Surgical Approach to Full Soft Tissue Face Allograft Procurement for Vascularized Composite Allotransplantation

Nonfatal severe craniofacial defects profoundly affect patients' social interactions and perceptions of their own self-image, often leading to significant psychological distress. Beyond appearance, intact facial anatomy is crucial for essential functions, including respiration, chewing, swallowing, speech, and non-verbal communication^1,2.

Facial allotransplantation has emerged as a transformative reconstruction option for patients with severe facial deformities resulting from congenital anomalies, trauma, or oncologic resections. Despite advances in conventional reconstructive surgery, restoration of both function and aesthetics remains especially difficult for centrally located defects^3,4.

Since the first partial face transplant in France in 2005⁵, techniques have continued to evolve^6,7, culminating most recently in 2023 with the landmark achievement of a combined whole-eye and face transplantation by Ceradini et al.⁸. Modern surgical planning and technological innovations have improved the reproducibility and predictability of outcomes, enabling better functional and aesthetic results^4,9. However, lifelong immunosuppressive therapy introduces risks of infectious, metabolic and neoplastic complications, which raise substantial ethical and medical challengess^10,11.

Procurement strategies have progressed from partial lower-face transplants¹² to full face allografts^8,13,14. Full-face procurement is indicated when extensive tissue loss involves multiple aesthetic and functional units, such as eyelids, nose, lips, cheeks, and when the restoration of vital functions (breathing, speech, mastication, swallowing) requires a three-dimensional reconstruction of the entire facial framework^6,15.

Facial vascularization is mainly provided by the external carotid artery system, with the facial artery serving as the principal vessel and the superficial temporal artery as an important supplementary source^16,17. Venous drainage occurs mainly via the facial vein into the internal jugular veins¹⁸. Preservation of neural structures is equally critical: motor function is restored through coaptation of the facial nerve while¹⁹ sensory innervation of the face depends on careful dissection of the trigeminal nerve, branches: V1, V2, and V3²⁰.

Here, we present a step-by-step protocol for harvesting a full-face vascularized composite allograft, including the forehead, eyelids, cheeks, nose, and lips from a cadaveric donor. The harvest incorporates only limited bony structures, restricted to the nasal framework, which is included primarily for pedagogical purposes to facilitate training reproducibility and minimize procedural complexity in cadaveric demonstrations.

The Anatomy Laboratory of the Faculty of Medicine of Nice, France, generously provided the specimens and materials used in this study. The study was approved by the French National Ethics Committee (IRB approval No. IRB00014528_2025_36) and conducted in accordance with the principles of the Declaration of Helsinki.

1. Positioning and airway preparation

1. Place the donor supine on the operating table.
2. Perform a tracheotomy to secure the airway.
   NOTE: Whenever possible, perform procurement under beating-heart conditions to minimize ischemic time. The facial allograft should be harvested prior to the retrieval of other solid organs to maintain tissue quality without compromising subsequent graft outcomes. Apply a cast mold to the donor's face (facial mask impression) before beginning procurement.
3. Delineate the planned incisions, using a surgical marking pen: Coronal incision; Pretragal incision; Lateral cervical incision; Transverse incision at the level of the hyoid bone.
4. Infiltrate with local anesthesia (lidocaine + epinephrine 2%)
   ​NOTE: Begin at the scalp and proceed inferiorly along the preauricular area. Extend the infiltration to a point approximately 5 cm below the mandibular angle, then continue anteriorly across the cervical region to join the contralateral side above the tracheotomy site.

Figure 1: Preoperative skin markings of the planned incisions. (A) Anterior view showing a transverse incision at the level of the hyoid bone. (B) Lateral view showing the lateral coronal incision, the preauricular incision and the lateral cervical incision along the sternocleidomastoid muscle contour. Please click here to view a larger version of this figure.

