Facial transplantation: A decade out, surgeons prepare for big demand


April 29, 2014
Health

A review of all 28 patients to date, including 7 Americans, reveals challenges but ‘moral imperative’ to offer the lifelong, life-changing treatment

Plastic and reconstructive surgeons leading the first retrospective study of all known facial transplants worldwide conclude that the procedure is relatively safe, increasingly feasible, and a clear life-changer that can and should be offered to far more carefully selected patients.

Reporting in The Lancet online April 27, NYU Langone plastic and reconstructive surgeon and senior author Eduardo Rodriguez, MD, DDS, says results after nearly a decade of experience with what he calls the “Mount Everest” of medical-surgical treatments are “highly encouraging.”

The review team noted that the transplants still pose lifelong risks and complications from infection and sometimes toxic immunosuppressive drugs, but also are highly effective at restoring people to fully functioning lives after physically disfiguring and socially debilitating facial injuries.

Surgeons base their claims on the experience of 28 people known to have had full or partial face transplants since 2005, when the first such procedure was performed on a woman in France.

Of the 22 men and six women whose surgeries were reported, including seven Americans, none have chronically rejected their new organs and tissues, says Dr. Rodriguez, chair of the Department of Plastic Surgery at NYU Langone Medical Center and director of its Institute of Reconstructive Plastic Surgery. All but three recipients are still living. Four have returned to work or school.

Dr. Rodriguez, the Helen L. Kimmel Professor of Reconstructive Plastic Surgery at NYU Langone, in 2012 performed what is widely considered the most extensive facial transplant (when he practiced at the University of Maryland Medical Center in Baltimore). The patient was a Virginia man who had lost the lower half of his face in a gunshot accident 10 years earlier. Dr. Rodriguez is currently readying his new team at NYU Langone to perform its first facial transplantation, expected later this year.

In The Lancet article, Dr. Rodriguez and his colleagues point out that although all recipients to date have experienced some complications from infection, and mild to moderate signs of rejection, the few deaths among patients were due to infection and cancer not directly related to their transplants. Indeed, most patients, he says, especially those in the United States, are “thriving”—speaking, chewing, and leading social lives from which most had completely withdrawn because of their disfigurement.

“By far the overriding factor in the success of face transplantation has been in selecting patients most likely to benefit from and succeed through what can best be described as the most complex of medical-surgical procedures,” says Dr. Rodriguez. “This is a life-changing treatment that can take years to prepare for and one that hopefully endures for the rest of the patient’s life.”

Dr. Rodriguez notes that only patients with the most severe facial disfigurement—not reparable by even the latest surgical techniques—are considered for the procedure. Patient histories range from victims of bear bites to multiple gunshot accidents and severe, electrical and house fire burn injuries. The extent of injuries may encompass any combination of the forehead, eyelids, nose, cheeks, lips, jaws, and chin.

“People who volunteer to undergo this procedure do so for very serious health and psychological reasons,” says Dr. Rodriguez. “It goes far deeper than looks. People willing to undergo facial transplantation are highly motivated to do so. Without facial transplantation as an option, many of these people would be at serious risk for severe depression, even potential suicide,” he says.

For those who do undergo facial transplantation, Dr. Rodriguez says success depends heavily on “total compliance” with their medication regiment and intense follow-up care. They must take immunosuppressive drugs as prescribed to ward off organ and tissue rejection, watch for early signs of infection, and keep up with their physical, occupational, and speech rehabilitation regimens. Having a strong family support system greatly helps.

Psychological improvements have been steep, the surgeons report in The Lancet, with most transplant recipients declaring a renewed sense of self and body image, showing fewer signs of depression, and experiencing fewer episodes of verbal outbursts than before their transplant. None had signs, as originally feared, of a “split” personality, in which they assumed their donor’s identity. Indeed, donor family members say recipients do not even resemble their donors after the surgical transformation. Dr. Rodriguez attributes this to the rigorous psychological screening and counseling that preceded surgery.

Because facial transplantation is life-changing and not life-saving, Dr. Rodriguez points out that the procedure still raises grave concerns about the ethics of putting otherwise healthy, mostly young people on a lifetime regimen of toxic immunosuppressive drugs and at risk of potentially fatal infections and vital organ compromise.

“These moral considerations must be taken very seriously as the number of face transplants and medical centers equipped to perform them grows,” says Dr. Rodriguez. “We have the medical ability to restore these people’s lives. With some victims from fire, police and military armed services, it can be argued that we have a moral imperative to restore them to society.”

