Facial transplantation
Facial transplantation is an advanced surgical procedure designed for individuals with severe facial disfigurements who have not found adequate solutions through conventional reconstructive surgery. This procedure is typically reserved for patients affected by extensive injuries from accidents, diseases, or congenital anomalies, which lead to significant loss of facial tissue. Unlike traditional surgical methods that often result in a masklike appearance due to the lack of subtle muscle transfer, facial transplantation aims to restore both function and aesthetic appearance by replacing the entire face, including underlying features like nerves and blood vessels.
The process involves three major surgeries: the removal of the donor's face, the preparation of the recipient's facial area, and the attachment of the new face. While this method can dramatically improve the quality of life, allowing for better facial movement and expression, it does come with inherent risks, including potential tissue rejection and complications from long-term immunosuppressant use. Despite its complexity and the experimental nature of the procedure, facial transplantation has seen success stories, with notable surgeries performed around the world since the early 2000s. However, it remains a highly specialized field, raising significant ethical considerations and requiring ongoing research to fully understand its implications and long-term outcomes.
Facial transplantation
Anatomy or system affected: Blood vessels, bones, circulatory system, ears, eyes, head, immune system, mouth, muscles, neck, nerves, nervous system, nose, skin
Definition: A surgical procedure to transplant all or part of the face from a donor’s corpse onto the severely disfigured face of a living person to provide a dramatic improvement in the appearance and function of the recipient's face
Indications and Procedures
Facial transplantation is a procedure that is reserved for people with extensive facial disfigurements who have exhausted all other options, including reconstructive surgery. Accidents such as burns, trauma, maulings, and gunshot wounds; diseases such as cancer and infection; and craniofacial anomalies affect thousands of people each year, causing disfigurement to the face. For most people, surgery can correct all or most of the disfigurement. For the few people who experience a great loss of tissue, however, reconstructive surgery is very limited in returning normal function and appearance.
Facial transplantation is technically easier than other facial reconstruction surgeries, should involve fewer surgeries, and can improve appearance and mobility. In traditional facial reconstruction, tissue is surgically reattached or taken from another part of the person’s own body. These reconstructions, however, do not transfer the subtle muscles needed for expression, which creates an expressionless, masklike appearance.
People with severe facial disfigurement may have limited facial movement, which can cause difficulty talking, eating, and even closing their eyes. People with facial disfigurement often have low self-esteem and experience social isolation, depression, anxiety, and poor quality of life. They may have difficulty making friends and finding employment.
Facial transplantation involves three separate surgeries. The first surgery, which takes ten to twelve hours, degloves the corpse of the donor. An incision is made across the hairline, down the temples, behind or around the ears, and around the jawline. The face, including the eyebrows, eyelids, nose, mouth, and lips, is then detached, as is underlying fat and connective tissue. Surgeons must be careful not to damage the nerves that control facial expression, eye movement, and facial sensation. If the donor’s face is healthy enough for the transplant, then the surgeons begin the second surgery, in which they deglove the patient’s face. This surgery takes longer since the surgeons must clamp off the veins and arteries and take special care not to damage the nerves. Bone grafts are performed if the patient needs bone replacement. The third surgery involves attaching the new face, including veins, arteries, and nerves and may take as long as twenty-four hours to complete. These medical procedures are performed by an extensive team of medical specialists.
Temporary tubing and drains are installed to remove fluid buildup. After about two months, the patient’s face returns to normal size. Depending on the nerve damage before the transplant and the success in nerve reattachment, the patient’s facial movements may not be normal for several months to over a year. The patient must take immunosuppressants for life to prevent the body from rejecting the donated tissue.
Uses and Complications
Few facial transplantations have been performed worldwide, and many of the risks involved remain unknown. In general, skin grafts are more susceptible to rejection than most organ or other tissue transplants. In addition, skin transplants carry a life-threatening risk, and a rejected facial transplant would leave the patient in worse condition physically, emotionally, and psychologically.
