International consensus recommendations on face transplantation: A 2-step Delphi study.

Face transplantation is a viable reconstructive approach for severe craniofacial defects. Despite the evolution witnessed in the field, ethical aspects, clinical and psychosocial implications, public perception, and economic sustainability remain the subject of debate and unanswered questions. Furthermore, poor data reporting and sharing, the absence of standardized metrics for outcome evaluation, and the lack of consensus definitions of success and failure have hampered the development of a "transplantation culture" on a global scale. We completed a 2-round online modified Delphi process with 35 international face transplant stakeholders, including surgeons, clinicians, psychologists, psychiatrists, ethicists, policymakers, and researchers, with a representation of 10 of the 19 face transplant teams that had already performed the procedure and 73% of face transplants. Themes addressed included patient assessment and selection, indications, social support networks, clinical framework, surgical considerations, data on patient progress and outcomes, definitions of success and failure, public image and perception, and financial sustainability. The presented recommendations are the product of a shared commitment of face transplant teams to foster the development of face transplantation and are aimed at providing a gold standard of practice and policy.

Evolution and limitations of conventional autologous reconstruction of the head and neck.

Conventional reconstruction in the head and neck has undergone a revolution as microsurgery has evolved and expanded our ability to reconstruct the most difficult defects. Vascularized composite allotransplantation (VCA) has provided a new paradigm of options to restore in 1 stage what in the past has been performed in multiple stages with multiple combinations of free flaps and local flap options. This review demonstrates an evolving perspective of head and neck reconstructive surgery incorporating the indications and advantages gained over a career that has developed in parallel with microsurgery, prefabrication, prelamination, and face transplant. All current conventional reconstructions for the most severe defects often involve multistage procedures, using every rung of the reconstructive ladder, and the end results can still be lacking despite our best efforts. Despite all the tailoring and planning of these multiple flap and multiple-stage reconstructions, in our experience, these interventions never quite exactly recapitulate the face and fall short of full restoration. The early experience with VCA has been very promising and yields results that are superior to those achieved using conventional methods of reconstruction. However, it will be synergistic efforts in both VCA and conventional reconstruction to take us to the next level of full face restoration.