2. Cervical dissection

1. Make a cervical incision extending from the superior border of the clavicle to the earlobe, using a No. 10 or 15 scalpel blade.
2. Raise the cervical skin flap in the subplatysmal plane using a fine-tip monopolar electrocautery set to approximately 20-30 °C and 80 W in coagulation mode and Adson tissue forceps.
3. Dissect the neck area to identify the sternocleidomastoid muscle using strabismus scissors.
4. Perform a circumferential dissection of the external jugular vein, which is ligated and divided using strabismus scissors.
5. Retract the sternocleidomastoid muscle laterally using a Farabeuf retractor to gain access to the vascular pedicles. Free up this muscle laterally to expose the vessels.
6. Dissect carefully using strabismus scissors to expose the internal jugular vein and subsequent thyro-linguofacial trunk and identify and preserve the facial vein. Control minor bleeding with low-intensity coagulation, using a standard monopolar electrocautery set to 10-20 W in coagulation mode, or a bipolar device set to 10-20 W to maintain precise hemostasis.
   NOTE: Use low-intensity coagulation and maintain constant visualization of the carotid bifurcation to avoid thermal injury to the vagus and hypoglossal nerves.
7. Dissect carefully using strabismus scissors to expose the common carotid artery to reveal the carotid bifurcation.
8. Dissect the external carotid artery using strabismus scissors cranially to reveal all of the branches: ligate and divide the superior thyroid, ascending pharyngeal, occipital arteries, and lingual. Preserve the facial branch.
9. Identify the posterior belly of the digastric muscle and stylohyoid muscle.
10. Transect both muscles near their insertions to enhance surgical exposure using a fine-tip monopolar electrocautery set to approximately 30 °C in coagulation mode.
11. Locate the hypoglossal nerve, and section it using a fine-tip monopolar electrocautery set to approximately 20-30 °C in coagulation mode proximally to obtain maximal length for potential nerve grafting.
12. Identify, ligate, and divide the submandibular gland, duct, and vessels. Exclude the submandibular gland from the allograft.
    NOTE: The submandibular gland is excluded to minimize postoperative salivary complications such as sialocele or infection, which are more frequent when the gland or its duct is included within the graft. This choice is consistent with clinical practice in face transplantation, where exclusion of salivary glands, particularly the submandibular gland, reduces bulk and improves contour definition²¹.
13. Repeat the above cervical dissection steps on the opposite side.

Figure 2: Cervical dissection and exposure of the neck structure at their origin. (1) Common carotid artery, (2) External carotid artery, (3) Occipital artery, (4) Posterior auricular artery, (5) Facial artery, (6) Lingual artery, (7) Superior thyroid artery, (8) Internal jugular vein, (9) Facial vein, (10) Vagus nerve, (11) Ansa cervicalis, (12) Hypoglossal nerve. Please click here to view a larger version of this figure.

3. Facial nerve dissection

1. Perform the pretragal incision using a No. 10 or 15 scalpel blade to dissect a preauricular skin flap using strabismus scissors in the sub-superficial musculoaponeurotic system plane.
2. Transect the external auditory canal using a fine-tip monopolar electrocautery set to approximately 30 °C in coagulation mode to expose the facial nerve at its origin (retro-auricular)
   NOTE: Transection of the external auditory canal is commonly used in cadaveric or experimental protocols, as it provides a faster and more straightforward exposure. A retroauricular dissection of the main trunk of the facial nerve, using a parotidectomy-type approach, can also be performed while preserving the external auditory canal. In clinical face transplantation, this latter approach is systematically preferred to preserve the integrity of the auditory canal and external ear structures. Avoid excessive traction on the facial nerve trunk to prevent avulsion or transection at the stylomastoid foramen.
3. Dissect using strabismus scissors and ligate using absorbable monofilament suture the maxillary artery (if not done previously).
4. Liberate all of the anterior soft tissues en bloc - including the superficial temporal vessels, using strabismus scissors.
   ​NOTE: For clinical purpose, the exclusion of parotid and remaining salivary glands should be realized to minimize the formation of sialocele⁶. This involves a superficial parotidectomy with facial nerve dissection. In the context of cadaveric training, it may be faster to include the parotid gland within the graft to avoid potential facial nerve injury and time-consuming dissection.
5. Isolate the facial nerve with a vessel loop and dissect it to obtain maximal length using strabismus scissors.
6. Repeat the same dissection on the contralateral side.

