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J Reconstr Microsurg 2017; 33(04): 244-251
DOI: 10.1055/s-0036-1597693
Original Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Nasal Unit Transplantation: A Cadaveric Anatomical Feasibility Study

Amir H. Dorafshar
1   Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, Maryland
,
Gerhard S. Mundinger
1   Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, Maryland
,
Brent Robinson
2   Division of Plastic Surgery, Saint Joseph Hospital, Chicago, Illinois
,
Sami Tuffaha
1   Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, Maryland
,
Gerald Brandacher
1   Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospital, Baltimore, Maryland
,
Patrick Byrne
3   Division of Facial Plastic Surgery, Department of Otolaryngology, Johns Hopkins Hospital, Baltimore, Maryland
,
Robert L. Walton
2   Division of Plastic Surgery, Saint Joseph Hospital, Chicago, Illinois
› Author Affiliations
Further Information

Publication History

17 August 2016

16 November 2016

Publication Date:
26 December 2016 (online)

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Abstract

Background The science and technical acumen in the field of vascularized composite allotransplantation has progressed rapidly over the past 15 years, and transplantation of specialized units of the face, such as the nose, appears possible. No study to date has evaluated the technical feasibility of isolated nasal unit transplantation (NUT). In this study, we explore the anatomy and technical specifics of NUT.

Methods In this study, four fresh cadaver heads were studied. Bilateral vascular pedicle dissections were performed in each cadaver. The facial artery was cannulated and injected with food dye under physiologic pressure in two cadavers, and with lead oxide mixture in two cadavers to evaluate perfusion territories supplied by each vascular pedicle.

Results The facial artery and vein were found to be adequate pedicles for NUT. Divergent courses of the vein and artery were consistently identified, which made for a bulky pedicle with necessary inclusion of large amounts of subcutaneous tissue. In all cases, the artery remained superficial, while the vein coursed in a deeper plane, and demonstrated consistent anastomoses with the superior transverse orbital arcade. While zinc oxide injection of the facial artery demonstrated filling of the nasal vasculature across the midline, dye perfusion studies suggested that unilateral arterial inflow may be insufficient to perfuse contralateral NUT components. Discrepancies in these two studies underscore the limitations of nondynamic assessment of nutritive perfusion.

Conclusion NUT based on the facial artery and facial vein is technically feasible. Angiosome evaluation suggests that bilateral pedicle anastomoses may be required to ensure optimal perfusion.

Keywords

vascularized composite allotransplantation - nasal unit transplantation - facial - reconstruction
 

