Face transplant

Face transplant
Intervention
MeSH	D054445

A face transplant is a medical procedure to replace all or part of a person's face. The world's first partial face transplant on a living human was carried out in France in 2005. The world's first full face transplant was completed in Spain in 2010.

Beneficiaries of face transplant

People with faces disfigured by trauma, burns, disease, or birth defects might aesthetically benefit from the procedure. Professor Peter Butler at the Royal Free Hospital first suggested this approach in treating people with facial disfigurement in a Lancet Article in 2002. This suggestion caused considerable debate around the ethics of this procedure at that time.

The alternative to a face transplant is to move the patient's own skin from their back, buttocks or thighs to their face in a series of as many as 50 operations to regain even limited function and a face that is often likened to a mask or a living quilt.

L. Scott Levin MD FACS, Chair, Department of Orthopaedic Surgery at University of Pennsylvania School of Medicine, has described the procedure as "the single most important area of reconstructive research."

History

Self as donor ("face replant")

The world's first full-face replant operation was on nine-year-old Sandeep Kaur, whose face was ripped off when her hair was caught in a thresher. Sandeep's mother witnessed the accident. Sandeep arrived at the hospital unconscious with her face in two pieces in a plastic bag. An article in The Guardian recounts: "In 1994, a nine-year-old child in northern India lost her face and scalp in a threshing machine accident. Her parents raced to the hospital with her face in a plastic bag and a surgeon managed to reconnect the arteries and replant the skin." The operation was successful, although the child was left with some muscle damage as well as scarring around the perimeter where the facial skin was sutured back on. Sandeep's doctor was Abraham Thomas, one of India's top microsurgeons. In 2004, Sandeep was training to be a nurse.

In 1996, a similar operation was performed in the Australian state of Victoria, when a woman's face and scalp, torn off in a similar accident, was packed in ice and successfully reattached.

Partial face transplant

The world's first partial face transplant on a living human was carried out on 27 November 2005 by Bernard Devauchelle, an oral and maxillofacial surgeon, and Jean-Michel Dubernard in Amiens, France. Isabelle Dinoire underwent surgery to replace her original face, which had been mauled by her black Labrador dog. A triangle of face tissue from a brain-dead human's nose and mouth was grafted onto the patient. On 13 December 2007, the first detailed report of the progress of this transplant after 18 months was released in the New England Journal of Medicine and documents that the patient was happy with the results but also that the journey has been very difficult, especially with respect to her immune system's response.

In April 2006, Dr Guo Shuzhong at the Xijing military hospital in Xian, China similarly transplanted the cheek, upper lip, and nose of Li Guoxing, who was mauled by an Asiatic black bear while protecting his sheep. On 21 December 2008 it was reported that Li had died in July in his home village in Yunnan. Prior to his death, a documentary on the Discovery Channel showed he had stopped taking immuno-suppressant drugs in favor of herbal medication – suggested by his surgeon to be a contributing factor to his death.

A 29-year-old French man underwent surgery in 2007. He had a facial tumor called a neurofibroma caused by a genetic disorder. The tumor was so massive that the man could not eat or speak properly.

In March 2008, the treatment of 30-year-old neurofibromatosis victim Pascal Coler of France ended after he received what his doctors call the world's first successful almost full face transplant.

Turkey's third face transplant was a partial one that was carried out on 17 March 2012 on Hatice Nergis, a twenty-year old woman, at Gazi University's hospital in Ankara by a team led by surgeon Dr. Selahattin Özmen. The patient from Kahramanmaraş had lost, six years before, her upper jaw including mouth, lips, palate, teeth and nasal cavity in a firearm accident, and was unable to eat. She had in the past undergone around 35 reconstructive plastic surgery operations. The donor was a 28-year old woman in Istanbul, who committed suicide.

Full face transplant

On 20 March 2010, a team of 30 Spanish doctors carried out the first full face transplant on a man injured in a shooting accident. It became the first full face transplant in the world.

On 8 July 2010, the French media reported that a full face transplant, including tear ducts and eyelids, was carried out at the Creteil Henri-Mondor hospital.

In March 2011, a surgical team, led by MUDr. Bohdan Pomahač at Brigham and Women's Hospital in Boston, performed a full face transplant on Dallas Wiens who was badly disfigured in a power line accident that left him blind and without lips, nose or eyebrows. The patient's sight couldn't be recovered but he has been able to talk on the phone and smell.