Despite accelerated psychological recovery in many cases, physical recovery can take years, the surgeons report. While recipients claim feeling sensations of cold and heat as early as a few months after surgery, sensing touch and pain on the skin often takes eight months or longer, as does recipients’ ability to open and close their mouths and move their lips.

For some, speech, smelling, chewing, and swallowing abilities can resume within months and rapidly improve within a year. Relearning how to smile and drink fluids, though, takes as long as two years. Powerful drugs are used to accelerate nerve repair and growth.

Surgical revisions to properly align teeth and jaw bones are common among the transplant recipients, in addition to cosmetic procedures to smoothen facial contours and remove excess skin. Complications have been few, the report states.

In the article, Dr. Rodriguez and his colleagues also note the significant financial costs and the serious ethical debate around them. The procedures cost roughly $300,000 each, not including fees associated with a lifetime of immunosuppressive therapy or need for additional surgery. These costs, they conclude, are only sustainable in the long term with committed public funding.

Dr. Rodriguez says his team at NYU Langone plans further research on developing better tools for screening patients best suited to the lifelong therapy and determining the relative value of full or partial face transplants. Additional efforts to forge a standardized surgical protocol will focus on complex instructions about how best to position and fit the new face and underlying bone, as well as match and attach nerves and muscle. The NYU Langone team also plans studies on the long-term health effects of immunosuppressive therapies and whether dose reductions are possible to lessen drug toxicity without compromising risk of organ rejection. The team also plans to explore the feasibility of performing face transplants on severely disfigured children.

In placing the first decade of facial transplantation in historical context, Dr. Rodriguez compares it to the beginnings of liver transplantation in the 1960s, when few procedures were performed and few patients lived longer than a year. Today, he says, liver transplantation is performed at more than 100 medical centers in the U.S. alone, and the vast majority of patients, including children, survive beyond a year, with outcomes continuously improving despite liver transplantation’s frequent complications.

“We are still very much in the early days of facial transplantation,” says Dr. Rodriguez. “So long as our patients need it—and they do—then, it is our medical duty to continue to advance science and medicine, and improve how we perform the procedure so that it is more widely available to future generations of people whose severe disfigurements go beyond the means of conventional surgery.”


Facial transplantation: A decade out, surgeons prepare for big demand

14 Responses to Facial transplantation: A decade out, surgeons prepare for big demand

  1. jack May 2, 2014 at 5:59 am #

    i agree

  2. Sakhau Refiloe (14160812) May 2, 2014 at 3:47 am #

    It is truly amazing how far medicine and science have come in ensuring that trauma patients have the chance to lead a somewhat normal life. Having to deal with a traumatic experience seems far more impossible to do when one of the outcomes is facial disfigurement. This not only leaves an unpleasant physical scar, it also creates an emotional scar that is even more difficult to face then the physical scarring. Facial transplantation most definitely has more advantages than disadvantages.

    However, it is highly unfortunate that this procedure will only be available to very few people due to the extremely high cost. Many people who have facial disfigurements and need serious medical assistance will not be able to reap the rewards of this amazing procedure because the price tag is far too hefty, especially considering the fact that it will most probably require life-long medication and possible further minor surgical operations even after the transplant. This means that the effect of this procedure is limited to the availability of funds. Which, as unfortunate as it may be, is understandable considering the complexity of the procedure.

  3. 14087775 (Nadine) May 1, 2014 at 5:54 am #

    This new development in facial transplantation is still a vast area, in which a lot of research needs to be done, but the results shown of the 28 patients, is truly amazing. The reconstructive surgery gives hope to people when they thought they had none.

    Although this surgery is life-changing, there are certain disadvantages that should be taken into consideration. There is always a possibility of life-threatening infections developing, or that the body might reject the organs, both of which can lead to the death of a patient. Other factors that are worrying is the effect of immunosuppressive drugs in the long term, as not enough research has been done in this area. The long term use of these drugs could lead to other health problems.

    People going through this type of surgery endure a lot of pain and suffering. This also places a huge emotional burden on the families involved. The recovery takes place over a long period of time, but despite all of this I think it is definitely worth it.
    Research should also be done on performing these facial transplants on children. An example of a child’s whose life has been saved and changed is young Pippie Kruger. She suffered severe 3rd degree burns over 80% of her body when she was only 2 years old. The skin and face transplantation surgery she received changed her life and gave her a second chance at a better life. Many children in South Africa suffer severe injuries especially burns, due to poor living conditions. If this type of surgery is more accessible then more children’s lives can be changed for the better.

