Facing the Facts: A Look at the Face Transplant Controversy

In November 2005, the world turned its attention to Amines, France, where Isabelle Dinoire became the first person ever to receive a partial face transplant. The surgery was greeted with intense controversy that has continued to this day.

The conflict has raised both medical and ethical concerns, and with experts weighing in on all sides of the issue, the controversy is still far from resolved. The main debate questions whether the benefits of a face transplant outweigh the many risks associated with the procedure. This September, researchers at the University of Cincinnati and the University of Louisville released a new study, which claims that the risks of facial transplantation have been exaggerated, making the procedure much safer than originally thought. To fully grasp the meaning of the new study, however, it is necessary to take a look at some of the main issues surrounding face transplants.

This is a reconstruction of the transplanted lips, nose and chin. Arteries are in red, veins are in blue, nerves are yellow and muscles are dark red

This is a reconstruction of the transplanted lips, nose and chin. Arteries are in red, veins are in blue, nerves are yellow and muscles are dark red

A Quick Overview

Only three partial face transplants have been performed to date, and none of these have occurred within the United States. The first was Isabelle Dinoire's on November 27, 2005. The second face transplant was given in April 2006 to a Chinese man who had survived a bear attack. The third, performed in January 2007, was given to a French man who suffered from von Recklinghausen, a genetic disorder that disfigures the face. Dinoire has publicly said that her surgery was a success, and the other two recipients have reported no problems with their transplants.

Right now, two US hospitals are publicly looking into performing face transplants: the Cleveland Clinic and Brigham and Women's Hospital in Boston. The latter only announced their plans this July.

Face transplants are different from other forms of facial reconstruction because they require a donor. The large amounts of muscle and nerve in the area make face transplants difficult. For the procedure to be considered a success, the patient would need to regain some sensation and muscle control; however, this recovery takes time and doctors are unsure to what extent patients will regain muscle movement and sensory control.

A Risky Business

Transplant rejection is one of the main risks associated with face transplants. According to the American Society for Reconstructive Microsurgery and the American Society for Plastic Surgeons' Facial Transplantation Guiding Principles, "It is estimated that 10 percent of facial transplant recipients will experience an episode of rejection within the first year, with a thirty to fifty percent rate in the second to the fifth year." They developed these estimates by looking at the success rate for hand transplants, a complex surgery with a difficulty comparable to face transplants.

In order to avoid this rejection, patients will have to take immunosuppressant drugs for the rest of their life. This would prevent their immune systems from attacking the foreign transplanted tissue. However, immunosuppressants have many severe complications of their own, such as diabetes, high blood pressure and an increased risk of cancer and other infections. Brigham and Women's Hospital suggested a way to get around this risk – they are only offering face transplants to those already taking immunosuppressant drugs, probably from previous transplants.

There are also psychological risks. Patients will end up looking different, a mixture between their old features and their new ones. Experts are unsure as to how people will react to their new looks. Because of these uncertainties, doctors will only consider performing the surgery on people who have passed psychological tests proving they have stable personalities and good support systems.

Going Ahead with Surgery

The question is, can the benefits of face transplants outweigh these risks? Because face transplants can help people who have been horribly disfigured by trauma or disease, many people say yes.

"Surveys from transplant professionals have shown that doctors underestimate what people will do for a cure," said Rita Alloway, a doctor of pharmacy at the University of Cincinnati. "Often, living disfigured is worse than the risk associated with this sort of operation."

But even once a doctor agrees someone is fit to undergo facial transplantation, a donor still needs to be secured. This too will prove very difficult. It is hard enough to find donors for organs such as the kidney or heart, but finding face donors will be even more challenging. People registered as organ donors are not automatically also face donors – the families will need to give special permission. In addition, the donor will have to match the recipient in not just blood type, but also race and gender. The challenges associated with face transplants may seem daunting, but proponents of the procedure contend that we have the technology to overcome them.

A New View

Researchers published a study in the September issue of Plastic and Reconstructive Surgery saying that the immunosuppressant risks of face transplants have been exaggerated, making the procedure safer than previously believed. The researchers, led by Steve Woodle and Rita Alloway of the University of Cincinnati, as well as John Barker of the University of Louisville, developed new risk estimates for face transplants.

For example, they said the risk of chronic rejection is actually less than 10% at five years. The study also provided new estimates for acute rejection (10-70%), acute rejection reversibility (100% with steroids), diabetes (5-15%) and high blood pressure (5-10%).

The researchers said that previous studies have compared face transplants with other organ transplants, which Woodle said was like "comparing apples and oranges." After all, the tissue composition of solid organs is different from that of facial tissues. In addition, the health status of traditional organ recipients is usually worse than that of face transplant recipients. Finally, previous risk estimates were based on immunosuppressants that are not being used in face transplants.

The current study instead looked only at kidney and hand transplants that used the latest immunosuppression technology.

"In considering the most recent and relevant data, we came to the conclusion that the expectations for face transplant recipients should be significantly better than those previously published," Woodle explained.

This new study adds another layer of complexity to the facial transplant debate. While the issue is still far from resolved, with two US hospitals actively planning for the procedure, it seems safe to say that another facial transplant will be attempted sometime in the near future.

References

Vasilic, Dalibor, et al. Risk Assessment of Immunosuppressive Therapy in Facial

Transplantation. Plastic and Reconstructive Surgery, September 2007, volume 120, issue 3.

Okie, Susan. "Facial Transplantation Brave New Face." The New England Journal of

Medicine, 2 March 2006, volume 354, issue 9.

Royal College of Surgeons of England. "Facial Transplantation Working Party Report."

November 2006. http://www.rcseng.ac.uk/rcseng/content/publications/docs/facial_transplant_report_2006.html

Facial Transplantation ASRM/ASPS Guiding Principles. http://www.microsurg.org/ftGuidelines.pdf

Author: Lisa Merolla

Reviewed by: Antje Heidemann, Nira Datta

Published by: Konrad Sawicki

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