Written by Michael Gleeson
The world’s first full-face re-plant operation was performed on a 9-year-old Indian child in 1994. Her face had been ripped off when her hair was caught in a thresher. She arrived in hospital unconscious with her face in two pieces wrapped in a plastic bag. A surgeon managed to reconnect the arteries and re-plant the skin. The child was left with some muscle damage as well as scarring around the perimeter where the facial skin had been sutured back on.
While the Indian child’s facial reconstruction was remarkable, a part of her successful outcome was due to the fact that she received an autograft. The prospect of performing an allograft to correct facial deformity posed many more problems. First, strategies to reduce the risks associated with immunosuppression specifically for face transplantation needed to be developed. In the post-operative period, complications such as infections could easily damage the transplanted face and necessitate a second transplant or reconstruction with skin grafts. Second, long-term immunosuppression increases the risk of developing life-threatening infections, kidney damage and cancer. Candidates for facial transplantation are otherwise physically healthy and would require lifelong immunosuppressant therapy. This had caused some plastic surgeons to suggest that the real issue was not “Can we do it?” but rather “Should we do it?” Partial facial transplants had been undertaken in other countries and four patients had died of complications. The operation had also attracted media attention, and it had become infused with nationalist import that possibly influenced the decision-making and ethical judgement of the involved parties.
The technical difficulties that needed to be overcome were addressed by a number of anatomical studies using fresh cadavers. After dissecting 10 fresh cadavers, allotransplantation of the lower two-thirds of the face were undertaken in two patients in March and August of 2009. The grafts included all perioral muscles, facial nerves, parotid glands, the anterior region of the maxilla, and part of the mandible. The mandibular osteotomy included only the chin in one case, and the mandibular arch from one angle to the other in the second case. Both cases were successful.
After 10 more cadaver dissections it was apparent that relying only on the anastomoses between the facial and the maxillary artery for vascularisation of the posterior part of the maxilla was unsafe. Periosteal vascularisation seemed essential. It was therefore proposed to use a single end-to-end arterial anastomosis to the left external carotid artery. In a further partial facial transplant, it was established that this was sufficient for full perioperative revascularisation of the flap and immediate re-establishment of bilateral venous flow.
In March 2008, a 30-year-old man with severe neurofibromatosis received the world’s first successful almost full-face transplant. The graft was harvested from a heart beating brain-dead donor before other tissues and organs were removed. Facial soft tissues were harvested en bloc to decrease graft harvest time and prevent tissue injury. A resin mask that covered the entire face of the donor provided excellent cosmetic results. All nerves and eyelid structures were easily reattached in the recipient. Induction immunosuppressive therapy included anti-thymocyte globulins, steroids, mycophenolate and tacrolimus.
In total, 5 patients have been transplanted with 7- to 38-months of follow-up. One patient had suffered from plexiform neurofibromas, two from third degree burns and two from gunshot injuries. Acute cellular rejections were controlled by conventional treatment. Opportunistic infections affected all patients and lead to one patient’s death two months after the transplantation. Voluntary facial activity appeared after 3 to 5 months. Major improvements in facial aesthetics and function allowed these patients to recover social relations and improved their quality of life. Disparity in age between donor and recipient seemed to be less of a problem than originally thought. Subsequent plastic procedures were conducted to remove redundant skin etc. The underlying bony architecture had a much bigger impact on the final appearance of the patient than had been anticipated. In other words, a hybrid graft had been produced, so that features of both donor and recipient were retained.
Face transplantation is undoubtedly indicated for a very select and equally small group of patients. It is hugely consumptive of healthcare resources from start to finish, that have an impact on the delivery of other services.
Lantieri, LA., Face transplantation : The view from Paris, France.
Southern Medical Journal 2006; 99 : 421-423.
Menigaud, J-P., Benjoar, M-D, Hivelin, M., Hermeziu, O., Toure, G & Lantieri, L. 2010; 126 : 1181-1190.