Figure 3: Facial nerve dissection. (1) Facial nerve, (2) External carotid artery, (3) Superficial temporal artery. Please click here to view a larger version of this figure.

4. Coronal approach for scalp dissection and periorbital management

1. Make a coronal incision using a No. 10 or 15 scalpel blade and elevate the scalp flap in a sub-periosteal plane posterior to anterior, until the supraorbital nerve is encountered using a fine-tip monopolar electrocautery set to approximately 30 °C in coagulation mode.
   NOTE: The temporalis muscle is excluded from the allograft.
2. Ligate and divide the supraorbital and supratrochlear neurovascular contents as close as possible to the bony foramen, using absorbable monofilament suture and strabismus scissors.
3. Locate the Levator Palpebrae Superioris (LPS) muscle with globe in situ and place a marking suture (Ethilon).
   NOTE: At this stage, hydrodissection may be used to facilitate dissection and reduce trauma to adjacent structures.
4. Proceed with the periorbital dissection using strabismus scissors in the subperiosteal plane to preserve the orbicularis oculi within the graft by dividing the upper eyelid horizontally.
5. Perform circumferential transconjunctival incisions using a No. 10 or 15 scalpel blade to maximally preserve the superior and inferior tarsal plates, orbital septum, levator palpebrae superioris, and Müller's muscle.
6. Isolate the lateral canthus and elevate it with a small segment of the lateral orbital rim using an osteotome, ensuring proper canthal support within the graft.
7. Excise the lower eyelid while preserving the conjunctiva. Dissect through the inferior fornix using strabismus scissors, just inside the orbital rim, allowing preservation of the orbital septum, fat, and lower lid retractors.
8. Identify and transect the infraorbital nerve near its foramen using a fine-tip monopolar electrocautery set to approximately 30 °C in coagulation mode, ensuring maximal nerve length for future neurorrhaphy.

Figure 4: Coronal dissection. (1) Supraorbital nerve, (2) Supratrochlear nerve. Please click here to view a larger version of this figure.

5. Elevation of the facial flap and extension toward the midface

1. Section the facial nerve using strabismus scissors at its exit from the stylomastoid foramen, shaving the masseter muscle to expose the mandibular surface
2. Raise the flap anteriorly on top of the masseter and identify the buccal fat pad at its anterior border, using a fine-tip monopolar electrocautery set to approximately 30 °C in coagulation mode. Continue anterior dissection along the buccal fat pad (left in situ) until reaching and harvesting the buccal mucosa in full.
3. Extend the dissection to the orbit and the zygoma.

6. Midface osteotomies

1. Perform a subperiosteal dissection lateral to the nose using strabismus scissors, preserving the medial tendon canthal attachments.
2. Perform a low-to-low lateral nasal osteotomy using a reciprocating saw and a curved osteotome, extending to the hard palate.
   NOTE: Control instrument orientation to avoid injury to the infraorbital nerve.
3. Extend the osteotomy laterally to include the zygomatic buttress and follow the zygomaticofrontal and sphenozygomatic sutures of the maxilla and zygoma.
4. Divide the nasal septum longitudinally using strabismus scissors. Harvest the nose along with the skin, cartilage (alar, triangular, and most of the septum), nasal bones, and mucosa.
   ​NOTE: For advanced training or research applications, the harvest can be extended to include osseous components such as the maxilla or zygoma, using donor-specific cutting guides. In these cases, the facial artery remains the primary vascular pedicle, with possible contribution from the infraorbital and transverse facial arteries depending on the extent of bone involvement.

Figure 5: Midface dissection. (1) Infraorbital nerve. For demonstration purposes, the infraorbital nerve was preserved and not divided prior to nasal harvest. Please click here to view a larger version of this figure.