    This life-changing experience comes at a very high cost and is unaffordable for most people. More research should be done on ways to improve methods and technology used in these procedures, to try and make it safer and more affordable.
    Families of these patients take a huge financial risk when this type of surgery is performed and there is no guarantee that the patient will recover. I feel that more foundations should be created to raise funds for further research and support of these families.
    The research that has been done and the success that has been achieved makes me excited as it has the opportunities to change more people’s lives for the better, but there is still a long way to go.

  4. Monique Redelinghuys ( 14110807 ) May 1, 2014 at 2:40 am #

    Isn’t it wonderful how far modern technology and medicine have come ? It makes me smile to read articles like this about how new medical technology can change peoples lives. Isn’t that what it is all about ? I know how I would feel if I was in a tragic accident that disfigured my face. I would feel totally helpless. It is good to know that there are scientists out there researching facial transplants and making them more safe and feasible. It really helps people regain their self confidence and will to live. I agree with the article that facial transplants are not life-saving but rather life-changing because of all the risk factors involved. I believe however that the price of these risk factors are greatly outweighed by all the positive outcomes. What good does it do to see someone live out their lives depressed and suicidal when something can be done ? There is undoubtedly a high cost associated with these transplants and it is not always possible for everyone that needs them, but there is still a long road of research ahead and I have hope that in the future facial transplants will be possible for everyone in dire need of it to change their lives.

  5. u14150400 April 30, 2014 at 12:05 pm #

    In my opinion facial transplantation is a great innovation to the medical science industry. I obviously do not recommend it to people with self-image and facial appearance issues. It is highly recommended, in fact it is necessary in cases of people losing their appearance die to fatal accidents that leave the face distorted. It is an effective process at restoring appearance and enduring a patient’s life. The disadvantage of it is that there are risks and complications involved, for instance; the rejection of the tissue, or infections. another disadvantageous factor is cost, not everyone that necessarily need it can afford it. What is sad is that, it can be expanded to the need but its experts tend to focus only on the rich and famous, who have no moral considerations in general. But overall I do believe it is good.

  6. 14053170 April 30, 2014 at 11:30 am #

    This is an article that gives you hope about a better future for those individuals who have already endured so much. Victims of fires, wars and severe abuse can be given a new life with these face transplants. Technology and information is progressing at a rapid rate making it possible for surgeons to begin effectively performing these surgeries. Although these surgeries are expensive, I think that they are ultimately necessary and should be done irrelevant of the cost. Governments can use taxes to fund these surgeries for people who will benefit the most from them. Theses surgeries, along with counselling will improve the lives of many people. Because we live in a world where there is so much abuse and tragedy, I believe that this knowledge fuels the need for these surgeries to be performed. If the surgeries, the funding and the patients are monitored properly, I think these surgeries can only have a positive effect on the medical world, on individuals lives and on humanity as a whole.

  7. u14007071 April 30, 2014 at 8:15 am #

    Facial transplantation has greatly improved in the field of plastic surgery as it has helped to better peoples lives and give them a sense of hope for the future. It allows victims of tragic experiences to regain their self-purpose and esteem as well as allow them to feel better about their appearance. The results of facial transplantation are unique and can be life-changing. It can improve physical functionality of the face if the surgery is successful, including the ability to speak, breathe, communicate etc. This type of surgery can also benefit the patient in that it restores a near-normal facial appearance which can in turn renew ones self and body image. Although there are risks involved in facial transplant surgery the advantage of possibly regaining the appearance and confidence that a person had before it had been drastically changed, immensely out weighs these risks. The facial transplant surgery has been a great innovation in comparison to the former skin grafts which was once the only possible way to fix disconfigured faces.

  8. Mamaila Manaka (14070872) April 30, 2014 at 6:27 am #

    Plastic surgery is not actually a bad thing, but people happen to be addicted to it nowadays. Doing a face lift ,a breast implant or removing fats under your skin is all part of what plastic surgeons do daily in their practices. The facial transplant gives other people a second chance at living a normal life and feeling confident again. Though it might sound very expensive as long as it makes people happy then its worth it. I strongly suggest that before the patient decides to go ahead with the transplant he/she should think wisely about it. This is because as people we are not the same, what works for me might not work for you.

