The second face transplant in the United States was performed earlier this week at Brigham and Women’s Hospital in Boston. The first U.S. face transplant was done in December 2008 at Cleveland Clinic. To date, there have been 7 face transplants done worldwide, 4 in France, 2 in the U.S. and one in China. While once only a concept for the movies (Darkman 1990, Faceoff 1997) and TV (Nip/Tuck, Grey’s Anatomy), real life face transplants appearing to be gaining ground and acceptance.
Face transplants capture imagination because one envisions a completely different face being used and appearing after or one building up a face from scratch……just like in the movies. In reality, the use of the operation is for horrendous facial injuries due to extensive loss of tissues or severe disfigurement from burns. In these cases, the loss of facial tissue is so severe that even extensive plastic surgery with conventional microsurgical techniques (tissue transfer from oneself) is still wholefully inadequate. This is a small handful of cases in any geographic region but these patients are true facial cripples and recluses from society. The goal of face transplants is to bring as much specialized pre-formed tissue as possible into the facial defect. This usually means such structures as the nose, lips, and eyelids if needed. Many external and some internal facial structures simply can not be reproduced or made with any known existing plastic surgery method.
Facial transplants are truly a plastic surgery marvel and are the result of years of research in the field, a long history of microsurgery evolution, the right donor situation, and the use of immunosuppressant drugs. The procedure consists of a series of operations requiring rotating teams of specialists. With issues of tissue type, age, sex, and skin color taken into consideration, the patient’s face is removed and replaced. (including skin, underlying fat, nerves, and blood vessels, but no muscles) Hooking up blood flow into and out of the transplant (tiny blood vessels) is the key to a successful take of the transplant. The surgery is quite long and may last anywhere from 10 to 20 hours, followed by up to two weeks in the hospital.
One of the keys to long-term success is the lifelong use of immunosuppressive drugs which are necessary to suppress the patient’s own immune system and prevent rejection of the transplant. Long-term immunosuppression increases the risk of developing life-threatening infections, kidney damage, and cancer. This is why face transplants currently are only for the most severe facial problems that can not be satisfactorily treated with contemporary plastic surgery techniques.
The face transplant does not make the patient’s face appear like the deceased donor’s face because only the outer cover of skin and fat is used. The underlying muscles and bone, for the most part, are the patient’s natural structure. Facial movements are due to the brain so the expressions and personality of the ‘new face’ remains that of the recipient patient.
What is the future for face transplants? I have no doubt that we will continue to see more and more done in the next few years. The techniques of the operation have been established and the limited factors are patient selection, institutional ethics, and underwriting of the expense of the procedure. Its use will continue to be for the most severe facial cripples and it will take at least another ten to fifteen years or so before it works its way into mainstream reconstructive plastic surgery. And another lifetime before it becomes like it has been portrayed on the screen. As an Indianapolis plastic surgeon, face transplants are a remarkable achievement that makes every plastic surgeon proud and a continuing part of the long legacy of innovations that is the hallmark of this surgical subspecialty.
Dr. Barry Eppley