Plastic Surgery Research Council
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Presenter: Philip Brazio, MD
Co-Authors: Bojovic B; Dorafshar AH; Garcia JP; Brown EN; Bartlett ST; Barth RN; Rodriguez ED
University of Maryland School of Medicine

Background: A full facial procurement should allow concurrent procurement of all solid organs and ensure their integrity. Procurement of facial vascularized composite allografts (VCA) challenges the surgical teams with complex defects potentially requiring far greater time than solid organ procurement. Simultaneous-start procurement in these cases could entail cold ischemia times over 12 hours, risking post-reperfusion bleeding and reperfusion injury.

Methods: A VCA including all facial skin, mimetic muscles, multiple sensory and motor nerve branches, anterior tongue, and maxillary and mandibular segments was procured from a brain dead donor. Solid organ recovery included heart, lungs, liver, kidneys, and pancreas. Bedside tracheostomy and facial mask impression were performed the day before procurement.

Results: Facial VCA dissection time was 12 hours, spaced over a 15 hour period to diminish ischemia while the recipient was being prepared (Fig 1). Solid organ dissection began at approximately 13.5 hours (1 hours after start of midfacial ostotomies) and recovery concluded immediately after facial explantation. Estimated blood loss was 1300 mL, requiring 5 units of pRBC and 2 units FFP. Facial, thoracic, and abdominal teams were able to work concurrently (Fig 2). Urine output was 6.4 mL/kg/hr. Mean arterial pressure averaged 849 mm Hg, pH 7.400.03, and PaO2 20628 mm Hg. All organs had good postoperative function.

Conclusions: We propose an algorithm that coordinates facial and solid organ procurement based on continual reassessment of donor hemodynamic status (Fig 3). This approach allows face first, concurrent completion isolation of a complex facial VCA by planning multiple pathways to expedient recovery of vital organs in the event of clinical instability. Preoperative tracheostomy and facial mask impression at bedside reduce operative time. Beginning the recipient operation first may reduce waiting time due to difficult recipient preparation caused by extensive scarring.

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