reconstructive - m. douglas gossman, md, pllc the art & … · 2017-02-24 · demonstrated...

RECONSTRUCTIVE

Facial Transplantation: An Anatomic andSurgical Analysis of the PeriorbitalFunctional Unit

Dalibor Vasilic, M.D.John H. Barker, M.D., Ph.D.

Ross Blagg, M.S.Iain Whitaker, M.D.

Moshe Kon, M.D., Ph.D.M. Douglas Gossman, M.D.

Louisville, Ky.; and Utrecht,The Netherlands

Background: Complete loss of eyelid pair is associated with chronic discomfort,corneal ulceration, and visual impairment. Contemporary reconstructive tech-niques rarely provide functionally acceptable results. Composite tissue allo-transplantation may provide a viable alternative. This study reports on neuro-vascular anatomy and technical details of harvesting an isolated periorbital unitand discusses its functional potential.Methods: Twenty-four hemifaces (12 fresh cadavers) were dissected to study sur-gically relevant neurovascular structures and to develop an efficient harvest method.Angiographic analysis was performed in seven hemifaces following harvest.Results: The superficial temporal and facial vessels demonstrated consistent loca-tion and diameters. Anatomic variability was characterized by the absence of thefrontal branch of the superficial temporal artery or facial-to-angular artery contin-uation, but never of both vessels in the same hemiface. Angiographic analysisdemonstrated filling of the eyelid arcades, provided the anastomoses between theinternal and external carotid branches were preserved. The facial nerve exhibitedconsistent planar arrangement and diameters in the intraparotid and proximalextraparotid regions, but less so in the distal nerve course. The inferior zygomaticand buccal branches frequently coinnervated the orbicularis oculi and lower facialmuscles with an unpredictable intermuscular course. Based on the foregoing, aneffective surgical harvest of the periorbital composite was developed.Conclusions: Surgical harvest of a functional periorbital allotransplant is techni-cally feasible. Revascularization of the isolated periorbital unit is influenced byvariations in regional anatomy and cannot be guaranteed by a single vascularpedicle. The orbicularis oculi muscle and its innervation can be preserved, andrecovery, albeit without the certainty of reflexive blinking, is expected. (Plast.Reconstr. Surg. 125: 125, 2010.)

Loss of an ipsilateral or bilateral eyelid pair isassociated with chronic discomfort, cornealulceration, and visual loss. Current recon-

structive methods include retrieval and reattach-

ment of original tissues1–3 or replacement withautologus grafts and flaps from remote sites.4,5

Given the complex functional anatomy of the eye-lid unit, this injury presents a reconstructive chal-lenge that is typically associated with poor func-tional and aesthetic outcomes (Fig. 1). Revisionsurgery provides limited improvement and carriesthe burden of additional donor-site morbidity.

Composite tissue allotransplantation, intro-duced recently for facial reconstruction, couldprovide an alternative to current treatments. Thecases performed so far have transplanted nasal

From the Department of Surgery and the Division of Plasticand Reconstructive Surgery, University of Louisville, andthe Department of Plastic, Reconstructive, and Hand Sur-gery, University of Utrecht.Received for publication March 16, 2009; accepted July 10,2009.Presented at the European Association of Plastic Surgeons Meet-ing, in Barcelona, Spain, May of 2009; in part at the BritishAssociation of Plastic, Reconstructive, and Aesthetic SurgerySummer Meeting, in Deauville, France, July of 2007; at Re-search!Louisville, in Louisville, Kentucky, October of 2007;and at the British Burn Association’s 40th Annual ScientificMeeting, in Swansea, United Kingdom, April of 2007.Copyright ©2009 by the American Society of Plastic Surgeons

DOI: 10.1097/PRS.0b013e3181c2a5cc

Disclosure: There are no financial conflicts of in-terests between any of the authors listed in this articleand the work described in it.

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and perioral tissues to treat midface and lowerfacial defects with encouraging preliminaryoutcomes.6–8 Replacing damaged or missing peri-orbital tissues with a healthy periorbital unit allo-graft is compelling; however, this methodologyhas yet to be addressed.

In this article, we report our anatomic analysisof myoneural and vascular constituents that areessential to the function of a periorbital and eyelidpair allograft. Specifically, we studied location andconstitution of vascular tributaries and facial nervebranches relevant to this unique surgical under-taking. The resulting anatomic knowledge pro-vided the foundation for preservational harvest ofa complete periorbital functional unit. To ourknowledge, this is the first study to analyze anddescribe the principal complexities of surgical re-construction of the periorbital functional unit byallotransplantation of an eyelid pair.

