Bedside preparation on preoperative day 1 decreased general anesthesia time, alleviated time burden to the operative teams and spared OR resources. Unlike smaller facial segments, full face VCA procurement including oromandibular segment is challenging without a tracheostomy. Tracheostomy did not interfere with lung procurement despite published concerns , and can be performed at the bedside along with facial mask impression [6, 9, 10].
Intraoperatively, isolation of the facial VCA vascular pedicle initially increases safety in case of donor instability. Vessels can then be rapidly cannulated for cold perfusion without resorting to time–consuming and potentially compromising emergency thoracic vascular access .
Early concerns surfaced regarding concurrent procurement [11, 12], with newer protocols describing procurement after cardiac death  and simultaneous procurement with approximately half the dissection under cold perfusion after cardiac death . These approaches would produce unacceptable cold ischemia times for complex full face allografts. Most facial VCA recoveries have been performed “face–first” .
The ischemia time tolerated by facial allografts is unknown, with concerns over muscular components  and relationship of ischemic times with rejection . Extrapolating from free tissue transfer and hand transplantation, ischemia times under 4 h should be well–tolerated [1, 16, 17]. Our approach minimizes facial VCA ischemic time while prioritizing the integrity of life–saving visceral organs.
The temporal–logistical imperatives of organ procurement are largely new to plastic surgery. While solid organ teams are accustomed to tightly choreographed recovery procedures, the typical plastic surgery scenario of free flap harvest usually occurs in relative isolation in a stable patient and does not demand extensive coordination with other teams.
In Figure 3, we propose an algorithm that coordinates the recipient room, facial procurement, and solid organ procurement teams. The solid organ teams remain on standby in–house and ideally scrubbed during any phase with elevated risk of blood loss.
Figure 3. Proposed algorithm for “face first, concurrent completion” total face and solid organ procurement. *Physiological threshold may be any set of prearranged parameters, including blood loss, coagulopathy, urine output, pressor requirements, blood product requirements, acidemia, etc.
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Hemodynamic deterioration can occur rapidly in a donor. It may therefore be helpful to establish access to thoracic and abdominal structures against the contingency of recipient instability requiring immediate aortic cross–clamping and procurement. Here, we discuss three possible approaches to timing thoracoabdominal incision.
First, dissection may begin prophylactically before high–risk facial dissection. While it saves minutes in the event of emergency, this approach may increase donor hypothermia, blood loss, and inflammatory mediators . It may be best in predictably high–risk cases such as extensive midfacial osteotomies or donors with renal, cardiac or hemostatic dysfunction.
Second, dissection may be triggered by a physiological indicators previously agreed on by surgical and anesthesia teams. This provision preempts serious donor deterioration without early thoracoabdominal incision.
The third option delays thoracic and abdominal incision until 60 min before anticipated facial segment explantation. This approach may be preferred in a lower–risk facial dissection comprising mostly soft tissue, or by solid organ teams that do not require extensive lead time or donor preparation.
Thoracic and abdominal teams may face different time requirements and may prefer to set their own thresholds for beginning their dissection. Cardiac surgeons may feel that saving minutes in preliminary dissection does not justify an open chest, given that thoracic recovery demands less time than abdominal organs. Meanwhile, abdominal surgeons may be able to isolate key abdominal vessels with minimal morbidity and significant time savings. Naturally, all three approaches describe preemptive dissection and would be superseded in the event of acute hemodynamic instability.
In our case, preemptive abdominal and thoracic dissection was begun empirically based on the potential for bleeding during midfacial osteotomies. This team decision reflected heightened caution toward an unfamiliar and high–profile procedure. Early preparation of solid organ recipients due to optimistic donor operation times estimates resulted in brief ischemic time and uneventful procurement, although more accurate timing could have decreased delays and the accompanying risk. The most prudent approach may be to delay thoracoabdominal dissection either until 60 min before facial vessel division or until a physiological threshold is met. Solid organ recipients do not require preparation before procurement of their respective organs.
Finally, the concurrent donor and recipient start forced donor surgeons to wait to avoid prolonged cold ischemia. The resulting donor room standby increased potential for complications. Beginning the recipient operation several hours before the donor (but not proceeding beyond a “point of no return” such as neurotomy, pedicle ligation, or complete hard/soft tissue removal) may avoid unnecessary prolongation of the donor operation. This also reduces unnecessary facial ischemia time if expedited explantation becomes necessary.
Our algorithm does not address simultaneous extremity transplant, outside institution procurement teams or outside institution donors. Although we do not have experience in extremity procurement, we suggest that it is compatible with our algorithm, especially if completed before face procurement begins. The algorithm also does not exclude outside institution solid organ teams, although they face the inconvenience of remaining available outside their institution for prolonged periods. Procurement at outside institutions remains challenging. Although published protocols allow for outside institution procurement , we currently consider the logistical demands too complex for a “face–first, concurrent completion” approach. To our knowledge, no full–facial osteomyocutaneous VCAs have been procured at outside institutions simultaneously with solid organs.