THREE partial face transplants have been performed worldwide and they have all
been successful. Overnight three people were given back a life where they
could interact with friends and family as well as strangers without feeling
ostracised for their facial disfigurement.
The first one took place in northern France in November 2005 when Isabelle
Dinoire had the bottom half of her face chewed by a dog. The second and
third partial face transplants followed swiftly afterwards, both on men. One
took place in China in April 2006 following a bear attack. The other, in
January 2007, was used to reconstruct in the case of a genetic condition
called neurofibromatosis, which can cause significant facial disfigurement.
There has been a significant level of debate on the moral and ethical as well
as medical issues. In essence the debate surrounding this type of transplant
is a trade-off between quality of life and quantity of life.
Nobody can be in any doubt that these three patients have benefited
significantly from this new type of facial reconstruction. What they have
shown is not only that this procedure is technically possible but that the
results are far superior to any other modern reconstructive technique.
In the past, loss of face tissue could only be repaired through a long drawn
out process of skin grafts and flaps involving many operations, often
producing unsatisfactory results.
My journey towards facial transplantation began when I met a 19-year-old boy
very early on in my career with severe facial burns. He had been
reconstructed using the same techniques we still use today. He had had more
than 30 operations but the end result was a face that not only had severe
functional problems but made it impossible for him to walk down the street
without getting extreme reactions from people.
When I realised that modern surgery was not the solution I searched for an
alternative and better approach. While continuing my training at the Harvard
Medical School I came across two potential solutions to this problem: one
was growing tissue - so far this technique has only been able to produce
something akin to a skin graft. The other option was transplantation.
Over the past 10 years, working at the Royal Free Hospital in London, I have
put together a facial transplant team of skilled professionals. All have
donated their time for free. The experimental work leading to this began
over 15 years ago and I set up the clinical research programme six years ago.
The team has over 30 members and many other support staff with key members
including surgeons, psychologists, a nurse coordinator, transplant
physicians and an ethicist. In 2006 our team received ethical committee
approval to proceed with screening patients for facial transplantation.
The screening and preparation of patients for this type of surgery takes time.
Each patient is unique. They not only have very specific injuries requiring
reconstruction,which are different in each patient, but also require very
different levels of psychological support and preparation for surgery.
The surgical technique involves removing the old scar tissue from the damaged
face and replacing it with the new tissue from an undamaged face. There are
three phases to the operation. The first involves the removal of the facial
tissue from the donor. The second phase is a difficult procedure as this is
when the old scar tissue from the damaged face is removed and it is
important to preserve the undamaged tissue beneath to optimise the end
result. This part of the operation would take four to five hours.
In the third phase the donor facial tissue is placed onto the recipient. The
first stage of this phase is to anchor the tissue in key areas, around the
eyes, the mouth and nose. The second stage of the final phase, the most
important, is to re-establish the blood supply to the facial tissue. This is
achieved by joining the small blood vessels supplying that facial tissue to
blood vessels of the patient. This is achieved using a microscope and
suture materials as fine as a human hair.
Once the blood supply has been reestablished the other structures, the
muscles, nerves, cartilage and skin can be rejoined. Following the operation
the patient is closely monitored for forty-eight hours and then subsequently
for a number of weeks.
Face transplant is not without risk. There is a risk of about 2% of technical
failure, which means, simply, that the microsurgery doesn’t work; the blood
supply doesn’t flow, causing the donor tissue to die.
The next risk is one of rejection. Following the aforementioned transplants
there have been episodes of rejection. These have all resolved successfully
with an increase in medication and no transplant has been lost due to
rejection.
Which leads me to the third risk and the one which has attracted a significant
level of debate, as it is key to the ethical debate. That is the risk
relating to the inherent complications of taking long term medication to
prevent rejection of the foreign facial tissue.
It has been estimated that these medications taken long term can shorten life
by up to 10 years. So each potential face transplant patient is confronted
with the choice of a shortened but higher quality life.
When assessed by people who do not have severely disfigured faces, these risks
would be perceived as unacceptable. Most patients with severe facial injury
who seek this type of surgery, however, have a poor quality of life. Some
even state that what they have is not a life but an existence.
It has been estimated that 400,000 people have facial disfigurement in the
United Kingdom and that 250,000 of them have severe facial disfigurement.
While many lead normal lives, some do not. It has been reported that up to
60% suffer from problems such as social isolation and have a significantly
elevated risk of suicide. That is why some seek this option.
Other presumed risks of face transplant are significant psychological problems
that were predicted following a facial transplant have not transpired. In
fact the patients have done remarkably well following surgery and have
reported positive experiences following transplantation.
In order to fund the UK face transplant operations, I set up the Face Trust
charity (www.facetrust.org). I felt
that to seek funding within the NHS, which was already over-stretched, was
inappropriate. Despite this being potentially a significant advance in
facial reconstruction, it has not been easy to encourage financial support
for this kind of work. I found with most people it was an uncomfortable area
to discuss and hence to raise funds.
These successful cases have encouraged many surgeons around the world to set
up facial transplant programmes. The transplants to date have been performed
in carefully controlled conditions, with teams including surgeons,
psychologists, transplant physicians and therapists. The main risk now to
face transplant is the surgeons attempting to perform the procedure without
due care and attention to the whole process and the long term management of
the face transplant patient. Already the debate has moved on. No longer are
we discussing the ethics of whether to perform a face transplant but merely
the ethics of how.