MATERIALS AND METHODSTwelve fresh cadavers (24 hemifaces, eight

male and four female; age range, 49 to 99 years)were dissected and studied using loupe magnifi-cation (3.5�) and an operative microscope(OPMI 1F; Zeiss, Oberkochen, Germany; 10 to25�). A Vernier caliper (1/20 mm; Kanon Instru-ments, Tokyo, Japan) and a grid (2 mm in 200parts; E. Leitz GmbH, Wetzlar, Germany) wereused to record all measurements. None of thedissected specimens had a history of congenitalfacial malformation, trauma, or surgery.

Location, pattern, dimensions, and anatomicvariations of the surgically relevant external ca-rotid and internal carotid arterial branches and

venous tributaries were studied from their proxi-mal origins to the orbicularis oculi. Facial nerveposition, diameter, and branch patterns relevantto the orbicularis innervation were measured andmapped.

Based on our anatomic observations and de-scriptions from the pertinent literature,6–28 differ-ent surgical planes of approach were evaluated.The resulting surgical sequences were designed topreserve essential functional constituents of theperiorbital unit, while assuring perfusion and fa-cial nerve input during the entire harvest.

Vascular integrity was evaluated angiographi-cally in seven harvested periorbital units. After thesurgical protocol (see Periorbital Unit HarvestProtocol in the Results section), each unit wasdelicately dissected en-bloc, removed from the ca-daver, and fixed to a radiolucent board for imag-ing. Each of the external carotid arterial branchesin five isolated periorbital units was identified,cannulated, injected with radiopaque fluid [Ox-ilan 350 (Ioxilan), Guerbet Group, Bloomington,Ind.], and flushed with saline. Extravasation ofradiopaque fluid was minimized using cauteriza-tion (bipolar coagulation) and ligation (monofil-ament nylon, 9.0 and 10.0). The periorbital allo-grafts were imaged in an angiographic suite(Innova 3100C, GE Healthcare, Waukesha, Wis.).The contribution of each arterial branch to per-fusion of the eyelids and the orbital arcadeswas analyzed by observing radiopaque filling pat-terns. The venous system was assessed using thesame angiographic technique in two isolated peri-orbital units.

RESULTS

Vascular AnatomyProximal superficial temporal and facial ves-

sels demonstrated consistent anatomic locationand diameter in all cadavers; however, their distalcomponents demonstrated variability. The frontalbranch of the superficial temporal artery was ab-sent in two hemifaces, while that of the superficialtemporal vein was missing in five of 18 dissectedspecimens. The course of the vessels was predom-inantly linear, although tortuosity was common inthe proximal segments of the frontal branch of thesuperficial temporal artery. The frontal branch ofthe superficial temporal vein was equally likely tooccur superior or inferior to the artery.

The facial vein followed the lateral margin ofthe artery in all cases. A distinct continuation ofthe facial to angular vessels, however, was missing infive of 18 hemifaces. In one hemiface, a varicosity was

Fig. 1. Quadrilateral full-thickness eyelid loss was recon-structed with mucous membrane and skin grafts. Nearly totaltarsorrhaphy is required to prevent corneal desiccation.

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the only vascular structure identified in the medialcanthus. Simultaneous absence of the frontalbranch of the superficial temporal artery and facial-to-angular artery continuation was not observed.

Based on observations in six hemifacial spec-imens, internal carotid branches were found to beunsuitable for primary allograft revascularizationdue to small caliber (0.6 � 0.2 mm and 0.8 � 0.2mm, respectively) for the supraorbital and su-pratrochlear arteries. The supraorbital artery bi-furcated in four of six hemifaces below the surfaceof orbicularis oculi. The supratrochlear artery wasabsent in one hemiface, and tortuosity marked theextraorbital course of both vessels.

Table 1 summarizes the course and diameter ofthe vessels, and Figure 2 depicts critical anatomiccoordinates of the external carotid tributaries.

Facial NerveDissection results are presented by facial nerve

regions supplying the orbicularis oculi muscle.

Temporal and Superior Zygomatic NervesTemporal and superior zygomatic branches

bifurcated within the parotid gland, emerging atits superior margin medial to the superficial tem-poral vessels. Crossing the zygomatic arch, thenerves (and vessels) were intimately apposed to afascial plane (superficial temporal fascia) that con-tinues cephalad as the galea aponeurotica (Fig. 3).

Temporal branches remained anteroinferiorto the frontal branch of the superficial temporalartery (Fig. 3) (see Harvest Protocol, SuperficialTemporal Artery Isolation). As the superior zy-

gomatic branches approached the lateral orbic-ularis oculi margin, they formed a delicate plex-iform architecture before entering the posteriormuscle surface.

