Face Transplantation

Face Transplantation

First partial transplant: France, Nov 2005, reported 2007Subsequent face grafts: China 2006, France 2007; little information available.First in US: Nov 2008, most complicated yet.

Ethical IssuesPrimum non nocereAny procedure, especially new procedures: risks vs.

benefitsFace transplant different than others: the risk-benefit

calculation is more complicated.What if the graft is rejected? Could be worse off.Is it “just cosmetic surgery”?Social consequences of regaining a face include ability

to speak, eat, express emotion.Would you be an organ donor? A face donor? Would

you allow your loved one’s face to be transplanted?Health care resource allocation

First Partial Face Transplant: Background

38 y.o. female badly bitten by dog, resulting in amputation of distal nose, upper and lower lips, entire chin, and adjacent parts of right and left cheeks. Face graft performed 6 mos. post injury (Nov. 2005, in France). Donor (brain-dead 46-year-old woman) and recipient had same blood group (O+) and shared five HLA antigens (out of 6 possible).

Dubernard et al. (2007), NEJM 357: 2451-2460.

Methods

“The figure shows vascular anastomoses of the bilateral facial arteries (red) and veins (blue); sutures of the sensory maxillary (V2) and mandibular (V3) nerves (yellow) and the inferior branch of the left facial motor nerve (green cross); and musculomuscular sutures on the levator and zygomatic muscles.”

Dubernard et al. (2007), NEJM 357: 2451-2460.

Methods

Immunosuppression and infection prevention and control:Various drugs used. Hematopoetic stem cells (bone marrow cells) harvested from donor before transplant and infused into recipient on postop days 4 and 11. Tacrolimus was an immunosuppressive drug initially, changed to sirolimus (also used in drug-eluting stents) at 14 months due to reduced renal function, which has since recovered. Rejection episodes at 18 days and 9 months (characterized by erythema and edema of the graft) were managed. Extracorporeal photochemotherapy (exposure of white blood cells to a photosensitizing agent and UV light, an established procedure for managing graft rejection) has been used prophylactically since month 10. No graft vs. host disease.

Physical therapy: Twice daily for first 4 months; once daily thereafter. Training in

passive and active facial exercises, focused on restoring lip movement and mouth occlusion.

Psychological support: Once daily for first 4 weeks; twice weekly for next 4 months; once a month or at patient's request since then.

Results

Recovery of sensation with time.A.TouchB.Heat & cold

Sensory function recovered faster than motor.

Dubernard et al. (2007), NEJM 357: 2451-2460.

Results

Recovery of lip occlusion. A.PassiveB.Active

Asymmetry in active closure (arrows) due to initial wound asymmetry.

Dubernard et al. (2007), NEJM 357: 2451-2460.

Dubernard et al. (2007), NEJM 357: 2451-2460.

Results: Aesthetic and Psychological

A. Pre-injury. B. 1 yr post-op with makeup. C. 18 mos. post-op, no makeup.

“By the end of the 12th postoperative week, the patient was capable of facing the outside world and gradually resumed a normal social life. The progressive return of expressiveness correlated well with psychological acceptance of the foreign graft. At present, the patient says she is not afraid of walking in the street or meeting people at a party, and she is very satisfied with the aesthetic and functional results.”

First Partial Face Transplant: Conclusion

“In this patient who underwent the first partial face transplantation, the functional and aesthetic results 18

months after transplantation are satisfactory.”Dubernard et al. (2007), NEJM 357: 2451-2460.

First U.S. Face TransplantNov 2008, reported Dec 2008 but few detailsMore complicated than previous transplants: more tissue and types of tissue transplanted: skin, nerves, muscles, arteries, veins, bones.Patient: female, unable to eat, one eye lost, other functions poorly, required tracheostomy tube to breathe. Lacked nose, palate, underlying bones.

First U.S. Face TransplantAbout 80% of face (500 cm2 tissue) transplanted.Lower eyelids, nose, nasal sinuses, cheeks back to the ears, upper lip, upper jaw, teeth.

Bones (probably): Maxillae, nasals, zygomatics, parts of temporals, ramus of mandible, maybe lacrimals.

NervesFacial (VII): motor to muscles of facial expression (five branches)Trigeminal, mandibular div. (V3): motor to muscles of mastication

Trigeminal (V1, V2, V3): sensory to face

Arteries & VeinsExternal carotid a. and its branches: facial, maxillary aa. (superficial & deep facial structures, respectively); zygomatico-orbital a. External jugular v. and its tributaries: facial v. and its branches.

First U.S. Face TransplantHarvesting: 9+ hours, careful to preserve vessels & nerves for attachment

Simultaneously: remove scar tissue from donor to make a space

Then: attach major vessels, 3 hours. Transplant turns pink – it is not being rejected!

Continue: 9+ hours attaching bone, nerves, muscles, small vessels, skin. Total: 22 hours.

Animation: http://www.clevelandclinic.org/lp/face_transplant/video/transplant_flash.swf

Dr. Risal Djohan, Dr. Maria Seimeionow (team leader), Dr. Daniel Alam. Source: www.clevelandclinic.org

Dr. Robert Lohman, Dr. Daniel Alam. Source: www.clevelandclinic.org