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

Our research focuses on standardizing full facial allograft procurement and identifying key anatomical landmarks to optimize safety, reproducibility, and training. Current challenges include minimizing ischemic time while achieving reproducible and safe dissections that preserve vascular and neural pedicle lengths. To begin the cervical dissection, use a number 15 scalpel blade to make a cervical incision extending from the superior border of the clavicle to the ear lobe.

Using strabismus scissors, dissect the neck area to identify the sternocleidomastoid muscle. Perform a circumferential dissection off the external jugular vein. Ligate the external jugular vein and divide it using strabismus scissors.

Next, with a Farabeuf retractor, retract the sternocleidomastoid muscle laterally to gain access to the vascular pedicles. Using strabismus scissors, dissect carefully to expose the internal jugular vein to reveal the thyrolinguofacial trunk and identify and preserve the facial vein. Dissect carefully to expose the common carotid artery to reveal the carotid bifurcation.

Using strabismus scissors, dissect the external carotid artery cranially and identify the arterial branches. Ligate and divide the superior thyroid artery, ascending pharyngeal artery, and occipital artery. Continue the dissection to ligate and divide the lingual artery.

Identify and preserve the facial branch of the external carotid artery. Now, identify and then transect the posterior belly of the digastric muscle and the stylohyoid muscle. Locate the hypoglossal nerve and section it proximally to obtain maximal length for potential nerve grafting.

Next, ligate and divide the submandibular gland, duct, and vessels, excluding the submandibular gland from the allograft. For facial nerve dissection, use a number 15 scalpel blade to perform the pretracheal incision. Using strabismus scissors, dissect a preauricular skin flap in the sub-superficial musculoaponeurotic system plane.

Transect the external auditory canal and expose the facial nerve at its origin. Then, using strabismus scissors, liberate all anterior soft tissues and block. Isolate the facial with a vessel loop and dissect the facial nerve with strabismus scissors to obtain maximal length.

To begin the coronal approach, using a number 15 scalpel blade, make a coronal incision. Elevate the scalp flap in a subperiosteal plane from posterior to anterior, until the supraorbital nerve is encountered. Using strabismus scissors, ligate the supraorbital neurovascular contents close to the bony foramen.

Divide the supraorbital contents, then ligate and divide the supratrochlear neurovascular contents close to the bony foramen. With the globe in situ, locate the levator palpebrae superioris muscle and place a marking suture using Ethilon on it. Next, proceed with periorbital dissection in the subperiosteal plane and divide the upper eyelid horizontally to preserve the orbicularis oculi within the graft.

Perform circumferential transconjunctival incisions. Now, with an osteotome, elevate the lateral canthus with a small segment of the lateral orbital rim to ensure proper canthal support within the graft. Excise the lower eyelid while preserving the conjunctiva.

Using strabismus scissors, dissect through the inferior fornix just inside the orbital rim. After identifying the infraorbital nerve, transect the infraorbital nerve near its foramen to ensure maximal nerve length for future neurorrhaphy. Employing a strabismus scissors, section the facial nerve at its exit from the stylomastoid foramen, and shave the masseter muscle to expose the mandibular surface.

Raise the flap anteriorly on top of the masseter muscle. Identify the buccal fat pad at its anterior border, and continue the anterior dissection along the buccal fat pad while leaving it in situ. After harvesting the buccal mucosa in full, extend the dissection superiorly to the orbit and continue the dissection laterally to include the zygoma.

To begin the midface osteotomies, perform a subperiosteal dissection lateral to the nose. Then, perform a low-to-low lateral nasal osteotomy, and then extend the osteotomy inferiorly to the hard palate with a curved osteotome. Next, extend the osteotomy laterally to include the zygomatic buttress.

Divide the nasal septum longitudinally. Harvest the nose together with the skin and cartilage, including aller, triangular, and most of the septum, nasal bones, and nasal mucosa. For intraoral dissection, pick up a number 10 or number 15 scalpel blade to make a circumferential intraoral incision along the gingivobuccal mucosal junction.

Then, incise the superior gingival mucosa following the maxillary dental arcade and the inferior gingival mucosa following the mandibular dental arcade. Now, incise the gingival mucosa along the mandibular line using the scalpel. After identifying the mental nerve near its mental foramen, divide it close to the foramen while preserving maximal length for potential neurorrhaphy.

Now, using strabismus scissors, divide the mental nerve close to its foramen on the contralateral side. Mobilize the cervical soft tissue planes medially and direct the tissues toward the oral cavity. Dissect in the plane above the sternohyoid and superior omohyoid muscles with or without inclusion of the anterior jugular vein.

Then, elevate the graft and block, and liberate the allograft from all remaining soft tissue attachments while preserving the bilateral vascular pedicles. Using absorbable monofilament, ligate the internal jugular veins as distally as possible. Ligate the carotid arteries as distally as possible.

Finally, detach the entire face. The donor face dissected for this study was a male measuring 1.72 meters in height with a malnourished body morphology. The facial nerve was marked with a blue suture on each side of the graft.

The internal view of the graft showed the orbital septum, superior gingival mucosa, and inferior gingival mucosa. The diameters of the harvested arteries and veins, including the facial artery, superficial temporal artery, facial vein, and internal jugular vein were generally consistent with or within the range of published literature values. The measured nerve diameters, including the facial nerve trunk and infraorbital nerve, were slightly smaller than published averages.

This protocol fills a gap by providing a visual step-by-step reference, often more effective than extensive texts for complex surgical procedures. Our protocol provides a standardized and visually guided approach that improves reproducibility, anatomical understanding, and safety compared to narrative descriptions alone. Future research will focus on dynamic perfused models, like SimLife, to evaluate graft viability, perfusion, and surgical training realism.