title: The procurement of allotransplants for ballistic trauma: a preclinical study and a report of two clinical cases.
abstract: BACKGROUND
  Maxillofacial trauma caused by severe ballistic injuries requires many steps of reconstruction and is often associated with disappointing results. The authors report on two clinical cases of facial allografting.
  
  
  METHODS
  After a preclinical anatomical study of 10 fresh cadavers, the authors performed allotransplantation of the lower two-thirds of the face in two patients in March and August of 2009. The grafts included all perioral muscles, facial nerves, parotid glands, the anterior region of the maxilla, and part of the mandible. The mandibular osteotomy included only the chin in one case, and the mandibular arch from one angle to the other in the second case.
  
  
  RESULTS
  The cadaveric study confirmed that relying only on the anastomoses between the facial and the maxillary artery for vascularization of the posterior part of the maxilla was unsafe. Periosteal vascularization seemed essential. The clinical results confirmed that complete revascularization from a single facial pedicle was possible: the first end-to-end arterial anastomosis to the left external carotid artery was sufficient for full perioperative revascularization of the flap and immediate reestablishment of bilateral venous flow. The facial appearance of both recipients improved gradually, with the development of changes in expression and the appearance of nasolabial folds. Preoperatively placed gastrostomies and tracheostomies were able to be removed in both patients within 6 weeks postoperatively. The procurement part of the operation was performed in 7 hours.
  
  
  CONCLUSIONS
  Partial facial composite tissue allotransplantation of the lower two-thirds of the face along with parts of the maxilla and mandible (chin or entire-toothed mandible) is technically feasible, with a good cosmetic and functional outcome in typical cases of attempted suicide with rifles.
authors.affiliation: Créteil, France From the Université Paris 12, Faculté de Médecine, IFR10, and AP-HP, Groupe Henri Mondor-Albert Chenevier, Service de Chirurgie Plastique, Reconstructrice et Esthétique.
authors.forename: Jean-Paul
authors.initials: JP
authors.lastname: Meningaud
authors.forename: Mickael
authors.initials: M
authors.lastname: Hivelin
authors.forename: Marc-David
authors.initials: MD
authors.lastname: Benjoar
authors.forename: Gaoussou
authors.initials: G
authors.lastname: Toure
authors.forename: Oana
authors.initials: O
authors.lastname: Hermeziu
authors.forename: Laurent
authors.initials: L
authors.lastname: Lantieri
mesh_terms: D002102:Cadaver; D054445:Facial Transplantation / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008446:Maxillofacial Injuries / Q000601:surgery*; D013524:Surgical Flaps; D009927:Tissue and Organ Procurement / Q000379:methods*; D014948:Wounds, Gunshot / Q000601:surgery