The success of facial transplantation throughout the world has positioned this technique as a new option for patients presenting with severe facial deformities. However, the transplantation of a cadaver’s donor face still poses important psychological, social, and ethical issues into medical community. A decade ago, Siemionow and Ogich pointed out that patients affected from severe facial deformity would improve dramatically their quality of life with facial transplantation. Thus, they signalled that patients should be involved in the decision-making process of facial transplantation. Patients’ informed consent is necessary, and a legally binding document and process are necessary for every single medical and surgical procedure. The patient is the person responsible for the decision to perform surgery, and therefore accepts the results and consequences of such a decision and the risks of the operation. The surgeon performs a player’s role, provided that patients are informed correctly and that the surgical procedure was performed properly and according to accepted standard clinical practice. Still, in 2004 the French National Ethics Advisory Committee affirmed that it was too soon for facial transplantation accreditation, and it did not grant permission for total facial transplantation, since it considered that the discipline could not answer positively to the risk-benefit ratio dilemma. In November 2005, though, the same French committee granted permission for the first partial human transplantation. Organ transplantation carries with it a series of psychosocial problems. They are exacerbated in the case of facial transplantation, especially as related to questions of identity, communication, psychological vulnerability, aesthetic results, possibility of death, treatment compliance, and the patient’s and relatives’ reactions to a new identity. These are scientific and ethical issues that need to be addressed by any facial transplantation protocol. The first human transplantation protocol approved ever by an ethics or IRB Committee occurred in 2004 in the Cleveland Clinic (Dr. Siemionow, USA). The accreditation of a human protocol must include the inclusion and exclusion criteria, patient screening, informed consents for recipients and donors, and multidisciplinary team to develop the program. Only under theses auspices—the “Facial Transplant Protocol”—may patients with severe facial deformity be evaluated for facial transplantation indication.

The surgical team must maintain the patient’s autonomy (inform and accept the patient’s decisions), which is more important and superior to the decision to operate and the surgical procedure itself. However, the patient’s autonomy is not absolute. The patient’s decisions and wishes to go through with a surgical procedure may have severe risks. Composite tissue allotransplantation carries significant risks, such as immunological rejection (acute and chronic) and drug-related side effects. The medical team is not obliged whatsoever to follow and perform a surgical intervention unless they are convinced that the outcomes and results are superior to the potential risks and possible complications and that they are proportionate. Autonomy, therefore, has to be universal (applying to all parties: patients, medical teams, surgeons) and in general and optimal terms be collaborative. Any new technology, though, has to be implemented through a well-supervised and audited process that preserves the dignity and safety of all parties, although it is patient centred. All protocols, processes, and indications are to be overseen by external ethics committees that will oversee that autonomy, safety, and all ethical questions are maintained and answered. The Research Ethics Committee (REC) or IRB in the USA has the mandate to warrant that any proposed research study conforms to the ethics recognised in the Helsinki Declaration. REC examines the research protocol and shall accept it if it protects the dignity, the legal rights, clinical safety, and well-being of all individuals participating in clinical research. It will allow participation in clinical research provided that patients have received all information and they have been offered the opportunity to express all their concerns and all questions have been properly answered in a timely fashion that allows unrushed decisions.

Face transplantation consists in the extirpation of facial tissues of a donor with the diagnosis of brain death (solid organ donor) and its transplantation to a patient to reconstruct his/her facial defect. All deformed and scarred recipient facial tissues are removed and replaced by normal tissues, which restore anatomy and function. In general terms, facial CVA procedures utilise a two teams technique approach: a donor’s team and a recipient’s team, similarly to that employed in SOT, especially in heart and lung allotransplantation. The fabrication of a facial prosthesis must precede any CVA procedure (limbs, face, etc.). Maintaining the dignity of the patient during the whole donation process is mandatory, and bioethics during procurement call for excellence in the care of the donor. Similarly to many other facial CVA transplantation teams, we recommend a heart-beating donation. It shortens the ischemia time, reduces the impact of ischemia-reperfusion injury, and allows for correct haemostasis during the facial procurement operation [3]. The donor operation starts by securing a patent and safe airway. If tracheotomy is selected, it should be performed in the first tracheal rings to allow for a long tracheal segment if a double-lung transplant is also planned. Major vessels are cannulated in the usual manner, which must include the carotid circulation to perfuse the graft when the in situ dissection is finished. The operation begins with the cervical incision and undermining under the platysma muscle. The external carotid artery is identified and dissected. Major external carotid artery branches are identified and preserved if necessary for the type of facial graft planned. In general terms, only the facial artery is necessary for nearly all facial transplants. Lingual artery is to be preserved if the tongue is included in the facial transplant. Similarly, the hypoglossal nerve is identified, dissected, and included in the transplant (face and tongue transplantation). A bicoronal incision is performed next. Dissection proceeds in the subperiosteal plane up to the level of the orbit. The supraorbital nerve is identified and dissected inside the orbit in order to lengthen it and allow for a tension-free neurorrhaphy. Attention is directed to the lateral aspect of the face next. An incision is made at the appropriate level. If the ears are not included, a rhytidectomy incision is chosen. When the ears are transplanted, the incision is more posterior. The soft tissues are lifted and undermined. A deep dissection plane is employed, in order to include all facial muscles and nerves; a more superficial plane is employed if only skin and soft tissues are transplanted. All five facial nerve branches are identified at the anterior margin of the parotid gland, cut, and included in the graft. The dissection approaches the infraorbital nerve and it is freed of adhesions. It is severed at the appropriate level for each individual case. If necessary, the mucosa and submucosa layers of the cheek are included with a full-thickness dissection of the lips. Inferiorly, the dissection connects with the cervical flap. The dental nerve is identified at the mental foramen and severed and included in the flap. The final step during procurement consists of dissection and inclusion of the soft tissues and cartilages of the nose and section of the eyelids at the desired level. Current evidence supports good vascularisation of an entire face graft by the facial vascular pedicle. However, the temporal vessels may be included in the flap if necessary, and they may be dissected in continuity with the facial arteries down to the external carotid. It adds difficulty in the dissection with uncertain benefits in blood flow; however, it is still our first choice in full-face grafts. If a facial transplant including bone is planned, bone osteotomies are performed at this stage, leaving them attached to the soft tissues; good periosteal vascularisation does exist. The entire face graft is then left pedicled on arteries and veins (retromandibular veins, facial veins, and external jugular veins). The graft is perfused with preservation fluid at 4 °C simultaneously with the rest of solid organs.

After transportation to the recipient operation theatre, the second part of the operation starts. The recipient neck has been prepared and major vessels dissected. Depending on the type of facial deformity, the deformed structures have been resected, creating a defect on the recipient’s face to be restored by the face transplant. Other teams prefer performing the resection of the recipient’s face after revascularisation. Arteries and veins are anastomosed in the standard fashion. Before reperfusion, one gram of prednisone is infused i.v. to prevent any immunological reaction during this phase of the operation; immunosuppression induction therapy starts when the patient arrives to the operation theatre. The reconstructive phase of the operation begins with bone osteotomies and osteosynthesis with titanium miniplates, intraoral insetting, nerve neurorraphies—dental nerve and infraorbital nerve are performed before the final miniplating—and the suture of soft tissues and skin.

To date, 29 face transplantations have been performed worldwide. Medicine is an ever-evolving science, and as such, since the time of this writing, it is certain that new and novel facial transplantations have been attempted and will continue to be attempted. The reader is therefore advised to keep updated with CVA literature and reports from the international society of hand and composite tissue allotransplantation.