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Thursday, December 18, 2008

A team of eight transplant surgeons in Cleveland Clinic in Ohio, USA, led by reconstructive surgeon Dr. Maria Siemionow, age 58, have successfully performed the first almost total face transplant in the US, and the fourth globally, on a woman so horribly disfigured due to trauma, that cost her an eye. Two weeks ago Dr. Siemionow, in a 23-hour marathon surgery, replaced 80 percent of her face, by transplanting or grafting bone, nerve, blood vessels, muscles and skin harvested from a female donor’s cadaver.

The Clinic surgeons, in Wednesday’s news conference, described the details of the transplant but upon request, the team did not publish her name, age and cause of injury nor the donor’s identity. The patient’s family desired the reason for her transplant to remain confidential. The Los Angeles Times reported that the patient “had no upper jaw, nose, cheeks or lower eyelids and was unable to eat, talk, smile, smell or breathe on her own.” The clinic’s dermatology and plastic surgery chair, Francis Papay, described the nine hours phase of the procedure: “We transferred the skin, all the facial muscles in the upper face and mid-face, the upper lip, all of the nose, most of the sinuses around the nose, the upper jaw including the teeth, the facial nerve.” Thereafter, another team spent three hours sewing the woman’s blood vessels to that of the donor’s face to restore blood circulation, making the graft a success.

The New York Times reported that “three partial face transplants have been performed since 2005, two in France and one in China, all using facial tissue from a dead donor with permission from their families.” “Only the forehead, upper eyelids, lower lip, lower teeth and jaw are hers, the rest of her face comes from a cadaver; she could not eat on her own or breathe without a hole in her windpipe. About 77 square inches of tissue were transplanted from the donor,” it further described the details of the medical marvel. The patient, however, must take lifetime immunosuppressive drugs, also called antirejection drugs, which do not guarantee success. The transplant team said that in case of failure, it would replace the part with a skin graft taken from her own body.

Dr. Bohdan Pomahac, a Brigham and Women’s Hospital surgeon praised the recent medical development. “There are patients who can benefit tremendously from this. It’s great that it happened,” he said.

Leading bioethicist Arthur Caplan of the University of Pennsylvania withheld judgment on the Cleveland transplant amid grave concerns on the post-operation results. “The biggest ethical problem is dealing with failure — if your face rejects. It would be a living hell. If your face is falling off and you can’t eat and you can’t breathe and you’re suffering in a terrible manner that can’t be reversed, you need to put on the table assistance in dying. There are patients who can benefit tremendously from this. It’s great that it happened,” he said.

Dr Alex Clarke, of the Royal Free Hospital had praised the Clinic for its contribution to medicine. “It is a real step forward for people who have severe disfigurement and this operation has been done by a team who have really prepared and worked towards this for a number of years. These transplants have proven that the technical difficulties can be overcome and psychologically the patients are doing well. They have all have reacted positively and have begun to do things they were not able to before. All the things people thought were barriers to this kind of operations have been overcome,” she said.

The first partial face transplant surgery on a living human was performed on Isabelle Dinoire on November 27 2005, when she was 38, by Professor Bernard Devauchelle, assisted by Professor Jean-Michel Dubernard in Amiens, France. Her Labrador dog mauled her in May 2005. A triangle of face tissue including the nose and mouth was taken from a brain-dead female donor and grafted onto the patient. Scientists elsewhere have performed scalp and ear transplants. However, the claim is the first for a mouth and nose transplant. Experts say the mouth and nose are the most difficult parts of the face to transplant.

In 2004, the same Cleveland Clinic, became the first institution to approve this surgery and test it on cadavers. In October 2006, surgeon Peter Butler at London‘s Royal Free Hospital in the UK was given permission by the NHS ethics board to carry out a full face transplant. His team will select four adult patients (children cannot be selected due to concerns over consent), with operations being carried out at six month intervals. In March 2008, the treatment of 30-year-old neurofibromatosis victim Pascal Coler of France ended after having received what his doctors call the worlds first successful full face transplant.

Ethical concerns, psychological impact, problems relating to immunosuppression and consequences of technical failure have prevented teams from performing face transplant operations in the past, even though it has been technically possible to carry out such procedures for years.

Mr Iain Hutchison, of Barts and the London Hospital, warned of several problems with face transplants, such as blood vessels in the donated tissue clotting and immunosuppressants failing or increasing the patient’s risk of cancer. He also pointed out ethical issues with the fact that the procedure requires a “beating heart donor”. The transplant is carried out while the donor is brain dead, but still alive by use of a ventilator.

According to Stephen Wigmore, chair of British Transplantation Society’s ethics committee, it is unknown to what extent facial expressions will function in the long term. He said that it is not certain whether a patient could be left worse off in the case of a face transplant failing.

Mr Michael Earley, a member of the Royal College of Surgeon‘s facial transplantation working party, commented that if successful, the transplant would be “a major breakthrough in facial reconstruction” and “a major step forward for the facially disfigured.”

In Wednesday’s conference, Siemionow said “we know that there are so many patients there in their homes where they are hiding from society because they are afraid to walk to the grocery stores, they are afraid to go the the street.” “Our patient was called names and was humiliated. We very much hope that for this very special group of patients there is a hope that someday they will be able to go comfortably from their houses and enjoy the things we take for granted,” she added.

In response to the medical breakthrough, a British medical group led by Royal Free Hospital’s lead surgeon Dr Peter Butler, said they will finish the world’s first full face transplant within a year. “We hope to make an announcement about a full-face operation in the next 12 months. This latest operation shows how facial transplantation can help a particular group of the most severely facially injured people. These are people who would otherwise live a terrible twilight life, shut away from public gaze,” he said.