  • References

  • 1 Burget GC, Walton RL. Optimal use of microvascular free flaps, cartilage grafts, and a paramedian forehead flap for aesthetic reconstruction of the nose and adjacent facial units. Plast Reconstr Surg 2007; 120 (5) 1171-1207 , discussion 1208–1216
    CrossrefPubMedGoogle Scholar
  • 2 Walton RL, Burget GC, Beahm EK. Microsurgical reconstruction of the nasal lining. Plast Reconstr Surg 2005; 115 (7) 1813-1829
    CrossrefPubMedGoogle Scholar
  • 3 Menick FJ, Salibian A. Microvascular repair of heminasal, subtotal, and total nasal defects with a folded radial forearm flap and a full-thickness forehead flap. Plast Reconstr Surg 2011; 127 (2) 637-651
    CrossrefPubMedGoogle Scholar
  • 4 Khalifian S, Brazio PS, Mohan R , et al. Facial transplantation: the first 9 years. Lancet 2014; 384 (9960): 2153-2163
    CrossrefPubMedGoogle Scholar
  • 5 Mohan R, Fisher M, Dorafshar A , et al. Principles of face transplant revision: beyond primary repair. Plast Reconstr Surg 2014; 134 (6) 1295-1304
    CrossrefPubMedGoogle Scholar
  • 6 Siemionow M, Gharb BB, Rampazzo A. Successes and lessons learned after more than a decade of upper extremity and face transplantation. Curr Opin Organ Transplant 2013; 18 (6) 633-639
    CrossrefPubMedGoogle Scholar
  • 7 Mathes DW, Edwards JA, Anzai Y, Neligan PC. A functional periorbital subunit allograft: vascular, anatomic, and technical considerations for future subunit facial transplantation. J Plast Reconstr Aesthet Surg 2014; 67 (10) 1371-1377
    CrossrefPubMedGoogle Scholar
  • 8 Vasilic D, Barker JH, Blagg R, Whitaker I, Kon M, Gossman MD. Facial transplantation: an anatomic and surgical analysis of the periorbital functional unit. Plast Reconstr Surg 2010; 125 (1) 125-134
    PubMedGoogle Scholar
  • 9 Sosin M, Mundinger GS, Dorafshar AH , et al. Eyelid transplantation: lessons from a total face transplant and the importance of blink. Plast Reconstr Surg 2015; 135 (1) 167e-175e
    CrossrefPubMedGoogle Scholar
  • 10 Pomahac B, Lengele B, Ridgway EB , et al. Vascular considerations in composite midfacial allotransplantation. Plast Reconstr Surg 2010; 125 (2) 517-522
    CrossrefPubMedGoogle Scholar
  • 11 Tuffaha SH, Sacks JM, Shores JT , et al. Using the dorsal, cavernosal, and external pudendal arteries for penile transplantation: technical considerations and perfusion territories. Plast Reconstr Surg 2014; 134 (1) 111e-119e
    CrossrefPubMedGoogle Scholar
  • 12 Rees MJW, Taylor GI. A simplified lead oxide cadaver injection technique. Plast Reconstr Surg 1986; 77 (1) 141-145
    CrossrefPubMedGoogle Scholar
  • 13 Pan WR, Cheng NM, Vally F. A modified lead oxide cadaveric injection technique for embalmed contrast radiography. Plast Reconstr Surg 2010; 125 (6) 261e-262e
    CrossrefPubMedGoogle Scholar
  • 14 Shimizu Y, Imanishi N, Nakajima T, Nakajima H, Aiso S, Kishi K. Venous architecture of the glabellar to the forehead region. Clin Anat 2013; 26 (2) 183-195
    CrossrefPubMedGoogle Scholar
  • 15 Onishi S, Imanishi N, Inoue Y, Sakamoto Y, Chang H, Okumoto T. Venous drainage of the face. J Plast Reconstr Aesthet Surg 2016; DOI: http://dx.doi.org/10.1016/j.bjps.2016.11.023.
    PubMedGoogle Scholar
  • 16 Dorafshar AH, Bojovic B, Christy MR , et al. Total face, double jaw, and tongue transplantation: an evolutionary concept. Plast Reconstr Surg 2013; 131 (2) 241-251
    CrossrefPubMedGoogle Scholar
  • 17 Bojovic B, Dorafshar AH, Brown EN , et al. Total face, double jaw, and tongue transplant research procurement: an educational model. Plast Reconstr Surg 2012; 130 (4) 824-834
    CrossrefPubMedGoogle Scholar
  • 18 Brown EN, Dorafshar AH, Bojovic B , et al. Total face, double jaw, and tongue transplant simulation: a cadaveric study using computer-assisted techniques. Plast Reconstr Surg 2012; 130 (4) 815-823
    CrossrefPubMedGoogle Scholar
