30th March 2012
There has been much media interest in the most recent facial transplant, performed by Eduardo Rodriguez and his team at the University of Maryland Medical Centre in the US. The patient, Richard Lee Norris, 37, was injured in a shotgun accident when he was 22. Richard approached the University of Maryland nearly 7 years ago and has been working with the team there ever since.
The interest, it appears, is due to this particular transplant reportedly being the ‘most extensive' yet. And it may well be: the allograft included maxilla and mandible with associated soft tissue, tongue, teeth, and skin extending from the scalp to the neck. Another reason for the media interest in this particular case is the impressive aesthetic outcome at just one week postoperatively. Suture lines are placed away from the face and an excellent skin tone match has been achieved. You can see some before and after images here:
This is the first face transplant performed at the University of Maryland. 19 face transplants have now been carried out worldwide, although this figure is often misquoted due to some centres not publishing their data, with others publishing more than once. The teams with the greatest experience are those of Laurent Lantieri in Paris (7 transplants) and Bohdan Pomahač in Boston (4 transplants). Both groups have published extensively and a consensus has formed regarding the indications for facial transplantation: the defect needs to be unreconstructable by conventional techniques; the patient must be suitably motivated, supported and informed; and the transplantation team must be adequately experienced.
Opponents of facial transplantation may argue that no defect is truly unreconstructable with our extensive armamentarium of techniques utilising autologous tissue. However, quoting Lantieri in the January 2012 issue of The Journal of Craniofacial Surgery: "putting surgical bravado aside, we must admit that there are elements of the face that we cannot satisfactorily reconstruct". The principal defects Lantieri refers to are those to the upper face necessitating the reconstruction of orbicularis oculi; and defects to the lower face requiring the reconstruction of orbicularis oris. Opponents may also argue that the risks of long-term immunosuppression are not outweighed by the benefit of facial transplantation. However, the side effects of immunosuppression are well documented and patients may make an informed and autonomous choice as to whether they are prepared to take on these risks. Finally, patients must be made aware of the risk of allograft loss due to rejection. While acute rejection episodes are common among composite allograft recipients, there have been few signs of chronic rejection. Nevertheless, an autologous reconstruction contingency plan must be put in place should a rejected allograft need to be removed.
Initial projections indicated that patients with burn injuries would be the largest group to benefit from facial transplantation. However, the majority of patients to undergo the procedure have suffered ballistic trauma. The largest group of patients who may therefore benefit from a composite transplant are troops injured in Iraq or Afghanistan. These patients are generally young, otherwise healthy, and highly motivated. Accordingly, research into composite allotransplantation has advanced significantly in recent years thanks to sizeable grants awarded by the US Department of Defense (DoD). Funding for the transplant procedures carried out in the US has also come from the DoD under clinical trial programs - a necessity given that insurance firms are yet to fully fund the procedure which costs between $250,000 to $350,000.
There is now sufficient evidence to demonstrate that when the procedure is performed to reconstruct an appropriate defect, on a suitable patient, by an experienced team, the results can be spectacular. The transplants performed to date have had an immeasurable impact on the quality of the patients' lives: all but one has returned to a normal social life after recovery; many have returned to work; and one has rebuilt the relationship with his ex-wife after divorce. Mainstream media is always interested in the ‘human story' behind groundbreaking procedures such as facial transplantation. Richard Lee Norris lived as a recluse. He avoided eating in public and would shop for groceries at night so as not to be seen. Now he is already learning how to speak again, is able to smell, is shaving, brushing his teeth, and after 15 years, is finally ready to face society again.
Fadi Issa, Specialty Registrar and Clinical Research Fellow
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