  9. Lourens Koekemoer, u14039517 April 30, 2014 at 4:22 am #

    In my opinion, facial transplantation is a great solution when treating patients that has experienced a scarring and traumatic event. But, seeing that the process is dependent on large scale funding or financial support, it is clear that the process may not be possible for some people who might be in dire need of recovery. The use of the plastic reconstructive surgery provides the patient the opportunity to recover not only in their personal environment, but also the social sphere where normal interaction with other people will be possible, without the thought that some might pity you because of your injury. When considering the complications such as toxicity of the drugs and possible organ failure of the surgery, patients and doctors that are included in the choice of performing the procedure needs to understand the full impact that it will have on the patients health and psychological state of mind. Therefore it is my belief that the choice of selecting only patients with severe facial disfigurement as stated in the articles above should be considered. The process is life changing, the recovery period is long and the fact that it is not the face you had could lead to severe depression. Your identity is still based on how you looked before the accident and the process should be focused on delivering you a face that you once had.

  10. E. Manhanga (u14182964) April 30, 2014 at 1:26 am #

    As humans it is only natural for us to be hesitant considering that we are still in the early days of the discovery of facial transplantation. Getting a facial transplant could be a significant way to recover from traumatic experiences. Sometimes change is good. On the other hand however there are cons to be considered. The duration of the healing process as well as the side effects of the toxic drugs that help speed up the healing process. Learning how to drink liquids again and learning how to talk. This will require a great deal of support from friends and family members.

  11. Michelle (14006902) Wears-Taylor April 29, 2014 at 2:17 pm #

    Facial transplants shed a new light on life for people whose faces have become so disfigured that they do not want to be seen in public anymore. In the past, the only way to fix this was by means of skin grafts – but this did not resolve the problem, because movement and appearance of the face could not be fully restored. Today, doctors are able to transplant part, or all, of a face from a donor, thanks to leading medical technologies. In my opinion facial transplants are beneficial to the medical field. Disfigured patients get the opportunity to lead a normal life and to regain certain movements of the face that they may have lost in an accident. However, there are a few ethical concerns about this procedure, mainly they involve the fact that the patient is undertaking a major risk in undergoing such a big surgery when his/her life is not in danger. Hence, it should be a requirement for possible patients to be thoroughly inspected before a doctor can give them the option of a face transplant. This procedure can drastically improve peoples lives.

  12. u14182506 .LS April 29, 2014 at 12:28 pm #

    This whole procedure of facial transplantation is in my opinion only good to a cetain point. Although it helps patient who have gone through traumatic experiences to be able to get out into the world again, it does not necessarily make their lives normal again. What these patients should consider as a more important factor is their psychological and spiritual being. Changing ones face does not change whats inside of them. I think that patients must first come to a point where they accept that because of their traumatic experinces life will never be the same and people will never treat them the same. Another thing is that the life long dosage of the immunosupressive drugs will mean that they will not be able to live a fully normal life due to their weak immune systems and having to be more cautious than ever so that they dont contract deseases and infection. facial transplant should be the last step taken in the recovery from a life changing traumatic event.

  13. 13053648 April 29, 2014 at 9:22 am #

    This is a major breakthrough in the medical field especial in the department of plastic surgery where it has been widely deemed as a cosmetic procedures, for the wealth to re-instate their images of what is beautiful.With facial reconstruction and facial transplants, plastic surgeons will be able to restore a person life, after they have suffered from a deflect.However I also believe a lot of a persons identity resides in their face and that having facial reconstruction could affect the patient physiologically , if not immediately, but possible long term, as this could lead to an identity crisis. That is why if such a procedure is to be come more widely spread full screening of patients be required.

  14. Kayla Beechey 14082153 April 29, 2014 at 8:18 am #

    I believe that this facial transplant is a major breakthrough in medical science and can only be beneficial in the future despite the slight cons in the present. This facial transplant is not a case of a person being ugly or pretty, this is about the person being able to live a normal life again after it being drastically altered. As said in the article the patients chosen for this complex surgery are only selected if the injury will cause drastic health or psychological problems. The decision to go ahead with the transplant is not taken lightly by the patient, their family or the doctors and therefore all of the parties involved know full well what lies ahead of them. Even though there are cons such as the toxic drugs that need to be taken, these are a minimal payment for the amount of happiness this surgery will bring in the future for the patient, if the surgery is successful. I believe that in the future with better technology this surgery will be very successful and will be used worldwide in order to help patients have a normal life like you and me.

Leave a Reply

* Copy This Password *

* Type Or Paste Password Here *