Facing the Future of Face Transplants

Published - Written by Rena Xu

There were many reasons to believe that face transplants wouldn’t work.  The blood supply was too complex.  The nerves were too difficult to rewire.  The body’s immune system would reject a face it didn’t recognize as its own.

But at least eighteen face transplants have now been performed world wide, with apparently encouraging results.  And in recent years, full-face transplants – complicated transplants involving the forehead, eyelids, nose, lips, chin, and cheeks – have proven to be feasible.  In 2010, a team of surgeons led by Dr. Laurent Lantieri at the Henri Mondor Hospital near Paris successfully performed what many consider the first full-face transplant.  Since then, surgeons at the Brigham and Women’s Hospital have performed three full-face transplants successfully; details of these cases were published in a recent article in NEJM.

Why do a full-face transplant? The story begins with horrifying accidents that essentially ablated the faces of the three patients.  Two of the patients suffered severe electrical burns; the third was the victim of an animal attack.  All three lost major facial structures: eyes, nose, cheeks, lips.  They couldn’t breathe through the nose or close the mouth; all three had impaired speech.

To prepare for each operation, the New England Organ Bank identified and obtained consent from next of kin for facial donation from a family member who had suffered irreversible brain damage and had already been declared brain dead.  Donation of organs from deceased donors is not new, but the donation of the complex tissue that constitutes a face is novel and fraught with many concerns, both for the recipient and for the donor’s family.  For the patient, the match needs to be compatible both immunologically and cosmetically.  Thus, a “good match” means that the donor is of the same gender and skin color as the patient and also meets a number of clinical criteria, including a negative cross-match for antibodies that might trigger graft rejection.

For the donor’s family, it is crucial to take special care of the psychological aspects of this special donation and to involve ethicists.  Because the face is the body part most closely tied to a person’s identity, donating the face of a deceased loved one carries unique emotional burdens.  It can be challenging to comprehend and prepare for the full range of possible outcomes, from transplant failure to the transformation of the face into a new identity unrecognizable to the donor’s family.

Once a match is made between a donor and the patient, the surgeons must recover the necessary tissue; this involves obtaining not only the face and underlying structures, but also additional tissue, from the donor.  In the cases reported, one team took charge of obtaining the facial graft, taking care to preserve the major nerves, arteries, and veins of the face.  Another team was charged with obtaining a sentinel flap of tissue from the donor’s arm; this would serve as a “test canary” of sorts, as it could be sampled easily to warn of impending graft rejection.

At the same time, a third team of surgeons worked on preparing the recipient’s face to receive the graft by removing the skin, contouring remaining facial tissue that would lie underneath the graft, and identifying any of the patients remaining intact facial vessels and nerves.  The donor facial graft was then transplanted, connecting vessels and nerves.  The sentinel flap was transplanted to an inconspicuous area on the patient’s body.

After surgery, all three patients were placed on immunosuppressive agents and prophylactic antibiotics.  Periodic biopsies of the grafts were taken to test for rejection.  Two patients had single episodes of rejection that were managed successfully.  All three patients regained facial sensation; two had regained facial movement at the time of the report.  In all three, facial aesthetics were substantially restored.  There was consensus among the surgeons and the donors’ families that the patients did not resemble the donors.

While these near-term follow-up data are encouraging, it remains to be seen how the long-term outcomes of face transplants compare to those of more conventional reconstructive surgery approaches.  It also remains unclear how complete transplant rejection, if it occurs, should be handled.  A patients’ guide to face transplants published by the surgeons notes, “If the facial transplant is completely rejected by the patient’s immune system, the transplanted tissues will, unfortunately, have to be removed…. In that case, different treatment options will have to be discussed with our surgical team. Options include conventional reconstructive facial surgery according to an already prepared plan or another facial transplant at a later time.”  Even if additional surgery manages to limit the medical complications of transplant rejection, however, the associated psychological damage and ethical dilemmas will likely prove exquisitely difficult to address.

For now, the notion that undertakings as complicated as full-face transplantation are possible with the use of a consistent protocol is cause for excitement as well as reflection.  If a procedure that to date has remained a relative novelty becomes increasingly reproducible in the years to come, then the place of face transplants in the medical armamentarium  — and in society at large – may also need to evolve.  Who should qualify or not qualify for a face transplant?  What will be the ethical, social, and financial implications?  As surgical techniques evolve, as protocols are refined, and as outcomes improve, it will be increasingly important to face these, and many more, difficult questions.