Face transplantation: the view from Vanderbilt University.

In 1997 when Americans first saw the John Travolta and Nicholas Cage movie entitled "Face Off," most assumed it was firmly rooted in the world of science fiction. In this movie an FBI agent played by Travolta, in order to infiltrate the inner circle of a nepharious criminal played by Cage, literally changes identities with him by having their faces surgically removed and cross transplanted one to the other. Even though this may seem somewhat far fetched and certainly in the realm of fiction, there have been, since 1992, several centers around the world investigating the possibility of composite tissue allotransplantation (CTA). The largest experience with CTA is in hand transplantation and approximately twenty have been reported world-wide. Two have been done in the United States at the University of Louisville in Louisville, KY. The functional results of hand transplantation have been reported as being equivalent to replantation at similar levels. There have also been reports of transplantation of vascularized nerve grafts, various joints, the larynx, the tongue, the abdominal wall and, of course, most recently a partial face transplantation in France. There are at least two institutions in the United States that have obtained IRB approval to proceed with identification of an appropriate recipient and an appropriate donor to perform a facial transplantation. These are the University of Louisville, previously mentioned, and the Cleveland Clinic.

Many feel that the French Team may have jumped the gun in performing a facial transplantation before many questions regarding this controversial procedure have been answered. The same criticism was leveled at Christian Barnard when he performed the first successful human cardiac transplantation in December of 1967. Even though the transplantation was successful, the patient died as a result of pneumonia 18 days postoperatively. It was felt that the pneumonia may have been brought on or exacerbated by drugs he was receiving to prevent rejection of the transplanted heart. However, a second patient operated on by Barnard in January of 1968 lived for 594 days after his transplantation. This clearly opened the door (or the flood gates) for multiple centers to begin performing cardiac transplantation. Again, many felt that the rush to transplantation preceded solving many of the problems related to the continued maintenance of the transplanted organ. These same questions remain unanswered in facial transplantation and other forms of CTA as well. The debate is further heightened by the fact that CTA transplants are usually not done in life or death situations

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No one knows what the effects of chronic rejection will be on a facial transplant. We do know from the limited experience with facial replantation that functional return is quite variable. We also know from our limited experience in CTA, most commonly in the hand, that the effects of chronic rejection are most manifest in the integument and vascular systems, which raises the specter of what these types of changes will do to a facial transplant over time. More critically, what happens if the transplant fails? Will the patient be worse off? Can another donor be found? What about the long term effects of immunosuppression in the recipient?

The American Society for Reconstructive Microsurgery has published a position paper concerning facial transplantation. In their paper, they advise cautious step wise advances before moving toward full face transplantation. Technically, the operation can certainly be done. As reported and described in the plastic surgery literature, it has been done successfully in experimental animals with very good results. However, these results are not directly transferable to the human condition.

Facial transplantation certainly offers a new avenue of hope and possible treatment for the facially disfigured patient. However, traditional methods of reconstruction in many cases may be preferable to facial transplantation. New techniques of innovative tissue transfer are constantly being developed and utilized by plastic surgery teams around the world. The myriad psychologic, physiologic and ethical questions that surround this controversial procedure would seem to mandate a studied and cautious approach. However, I feel that we must move forward and investigate this exciting new technology to its fullest.

When the French novelist Jules Verne published his novels toward the end of the nineteen century, they were clearly outrageous. De la Terra a La Lune (From the Earth to the Moon) published in 1865 and Vingt Mille Lieues Sous Les Mers (Twenty Thousand Leagues Under the Sea) published in 1870 imagined technologies that were obvious impossibilities at that time. However, today they are taken for granted. Hopefully, in the future, if we can solve the problems of rejection and if we can develop the technique to improve the functionality of facial transplantation, it may indeed become the procedure of choice for the facially disfigured.

"Science, my lad, is made up of mistakes, but they are mistakes which it
is useful to make, because they lead little by little to the truth."
--Jules Verne

Bruce Shack, MD

From Vanderbilt University, Nashville, TN.

Reprint requests to Bruce Shack, MD, Vanderbilt University, 2100 Pierce Avenue, Suite 230 MCS, Nashville, TN 37232. Email: [e-mail]