Two Cases of Facial Transplantation Shown Useful for Severe Disfigurement
Facial transplantation can be a useful treatment for severe disfigurement, although it is not without risks, according to two case reports involving facial damage caused by a bear attack and by growth of a rare aggressive tumor. Both reports appear in the August 23rd issue of The Lancet.
In the first report, Dr. Shuzhong Guo and colleagues from the Fourth Military Medical University in Xian, China, describe the 2-year outcomes of a 30-year-old man on whom they performed a partial facial allotransplantation in 2006.
In October 2004, the man was attacked by a bear, causing severe damage to the right side of his face. Debridement and wound repair with a forearm pedicle flap was performed at the time, but the injury did not heal. The patient presented to the authors' center in March 2006 for evaluation and further treatment.
The transplantation, which was performed in April 2006, involved anastomoses of the right mandibular artery, anterior facial vein, and facial nerve as well as whole repair of the nose, upper lip, parotid gland, zygomatic bone, frontal wall of the maxillary sinus, and part of the infraorbital wall. The graft came from a 25-year-old man who had died in a car accident.
The subject's immunomodulatory regimen included tacrolimus, mycophenolate mofetil, corticosteroids, and humanized IL-2 receptor monoclonal antibody.
Good survival of the tissue flap was seen, although acute rejection episodes occurred at 3, 5, and 17 months following surgery. All of these episodes were effectively controlled with adjustments in the immunomodulatory regimen. The patient had no impairments in renal or hepatic function and no infections arose.
Hyperglycemia occurred soon after surgery and then reappeared 3 months later. After being effectively treated with insulin therapy, the patient successfully switched to oral agents.
Although the facial nerve was not fully functional, the patient was able to speak, eat, and drink normally, the report indicates.
The second report describes the 1-year results of a 29-year-old man who underwent facial transplantation for damage caused by massive plexiform neurofibroma. Resection of the tumor, which diffusely infiltrated the patient's middle and lower face, and composite tissue allotransplantation took place in January 2007.
According to lead author Dr. Laurent Lantieri from CHU Henri Mondor in Creteil, France, and colleagues, the main goal of the operation was to restore the cutaneous appearance and function of the face, with a particular focus on contraction of the orbicularis oculi and oris muscles. The graft came from a brain-dead, beating-heart donor.
The patient's immunosuppressive regimen included antilymphocyte serum, tacrolimus, mycophenolate mofetil, and prednisone.
Following an uneventful immediate postoperative course, the patient experienced rejection episodes 28 and 64 days after surgery, the latter of which was complicated by cytomegalovirus infection. Both episodes, however, resolved without any further evidence of rejection and the patient's immunosuppressive regimen was able to be reduced.
At 1 year, the functional results were very good, the authors state, and both sensory and motor reinnervation of the graft were noted. Psychological recovery, they add, has been excellent, the patient's social life has improved, and he now holds a full-time job.
"Important contributions of the teams from Xi'an and Paris in addressing the issues of face transplantations have shown the need for progress in three directions: surgery, immunology, and psychology," French physicians comment in a related editorial.
Dr. Jean-Michel Dubernard, from University Lyon I Hospital, and Dr. Bernard Devauchelle, from Amiens-Nord University Hospital, note that cooperation among teams will be needed "to answer the many technical, functional, immunological, and psychological questions raised by face transplantation."
Truth about Facial Transplantation:
The world’s first partial facial transplantation, using facial tissue from another person, was performed in France last year. Maria Siemionow, MD, and colleagues at Cleveland Clinic in the United States received clearance to perform full facial transplantation, using facial tissue from another person, in 2004. The study published in PRS focuses on a procedure in which bone and soft tissues of the face are transplanted. The procedure is in the experimental phase and has not yet received clearance to be performed on humans.
Changing Faces believes that face transplantation may, at some time in the future after much more research, be a part of the reconstructive surgeon's repertoire. Whether or not this happens, it is vital that we continue to push for comprehensive health and social services for people with disfigurements (in which surgery is complemented by psycho-social and other interventions) and a fairer, more informed society for the 400,000 people living with disfigurements in Britain today.
Despite the excitement surrounding facial transplantation, the procedure is currently limited to treating severe skin disfigurements. Plastic surgeons are testing ways to extend facial transplantation to include not only skin and tissue, but bone as well. According to an experimental study in Plastic and Reconstructive Surgery® (PRS), the official medical journal of the American Society of Plastic Surgeons (ASPS), they may be a step closer to making the reconstructive process easier for patients with extensive skull and facial deformities.
The American Society for Reconstructive Microsurgery (ASRM) and the American Society of Plastic Surgeons (ASPS) recognize the innovative and revolutionary prospects of facial transplantation and the hope it offers to those who suffer from severe facial disfigurement for an improved quality of life. As remarkable as the potential possibilities are for facial transplant recipients, we acknowledge the controversy and the many questions associated with the procedure. The ethics of facial transplantation go beyond the life and death issues common to most transplant procedures and raise other issues that heretofore have not influenced medical decision making processes.
A face transplant first requires a donor. A donor is typically someone who has been declared brain dead but with blood still flowing to the tissue to be used. The healthy tissue is extracted from the donor. Then the traumatized tissue is removed from the patient. The healthy tissue from the donor is then surgically attached to the problem-area of the recipient patient. Face transplants may require other surgical procedures at the same time.
Speaking about the lecture Professor Rumsey said:
“While the surgical techniques are not new, the psychological effects on the recipient and their families are essentially unknown. The significance of ‘wearing’ someone else’s face may present particular challenges, including issues of identity, or feeling toward the donor.
“There is also the issue of rejection to consider. Any transplant recipient is required to take lifelong anti-rejection drugs which are known to increase the risk of cancer and significantly lower life expectancy. And, should the face be rejected, it would be unlikely that another transplant would be possible. Psychologically, this must be planned for.”
Face transplantation is still an unusual and emerging field of surgery that often conjures up images from science-fiction movies. But major advances in recent years mean the surgery is moving from the realm of novelty to a more common procedure that promises to enhance quality of life significantly for individuals with extreme deformities.
But one major obstacle threatens further developments: Few people are willing to donate their faces after they die, according to a report published today in The Lancet.
"People are still unsure about it," said Laurent Lantieri, head of the department of plastic surgery at Henri Mondor Hospital outside Paris. "People are thinking, 'Maybe I'm going to see my husband or my son or my sister walking the street after she's dead.' That's not the case."
Although still in its infancy, face transplantation has been performed by surgeons around the world on several disfigured patients. The procedure involves attaching a donor's facial tissue to reconstruct the deformities on the patient.
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