title: Principles of face transplant revision: beyond primary repair.
abstract: BACKGROUND
  Over the past decade, facial vascularized composite allotransplantation has earned its place at the top of the reconstructive ladder. However, as in free tissue transfer, postoperative revisions are necessary to achieve optimal functional and aesthetic results. Although revising a facial vascularized composite allotransplantation may potentially risk the integrity of the graft, the authors believe that the advantages of appropriately chosen revisions may provide great benefit.
  
  
  METHODS
  Following the most extensive face transplant performed to date, revisions were performed in two surgical procedures. The first included a Le Fort III osteotomy for malocclusion correction, midface tissue resuspension and coronal eyebrow lift to correct soft-tissue ptosis, and submental lipectomy. Bilateral blepharoplasty to minimize tissue excess and scar revision were performed at a subsequent operation. Cephalometric analysis and angiography were performed and blink data collected.
  
  
  RESULTS
  Before transplantation, the patient was in class III malocclusion. After transplantation, class I occlusion was obtained; however, the patient subsequently returned to class III occlusion. After skeletal revision, class I occlusion was obtained; however, a corneal blink deficit was noted. Eight months after skeletal revision, blink had improved spontaneously. Angiography revealed collateralization providing retrograde flow from the flap to the recipient.
  
  
  CONCLUSIONS
  Although the necessity for revisions is clear, determining which revisions to safely perform and their timing and execution have not been explored. The authors address four distinct categories of revisions, including soft-tissue revision, hard-tissue mismatch, and craniofacial skeleton and dental occlusion. The authors illustrate the success of these revisions and assess their advantages, disadvantages, and relative risk.
authors.affiliation: Baltimore, Md.; and New York, N.Y. From the Division of Plastic Surgery, R Adams Cowley Shock Trauma Center, and the Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine; the Wilmer Eye Institute, Johns Hopkins School of Medicine; and the Department of Plastic Surgery, New York University Langone Medical Center.
authors.forename: Raja
authors.initials: R
authors.lastname: Mohan
authors.forename: Mark
authors.initials: M
authors.lastname: Fisher
authors.forename: Amir
authors.initials: A
authors.lastname: Dorafshar
authors.forename: Michael
authors.initials: M
authors.lastname: Sosin
authors.forename: Branko
authors.initials: B
authors.lastname: Bojovic
authors.forename: Dheeraj
authors.initials: D
authors.lastname: Gandhi
authors.forename: Nicholas
authors.initials: N
authors.lastname: Iliff
authors.forename: Eduardo D
authors.initials: ED
authors.lastname: Rodriguez
mesh_terms: D019882:Blepharoplasty; D054445:Facial Transplantation / Q000379:methods*; D006801:Humans; D015187:Lipectomy; D008297:Male; D008313:Malocclusion, Angle Class III / Q000209:etiology / Q000601:surgery*; D019340:Osteotomy, Le Fort / Q000379:methods*; D011183:Postoperative Complications / Q000601:surgery*; D012086:Reoperation / Q000379:methods