Table 1. Vascular Anatomy: External Carotid Tributaries and Their Correlation to Periorbital Region

No. of DissectedHemifaces (no. ofDissected Cadavers)

AnatomicStructure

Vascular CephalometricsFacial

Coordinates*Anatomic Location Diameter (mm) Surgical Plane

18 (9) STA Anterior to the tragus – SMAS AB � 1.65 � 0.20 cmProximal to the

bifurcation2.2 � 0.4 STF BC � 4.0 � 0.9 cm

18 (9) STV Anterior to the tragus – SMAS Apposition to STAProximal to the

bifurcation2.6 � 0.5 STF BD � 4.8 � 1.2 cm

18 (9) fSTA Bifurcation origin 1.8 � 0.4 STF BC � 4.0 � 0.9 cmSuperior to lateral canthal

tendon– STF EF � 4.3 � 0.6 cm

18 (9) FA Superior mandibularborder

2.7 � 0.6 Sub-SMAS GH � 6.7 � 0.8 cm

Lateral to nasalala

1.2 � 0.3 Sub-SMAS JK � 1.5 � 0.3 cm

18 (9) FV Superior mandibularborder

3.0 � 0.8 Sub-SMAS GI � 7.3 � 0.9 cm

Lateral to nasal ala 1.0 � 0.5 Sub-SMAS JK � 1.8 � 0.5 cmSTA, superficial temporal artery; SMAS, superficial musculoaponeurotic system; STV, superficial temporal vein; STF, superficial temporal fascia;fSTA, frontal branch of the superficial temporal artery; FA, facial artery; FV, facial vein.*Facial coordinates correspond with Figure 2.

Fig. 2. The topographical coordinates of the external carotidtributaries that supply the periorbital unit depicted here are de-tailed in Table 1. AB denotes distance from the tragus to STA/STV;BC and BD denote distances to the STA and STV bifurcation, re-spectively; EF denotes distance from the frontal branch of theSTA to the lateral canthus; GH and GI denote distances from themid–mandibularbordertoFA/FVatthesuperiormandibularbor-der; JK denotes distance from the nasal ala to FA/FV. STA, super-ficial temporal artery; STV, superficial temporal vein; FA, facial ar-tery; FV, facial vein.

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Inferior Zygomatic and Buccal NervesInferior zygomatic branches emerged at the

lower medial border of the parotid gland and werein apposition to or fused with the deeper-coursingbuccal branch. Both branches passed under thezygomaticus major and minor muscles and levatorlabii superioris muscle on their medial course.They entered the inferomedial orbicularis oculi,at times in plexiform configuration (Table 2).

Atraumatic skeletonization of intermuscularcourse of the inferior zygomatic and buccalbranches was challenging. Their preservationcould be assured only by en-bloc harvest of thezygomaticus major and minor and levator labiimuscles (see Harvest Protocol). Table 2 summa-rizes branch patterns, dimensions, and positionalplanes of the facial nerve at its origin, medial mar-gin of the parotid gland, and the orbicularis oculimuscle.

Periorbital Unit Harvest ProtocolHarvest of a periorbital unit allograft that re-

tains its functional potential requires (1) preser-

vation of its proximal neurovascular supportthroughout removal and (2) a release techniquethat preserves its intricate vascular and myoneuralconstituents. The surgical sequences described be-low are designed to maintain composite perfusionduring (and after) its removal from the orbitalframe.

Superficial Temporal and Facial Artery andVein Isolation

Superficial Temporal VesselsIsolation of the distal superficial temporal ar-

tery and superficial temporal vein initiates harvest.A cutaneous incision descends to the level of thesuperficial temporal fascia 1.0 cm medial to thesuperior pole of the auricle and 4.0 cm cranial tothe tragus. Progressive cephalad extension of theskin and fascia incision exposes the vessels to theirfrontoparietal bifurcations. The arterial branchascends after bifurcating, then descends to a pointapproximately 4.3 cm above the lateral canthus(Fig. 2 and Table 1). Thereafter, the vessels joinbranches of the supraorbital and supratrochleararteries and veins as they travel to the midline. Thecutaneous incision continues to the glabella in theperiosteal plane, cephalad to the aforementionedintersections. The proximal superficial temporalartery and superficial temporal vein are subse-quently exposed as a prelude to facial nerve iso-lation (Fig. 4).

Facial VesselsFacial vessels are located approximately 1.5 cm

lateral to the nasal ala (Fig. 2 and Table 1). Theartery lies medial to the vein. The distal inferiorzygomatic and superior buccal nerve branches tothe medial orbicularis lie in the submuscularplane immediately deep to these vessels. After fa-cial vessel isolation, the cutaneous incision turnsimmediately to the nasal dorsum, at the level ofthe periosteum. Continuing cephalad, it intersectsthe transverse frontal incision at midline.

