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Rebecca Moore
Dr. Rance LeFebvre, Derek Dockter
COSMOS Cluster 7; Biomedical Sciences
27 July 2015
Looking Back and Looking Ahead: Face Transplantations
Face transplantations are the culmination of many years of hard work by doctors willing
to help those who were unable to function in society due to massive facial deformities.
These deformities often prevent sufferers from speaking, eating, or even showing a full
range of emotion. Nowadays doctors can help these people, but at a high cost, something
the are trying to lower. Once lowered face transplants will become a more affordable
treatment.
When one mentions face transplants people often think about a random person with a
severely deformed face receiving a long surgery resulting in a new face; however, they rarely
think about the preclinical testing or future uses of the operation. Face transplantations marked
another step in the progression of skin and soft tissue transplantations which started with a failed
hand transplant 40 years ago. The pathway from failed hand to complete face transplantation was
made possible by laboratory work on animals, especially rats, pigs, and primates, which allowed
doctors to test multiple procedures without risking human lives. After multiple successful animal
procedures the testing continued, but this time on corpses. This cadaver testing allowed doctors
to gain valuable experience before carrying out operations on actual patients. Facial
transplantation operations require hundreds of thousands of dollars, a carefully selected patient,
and a strong, multidisciplinary medical team. One goal of these professionals is to eventually
have full and partial face transplants be accessible options for war-injured members of the
military. The past 51 years have shown the evolution of face transplants from a distant idea to a
repeatedly successful procedure that still has room for improvement.
History
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Although solid organ transplantations have become relatively common since the 1950s,
skin and soft tissue transplants were not even attempted until 1964 and were not successful until
1988 (Barret and Tomasello 8). In 1964 doctors in Ecuador attempted the first soft tissue
transplantation, a hand, which the patient’s body ultimately rejected even though they were given
multiple immunosuppression medications. This setback took over 30 years to overcome, with
scientists and doctors working during those years to improve and introduce more
immunosuppression drugs and medications. They also began to test new transplantation methods
on small animals which proved successful, so they continued their testing on larger experimental
animals. After more positive test results testing on humans began in Louisville, Kentucky and
Lyon, France. All those tests eventually led to “the first human hand allotransplantation was
performed in France (Lyon) in September 1998, followed by the Louisville team in January
1999” (Barret and Tomasello 9). “Since the first hand transplant in France in 1998, 35 hand
allograft transplants have been performed worldwide” (Siemionow and Yalcin 259). The
plethora of successes have allowed doctors to better understand immunosuppression drugs, and
they have shown that a large team and well-selected patient are necessary for the best possible
results (Barret and Tomasello 9). The successful soft tissue operations also marked the first
major step on the path to full face transplantations.
Before operations could be performed on humans they first had to be tested, which
doctors did using animals such as rats, pigs, and monkeys. Rats are the most commonly used
species due to the low cost to maintain them, a short operation time, and only one surgeon is
needed to do the complete operation. Soft tissue only transplants that started in 2003 led to
operations that also transplanted bone in 2006, and both of these steps led to full face transplants
that allowed the rat to gain sensory and motor neuromuscular units in 2010 (Siemionow and Zor
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42). In between each major step there were smaller steps with operations that focused on
transplanting specific bones and other facial features. For example, during one hemiface
operation in 2010 doctors focused on, and successfully transplanted, the jaw bone, multiple teeth,
the masseter muscle, and the tongue. Although rats provided cheaper test subjects, their immune
systems differ fundamentally from humans’ systems making the use of swine and primate
subjects more valuable because of the closer similarity between their immune systems and those
of humans (Kuo 56). Test hemiface operations on miniature swine took place in Taiwan with the
goal of learning what immunosuppressants worked the best during postoperative care to prevent
the subject from rejecting the allograph (Kuo 59). Nonhuman primates, primarily cynomolgus
monkeys, were also used to test various immunosuppressants in order to see which options have
the highest probability of effectively working on humans. Doctors transplanted “an
oromandibular segment including masseter muscle, overlying skin, common carotid artery, and
external and internal jugular veins, harvested from the left jaw” from one monkey’s face to the
“left lower abdominal wall of the recipient monkey” (Rodriguez et al. 64). The results from this
experiment showed that success was greatest when using “tacrolimus-based
immunosuppression” with “the addition of a second venous anastomosis to reduce postoperative
graft swelling” (Rodriguez et al. 70). Testing on animals led scientists to begin testing different
face transplant methods on cadaver models.
