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Pang et al. Plast Aesthet Res 2021;8:49 https://dx.doi.org/10.20517/2347-9264.2021.42 Page 9 of 11

Initial results with VSP-aided free flap reconstruction of the traumatized face have been encouraging.
[39]
May et al. performed 28 VPS-guided fibula reconstructions using 3D-printed surgical guides. There was a
significant decrease in nonunion rate (20% vs. 4%) and complications, with fewer flap losses and fistula.
[40]
Operating room time was also shorter in the VSP group by 70 min. Seruya et al. compared 10 computer-
aided reconstructions of the craniofacial region to 58 conventional reconstructions and found a reduction in
ischemia time from 170 to 120 min. This was despite patients who underwent computer-aided
reconstruction requiring more osteotomies than those who underwent conventional reconstruction (2 vs.
1). However, no significant difference was observed in the number of subsequent revision or secondary
procedures between the computer-aided and conventional groups. Navarro Cuéllar et al. also compared
[41]
VSP-aided maxillary reconstruction with dental implants to standard surgery (both techniques using a
fibular free flap) and found that both had high rates of dental implant success at approximately 95%. On
unblinded review of post-operative CT scan, the VSP-aided group was observed to have improved post-
operative fibula positioning, with 100% bony opposition in the VSP group vs. 83% in the standard group,
with improved vertical distance change and horizontal shift in the VSP group.

Facial transplantation
One major limitation of autologous free tissue transfer is the satisfactory reconstruction of the central face
and mimetic structures such as the lips and eyelids. Nasal defects can be satisfactorily reconstructed with a
paramedian forehead flap, but local and rotational flaps lack the delicate pliability needed to reconstruct the
periorbita, including eyelids. Moreover, the central face and the relative relationships and contours of the
eyes, nose, and lips are described by Alam and Chi as being the most key to personal identity. Relative
[10]
indications for facial transplantation have been stated as being defects that are severe and involved the
[42]
central face, including both upper and lower lids and upper and lower lips .
To that end, facial transplantation has evolved as a last-resort option to reconstruct defects from massive
facial trauma failing free flap repair. Indeed, the first face transplant in the United States was performed
after the patient had undergone 23 prior procedures and 4 failed free flaps. Since then, more than 40 facial
transplants have been performed worldwide. The vast majority of such injuries have been due to ballistic,
thermal burn, blunt force, or animal-related facial traumas . Short-term outcomes have been excellent,
[43]
with full graft take, recovery of sensory and motor nerve function, and improved cosmesis and quality of life
[44]
being the norm [10,42,43] . Although 10-year allograft survival exceeds 80% , the greatest challenge is the need
for lifelong triple-drug immunosuppression. Acute rejection often responds to steroid therapy or
plasmapheresis, but chronic rejection has been more difficult to treat, and chronic antibody-mediated
rejection has resulted in graft loss in several patients. One of these was a patient with neurofibromatosis
[45]
who suffered complete graft loss at year 7 but became the first successful facial retransplantation . He was
treated with an aggressive immune desensitization regimen and endured a 1-year post-retransplantation
hospitalization but has enjoyed graft survival > 30 months after retransplantation.

CONCLUSION
Severe facial trauma continues to be a significant health burden. After stabilization of the initial injury, early
definitive free tissue transfer performed after 72 h results in improved function and cosmesis. Special
considerations must be taken to the closure of intracranial defects and the separation of sinonasal and
oropharyngeal cavities. Additional secondary aesthetic restoration procedures are often necessary. For
severe central face defects, facial transplantation is evolving as a viable option.