7. Intraoral dissection and flap liberation

1. Make a circumferential intraoral incision using a No. 10 or 15 scalpel blade, along the gingivobuccal mucosal junction.
2. Proceed by incising both the superior (maxillary) and inferior (mandibular) gingival mucosa using the scalpel, following the dental arcades precisely.
3. Incise the gingival mucosa along the mandibular line.
4. Identify and divide the mental nerve close to its mental foramen, preserving as much length as possible for potential neurorrhaphy, using strabismus scissors.
5. Cut the mucosa at the gingiva, on the dental part of the maxilla and mandible.
6. Divide the mental nerve close to its foramen using strabismus scissors.
7. Mobilize the cervical soft tissue planes medially and direct them toward the oral cavity using a fine-tip monopolar electrocautery set to approximately 30 °C in coagulation mode, dissect in the plane above the sternohyoid and superior omohyoid muscles, with or without inclusion of the anterior jugular vein.
8. Elevate the graft en bloc, by liberating the allograft from all soft-tissue attachments using the monopolar electrocautery besides the bilateral vascular pedicles.
9. Ligate the internal and external jugular veins and carotid arteries using absorbable monofilament as distally as possible.
10. Detach the face entirely.

Figure 6: Final aspect of the harvested graft. The facial nerve is tagged with a blue suture on each side of the graft. (A) Internal view, soft tissue side. White arrow: orbital septum. Black arrow: superior gingival mucosa. Green arrow: inferior gingival mucosa. (B) External view, epidermal surface. Please click here to view a larger version of this figure.

8. Packaging of the graft

1. Cannulate the external carotid arteries with vascular cannulas secured by silk ties.
   NOTE: Confirm hemostasis before perfusion and handle cannulas with care to prevent vessel wall tearing.
2. Connect a cysto irrigation set to the stopcock and flush with the institution transplant preservation solution until clear venous effluent is observed.
   NOTE: For graft perfusion and storage, preservation solutions such as University of Wisconsin (UW) at 4 °C or Histidine-Tryptophan-Ketoglutarate (HTK) supplemented with 5,000 units of unfractionated heparin may be used.
3. Disconnect the Cysto Irrigation Set and close the stopcock.
4. Wrap the graft in saline-moistened sterile towels, place it in a sealed sterile bag, and label. Enclose in a second sterile empty bag, then a third sterile bag containing ice water, in accordance with standard solid organ transplantation preservation strategies. In line with solid organ transplantation, the recommended target cold ischemia time for VCA grafts is ideally maintained under 4-6 h to optimize tissue viability.
   NOTE: Following procurement, reconstructive measures are undertaken to ensure a respectful presentation of the donor. These typically include re-approximation of skin edges, placement of an acrylic mask or prosthetic facial covering, and restoration of the overall facial contour to preserve dignity during subsequent donor management. Restoration of the donor's facial integrity is both an ethical and legal obligation. A resin or 3D-printed mask can be fabricated from an alginate mold within approximately 30 min to recreate the donor's facial features. This procedure ensures a dignified presentation for funeral ceremonies and should be systematically performed as part of every facial allograft procurement.

The donor face dissected for this study was a male measuring 1.72 m in height with a malnourished body morphology. During graft dissection, vessel and nerve dimensions were measured bilaterally at the usual transection levels using a caliper, and mean values were calculated.

Mean vessel and nerve diameters from the donor were compared with averages reported in cadaveric and surgical literature. The harvested facial artery measured 1.5 mm at the mandibular border, closely matching cadaveric means for the diameter at the same level (1.9 ± 0.4 mm)22. The superficial temporal artery measured 1.7 mm, consistent with pooled estimates from a meta-analysis that showed a mean diameter of 1.5 mm23. The facial vein measured 3.3 mm at the mandibular border, slightly larger than CTA-based facial vein averages (2.42 ± 0.58 mm)24. The measured diameter of the internal jugular vein was 8.1 mm, which falls within the range of 2.5-9.0 mm which has been previously reported (mean 6.2 ± 1.81 mm)25. The diameter obtained of the external jugular vein was 6.7 mm, which is smaller than the average diameter reported of 9.3 mm. Neural structures were also slightly smaller than published averages (facial nerve trunk 1.6 mm vs 2.66 ± 0.55 mm; infraorbital nerve 2.4 mm vs 3.31 ± 0.68 mm), although differences likely relate to level and measurement technique26,27,28.

