2.1 Waiting time

This period is critical because each member must be motivated to be able to be mobilized at any time. The team leader should organize and control the preparation for the operative day; the patient should be frequently contacted and regularly interviewed. Follow-up is carefully organized and the psychological, medical, and physiological goals are defined. The final decision is always with the patient, so that contact, trust and regular discussions are crucial to prepare for a smooth operative day.

2.2 Operative day

When the leader is alerted that a corresponding potential brain-dead donor is somewhere in France, the first decision must involve analysis of a picture of the potential donor and then to accept or refuse the donor. The coordination team will ask the family, who had already accepted the organ procurement permission, if they would also accept to give a part or the whole face of their relative. In the case of a positive decision, the surgery is scheduled, and all members of the transplant team are notified to prepare and proceed according to the protocol. At the same time, the recipient patient is also contacted to come to the hospital to sign a new consent form and be prepared for surgery.

As soon as the positive answer from the donor’s family is known, the patient will then receive the first immunosuppressive treatment. The decision on the timing of the operation is taken, and the distribution into two teams (one near the recipient to prepare the defect and one who will travel to the donor to harvest the face transplant) is carefully organized depending on the city and distance to the donor. The specific members and material to manufacture the donor face mask will accompany the latter part of the team near the donor. For now, there is no agreement in France to transport the brain-dead donor near to the recipient, which would make the procedure easier.

2.3 Team near the donor

For us and other transplant surgeons [Petruzzo et al, 2012] the face transplant procurement is always done first before other organs are harvested because the facial dissection should be done carefully on a body with the heart beating in the way that the face transplant will exactly match the defect as decided during the dissection procedures.

• First step—low level tracheotomy, if not previously made.

• Second step—print of the donor face to reconstitute the silicone mask for the end of the procedure.

• Third—surgical steps, depending on the size and topography; all steps will follow the preoperative dissection.

  • Precise drawing of the skin margins.

  • Skin incision and progressive dissection from upper margin to the cervical area toward the vessel dissection of the chosen vascular pedicle (ie, facial arteries, carotid arteries, external and internal jugular veins).

  • All nerves and their branches (sensory and motor) should be respected and marked to facilitate coaptation.

  • All facial muscles and ducts involved will be identified and marked.

  • In case of bone inclusion, the preoperative dissection will define the types and the orientation of the osteotomies. Problems arise if only one jaw is included in the VCA, and the recipient and donor jaw do not match. The possibility to remove and replace the opposite jaw should always be favored because of problems in the dental occlusion, which will never be better than after a bimaxillary incorporation (if a replacement of both jaws is not accepted, it will be necessary to build a temporary occlusal dental splint). The inferior alveolar nerve should be resected with a lengthening process by infratemporal dissection. For the infraorbital nerve, the removal of the infraorbital bone margin permits dissection to the pterygoid space. Teeth are often transplanted without any preparation because they belong completely to the vascularized transplant.

• The tongue and the soft palate can also be harvested. However, a careful dissection of all the suprahyoid muscles attached to the hyoid bone which can be inserted in the transplant and the muscles of the pharyngeal wall to restore the oropharyngeal motility are necessary.

• At the time of the final venous and arterial dissection (usually external carotid or its branches), the time should be noted because it constitutes the beginning of the ischemic time, which is imperative regarding the functional recovery and the vitality of the transplant.

In our group at the same time a forearm flap is also dissected as “sentinel flap” because serial skin biopsies of allogenic skin are needed for life. Thus, it was decided to perform a skin sentinel flap for biopsies to avoid any additional facial scarring.

After that the transplant is prepared with a washout by a serum solution and then conservative preparation is done, which functions as a transporting liquid and for organ preservation. A part of the team may leave the donor operating room to join the recipient operating room. In the operating room with the donor, the other teams then harvest the other organs. During that time, the prosthetist and one or two assistants prepare and build the silicone mask according to the first imprint. This includes coloration to match and respect the cadaver. After the donor surgery is completed, the restitution of the face of the donor is achieved due to an exact adaptation of the mask and a color duplicate junction prepared with specific make-up and hair arrangement to provide camouflage.