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Results of three full-face transplants released

Robin Wulffson MD's picture
full-face transplant, facial injury, imunosuppression, infection

BOSTON, MA - Physicians at Brigham and Women’s Hospital published the results of three successful full-facial transplants in the December 28 issue of the New England Journal of Medicine. Facial transplantation is a complex operation, which has the goal of transforming severely deformed features to near-normal appearance and function with the use of techniques that conventional plastic surgery cannot equal.

Since 2005, a total of 18 patients have received transplants with promising results; however, most of these procedures were tailored to restore partial-face defects. A full-face procedure is much more extensive: it includes the forehead, eyelids, nose, lips, chin, and cheeks, with or without underlying bone. The procedure is understandably extremely complex; it includes grafting not only the skin, but also nerves, muscles, blood vessels, and structures such as the nose.

This year, three individuals at Brigham and Women’s Hospital in Boston underwent a full-face transplant. The first two patients suffered severe facial injuries following an electrical burn. The third patient was the victim of a chimpanzee attack. The third patient not only underwent a full-face transplantation but also underwent a transplantation of both arms. In addition to the surgical complexity, the procedure requires the acquisition of a suitable donor with a good tissue match as well as similar cosmetic features. In addition, the patients had to be placed on immunosuppressant medication to prevent rejection.

According to lead author Bohdan Pomahac, director of the plastic surgery transplantation program at Brigham and Women’s, the chief obstacle to the surgery had been the belief that you would need to connect four arteries and a corresponding number of veins in order to provide enough blood flow to the transplanted tissues. He explained, “If that were the case, it would be extremely complicated.” However, the surgical team used a simplified method, connecting just one artery and one vein on each side of the face.

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In an attempt to restore facial function, the team also connected all the main available motor and sensory nerves. “When the patient wants to blink,” he can do so, said Dr. Pomahac. He explained that the patients can expect to regain between 75-90% of facial function. However, that return of function may take time. For example, patient 3 (chimpanzee attack), now three months postoperative, has regained a return of sensation; however, motor function has not returned..

The major complication experienced by the patients was infection due to the immunosuppressive drugs they received to prevent rejection of the transplanted tissues. Fortunately, however, all of them fully recovered. In addition, Dr. Pomahac noted, over time their drug regimen has been tapered down from four drugs to two, to minimize the incidence of side effects. He added that the drug regimen could be further decreased in the future by lowering the dosage of the two drugs or even placing the patients on a single drug. All patients received mycophenolate mofetil, methylprednisolone, and rabbit antithymocyte globulin during the surgery. Afterwards, they were placed on mycophenolate mofetil, tacrolimus, and a tapering dose of prednisone.

Prior to the surgery, all patients were fully apprised of the indications, risks, and benefits of the surgery. In addition, they received input from an ethicist. Postoperatively, the patients received extensive counseling, particularly during the first three months.

The hospital received a Department of Defense (DOD) grant to fund these transplants in civilians and veterans. Potential candidates must meet certain requirements, including the loss of at least 25% of the facial tissue or a major, irreplaceable part of the face such as the nose or the lips. Candidates are also screened to insure that they are sufficiently medically and psychologically fit for the procedure.

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