Face transplantation: the view from Duke University and the University of Chicago.

The partial face transplant performed in France last November 27, 2005, ushered a whole new arena of reconstructive surgery into the public eye. Unfortunately, this event has not been universally well received by the international community of reconstructive microsurgeons and medical ethicists. Early in 2005, the American Society for Reconstructive Microsurgery recognized the need to come forward with a position paper on facial transplantation, as there was growing evidence that the procedure would go forward in the very near future. In the interest of public safety and to establish a medical standard of engagement, criteria were developed to guide surgeons who were contemplating performing a facial transplant procedure.

The ASRM position paper (1) acknowledges the numerous issues of concern regarding facial transplantation, and identifies several major obstacles requiring resolution. Perhaps the most important issue is that of immunologic modulation of the host to prevent rejection of the transplanted face. To date, the world experience with composite tissue allotrans-plantation suggests that our current immunologic protocols fall miserably short in preventing both acute and chronic rejection. It is well accepted among transplantation immunologists that acute rejection will predict the likelihood of chronic rejection and chronic rejection predicts transplant failure. Therefore, we must anticipate that the facial transplant, a composite tissue allograft, will undoubtedly be rejected. Significantly, patients receiving facial transplants are doomed to receive immune suppressive agents for as long as the transplant remains viable. These agents are not benign and expose the recipient to high risk for the development of diabetes, decreased kidney and lung function, avascular necrosis of the hip, and the stigmata of chronic immunosuppression such as neoplasia, and opportunistic infection.

Considering the known limitations and controversies surrounding composite tissue allotransplantation at this time, it is surprising that the French team elected to go forward with their partial facial transplant. As well, it was very disconcerting to learn that the patient may have sustained injuries as the result of an unstable psychologic profile and had also signed a monetary contract for a film documentary of her transplant before the event. The French team that performed this partial facial transplant has not been far from controversy as the leader of this transplant team. Dr. Jean-Michel Dubernard also performed the first hand transplant in 1998. This surgery was noteworthy because it was performed on an ex-convict who soon proved to be very noncompliant with taking his immunosuppressive meds and undergoing appropriate physiotherapy, in favor of seeking notoriety on media talk shows and the press. The result was failure of the transplant requiring amputation. The French team's exuberance to become the "first" to perform a hand transplant seems to have been prompted more by self-aggrandizement than by any concerns of appropriate patient selection and patient safety. That another French team, lead by the same surgeon, a urologist, has now performed a partial face transplant gives rise to suspicions of medical impropriety at all levels. It is not, therefore, a question of if the transplant will fail, but when will this happen.

[ILLUSTRATION OMITTED]

[ILLUSTRATION OMITTED]

In January 2006, The ASRM in conjunction with the American Society of Plastic Surgeons (ASPS) (2) published a joint compendium outlining ten Guiding Principles for facial transplantation. Outstanding in this document is the condition that facial transplantation should not be performed for defects that could be functionally and esthetically reconstructed using conventional techniques. Combined with the ASRM position paper, the ASRM/ASPS document clearly establishes a therapeutic standard for clinical experimentation in facial transplantation. While this will not stop surgeons from performing facial transplantation, these papers offer a means to assure public and patient safety.

The microsurgical and transplant community will closely scrutinize the progress of the French partial facial transplant. Hopefully, this event will define for others what not to do at this stage of understanding and development. In their Working Party Report, the Royal College of Surgeons (3) advised against proceeding with human facial transplantation at this time, primarily for the reasons cited above. Similarly, most medical ethicists would not favor proceeding with facial transplantation at this time. It is our opinion that a major advancement in immune system modulation that promotes transplant tolerance of the recipient with little or no systemic risks must occur for facial transplant to progress to the stage of clinical application. Only then will the issues of surgical technique, facial re-animation, and psychosocial adjustment appropriately come to the front. Until that time, continued laboratory investigation is warranted to elucidate the nuances of composite tissue transplant tolerance in primates.

The potential applicability of full or partial facial transplants in reconstructing acquired or congenital defects of the head and neck is enormous. Were there to be a significant advancement in immune modulation as noted above, it would revolutionize how surgeons do reconstructive surgery. Until then, it is appropriate to proceed incrementally, and, above all, do no harm to our patients.

References

1. ASRM Position Paper. Facial Transplantation, 2005. Available at: http://www.rcseng.ac.uk/publications/docs/facial_transplantation.html.

2. ASRM/ASPS. Facial Transplantation: Guiding Principles, 2006. Available at: http://www.plasticsurgery.org.

3. Morris P, Bradley A, Doyal L, Earley M, Milling M, Rumsey N, RCS Working Party. Facial Transplantation: Working Party Report. London, Royal College of Surgeons of England, 2003.

Music washes away from the soul the dust of everyday life.
--Berthold Auerbach

Robert L. Walton, MD, FACS and L. Scott Levin, MD, FACS

From the Department of Surgery, Section of Plastic Surgery, The University of Chicago, Chicago, IL, and the Department of Plastic Surgery and Orthopaedic Surgery, Duke University Medical Center, Durham, NC.

Reprint requests to Scott L. Levin, MD, FACS, Duke University Medical Center, DUMC 3945, Durham, NC 27710. Email: [e-mail]