Face Transplant: Benefits, Risks and Rejections

For individuals with severe facial damage or noticeable facial differences, a potential treatment option available is a face transplant. This intricate procedure involves replacing some or all of the face with donor tissue obtained from a deceased individual.

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The process of a face transplant is a complex one, requiring several months of meticulous planning and the collaboration of multiple surgical teams. It is typically carried out in select transplant centres worldwide. Each candidate for a face transplant undergoes a thorough evaluation to ensure optimal outcomes in both appearance and function.

While a face transplant has the potential to significantly improve one’s quality of life, it is essential to acknowledge the associated risks. The procedure involves a high level of risk, as it is not possible to precisely predict the outcome in terms of appearance and the recipient’s immune system response. Lifelong administration of specialized medications (immunosuppressants) is necessary to minimize the chances of rejection by the body and maintain the viability of the transplanted face.

Image source: La Padula, S., Pensato, R., Pizza, C., Coiante, E., Roccaro, G., Longo, B., … & Meningaud, J. P. (2022). Face Transplant: Indications, Outcomes, and Ethical Issues—Where Do We Stand?. Journal of Clinical Medicine, 11(19), 5750.

Face Transplant Indications

The criteria for selecting patients and indications for face transplantation are highly stringent. A multidisciplinary team, consisting of plastic surgeons, psychological therapists, speech therapists, dentists, and transplant specialists, establishes the inclusion criteria. This team thoroughly evaluates the patient’s background, social network, and support system, as these factors play a critical role in successful recovery, psychological resilience, and compliance with lifelong immunosuppressive treatment. When considering face transplantation, it is essential to consider immunological risk factors. Patients with a medical history of burns and transfusions may have developed immunosensitization, which can complicate donor selection and result in poor post-procedural outcomes. Moreover, lifelong immunosuppressive treatment increases the risk of developing new malignancies.

The primary indication for facial transplantation is major facial trauma that causes substantial tissue loss in the middle third of the face and extensive damage to essential anatomical structures such as the nose, lips, and eyelids. Patients who have experienced ballistic trauma, burns, or animal bites are the most common candidates for facial transplantation. Furthermore, surgeons have performed facial transplantation on patients who have extensive facial plexiform neurofibromas or have experienced significant facial disfigurement after cancer excision.

Preoperative Factors to Consider

DONOR SELECTION Donor Selection and Matching in Facial Vascularized Composite Allotransplantation (VCA) presents a significant challenge that surpasses solid organ transplantation in complexity. The process requires meticulous matching of donor and recipient based on factors like blood type, immunological criteria, demographics, and physical traits. This shortage of suitable donors in facial VCA leads to extended waiting times for candidates. Regarding donor gender, theoretically, it is possible to transplant tissues from a woman to a man without complications due to hormonal influences. However, in practice, to date, donors and recipients have typically been of the same sex. Size compatibility emerges as a crucial criterion, as grafting a small face onto a larger head is impossible.

RECIPIENT PREPARATION Ensuring the patient’s psychological well-being is of utmost importance in recipient preparation. Disfigurement often necessitates psychotropic treatment and long-term psychological support, spanning months or even years. Establishing a climate of trust with the entire healthcare team is crucial as the transplant process can be an arduous ordeal for the patient. Open and respectful communication is vital, regardless of the patient’s unique history.

A comprehensive clinical and paraclinical evaluation, including biological and radiological assessments, must be conducted. This entails HLA grouping, antibody screening, and serological tests for human immunodeficiency virus (HIV), hepatitis, cytomegalovirus, and herpes. In most cases, a CT angiography of the supra-aortic axes is necessary to evaluate the recipient’s vascular system. Some face transplant teams may also require conventional digital subtraction angiography. Electromyography (EMG) is performed to assess residual motor (facial nerve) and sensory (trigeminal nerve) functions.

How many facial transplants have surgeons performed?

