Article Figures & Data
Figures
- Fig 1.
A 59-year-old man who underwent partial face transplantation. A, Severe disfigurement of the midface caused by a high-voltage burn injury is demonstrated, despite multiple conventional reconstructive attempts. B, Two-year postoperative follow-up illustrates restoration of form and function.
- Fig 2.
Candidate for full face transplantation. A, After catastrophic loss of facial tissues, muscle flaps and skin grafts placed during >20 surgeries rendered the patient's face featureless. B, Surgical-planning volume-rendered CT angiography depicts residual arteries after previous reconstructions using bilateral free latissimus muscle and serratus muscle flap arteries (dashed arrows), which are anastomosed end-to-end to the bilateral facial artery stumps (arrows). While not ideal, those facial and/or flap arteries are technically available and considered for microsurgical anastomoses. Prior surgical clips are rendered in green using the multiobject segmentation described in the text. C, Venous images from the same CT acquisition show occluded or absent bilateral anterior, posterior facial, and left external jugular veins. Patency of the right external jugular vein (arrow) and bilateral internal jugular veins (dashed arrows) is confirmed.
- Fig 3.
Candidate for full face transplantation. A, After a high-voltage injury, several flap and graft procedures resulted in persistent disfigurement. The patient wore a nasal prosthesis, removed for this photograph. B, Representative sagittal (left) and anteroposterior (right) projections from CT volume rendering. Volumes are viewed from an arbitrary angle to characterize branch and smaller vessels—for example, those from the external carotid artery that may be available for anastomoses. The nasal prosthesis was included in the CT acquisition. C, Sagittal cine CT images provide time resolution and enable separation of arteries and veins so that each dataset can be individually postprocessed. D, Angiosomes of the face overlaid on a volume-rendered CT image, including all soft-tissue components and numbered according to the source artery: 1) facial, 2) internal maxillary, 3) ophthalmic and internal carotid, 4) superficial temporal, 5) vertebral, and 6) posterior auricular. Lower and midface (orange) allografts can be perfused solely by facial arteries. Although the lower two-thirds of the face includes internal maxillary artery angiosomes, this territory can also be perfused by the facial artery via neighboring angiosome collateral vessels. For procedures in which the allograft includes the upper face and scalp (green and blue), the facial and superficial temporal arteries should be included, with the external carotid artery as the source vessel.
- Fig 4.
Volume-rendered venous-only reformatted images from a candidate who had a blast injury. A, Anterior and posterior facial veins and the external jugular vein are absent on the right, presumably from the injury. Imaging confirms the patency of the anterior jugular vein (arrow), a potential alternative for flap drainage. B, On the left, the external jugular vein (dashed arrow) and anterior facial vein (arrowhead) are available for flap drainage.
- Fig 5.
Major variations in branching patterns of the external carotid artery (3 types) and variations of the confluence of the facial, lingual, and superior thyroid veins with the internal jugular vein (5 types), described by Shima et al.24 Descriptions of each variation are found in the Table.
- Fig 6.
Timing diagram for a 320–detector row CT acquisition for face transplantation candidates. Each bar refers to 1 phase of the multiphasic axial acquisition; each volume includes the entire anatomy required for surgical planning.
- Fig 7.
Candidate for full face transplantation. A, Volume-rendered image including full soft tissues. B, Skin and superficial soft tissues have been shadowed. This view depicts the relationship of the bones, postsurgical hardware (green arrow), and segmented arteries. C, Volume rendering that exclusively shows the bones, postsurgical hardware, and arteries. The superior thyroid artery (yellow arrow) is used for the anastomosis of free flap, and its surgically altered course is demonstrated.
- Fig 8.
Face transplantation candidate shown with fusion of the preoperative photograph and CT venography images. Meticulous CT segmentation and feature mapping are used to depict preoperative structures critical for rapid, precise, surgical dissection.
- Fig 9.
Candidate for full face transplantation who was attacked by a chimpanzee. A, Photograph of the victim after multiple conventional reconstructive surgeries for catastrophic facial injury, demonstrating the limitation of conventional surgical options. B, Volume-rendered reformations of CT images by using multiobject segmentation to rapidly communicate information to the surgical team. In red, the arteries, including the course of right facial artery, are clearly demonstrated. The facial artery was used for the anterolateral thigh flap immediately after the injury. The anastomosis can be identified via surgical clips rendered in green.
Tables
Major variations in branching patterns of the external carotid artery (3 types) and variations in the confluence of the facial, lingual, and superior thyroid veins with internal jugular vein (5 types)
Variant Type Description Arterial Noncommon trunk Facial, lingual, and superior thyroid arteries arise separately from the ECA Truncus linguofacialis Facial and lingual arteries arise from the ECA in a common trunk Truncus thyrolingualis Superior thyroid and lingual arteries arise from the ECA in a common trunk Venous Thyrolinguofacialis Facial, lingual, and superior thyroid veins form a thyrolinguofacialis vein Linguofacialis Facial and lingual veins form a venous stem Thyrofacialis Facial and superior thyroid veins join together, and separate lingua l vein joins into the IJV Nonfacial vein Superior thyroid and lingual veins join together into the IJV Separation Lingual and superior thyroid veins fuse independently with the IJV Note:—ECA indicates external carotid artery; IJV, internal jugular vein.