Facial Nerve IsolationTemporal and Superior Zygomatic BranchesExtending the preauricular incision inferiorly,

parallel, and lateral to the course of the superficialtemporal vessels provides proximal facial nerveexposure (Fig. 4). Elevation of the superficial mus-culoaponeurotic system, followed by superficialparotidectomy, reveals temporal and zygomaticnerve bifurcations. As the nerve branches ascend,they are apposed to the superficial temporal fascia(Figs. 3 and 4). Cephalad to the zygomatic arch,

Fig. 3. Discrete distal temporal facial nerve branches (A) formplexiform architecture at the margin of the orbicularis oculi mus-cle (B). The superotemporal orbicularis has been removed (theblack line indicates the medial margin of the resection) to dem-onstrate the perimuscular facial neural anatomy. Note that thesuperficial temporal artery (C) and its frontal branches (D) lie inintimate apposition to the superficial temporal fascia (E). Alsonote the planar distinction between the deep temporal fascia (F)and superficial temporal fascia (E). Elevating the composite in theplane of the deep temporal fascia (F) protects this neurovascularanatomy.


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dissection deep to this layer over the deep tem-poral fascia releases the superotemporal compos-ite, while protecting nerve branches and vasculartributaries.

Inferior Zygomatic and Buccal BranchesInferior zygomatic and contiguous superior

buccal branches are skeletonized to the lateralborder of the zygomaticus major muscle. There-after, the nerve branches pass deep to the zy-gomaticus major, minor, and levator labii mus-cles before entering the posterior surface of themedial orbicularis. Medial nerve isolation ishampered by its small caliber and serpentinecourse. Division of the aforementioned musclesinferior to the nerve branch assures preserva-tion. Dissection terminates at the pyriform ap-erture. (In a clinical harvest, potential coinner-vation by inferior zygomatic and buccalbranches demands innervation mapping bynerve stimulation to ensure full composite re-innervation potential. This constraint also ap-plies to host debridement.)

Osseous Release of the Periorbital Unit

Medial and Superior ReleaseAfter isolation and protection of the proximal

neurovascular constituents, final separation of thecomposite from the orbit begins superomedially.This region harbors critical tributaries to the or-bital and eyelid arcades,9 which are protected byworking within the subperiosteal plane. Dissectionadvances to the medial inferior orbital rim, lysingorbicularis oculi insertions and the medial canthaltendon’s osseous attachments. The lacrimal sac istransected at the nasolacrimal duct.

Superomedial dissection resumes at the or-bital margin, revealing the trochlea, supraor-bital, and supratrochlear vessels as corrugatorand orbicularis attachments are released(Fig. 5). Osteotomy of the superior orbital fo-ramen releases the supraorbital nerve, artery,and vein. The supraorbital vein ascends to theeyebrow fat pad. It parallels the orbital rim andinterconnects with the superior temporal ve-

Table 2. Pertinent Extracranial Facial Nerve Anatomy and Its Planar Correlation to the Periorbital Region

No. of DissectedHemifaces (no. ofDissected Cadavers)

Anatomic Structure(Facial Nerve)

Anatomic Location(Surgical Planes)

No. ofBranches*

Diameter(mm)*

PeriobitalPlexus

14 Main trunk Lateral and prior to entranceinto parotid gland

1 2.6 � 0.2

14 (7) Proximal superior trunk Inside of the parotid gland 1 1.7 � 0.414 (7) Proximal inferior trunk Inside of the parotid gland 1 1.3 � 0.414 (7) Temporal nerve branches Superior peripheral border

of the parotid gland(subparotid-massetericfascia plane)

1.6 (1–2) 0.8 � 0.3

Superior to zygomatic arch(superficial temporalfascia plane)

14 (7) Zygomatic nerve branches Superomedial border of theparotid gland (subparotid-masseteric fascia plane)

2.5 (2–4) 0.6 � 0.3

At and below zygomaticarch (superficial temporalfascia plane andsub-SMAS plane)

14 (7) Buccal nerve branches Medial border of theparotid gland (subparotid-masseteric fascia plane)

3.1 (2–5) 1.0 � 0.4

Lateral border of superficialfacial musculature (sub-SMAS,ventral and dorsal to superficialfacial musculature); bewareextraplanar branches

8 (7) Temporo-zygomaticconnection

Lateral to orbicularis oculimuscle (superficial temporalfascia plane)

75%

8 (6) Zygomatico-buccalconnection

Inferior to orbicularis oculimuscle (dorsal to superficialfacial musculature)

50%

SMAS, superficial musculoaponeurotic system.*Number and diameter of facial nerve branches measured at their exit point from the parotid gland.


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nous tributaries, providing venous drainage ofthe allograft (see also Fig. 10).

Superolateral ReleaseSubperiosteal elevation tracing the orbital mar-

gin to the zygomatic process of the frontal bone andlateral orbital wall completes superolateral release.Separation of the posterior crus of the lateral canthal

tendon from the medial zygoma increases tissue mo-bility, facilitating dissection over the zygomatic archto the preauricular exposure.