Since the first partial face transplant in 2005 by Drs. Dubernard and Devauchelle in Amien, France, a total of 19 face transplants have been reported in the literature. These transplants involved 16 males and three females. France has performed the highest number of transplants (9), followed by the United States (6), Spain (3), and China (1). Among the reported cases, 12 were partial transplants, one was near-total, and six were full transplants. The surgical team incorporated osteomyocutaneous components in 12 cases, and they utilized myocutaneous components in seven cases. The indications for transplantation included trauma (animal bite: 3, burn: 3, ballistic: 9) in 15 cases, congenital deformities in three cases, and tumor ablation in one case.

Risks Involved

Rejection Risks Immunological rejection poses a significant challenge in facial transplantation, leading to major complications. Clinical examination plays a crucial role in detecting signs of rejection, such as erythema and edema. In such cases, skin and mucosal biopsies of the facial vascularized composite allograft (VCA) are performed. The degree of epithelial damage and infiltration of inflammatory cells can vary. Biopsies of the transplanted mucosa often exhibit more pronounced inflammatory changes compared to cotransplanted allogeneic skin.

It is important to distinguish three forms of facial transplant rejections based on their timing. Hyperacute rejection occurs within hours after the transplant, resulting in graft infarction. Acute rejection (AR) typically manifests around the fourth day post-transplant, characterized by infiltration of immunocompetent cells into the transplanted organ. Chronic rejection (CR) is a leading cause of transplant failure. Clinical signs of AR involving the skin commonly include erythema and edema of the facial VCA. AR of the oral and nasal mucosa often presents with ulcerations, erosions, and diffuse erythema.

Immunosuppressant Risks Immunosuppressant medications, which are essential for preventing tissue rejection, carry certain risks. These drugs, taken daily for the long term, work by weakening your immune system. While they help reduce the chances of rejection, they also make you more susceptible to various infections. Furthermore, researchers have associated immunosuppressant drugs with an increased risk of kidney damage, cancer, diabetes, and other significant health conditions.

Full Face Transplant: Case Study

Methods: On March 27, 2010, a comprehensive face transplant procedure was carried out at the University Hospital Vall d’Hebron in Barcelona, Spain. This involved transplanting all soft tissues and a portion of the underlying bony structure. The donor was a 41-year-old male who had passed away due to a severe brain hemorrhage. The recipient was a 30-year-old male who had suffered from a severe facial deformity resulting from a ballistic trauma in 2005. The entire process of harvesting and implantation took 24 hours.

Results: The surgery proceeded without any intraoperative complications. However, postoperative complications arose, including thrombosis of venous anastomoses, an acute oro-cutaneous fistula, right parotid sialocele, and two episodes of acute rejection. The medical team successfully managed these complications by performing anastomosis revision, conducting extensive irrigation, and making adjustments in immunotherapy. After four months following the transplant, the hospital discharged the patient. He experienced near-total sensation and partial motor recovery, showed no psychological complications, and displayed excellent acceptance of his new facial appearance.

Conclusions: This case report demonstrates the technical and clinical feasibility of a full face transplant, encompassing all tissues and maintaining the integrity of aesthetic and functional units. The early success observed in this case highlights the potential of such procedures in restoring facial form and function.

Conclusion

Due to its ability to restore critical functions and improve social interactions for individuals with severe facial disfigurements, facial transplantation is regarded as a significant therapeutic option. Currently, there are no alternative treatments available that offer comparable outcomes. Recent advancements in the field of facial transplantation can be synergistically combined with state-of-the-art regenerative medicine techniques and innovative immunological approaches. To attain superior results and minimize complications, it is essential to establish robust international networks among leading experts in facial transplantation. However, cautious patient selection, thorough clinical assessment, diligent follow-up, and effective rejection management are paramount.

The question remains, is face transplant ethical?

Continue reading for more!

Team MBD

References:

1. La Padula, S., Pensato, R., Pizza, C., Coiante, E., Roccaro, G., Longo, B., … & Meningaud, J. P. (2022). Face Transplant: Indications, Outcomes, and Ethical Issues—Where Do We Stand?. Journal of Clinical Medicine, 11(19), 5750.
2. Barret, J. P., Gavaldà, J., Bueno, J., Nuvials, X., Pont, T., Masnou, N., … & Martínez-Ibáñez, V. (2011). Full face transplant: the first case report. Annals of surgery, 254(2), 252-256.

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