Face Transplant

Kate Roach

November 2006

The first partial face transplant was carried out in November 2005 in Amiens, France. In April 2006, media reports from China proclaimed the world's second face transplant. In November 2006, the UK's Royal College of Surgeons prepared the way for bioethics committees at British hospitals to grant permissions to carry out the procedure. This development has removed one of the barriers to UK facial transplant surgery. So just how far past the experimental phase is the procedure? And is current transplant technology really safe enough to give someone a new face in the long-term?

Face Transplants

For someone unable to adjust to the way they look after an awful accident or illness, face transplant surgery could be the one and only source of new hope. That said, whether the operation can really be a success is what's been at the crux of the debate in medical circles.

Peter Butler, the UK surgeon who is tipped to be the first man to transplant a face in Britain, has been cautious thus far on the basis that a failed transplant would leave patients in a far worse state than when they started out. Previous skin grafts would have been removed for the purpose of the operation, leaving nothing underneath to work with should the transplant fail. The pain and disappointment for the patient in this scenario is unthinkable.

However, recent surgical developments point in a more positive direction for potential face transplant patients. Notably, the partial face transplant carried out by professors Bernard Devauchelle and Jean Michel Dubernard in Amiens, France, in November 2005 on Isabelle Dinoire, a 38-year-old woman who had lost her nose, lips and chin in a dog attack. She received the lower face of a dead donor. She had been unable to talk or eat properly before her operation. Six months later she was reported to be fit and well and had gained weight as a result of regained ability to eat and talk. She has no regrets, nor do her surgeons.

Surgeon Jean-Michel Deubernard was quick to point out: 'When you saw this person's face, how severely disfigured, you'll understand why we had to take this challenge.' This is an important point – face transplantation is a drastic procedure that is designed for drastic circumstances.

The French experience has allayed some of the fears about the psychological effects on transplant patients. Dinoire has been monitored and aided by psychologists and is reported as doing well. She doesn't resemble her donor in any way, apart from skin texture, and neither does she look like she did before the dog attack. But the function of her face has made such a marked improvement to her quality of life that so far it has all been worth it.

In April 2006, news broke that a Chinese victim of a bear attack had undergone a partial face transplant. Reports indicate that he is also doing well.

However, the Royal College of Surgeons second working party report on facial transplantation has warned that the procedure is still experimental.

Patients must be kept on a long-term regimen of immunosuppressant drugs that can cause health problems in themselves. But evidence from 18 hand transplant patients worldwide who are on similar drug regimes suggest that the hands, which like the face include skin transplants, have not been rejected after several years. However, the long long-term remains an unknown for both hand and face transplants.

Transplant Rejection

The necessary microsurgical techniques for face transplantation have been in place for a good 10 years now. But what has held up progress so far is largely the problem of transplant rejection. All of us have an immune system that recognises anything that is foreign to our bodies and attacks it (this is how we get over colds and other infections) but it's a problem for transplant surgery.

Transplants like face and the hands involve transposing skin. The biological role of skin is to create a protective barrier against the outside world, making it one of the most immunologically active of organs, and the hardest to transplant. A team of US surgeons led by Dr John Barker at the Univeristy of Louisville, were the first to show that a cocktail of drugs could prevent rejection in pigs that had received transplanted limbs. Similar drugs have since been successfully used to protect human hand transplants by John Barker and his team, who carried out the first hand transplant in 1999.

All transplant patients have a lifelong regimen of immunosuppressant drugs, which have serious side-effects, increasing the risk of infections and of all types of cancer. Even so, these drugs only protect against a full-blown immune attack – 'acute rejection'. But the experience of kidney transplantation shows that there is also a process of 'chronic rejection'. This works over time, gradually turning a new kidney into a fibrous lump of tissue, which is no good to anyone. On average, transplanted kidneys fail within 10 years and have to be replaced.

Given that it's been more difficult to get skin transplants to survive acute rejection, it wouldn't be unreasonable to assume that transplanted skin is unlikely to fair well against chronic rejection. It's here that face transplants are still in a highly experimental phase.

In their 2003 working party report on facial transplantation, the Royal College of Surgeons stressed: 'We don't know the risks. What we do know is that the risks of long-term rejection in some standard forms of transplantation are high, between 30% and 50% over a period of two to five years, along with other serious risks associated with immunosuppression, such as infection and cancer.' These risks are as real as ever.

Grafts Versus Transplants

Underlying plastic or reconstructive surgery are grafting techniques that have been honed for well over a century, so why aren't they a satisfactory alternative to face transplants?