The graph demonstrates the mean lengths of the vascular and nerve structures in our cadaveric dissection in comparison with averages in the literature.

Figure 7: Comparison of cadaveric vessel and nerve diameters with published averages. Bars represent mean diameters (mm); error bars indicate standard deviation from literature values. Cadaveric measures are shown in blue, literature values in purple. Please click here to view a larger version of this figure.

Face allotransplantation has become a milestone in reconstructive surgery, offering a unique solution for patients with otherwise unsalvageable facial defects⁴. Our harvested bipedicle graft included the skin, the eyelids, and the nose, together with the facial, supraorbital, infraorbital, and mental nerves. Both external carotid arteries should be isolated at their origins. In terms of neural structures, the main branches of the trigeminal nerve (supraorbital, infraorbital, and mental) should be consistently identified bilaterally, as well as the branches of the facial nerve within the graft. To minimize vascular injury, especially in the inferior portion of the flap, the dissection should be carried out as close as possible to the mandibular border.

Multiple strategies have been described for facial allograft procurement. The current technique enables harvest of the entire facial skin envelope, excluding the scalp, based on various published studies^6,12,14. However, variations may exist depending on coverage requirements. For example, the scalp can be harvested, including the posterior auricular and occipital arteries²⁹. Supraorbital and infraorbital neurovascular bundle lengths can be extended by osteotomies of the cranial/orbital bone (require osteotomizing the supraorbital notch, the infraorbital rim and infraorbital groove)³⁰.

The facial trunk can also be reached through different approaches³¹. While this technique focused on a proximal retroauricular facial nerve dissection, some technique focuses on the neurorrhaphy at the level of distal facial nerve branches. Proximal coaptations of the facial nerve, performed near the main trunk, may result in unpredictable reinnervation and synkinesis. Distal neurorrhaphy, closer to the peripheral branches within the parotid gland, can allow for faster and more selective reinnervation of the facial mimetic muscles, although it carries a higher risk of synkinesis. In contrast, proximal repairs offer more reliable anatomical landmarks and may reduce the risk of incomplete palsy. Clinical outcomes have reflected these trade-offs: distal approaches may lead to earlier recovery of movement but with a higher likelihood of synkinesis, whereas proximal approaches tend to provide more stable, long-term function^14,29,31. Thus, nerve harvesting strategy should be individualized, balancing targeted reinnervation against the risk of synkinesis.

A characteristic of this protocol is the absence of bony harvest, except for the nasal framework. Bone support can, however, help maintain the shape of the transplant. Also, the inclusion of bony components via osteotomies can further increase the length of the nerve structure³⁰. This limitation can be countered by the fact that sensory restoration may also be retrieved without the coaptation of these nerves³². Osteotomies of the maxilla, mandible, or zygomatic complex allow for preservation of ligamentous and muscular attachments, providing structural support, maintaining proper anatomical relationships, and optimizing both function and aesthetics³³. Across studies and procedures reported in the literature, the inclusion of bony structures has been inconsistent⁴. The decision to incorporate bone should be guided by the recipient's specific needs, as it can provide critical structural support and help preserve facial contours. This protocol, which involves only a limited bony harvest (restricted to the nasal framework), is particularly suited as a pedagogical article, as it facilitates standardization, reduces procedural complexity, and provides an efficient platform for both surgical training and preclinical research.

Cadaveric rehearsals provide opportunities for surgical refinement through repetition, objective outcome assessment, and high-fidelity simulation^6,34,35,36. This protocol illustrates the procurement of a full soft tissue face allograft; however, in clinical practice, each protocol must be tailored to the specific recipient following preparatory sessions in the anatomy laboratory. Moreover, a comprehensive evaluation of the recipient's defect and dedicated training in the selected surgical approach remain essential steps that extend beyond the scope of this protocol.

