Two-stage face transplantation: A new concept in vascularized composite allotransplantation

Background: Animal models and clinical cases of facial allotransplantation have been performed as a single stage procedure. A staged surgery might offer some advantages in selected cases. In this study, a two-stage face transplantation approach was performed on rat and the feasibility and safety were evaluated. Methods: Brown Norway rats were used as donors and Lewis rats as recipients in the allotransplantation groups. A total of 33 hemiface-scalp transplantations were performed. Syngeneic orthotopic transplantations were performed either in one-stage (one single stage surgery; N = 3), local two-stage [heterothopic transplantation to the neck during the first stage and graft rotation as a pedicled flap to cover the facial defect on postoperative day (POD) 2; N = 3], or distant two-stage approaches (heterothopic transplantation to the groin during the first stage and free graft transfer to the face on postoperative day 2; N = 3). In the allotransplantation groups using the same approaches, 12 received no treatment (N = 4 each subgroup) and 12 received the same tapering dose of cyclosporine (10 to 2 mg/Kg/day; N = 4 each subgroup). Graft survival and the rejection grades were assessed clinically and pathologically. Results: All syngeneic transplants survived for the follow-up period of 180 days. The mean rejection-free survival and total survival of the allograft in the no treatment group was 6 ± 0.3 and 14.3 ± 4.5 days in the one-stage group, 6 ± 0.4 and 18.5 ± 1 days in the local two-stage group and 6 ± 0.2 and 14.3 ± 5.7 (P > 0.05). All allografts in the treatment groups did not develop rejection during the 42 days follow-up period. Conclusions: It is feasible, reliable, reproducible, and safe to perform a two-stage face transplantation in rats. This novel approach has the potential to be applied in research and eventually in selected clinical cases of facial allotransplantation.