Other risks include tissue damage that occurs because of cell death from the time of removal to reattachment. If the sensory nerves are not properly reconnected, then permanent numbness will occur. Long-term risks, including tissue mutation or psychological impact, are unknown. Short-term risks include infection, additional scarring, potential tissue rejection, and complications in long-term healing. The side effects of immunosuppressants include infections, metabolic disorders such as diabetes, malignancies, and decreased kidney and lung function.
Perspective and Prospects
With the introduction of immunosuppressive drugs in the 1980s, composite tissue allotransplantation (CTA) became possible. Prior to the introduction of these drugs, hand and face transplants had been considered almost impossible because of the tissue involved and the high risk of rejection.
In 1994, a surgeon successfully reattached the face of a nine-year-old in India whose face and scalp had been ripped off by a threshing machine. Two other surgeries, one in Australia and one in the United States in 2002, also reattached entire faces. Facial transplantation was discussed as a serious therapeutic option in a 2002 meeting of the Plastic Surgical Research Council in Boston, Massachusetts, and by early 2006, teams in the United States, France, and Great Britain had been working for years to develop surgical techniques and protocols for immunosuppression, psychological assessment, and informed consent for potential patients.
In France, on November 27, 2005, doctors transplanted a chin, lips, and nose onto Isabelle Dinoire, a woman who had been mauled by her dog while she was unconscious. In April 2006, doctors in China grafted a nose, cheeks, and upper lip onto a man mauled by a bear years before. In December 2008, doctors in the United States performed the first near-total face transplant on a woman who had been shot in the face four years earlier. By 2012, full-face transplants had been successfully performed in France, Spain, and the United States.
Despite these successes, the procedure is still very experimental, involves great risks, and raises numerous ethical questions. Patients are participating in research, not receiving traditional medical care. The results are promising, however, and will likely inspire further procedures. As of 2022, less than fifty face transplants had been performed worldwide, with an oversale survival rate of patients of 89 percent.
Bibliography
Baylis, Françoise. “Changing Faces: Ethics, Identity, and Facial Transplantation.” Cutting to the Core: Exploring the Ethics of Contested Surgeries, edited by David Benatar, Rowman & Littlefield Publishers, 2006, pp. 155–67.
Concar, David. “The Boldest Cut.” New Scientist , 29 May 2004, pp. 32–37. Academic Search Complete, search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=13342905. Accessed 9 Jan. 2017.
“Crossing New Frontier: Paving the Way to Make Face Transplantation Reality.” Medical Ethics Advisor, 1 July 2006, www.ahcmedia.com/articles/121017-crossing-new-frontier-paving-the-way-to-make-face-transplantation-reality. Accessed 9 Jan. 2017.
"Face Transplant Surgery." Brigham and Women's Hospital, 13 Apr. 2016, www.brighamandwomens.org/Departments‗and‗Services/surgery/services/PlasticSurg/Reconstructive/FaceTransplantSurgery/default.aspx. Accessed 9 Jan. 2017.
"Face Transplant Surgery." Comprehensive Transplant Center, Johns Hopkins Medicine, www.hopkinsmedicine.org/transplant/programs/reconstructive‗transplant/face‗transplant‗surgery.html. Accessed 9 Jan. 2017.
“Face Transplant: Surgery, How It Is Done & Rejection.” Cleveland Clinic, 15 June 2022, my.clevelandclinic.org/health/treatments/23281-face-transplant. Accessed 27 July 2023.
McLaughlin, Sabrina. “Face to Face.” Current Science, 12 Sept. 2003, pp. 8–9. Academic Search Complete, search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=10740588. Accessed 9 Jan. 2017.
Wilson, Jim. “Trading Faces.” Popular Mechanics, Nov. 2003, pp. 76–79. Academic Search Complete, search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=11103902. Accessed 9 Jan. 2017.