Eyelid Retractor Release and TarsoconjunctivalHarvest

The aforementioned maneuvers allow furthercomposite retraction and lid retractor isolation.Incision of the superior periorbita at the orbitalmargin exposes the preaponeurotic eyelid adi-pose tissue. The aponeurosis lies deep to the fatand is followed to the superior tarsal margin. Atthis coordinate, the peripheral eyelid arcade liesbetween the aponeurosis and superior sympa-thetic muscle (Fig. 6).

Fig. 6. (Above) The medial palpebral artery (A) arises from thesupratrochlear vessels and descends to the eyelid, supplying theupper and lower eyelid arcades. Division of the distal levator apo-neurosis (C) reveals the peripheral upper eyelid arcade (B), whoseorigin from the medial palpebral is obscured by medial orbital fatpad. Note the aberrant position of the arcade (B) lying on thetarsus (D). (Below) Forceps hold the cut edge of the distal levatoraponeurosis, exposing the peripheral arcade (A) lying on Muel-ler’s muscle (B). Preaponeurotic fat (C) extending from the ante-rior orbit obscures the levator palpebrae superioris muscle. Themedial palpebral artery is concealed by the medial fat pad (D).

Fig. 4. Proximal facial nerve dissection demonstrates the relation-ship of the temporal (A), zygomatic (B), and buccal (C) branches tothe superficial temporal artery (D) and vein (E) and the superficialtemporal fascia (F).

Fig. 5. Supraorbital vessels and nerves (A) and supratrochlearartery (B) contribute to perfusion of both the supraorbital andeyelid arcades, along with external carotid tributaries. Intraor-bital exposure of these internal carotid tributaries preservesanastomotic connections between these two primary eyelid per-fusion sources within the eyelid.


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Through-and-through incision of the retrac-tor-conjunctival composite cephalad to the arcadeis first carried to the lateral eyelid. Lacrimalductules in the superior conjunctival fornix liesuperior to the incision plane (assuming preser-vation of the host lacrimal gland, and its ductulesand conjunctiva with accessory tear glands). Thedistal lacrimal artery is ligated. Medial division ofthe upper retractors completes superior retractorrelease. As the incision descends to the lower eye-lid and the plica semilunaris, it passes deep to themedial palpebral vessels. The conjunctival incisionthen resumes caudal to the peripheral arcade, tra-versing the lower fornix to the lateral eyelid.

Inferior ReleaseLower orbicularis attachments to the inferior

orbital rim and antral face are separated via theinferior conjunctival incision. Dissection over themaxilla exposes the inferior orbital nerve and ves-sels, which are ligated and divided.

Terminal Facial Nerve Exposure and AllograftDevascularization

Medial to lateral elevation of the allograft nowaffords an unobstructed view of the anterior max-illa, the medial margin of the masseter muscle,and the inferior buccal fat pad (ligation of thesupraorbital and supratrochlear vessels may benecessary for sufficient composite mobility). Ter-minal exposure of the proximal facial nervebranches begins in the premasseteric plane, at theinferior margin of the zygomatic arch. Alternatingviewing perspective between the premassetericand lateral dissection planes facilitates nervebranch localization and protects their distal archi-tecture (Figs. 3 and 4). Temporal, zygomatic, andselected buccal branches are tagged and dividednear the nerve trunk.

Supratrochlear and supraorbital vessels are li-gated within the anterior orbit, preserving anas-tomotic connections to the orbital and eyelid ar-cades (i.e., medial palpebral branch of thesupratrochlear artery). The superficial temporalvessels are divided at the level of the tragus and thefacial vessels at their intersection with the angle ofthe mandible, completing final release of the peri-orbital unit form the donor (Fig. 7).

Six periorbital subunits harvested by the fore-going approach required an average operativetime of 2.5 � 0.5 hours by two experienced sur-geons (D.V. and M.D.G.) (Fig. 8). In a clinicalharvest, modifications to the foregoing techniqueembrace host injury characteristics, host and do-nor dynamic vascular features, and host-donorcephalomorphic dimensions.

Angiographic Assessment of Allograft VascularIntegrity

Angiographic analysis of the eyelid perfusionpatterns was performed in seven harvested peri-orbital units. Perfusion of the superficial temporal

Fig. 7. The final periorbital allograft, before release from the do-nor, is based on the peripheral branches of the facial nerve andthe superficial temporal and facial vessels. The preauricular andpremasseteric biplanar dissection planes protect proximal facialnerve branches (A) and their terminal arborization at the orbic-ularis oculi. The vascular supply of the periorbital unit [superficialtemporal (B) and facial (C) vessels] is preserved throughout thedissection by this technique. Note the ligated supraorbital/su-pratrochlear vessels and medial palpebral artery (D).

