Cytomegalovirus and other infectious issues related to face transplantation: Specific considerations, lessons learned, and future recommendations

Background: Composite tissue allotransplantation is fraught with complexities similar to those of solid organ transplantation, including donor-related cytomegalovirus transmission. With this in mind, the authors' objective was to (1) report their team's experience with infections and donor-related cytomegalovirus transmission in relation to face transplantation and (2) review the facial composite tissue allotransplantation literature as it pertains to cytomegalovirus and other various infections. Methods: A MEDLINE literature search and article review was performed in July of 2010 on all published articles specific to face transplantation, cytomegalovirus disease, and all related infections and/or complications. In addition, the authors retrospectively reviewed their own institution's experience with face transplantation. Results: Two of the world's first four face transplant recipients acquired cytomegalovirus viral infection by means of their donated facial organs. Also, the French experience, and our own, has been challenged by cytomegalovirus reactivation and graft rejection, therefore necessitating a critical evaluation. The authors have also learned, from their own experience, that facial composite tissue allografts containing mucosa and paranasal sinuses present a distinct challenge with regard to their accompanying flora. Conclusions: Although the risk of donor-derived cytomegalovirus is acceptable in life-saving solid organ transplantation, for face transplantation patients, the scenario is different. When the authors' team performed the first nearly total face/maxilla transplantation (December of 2008), there was little known regarding the consequences of cytomegalovirus-related donor transmission in face transplantation. Therefore, the authors now recommend that all candidates be fully informed as to the risks of cytomegalovirus/infectious transmission and that aggressive viral, bacterial, and fungal prophylaxis be instituted.