On 19 March 2012, one of the longest and most extensive facial transplants ever (36 hours, from 4 am 19 March to 2–3 PM 20 March; the 23rd ever to occur; from the hairline to the neck, replacing essentially everything but the eyes and the back remnants of the throat) took place on a Richard Lee Norris of Hillsville, Virginia, who had suffered a gunshot wound in 1997 that left him with extensive facial trauma, at the R Adams Cowley Shock Trauma Center at the University of Maryland Medical Center in Baltimore, Maryland. Seven months after the procedure, Norris exhibits remarkable progress. Norris can smile and show facial expressions, and also smell, taste and eat. The motor function on the right side of his face is about 80 percent of normal and motor function on the left side is about 40 percent, according to his doctors.

In Turkey

On 21 January 2012, Turkish surgeon Dr. Ömer Özkan and his team successfully performed a full face transplant at Akdeniz University's hospital in Antalya. The 19-year-old patient, Uğur Acar's face was badly burnt in a house fire when he was a baby. The donor was 39-year-old Ahmet Kaya, who died on 20 January. The Turkish doctors declared that his body had accepted the new tissue.

Almost one month later on 24 February 2012, a surgical team led by Dr. Serdar Nasır conducted the country's second successful full face transplant at Hacettepe University's hospital in Ankara on 25-year-old Cengiz Gül. The patient's face was badly burned in a television tube implosion accident when he was two years old. The donor was 40-year-old N. A. (his family did not allow revealing of his identity), who experienced brain death two days before the surgery following a motorcycle accident occurred on 17 February.

On 16 May 2012, surgeon Dr. Ömer Özkan and his team at the Akdeniz University Hospital performed country's third and their second full face transplant, fourth face transpant in Turkey at all. The face and ears of the 27-year old patient Turan Çolak from Izmir were burnt as he fell into an oven when he was three and half years old. The donor was Tevfik Yılmaz, a 19-year young man from Uşak, who had attempted suicide on 8 May. He was declared brain dead in the evening hours of 15 May after having been in intensive care station for seven days. His parents donated all his organs.

In the United Kingdom

In October 2006, surgeon Peter Butler at London's Royal Free Hospital in the UK was given permission by the NHS ethics board to carry out the face transplant. His team will select four adult patients (children cannot be selected due to concerns over consent), with operations being carried out at six-month intervals.

In the United States

In 2004, the Cleveland Clinic in Ohio, United States, became the first institution to approve this surgery and test it on cadavers.

In 2005, the Cleveland Clinic became the first US hospital to approve the procedure. In December 2008, a team at the Cleveland Clinic, led by Dr Maria Siemionow and including a group of supporting doctors and six plastic surgeons (Dr Steven Bernard, Dr Mark Hendrickson, Dr Robert Lohman, Dr Dan Alam and Dr Francis Papay) performed the first face transplant in the US on a woman named Connie Culp. It was the world's first near-total facial transplant and the fourth known facial transplant to have been successfully performed to date. This operation was the first facial transplant known to have included bones, along with muscle, skin, blood vessels, and nerves. The woman received a nose, most of the sinuses around the nose, the upper jaw, and even some teeth from a brain-dead donor. As doctors recovered the donor's facial tissue, they paid special attention to maintaining arteries, veins, and nerves, as well as soft tissue and bony structures. The surgeons then connected facial graft vessels to the patient's blood vessels in order to restore blood circulation in the reconstructed face before connecting arteries, veins and nerves in the 22-hour procedure. She had been disfigured to the point where she could not eat or breathe on her own as a result of a traumatic injury several years ago, which had left her without a nose, right eye and upper jaw. Doctors hoped the operation would allow her to regain her sense of smell and ability to smile, and said she had a "clear understanding" of the risks involved.

The second partial face transplant in the US took place at Brigham and Women's Hospital in Boston on 9 April 2009. During a 17-hour operation, a surgical team led by MUDr. Bohdan Pomahač, replaced the nose, upper lip, cheeks, and roof of the mouth – along with corresponding muscles, bones and nerves – of James Maki, age 59. Mr. Maki's face was severely injured after falling onto the electrified third rail at a Boston subway station in 2005. In May 2009, he made a public media appearance and declared he was happy with the result. This procedure was also shown in the eighth episode of the ABC documentary series Boston Med.

