/jamaoto.2020.0774
Author Contributions: Dr Bergmark had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Haug, Yamasaki, Fullerton, Pomahac, Bergmark, Annino.
Acquisition, analysis, or interpretation of data: Haug, Yamasaki, Maxfield, Pomahac, Bergmark.
Drafting of the manuscript: Haug, Yamasaki, Fullerton, Maxfield, Bergmark.
Critical revision of the manuscript for important intellectual content: Haug, Yamasaki, Pomahac, Bergmark, Annino.
Statistical analysis: Haug, Yamasaki, Bergmark.
Administrative, technical, or material support: Haug, Yamasaki, Fullerton, Annino.
Study supervision: Haug, Maxfield, Pomahac, Bergmark, Annino.
Conflict of Interest Disclosures: Dr Bergmark reported receiving a grant from the American Board of Medical Specialties for research on health care outcomes outside the submitted work. No other disclosures were reported.
Finding/Support: Dr Pomahac received partial salary support from a research contract with the US Department of Defense (No. W911QY-09-C-0216). Dr Haug is recipient of the German Research Foundation Scholarship. This work was conducted with support from the Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts.
Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the US Department of Defense.
Additional Contributions: We want to thank Martin Kauke, MD, for his invaluable contribution to this project. There was no financial compensation for this contribution.