Cadaver experiments allowed doctors to learn more about the actual procedure and what
to expect when they operated on living patients. In using cadaver models doctors learned that in
order for a full face transplant to work using a single flap transfer the flap must come from
another person because no sections of skin on the patient’s own body would be able to provide
enough skin coverage for total face reconstruction (Gordon and Siemionow 74). During an
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experiment in July 2006 doctors learned that a recipient’s post transplant appearance would be “a
hybrid mixture of various features resembling both the donor and the recipient” (Gordon and
Siemionow 75). This result allowed doctors to answer many critics who complained that the
patient who underwent a face transplant would lose their facial identity, which ended up not
being completely accurate. Doctors not only used cadaver testing during preclinical experiments,
they also used specialized cadaver studies before carrying out individual face transplants on
actual patients. These specialized studies allowed for doctors to perform a practice run that gave
them estimates of how long individual parts of the procedure would take and an estimated total
time of the operation.
Present
All the years of testing led to face transplants becoming an actual operation performed
around the world. 2004 and 2005 marked important years in the history of face transplantations
with teams in France and America being granted permission by ethic committees to perform
partial face transplants and full face transplants respectively. Doctors in Amiens, France soon
made face transplants a reality, performing the first human partial face transplant in 2005 on a
woman who had lost the lower part of her face after a domestic dog attack. This operation was
soon followed by another partial face transplantation on the lower face in Xian, China in April
2006. Results for both operations were positive with both patients reporting good to excellent
recovery of senses and functions (Barret and Tomasello 11-12). Multiple partial face transplants
followed these taking place in the United States, Spain, and France, but a full face transplant did
not occur until 2010. March 2010 marked the final step in face transplantation with the
performance of a full face transplant in Barcelona, Spain that gave a 30-year-old male patient
“new skin, muscle, lips, eyelids, lachrymal apparatus, mucosa, palate, upper and lower teeth, and
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nerves” (Barret and Tomasello 12). “The past 9 years, 31 face transplants have been performed
worldwide” (Blondeel et al. 1). These operations have taken place in seven different countries
throughout Europe, Asia, and North America providing doctors around the world with valuable
experience and people around the world the ability to reenter society.
But patients’ return to society comes at a large cost and involves many medical
professionals in order for the transition to succeed. The cost of a face transplantation for a 46year-old female victim of a shotgun blast was $349,959, and the cost of immunosuppressants
was $21,506 plus a yearly payment varying between $14,000 to $20,000. (Siemionow et al. 380,
384). Although these costs may prevent some from wanting a face transplant, to others this is a
small price to pay for a new life. Before they can begin their new life patients must go through a
detailed selection process, a long operation involving many doctors and nurses, and a lifetime of
post-operational care. The selection process for patients able to receive face transplants includes
an evaluation by a multidisciplinary team in order to make sure the patient’s deformity qualifies
them for a face transplant and to learn whether the patient could psychologically handle the
transplant. The actual procedure involves a large team of doctors from many different disciplines
from plastic surgery and immunologists to occupational therapists (Barret and Tomasello 2).
This combination allows the patient to achieve the best results and to adjust as best as possible to
having a new face. After receiving a face transplant, patients face a life time of
immunosuppression medication called maintenance therapy. Patients also receive physiotherapy
to help them adapt to their new face and complete functions such as speaking and movement.
(Barret and Tomasello 69). The high cost and lifelong treatments are just a few of the things that
doctors hope to change in the future of face transplants.
Future
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Doctors hope to make face transplantations a possible treatment option for soldiers
injured in battle. This change would help all the soldiers who are “survivors of major face
avulsions characterized by loss of central facial features, notably portions of the jaws, lips, and
nose” (Hale 403). For many soldiers who suffer from severe facial injuries “conventional
treatments with autogenous flaps are futile … too often, surgical fatigue terminates
reconstruction, not achievement of an adequate result” (Hale 408). But this change will not
become possible until “the immune system can be safely and predictable down-modulated or
immunotolerance established in the recipients” (Hale 408). If either of these things happen
immunosuppressants will become unnecessary, limiting the amount of money spent on lifetime
post-operative care and allowing even more people, soldiers and civilians, to consider receiving a
face transplant.
Although doctors continue to make improvements, the past 51 years have shown the level
of improvement in transplant surgeries with hand transplants leading to full face transplants. This
evolution would have been impossible if not for animal and cadaver testing that allowed doctors
to practice mock operations. The actual operations involve a lot of money, a carefully selected
patient, and a large medical team consisting of professionals from a multitude of disciplines.
Doctors eventually want to lower the cost by erasing the need for lifelong treatments of
immunosuppressants which would open up this operation to more people, especially war-injured
soldiers. Although there are still improvements to make, face transplantations have already and
will continue to drastically improve the lives of people around the world suffering from severe
facial trauma.
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Artistry. Berlin: Springer, 2015. Print.
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