Fig. 8. A harvested periorbital unit demonstrating preserved fa-cial nerve branches (A) and the course of superficial temporal (B)and facial (C) vessels. Also note the retained zygomatic muscu-lature (D), which contains the superior buccal branch that inner-vates the medial orbicularis oculi muscle.


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artery filled both eyelid and orbital arcades in fourof five units (Fig. 9). Facial artery injection filledthe orbital and eyelid arcades in three of five units.Single selective facial venograms of two allograftsshowed intact drainage of the periorbital unit inboth cases (Fig. 10). These data establish the va-lidity of the harvest protocol and confirm the an-atomic vascular variability of the region.

Periorbital Unit Allograft ImplantationRecipient preparation or debridement pre-

cedes or occurs simultaneously with harvest toidentify skin and mucous membrane require-ments and clarify the status of neurovascular tis-sues. Recipient facial nerve mapping, in particularof the inferior zygomatic and buccal branches, isimperative to ensure full allograft reinnervationpotential and avoid the injury to the branches thatmay coinnervate contiguous facial muscles. Insuch cases, end-to-side neural anastomosis isconsidered29 as a reinnervation option.

Implantation of the periorbital unit into therecipient site largely recapitulates harvest, in mod-ified order, using standard microsurgical andcraniofacial techniques. The initial priority is do-nor-to-host arterial and venous revascularization,followed by nerve repair, reconstitution of hostand donor lacrimal excretory components, can-

Fig. 9. Superficial temporal arterial injection (A) perfuses the orbital (B)and eyelid arcades (C) via the medial palpebral artery (D), indicating pres-ervation of the intrinsic eyelid perfusion system during harvest. The or-bital arcades lie on the superficial and deep surfaces of the orbital com-ponent of the orbicularis oculi muscle. Anastomotic connectionsbetween periorbital branches of the internal and external carotid arteriesperfuse the arcades.9,10,27,28 They connect with the eyelid arcades viatributaries that course over the anterior and posterior orbicularsurfaces.9 –11 Accordingly, orbicularis release from the orbit must pro-tect this delicate and vulnerable vascular system. The diamond sym-bol denotes the eyelid aperture.

Fig. 10. Facial venous injection demonstrates filling of the fa-cial (A), angular (B), and superior orbital veins (C). Note thepotential of the alternative venous drainage route throughsuperficial temporal venous conduits (D). Primary venousdrainage of the periorbital composite follows venous tribu-taries that flow terminally to the external jugular vein and viathe cavernous sinus. The largest constituent of the network,the superior orbital vein of the internal jugular system, paral-lels the orbital rim upon exiting the orbit. It joins the superficialtemporal venous watershed at the lateral canthus and con-nects medially with branches of the angular vein.11


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thal tendon attachment to the orbital margins,attachment of eyelid retractors, and finally, skinclosure.

DISCUSSIONCurrent methods used to reconstruct an eyelid

pair must compromise visual function to achievecorneal protection and comfort. The visual hand-icap is profound and aesthetic results are neces-sarily unsatisfactory. A composite eyelid pair allo-transplant, as described herein, could offer theultimate reconstructive solution.

Preservation of the eyelid’s neurovascular in-tegrity was of utmost importance in harvest design.The myoneural, myocutaneous, and adnexal ele-ments comprising its functional triad were pre-served by meticulous adherence to the subperios-teal dissection plane during release of osseousattachments. Biplanar exposure protected thecomposite’s proximal and distal facial nervebranches.

Selective postharvest angiography and venog-raphy demonstrated integrity of external carotidvessels, the principal vascular arcades and venousdrainage routes within the allografts. Internal ca-rotid tributaries (supraorbital and supratroch-lear) demonstrated small caliber and unpredict-able course during preliminary dissection andare not primary perfusion sources. Their distalanastomotic connections to the orbital and eye-lid arcades, however, are essential to posttrans-plant perfusion.9,10

Several reports document viable facial/scalp re-plantation based on a single vascular pedicle.30–34 Morerecently, perfusion of facial tissue allotransplants6–8

suggests that effective perfusion of an eyelid com-posite is probable. The superficial temporal ves-sels, based on their caliber and extensive inter-connections within the composite, are consideredthe primary revascularization option. In their ab-sence in either donor or recipient, facial vesselsprovide an alternative.

Our anatomic findings underscore the impor-tance of anatomic variability in reperfusion plan-ning. Absence of the facial-to-angular artery con-tinuation and of the frontal branch of thesuperficial temporal artery occurred in 28 and 11percent of hemifaces, respectively. Further, angio-graphic data showed inconsistent filling pattern ofthe harvested periorbital units by the superficialtemporal artery and facial artery alone. These an-atomic results, however, are not equivalent to dy-namic perfusion analysis. Accordingly, study ofhost and donor periorbital arterial and venous

phases during selective external carotid angiogra-phy is needed to refine reperfusion options.