  • 19 Kaufman CL, Ouseph R, Marvin MR, Manon-Matos Y, Blair B, Kutz JE. Monitoring and long-term outcomes in vascularized composite allotransplantation. Curr Opin Organ Transplant 2013; 18 (6) 652-658
    PubMedGoogle Scholar
  • 20 Mundinger GS, Drachenberg CB. Chronic rejection in vascularized composite allografts. Curr Opin Organ Transplant 2014; 19 (3) 309-314
    CrossrefPubMedGoogle Scholar
  • 21 Petruzzo P, Kanitakis J, Testelin S , et al. Clinicopathological findings of chronic rejection in a face grafted patient. Transplantation 2015; 99 (12) 2644-2650
    CrossrefPubMedGoogle Scholar
  • 22 Kaufman CL, Marvin MR, Chilton PM , et al. Immunobiology in VCA. Transpl Int 2016; 29 (6) 644-654
    CrossrefPubMedGoogle Scholar
  • 23 Chadha R, Leonard DA, Kurtz JM, Cetrulo Jr CL. The unique immunobiology of the skin: implications for tolerance of vascularized composite allografts. Curr Opin Organ Transplant 2014; 19 (6) 566-572
    CrossrefPubMedGoogle Scholar
  • 24 Fryer M, Grahammer J, Khalifian S , et al. Exploring cell-based tolerance strategies for hand and face transplantation. Expert Rev Clin Immunol 2015; 11 (11) 1189-1204
    CrossrefPubMedGoogle Scholar
  • 25 Barret JP, Gavaldà J, Bueno J , et al. Full face transplant: the first case report. Ann Surg 2011; 254 (2) 252-256
    CrossrefPubMedGoogle Scholar
  • 26 Brandacher G, Lee WPA, Schneeberger S. Minimizing immunosuppression in hand transplantation. Expert Rev Clin Immunol 2012; 8 (7) 673-683 , quiz 684
    CrossrefPubMedGoogle Scholar
  • 27 Schneeberger S, Gorantla VS, Brandacher G , et al. Upper-extremity transplantation using a cell-based protocol to minimize immunosuppression. Ann Surg 2013; 257 (2) 345-351
    CrossrefPubMedGoogle Scholar
  • 28 Lin CH, Wang YL, Anggelia MR , et al. Combined anti-CD154/CTLA4Ig costimulation blockade-based therapy induces donor-specific tolerance to vascularized osteomyocutaneous allografts. Am J Transplant 2016; 16 (7) 2030-2041
    CrossrefPubMedGoogle Scholar
  • 29 Leonard DA, Kurtz JM, Mallard C , et al. Vascularized composite allograft tolerance across MHC barriers in a large animal model. Am J Transplant 2014; 14 (2) 343-355
    CrossrefPubMedGoogle Scholar
  • 30 Sosin M, Mundinger GS, Dorafshar AH , et al. Optimizing reconstruction with periorbital transplantation: clinical indications and anatomic considerations. Plast Reconstr Surg Glob Open 2016; 4 (2) e628
    CrossrefPubMedGoogle Scholar
  • 31 Ulusal BG, Ulusal AE, Lin JY , et al. Anatomical and technical aspects of harvesting the auricle as a neurovascular facial subunit transplant in humans. Plast Reconstr Surg 2007; 120 (6) 1540-1545
    CrossrefPubMedGoogle Scholar
  • 32 Graham BH, Walton RL, Elings VB, Lewis FR. Surface quantification of injected fluorescein as a predictor of flap viability. Plast Reconstr Surg 1983; 71 (6) 826-833
    CrossrefPubMedGoogle Scholar
  • 33 Whetzel TP, Mathes SJ. Arterial anatomy of the face: an analysis of vascular territories and perforating cutaneous vessels. Plast Reconstr Surg 1992; 89 (4) 591-603 , discussion 604–605
    CrossrefPubMedGoogle Scholar
  • 34 Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987; 40 (2) 113-141
    CrossrefPubMedGoogle Scholar
  • 35 McGregor AD. The angiosome--an in vivo study by fluorescein angiography. Br J Plast Surg 1992; 45 (3) 219-221
    CrossrefPubMedGoogle Scholar
  • 36 Taylor GI, Caddy CM, Watterson PA, Crock JG. The venous territories (venosomes) of the human body: experimental study and clinical implications. Plast Reconstr Surg 1990; 86 (2) 185-213
    CrossrefPubMedGoogle Scholar
  • 37 Banks ND, Hui-Chou HG, Tripathi S , et al. An anatomical study of external carotid artery vascular territories in face and midface flaps for transplantation. Plast Reconstr Surg 2009; 123 (6) 1677-1687
    CrossrefPubMedGoogle Scholar