title: Watershed Areas in Face Transplantation.
abstract: BACKGROUND
  The maxillary artery has traditionally been considered the main blood supply of the facial skeleton. However, the deep and concealed location makes the harvest of facial allografts based on this artery challenging, giving preference to the facial artery. There is growing evidence that the junction between the hard and soft palate may represent a watershed area in facial artery-based allografts. The aim of this study was to review the occurrence of partial allograft necrosis and modify the available craniofacial techniques, allowing for a reliable harvest of maxillary artery-based facial allografts.
  
  
  METHODS
  PubMed/MEDLINE databases were searched for articles presenting allograft perfusion details and the occurrence of partial flap necrosis. Next, 25 fresh cadaver heads were used: eight allografts were harvested by means of a traditional Le Fort III approach, in six the maxillary artery was injected with latex, in three cadaver heads lead oxide gel was injected in the maxillary artery, and eight full facial allografts were harvested through a modified approach.
  
  
  RESULTS
  Seven patients developed palatal fistulas or palatal necrosis (41 percent) when allograft was perfused through the facial artery. The traditional Le Fort III approach demonstrated consistent injury to maxillary artery/branches. The modified approach allowed for preservation of the maxillary artery under direct vision.
  
  
  CONCLUSIONS
  Current facial transplantation outcomes indicate that facial artery-based allografts containing Le Fort III bony components can experience compromised palate perfusion. The described modified Le Fort III approach allowed safe dissection of the maxillary artery, preserving the arterial blood supply to the facial skeleton.
  
  
  METHODS
  Therapeutic, V.
authors.affiliation: Cleveland, Ohio; and Chicago, Ill.|From the Department of Plastic Surgery, Cleveland Clinic; and the Department of Orthopaedics, University of Illinois.
authors.forename: Bahar
authors.initials: B
authors.lastname: Bassiri Gharb
authors.affiliation: Cleveland, Ohio; and Chicago, Ill.|From the Department of Plastic Surgery, Cleveland Clinic; and the Department of Orthopaedics, University of Illinois.
authors.forename: Russell S
authors.initials: RS
authors.lastname: Frautschi
authors.affiliation: Cleveland, Ohio; and Chicago, Ill.|From the Department of Plastic Surgery, Cleveland Clinic; and the Department of Orthopaedics, University of Illinois.
authors.forename: Brianna C
authors.initials: BC
authors.lastname: Halasa
authors.affiliation: Cleveland, Ohio; and Chicago, Ill.|From the Department of Plastic Surgery, Cleveland Clinic; and the Department of Orthopaedics, University of Illinois.
authors.forename: Gaby D
authors.initials: GD
authors.lastname: Doumit
authors.affiliation: Cleveland, Ohio; and Chicago, Ill.|From the Department of Plastic Surgery, Cleveland Clinic; and the Department of Orthopaedics, University of Illinois.
authors.forename: Risal S
authors.initials: RS
authors.lastname: Djohan
authors.affiliation: Cleveland, Ohio; and Chicago, Ill.|From the Department of Plastic Surgery, Cleveland Clinic; and the Department of Orthopaedics, University of Illinois.
authors.forename: Steven L
authors.initials: SL
authors.lastname: Bernard
authors.affiliation: Cleveland, Ohio; and Chicago, Ill.|From the Department of Plastic Surgery, Cleveland Clinic; and the Department of Orthopaedics, University of Illinois.
authors.forename: Brian R
authors.initials: BR
authors.lastname: Gastman
authors.affiliation: Cleveland, Ohio; and Chicago, Ill.|From the Department of Plastic Surgery, Cleveland Clinic; and the Department of Orthopaedics, University of Illinois.
authors.forename: Maria Z
authors.initials: MZ
authors.lastname: Siemionow
authors.affiliation: Cleveland, Ohio; and Chicago, Ill.|From the Department of Plastic Surgery, Cleveland Clinic; and the Department of Orthopaedics, University of Illinois.
authors.forename: Francis A
authors.initials: FA
authors.lastname: Papay
authors.affiliation: Cleveland, Ohio; and Chicago, Ill.|From the Department of Plastic Surgery, Cleveland Clinic; and the Department of Orthopaedics, University of Illinois.
authors.forename: Antonio
authors.initials: A
authors.lastname: Rampazzo
mesh_terms: D000328:Adult; D002102:Cadaver; D005145:Face / Q000098:blood supply*; D054445:Facial Transplantation / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008438:Maxillary Artery; D008875:Middle Aged; D014680:Veins