The first full face transplant performed in the US was done on a construction worker named Dallas Wiens in March 2011. He was burned in an electrical accident in 2008. This operation, performed by Dr. Bohdan Pomahač and Dr. Jeffrey Janis, was paid for with the help of the US defense department. They hope to learn from this procedure and use what they learn to help soldiers suffering from facial injuries. One of the top benefits of the surgery was that Dallas has regained his sense of smell.

57-year old Charla Nash, who was mauled by a chimpanzee in 2009, underwent a 20-hour full face transplant in May 2011 at Brigham and Women's Hospital in Boston. Nash's full face transplant was the third surgery of its kind performed in the United States, all at the same hospital.

In March 2012, a face transplant was completed at the University of Maryland Medical Center and R Adams Cowley Shock Trauma Center under the leadership of plastic surgeon Eduardo Rodriguez, DDS, MD and his team (Amir Dorafshar MBChB, Michael Christy MD, Branko Bojovic MD, Daniel Borsuk MD). The recipient was a 37-year old man who had suffered a facial ballistic injury in 1997. This transplant represents the most extensive to date, and included all facial and anterior neck skin, both jaws, and the tongue.

Ethics, Surgery and Post-Operation treatment

The procedure consists of a series of operations requiring rotating teams of specialists. With issues of tissue type, age, sex, and skin color taken into consideration, the patient's face is removed and replaced (sometimes including the underlying fat, nerves, blood vessels, bones, and/or musculature). The surgery may last anywhere from 8 to 15 hours, followed by a 10–14-day hospital stay.

There has been a substantial amount of ethical debate surrounding the operation and its performance. The main issue is that, as noted below, the procedure entails submitting otherwise physically healthy people to potentially fatal, life long immunosuppressant therapy. So far, two people have died of complications related to the procedure. Citing the comments of various plastic surgeons and medical professionals from France and Mexico, anthropologist Samuel Taylor-Alexander suggests that the operation has been infused nationalist import, which is ultimately influencing the decision making and ethical judgements of the involved parties.

After the procedure a lifelong regimen of immunosuppressive drugs is necessary to suppress the patient's own immune systems and prevent rejection. Long-term immunosuppression increases the risk of developing life-threatening infections, kidney damage, and cancer. The surgery may result in complications such as infections that could turn the new face black and require a second transplant or reconstruction with skin grafts.

Popular culture

• The procedure was very grotesquely, yet somewhat accurately, highlighted in Georges Franju's 1960 cult horror film Les Yeux sans visage, which translates to "Eyes Without a Face."
• Kōbō Abe, Japanese author and playwright, wrote The Face of Another (1964) about a plastics scientist who loses his face in an accident and proceeds to construct a new face for himself. With a new face, the protagonist sees the world in a new way and even goes so far as to have a clandestine "affair" with his estranged wife. This novel was made into a film of the same name by Hiroshi Teshigahara in 1966.
• The plot of the 1997 film Face/Off is based on a face transplant operation that involved changing the underlying structure and actual face shape. In the film, the transplant is shown to be reversible, with the patient being able to replace his original face if desired.
• An episode of The Simpsons, The Bob Next Door, features Sideshow Bob using face transplants to exchange his face with a cellmate as part of an elaborate prison escape plan so he can murder Bart.
• The procedure is included in the eighteenth episode of fifth season of Grey's Anatomy, titled Stand By Me.
• Episode 9 of Season 3 of Nip/Tuck includes the procedure.
• In the 30 Rock episode Somebody to Love Jack's girlfriend Celeste receives a face transplant after she was attacked by her neighbor's dog.
• There are advertisement posters in Repo! The Genetic Opera that display "Replace Your Face, Coming in 2057", that promote cosmetic face transplants.

External links

• Face Transplant Surgery at Brigham and Women's Hospital
• University of Louisville Plastic Surgery Research
• BBC News – Q&A: First face transplant
• Research Ethics Blog – Facial Transplantation
• Saving Faces: The Facial Surgery Research Foundation
• CTV News – Face transplant woman goes public for first time
• UK Face Transplant Information Website
• Face transplants inch toward reality
• New York Times
• Cleveland Clinic Face Transplant Video and Surgery Fact Sheet
• Dallas Wiens Home Page
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