Although viable wound coverage is the pen-ultimate reconstructive goal, the degree of orbic-ularis functional recovery is the ultimate measureof allograft effectiveness. Classic end-to-end facialnerve trunk repair restores tonus and volitionalblink but rarely reflexive eyelid closure.35,36 In ourmodel, proximal anastomosis of homologous do-nor and recipient facial nerve branches preservesthe pedicle’s distal innervation and that of otherrecipient facial subunits. Theoretical advantagesinclude direct connection between functionallyappropriate nerves, neurorrhaphy in proximity tothe target muscle, and single facial muscle dener-vation. These modifications may improve axonguidance and animation recovery37–39; however,absent a comparable model, functional outcomesare unknown.

Facial transplants performed thus far7 havedemonstrated early sensory recovery, but long-term functional outcomes and corresponding re-innervation etiology have yet to be studied.40 Ac-cordingly, the orbicularis oculi response to thecombined stresses of ischemia and denervation, towhich its fast-twitch fibers are comparatively vul-nerable, is unknown.41 Of interest, Lantieri et al.8in replacing the lower and middle section of theface reported a blink reflex of the autochthonousorbicularis oculi that was absent before surgery.

An eyelid pair allograft may ultimately be in-cluded in the reconstructive surgeon’s armamen-tarium. Limitations in estimation of functional po-tential, however, highlight the need for an animalmodel to clarify the impact of ischemia, immuno-logical, and denervation effects on posttransplantmyoneural reconstitution during allograft recovery.

M. Douglas Gossman, M.D.2302 Hurstbourne Village Drive, Suite 700

Louisville, Ky. [email protected]

ACKNOWLEDGMENTSThe authors gratefully acknowledge Robert D.

Acland, M.D., for his invaluable support, advice, andtechnical assistance during all stages of this project. Theyalso acknowledge Thomas G. O’Daniel, M.D., and JacobYunker, M.D., for their insightful contributions to facialnerve dissections. The authors thank Leigh B. Kleinertand Robert Reed of the Cardiovascular Innovation In-stitute, Louisville, for their assistance on angiographicdata rendition. Cadaver specimens for this study wereprovided through the Body Bequeathal Program of theUniversity of Louisville School of Medicine. The authors


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thank Steve Anderson and Troy Nukes from the programfor their help.

REFERENCES1. Achauer BM, Menick FJ. Salvage of seeing eyes after avulsion

of upper and lower lids. Plast Reconstr Surg. 1985;75:11.2. Hay D. Reconstruction of both eyelids following traumatic

loss. Br J Plast Surg. 1971;24:361.3. Bedrossian RH, Sperry DW. Repair of avulsion of eyelids and

cheek. Ann Ophthalmol. 1988;20:31.4. Thai KN, Billmire DA, Yakuboff KP. Total eyelid reconstruc-

tion with free dorsalis pedis flap after deep facial burn. PlastReconstr Surg. 1999;104:1048.

5. Nose K, Isshiki N, Kusumoto K. Reconstruction of both eye-lids following electrical burn. Plast Reconstr Surg. 1991;88:878.

6. Devauchelle B, Badet L, Lengele B, et al. First human faceallograft: Early report. Lancet 2006;368:203.

7. Dubernard J.-M, Lengele B, Morelon E, et al. Outcomes 18months after the first human partial face transplantation.N Engl J Med. 2007;357:2451.

8. Lantieri L, Meningaud JP, Grimbert P, et al. Repair of thelower and middle parts of the face by composite tissue allo-transplantation in a patient with massive plexiform neuro-fibroma: A 1-year follow-up study. Lancet 2008;372:639.

9. Kawai K, Imanishi N, Nakajima H, et al. Arterial anatomicalfeatures of the upper palpebra. Plast Reconstr Surg. 2004;113:479.

10. Erdogmus S, Govsa F. Arterial features of inner canthusregion: Confirming the safety for the flap design. J CraniofacSurg. 2006;17:864.

11. Whitnall SE. The Anatomy of the Human Orbit. Huntington,N.Y.: Kreiger Publishing Company Inc.; 1979; pp. 168, 173.

12. Gosain AK, Sewall SR, Yousif NJ. The temporal branch of thefacial nerve: How reliably can we predict its path? Plast Re-constr Surg. 1997;99:1224.

13. Hwang K, Cho HJ, Chung IH. Pattern of the temporal branchof the facial nerve in the upper orbicularis oculi muscle.J Craniofac Surg. 2004;15:373.

14. Hwang K, Jin S, Hwang SH, et al. Innervation of upperorbicularis oris muscle. J Craniofac Surg. 2006;17:1116.

15. Nemoto Y, Sekino Y. Anatomical reasons for problems afterneurectomy for blepharospasm: A study in cadavers. ScandJ Plast Reconstr Surg Hand Surg. 2000;34:21.

