*Purpose: Facial vascularized composite allotransplantation (VCA) has emerged as a groundbreaking reconstructive solution for patients with severely disfiguring facial injuries. It allows simultaneous “like with like” restoration of both aesthetic and functional deficits in a single-stage procedure with superior results. We report on the 1st Canadian and 42nd worldwide face transplant performed in Montreal in May 2018.

*Methods: A 64-year-old male sustained a gunshot wound in 2011. The injury involved the lower two-thirds of the face and resulted in extensive midface bony and soft tissue damage. Three years of planning and numerous cadaveric dissections preceded the operation. The allograft was procured from a beating-heart donor with similar blood type and partial match in HLA. The transplant consisted of Le Fort III and BSSO osteotomies and skin from the lower 2/3 of the face and neck. Virtual surgical planning was used to fabricate osteotomy guides and stereolithographic models. Microvascular, facial nerve (3 branches) and infraorbital nerve anastomoses were performed bilaterally. Immunosuppression protocol was initiated during procurement and consisted of thymoglobulin, tacrolimus, mycophenolate and solumedrol. Maintenance consisted of tacrolimus, mycophenolate and prednisone.

*Results: At 6-month follow-up, the aesthetic outcome is excellent. Partial restoration of light touch sensation has been observed over the majority of graft. Electromyography has confirmed muscle activity in the facial musculature bilaterally and the patient is able to produce mild spontaneous smile. Although significantly affected, speech, mastication and deglutition are continuously improving with intensive daily therapy. Despite these limitations, the patient reports high satisfaction with the procedure and has reintegrated in the community. Post-operative complications were mainly infectious, including mucormycosis of the left thigh, treated with surgical resection and anti-fungal therapy. Two Grade I episodes of acute rejection successfully treated with solumedrol.

*Conclusions: At 6 months follow-up, we report an overall good functional outcome in Canada’s 1st and world’s oldest face transplant recipient to date. Physical condition and mental readiness are more important factors than age alone. Meticulous planning, a multi-disciplinary approach and use of technology is paramount to the success of this procedure. Continuous long-term follow-up is mandatory for surveillance of immunosuppression-related complications and functional assessment of the graft.

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