Devauchelle Bernard, Badet Lionel, Lengelé Benoit, Morelon Emmanuel, Testelin Sylvie, Michallet Mauricette, D'Hauthuille Cédric, Dubernard Jean-Michel
Departement of Maxillofacial Surgery, Centre Hospitalier Universitaire Amiens, France.
Lancet. 2006 Jul 15;368(9531):203-9. doi: 10.1016/S0140-6736(06)68935-6.
Extended soft tissue defects of the face are difficult to reconstruct, and autologous tissue transfers usually lead to poor cosmetic and functional outcomes. We judged that composite tissue transplantation could be valuable in facial reconstructive surgery.
We transplanted the central and lower face of a brain-dead woman onto a woman aged 38 years who had suffered amputation of distal nose, both lips, chin, and adjacent parts of the cheeks. Transplantation consisted of revascularisation of right and left facial arteries and veins (ischaemic time 4 h), mucosal repair of oral and nasal vestibules, bilateral anastomoses of infraorbital and mental sensitive nerves, joining of mimic muscles with motor nerve suture on mandibular branch of the left facial nerve, and skin closure. Immunosuppressive treatment was with thymoglobulin, tacrolimus, mycophenolate mofetil, and prednisone. Two infusions of donor bone-marrow cells were given. Follow-up included routine tests, biopsies, physiotherapy, and psychological support.
The initial postoperative course was uneventful. No surgical complication occurred. Bone-marrow graft and immunosuppression were well tolerated. Mild clinical signs of rejection were seen at day 20. Increased corticoids initially did not reverse rejection, but signs of rejection disappeared after three boluses of prednisone. Anatomical and psychological integration and recovery of sensation were excellent. At the end of the first postoperative week, the patient could eat, and speech improved quickly. Passive transmission of muscle contractions to the graft already exists; physiotherapy is being done to restore dynamic motions around the lips.
The 4-month outcome demonstrates the feasibility of this procedure. The functional result will be assessed in the future, but this graft can already be deemed successful with respect to appearance, sensitivity, and acceptance by the patient.
面部广泛的软组织缺损难以修复，自体组织移植通常会导致不良的美容和功能效果。我们认为复合组织移植在面部重建手术中可能具有重要价值。
我们将一名脑死亡女性的中下面部移植到一名38岁女性身上，该女性远端鼻子、双唇、下巴及脸颊相邻部位均被截肢。移植过程包括左右面动脉和静脉的血管重建（缺血时间4小时）、口腔和鼻前庭的黏膜修复、眶下神经和颏神经的双侧吻合、将表情肌与左侧面神经下颌支的运动神经进行缝合连接以及皮肤缝合。免疫抑制治疗采用抗胸腺细胞球蛋白、他克莫司、霉酚酸酯和泼尼松。进行了两次供体骨髓细胞输注。随访包括常规检查、活检、物理治疗和心理支持。
术后初期过程顺利。未发生手术并发症。骨髓移植和免疫抑制耐受性良好。术后第20天出现轻度排斥临床体征。最初增加皮质类固醇并未逆转排斥反应，但在给予三次大剂量泼尼松后排斥体征消失。解剖和心理整合以及感觉恢复情况良好。术后第一周结束时，患者能够进食，言语功能迅速改善。肌肉收缩已能被动传递至移植组织；正在进行物理治疗以恢复唇部周围的动态运动。
4个月的结果证明了该手术的可行性。未来将评估功能结果，但就外观、感觉和患者接受度而言，此次移植已可视为成功。