Clinical experience has demonstrated that full-face reperfusion can be achieved through a single facial artery, with exclusion of the parotid glands and distal coaptation of the facial nerve branches to minimize salivary complications³⁷. In contrast, this cadaveric protocol includes the parotid glands to simplify the dissection and avoid the need for delicate facial nerve isolation, which would be unnecessarily time-consuming and carry a higher risk of nerve damage in a research or training setting. In clinical face transplantation, the parotid glands are routinely excluded from the graft to prevent postoperative salivary complications such as sialocele or salivary fistula. Inclusion of parotid tissue carries a risk of persistent salivary leakage, infection, and delayed healing, particularly if the Stensen duct or gland capsule is violated during inset, and can result in unaesthetic fullness of the cheeks ^38,39. Moreover, excluding the parotid facilitates distal coaptation of the facial nerve branches and reduces the risk of traction or injury to the main nerve trunk during inset. Similarly, the submandibular glands are systematically excluded to prevent postoperative salivary collections and infection, as inclusion has been associated with a higher risk of sialocele and excessive bulk formation²¹. This protocol also uses bilateral external carotid artery pedicles to facilitate exposure, improve reproducibility during dissection, and save time when the model is intended for research purposes only. This design improves visualization of both vascular axes and ensures complete harvest of the soft-tissue envelope, which is valuable for anatomical teaching and surgical training. However, this divergence from current clinical practice should be acknowledged, and the decision to train on a dual-pedicle model should be understood as a didactic simplification rather than a clinical recommendation.

Although a mock revascularization or perfusion simulation was not performed in this study, it represents a valuable next step for functional validation of the harvested allograft⁴⁰. Future studies could incorporate perfusion tests or pulsatile reperfusion models, which allows simulation of near-physiologic arterial pulsation and venous drainage in perfused human cadavers. This approach would provide an opportunity to assess real-time graft perfusion, venous outflow, and the functional patency of vascular pedicles before transplantation. The integration of such dynamic reperfusion models could also enhance surgical training and improve understanding of vascular territories in complex facial allografts⁴¹.

Additionally, this protocol has inherent limitations related to its cadaveric nature. Even when latex or contrast perfusion is used to mimic more realistic conditions, it only provides a static visualization of the vascular network and does not reproduce dynamic flow, collateral circulation, or the physiologic responses of living tissue⁴². Consequently, the number of pedicles required or their perfusion dominance cannot be directly extrapolated to clinical transplantation. Similarly, nerve dissection and coaptation in cadavers do not reproduce synkinesis or functional recovery, and anthropometric discrepancies between specimens limit direct donor-recipient comparison. Therefore, pedicle selection and tissue inclusion should always be guided by intraoperative findings and outcomes in living donors. Additionally, certain steps, such as transection of the external auditory canal or inclusion of the parotid glands, represent cadaveric simplifications intended to facilitate exposure and dissection efficiency. In clinical practice, the auditory canal is preserved, and the parotid glands are excluded from the graft to minimize salivary complications and improve aesthetic outcomes.

Beyond the technical and anatomical aspects, donor face restoration represents a critical ethical component of facial allotransplantation. Proper restoration of the donor's facial appearance is a legal and moral obligation in many countries and plays a key role in maintaining public trust and supporting family consent for donation. Techniques such as rapid alginate molding followed by the production of a resin mask can restore the donor's integrity within 30 min without delaying organ procurement. This approach provides highly satisfactory morphologic outcomes and positive feedback from donor families, reinforcing the importance of respectful donor management⁴³.

This protocol provides a comprehensive and reproducible platform for harvesting the full soft tissue facial allograft suitable for further research, including studies on preservation strategies if applied on a brain-dead donor^44,45,46 and tissue engineering approaches, such as decellularization/recellularization techniques^40,47.