To date, almost everyone who has lost the outer protective layer of skin through injury, anywhere on their body, will have been treated with skin grafts. These are thin pieces of skin taken from healthy parts of the body and grafted onto the damaged area. They have no blood supply of their own and rely on the in-growth of blood vessels from the new site. Their main function is to cover exposed tissue laid bare by trauma and prevent infection.

These kinds of grafts are the most basic and have been in use since 1869, when they were first reported by two surgeons in the same year – Felix Jean Casimire Guyon of Paris and Jacques Reverdin of Geneva.

The advancement and development of techniques for operating on the smallest of structures in the body has since transformed the field of plastic surgery. The ability to reconnect blood and nerve supplies with microscopic techniques gives surgeons the opportunity to transpose much larger tissue sections which can include underlying fat, muscle and sometimes bone.

State-of-the-art plastic surgery utilises a variety of grafting methods and tissue sections alongside microsurgery. All of which is aimed at restoring sensation, flexibility and looks.

The advantage of grafting over transplantation is that there is a wealth of surgical experience in the technique, many of the pitfalls are understood, tissue rejection is not such a serious issue and the procedure usually works.

The downside is mainly in the way that grafts look – not a trivial point when you're talking faces. Typically, grafted skin adopts a tight, scarred look and the face takes on a frozen appearance because of its lack of mobility and expression. We all communicate via a stream of facial expressions; as much as two-thirds of what we communicate to others happens through this channel.

A face without expression then is a face that has lost its function, at least in part. Reconstruction of natural-looking noses and mouths is also notoriously difficult. Severely injured patients can undergo a long and painful programme of operations with little to show for it.

As a consequence, an intense research effort is focused on the formation of scar tissue. Skin that has re-grown after trauma is often thicker, less flexible and has a different colour and texture to normal skin. It's known as keloid formation. If the mechanisms for its growth could be understood, then it might be preventable in certain circumstances.

Tantalisingly, researchers have long known that babies under three weeks old don't scar in the same way, and nor does penile tissue. If keloid formation could be prevented following adult skin grafts, then grafting might be a better option for most patients requiring an organ transplant that includes skin.

At the current state of play, reconstructive skin grafting is less than satisfactory, and usually results in a mass of thick, disfiguring scar tissue which makes face transplantation a more attractive option even with all its attendant problems.

Transplant History

In the 1940s, Sir Peter Medewar, a British biologist, clarified how transplanted organs were attacked by the immune system. Transplanted organs were attacked as though they were an alien invader within the bodies of the animals he experimented on, reducing the lifespan of the transplant to a matter of days in the worst cases (and putting the life of the animal in jeopardy to boot). The same process goes on in human transplant patients.

In 1951, Medewar had the idea of drawing on cortisone, a new drug that was known to be immunosuppressive. If the immune system could be quietened down, perhaps the recipient would be able to integrate the transplanted organ. But it didn't work.

Not until the 1970s did a breakthrough occur in immunosuppressant drug therapy, with the discovery of a drug called cyclosporin that was effective enough to prevent organ rejection.

Meanwhile, transplant surgeons were not dissuaded from practicing their art. Human kidney transplants were attempted in the US from 1951 onwards, with awful results. The failure rate was high and all too often resulted in death. In nearly all cases, analysis showed that the immune system had been mobilised and the transplanted kidneys had been rejected.

The first successful human kidney transplant was performed between identical twins in 1954, demonstrating that the immunological barrier doesn't exist between genetically identical individuals. This experience emphasized the need for tissue typing, or matching compatible tissues as far as possible.

The first human heart transplant was famously performed by Christiaan Barnard in 1967 in South Africa. Barnard's patient, 53-year-old Louis Washkansky, survived the transplant operation, only to die of pneumonia 18 days later. It seemed as though publicity took precedence over health as the press were admitted to see Washkansky only days after the operation and could have passed on the infection. By the time Washkansky began deteriorating, Barnard was jetting around the world conducting media interviews and giving talks.

In the year following Barnard's pioneering operation, a media furore generated interest from all quarters and funding followed. More than 100 heart transplants were performed around the world, but two-thirds of the patients died within three months. Criticism mounted as it became clear that there had been a general lack of attention to tissue typing and organ rejection nearly always followed.

It wasn't until cyclosporin became available over 10 years later that the rejection problem was overcome. The drug brought an end to the period when organ transplants were more beneficial to researchers than to patients.

The disastrous results that accompanied the early attempts of inexperienced heart surgery teams are a lesson for would-be face transplant surgeons today. As the Royal College of Surgeons 2006 working party report makes clear: 'We are anxious to avoid a repetition of the media and medical frenzy that accompanied the first heart transplants in the late 1960s.' Alleluia!

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