16. Nemoto Y, Sekino Y, Kaneko H. Facial nerve anatomy ineyelids and periorbit. Jpn J Ophthalmol. 2001;45:445.

17. Ouattara D, Vacher C, de Vasconcellos JJA, et al. Anatomicalstudy of the variations in innervation of the orbicularis oculiby the facial nerve. Surg Radiol Anat. 2004;26:51.

18. Ramirez OSR. Spatial orientation of motor innervation to thelower orbicularis oculi muscle. Aesthet Surg J. 20: 107, 2000.

19. Saylam C, Ucerler H, Orhan M, et al. Anatomic guides toprecisely localize the zygomatic branches of the facial nerve.J Craniofac Surg. 2006;17:50.

20. Bernstein L, Nelson RH. Surgical anatomy of the extrapa-rotid distribution of the facial nerve. Arch Otolaryngol. 1984;110:177.

21. Davis RA, Anson BJ, Budinger JM, et al. Surgical anatomy ofthe facial nerve and parotid gland based upon a study of 350cervicofacial halves. Surg Gynecol Obstet. 1956;102:385.

22. Freilinger G, Gruber H, Happak W, et al. Surgical anatomyof the mimic muscle system and the facial nerve: Importancefor reconstructive and aesthetic surgery. Plast Reconstr Surg.1987;80:686.

23. Lei T, Xu D-C, Gao J-H, et al. Using the frontal branch of thesuperficial temporal artery as a landmark for locating thecourse of the temporal branch of the facial nerve duringrhytidectomy: An anatomical study. Plast Reconstr Surg. 2005;116:623.

24. Marano SR, Fischer DW, Gaines C, et al. Anatomical study ofthe superficial temporal artery. Neurosurgery 1985;16:786.

25. Muzaffar AR, Mendelson BC, Adams WP, Jr. Surgical anat-omy of the ligamentous attachments of the lower lid andlateral canthus Plast Reconstr Surg. 2002;110:873.

26. Rosenstein T, Talebzadeh N, Pogrel MA. Anatomy of thelateral canthal tendon. Oral Surg Oral Med Oral Pathol OralRadiol Endod. 2000;89:24.

27. Sutcliffe T, Baylis HI, Fett D. Bleeding in cosmetic blepha-roplasty: An anatomical approach. Ophthal Plast Reconstr Surg.1985;1:107.

28. Tucker SM, Linberg JV. Vascular anatomy of the eyelids.Ophthalmology 1994;101:1118.

29. Sundine MJ, Quan EE, Saglam O, et al. The use of end-to-sidenerve grafts to reinnervate the paralyzed orbicularis oculimuscle. Plast Reconstr Surg. 2003;111:2255.

30. Chen IC, Wan HL. Microsurgical replantation of avulsedscalps. J Reconstr Microsurg. 1996;12:105.

31. Gatti JE, LaRossa D. Scalp avulsions and review of successfulreplantation. Ann Plast Surg. 1981;6:127.

32. Thomas A, Obed V, Murarka A, et al. Total face and scalpreplantation. Plast Reconstr Surg. 1998;102:2085.

33. Wilhelmi BJ, Kang RH, Movassaghi K, et al. First successfulreplantation of face and scalp with single-artery repair:Model for face and scalp transplantation. Ann Plast Surg.2003;50:535.

34. Nahai F, Hurteau J, Vasconez LO. Replantation of an entirescalp and ear by microvascular anastomoses of only 1 arteryand 1 vein. Br J Plast Surg. 1978;31:339.

35. House JW, Brackmann DE. Facial nerve grading system. Oto-laryngol Head Neck Surg. 1985;93:146.

36. Jaaskelainen J, Pyykko I, Blomstedt G, et al. Functional resultsof facial nerve suture after removal of acoustic neurinoma:Analysis of 25 cases. Neurosurgery 1990;27:408.

37. Brushart TM, Gerber J, Kessens P, et al. Contributions ofpathway and neuron to preferential motor reinnervation.J Neurosci. 1998;18:8674.

38. Fawcett JW, Keynes RJ. Peripheral nerve regeneration. AnnuRev Neurosci. 1990;13:43.

39. Horsch Kw BPR. Functional specificity and somatotopic or-ganization during peripheral nerve regeneration. In JewettJL, McCarrol HR, eds. Nerve Repair and Regeneration. St. Louis,Mo.: Mosby.

40. Guntinas-Lichius O. Outcomes 18 months after the first hu-man partial face transplantation. N Engl J Med. 2008;358:2179.

41. Chan RK, Austen WG, Ibrahim S, et al. Reperfusion injury toskeletal muscle affects primarily type II muscle fibers. J SurgRes. 2004;122:54.


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