The extreme disfigurement of a face by trauma, burns or birth defects has long been the realm of horror films (think Freddy Kreuger). There is something about the disfigurement of a face that evokes a revulsion and fear that mutation of a limb or other part of the body would not. Sadly, for those who have suffered such disfigurement, the distress is far from merely cosmetic. Patients who have experienced loss of part or the entirety of their face have difficulty with breathing, eating, speaking, sight and taste. They most often cannot smile or express other facial emotions and their appearance frequently evokes extreme negative reactions from those they encounter. Fortunately, today face transplantation has emerged from the realm of science fiction and is a reality for patients with severe facial disfigurement.
A face transplant can be partial or total. In a partial face transplant, only a part of the face is replaced with tissue from a donor. During a total face transplant, a person’s entire face is replaced with that of a donor. During face transplantations, a face is removed from a deceased donor during a lengthy operation. Special caution is taken to preserve the donor’s veins, arteries and nerves which are then stitched (connected) to the recipient’s face in a complex microvascular surgery. Sensation returns to the patients face at about three to six months, whereas return of motor function occurs generally at nine to twelve months. The first partial face transplant, was performed in France in 2005 on Isabelle Dinoire, whose face had been partially destroyed by her dog.
In December 2008, a group in the Cleveland Clinic lead by Dr. Maria Siemionow completed the first partial face transplant in the U.S., on Connie Culp who had been shot in the face by her husband.
Ms. Culp’s face transplant consisted of the transplantation of muscle, skin, blood vessels, nerves and even teeth from the donor. The first full face transplant was completed in Spain in 2010 on a man left disfigured by a shooting accident. The first full face transplant done in the US was done in March 2011, on Dallas Wiens who had been burned in an electrical accident in 2008.
Most recently in August 2015 the most extensive face transplant ever was done in NYU Langone Medical Center under the direction of Eduardo D. Rodriguez MD, DDS on a 41 year old fireman from Senatobia, MS, Patrick Hardsion.
Face transplants remain exceedingly rare. To date, there have been under 30 face transplants done worldwide and face transplantation is still considered an experimental technique since little is known of the long term outcome. Most recently the American Journal of Transplantation followed three face transplant patients over the course of 37 months and found that the patients were experiencing accelerated aging of the face. However, as opposed to having loss in facial fat and skin thickness which would be consistent with normal aging of the face, these patients were experiencing loss of muscle mass and bone which caused the face to sag. The study found that on average, 20% of face volume was lost over the three years the recipients were studied. Researchers explained that the muscle loss was expected due to the inability of surgeons to attach every existing nerve to the underlying muscle, thereby causing atrophy of the muscle. Loss of bone was more difficult to account for. Some attributed this to the immune suppression drugs all face transplant patients must take to avoid rejection of the transplant, while others felt it was the body’s way of rejecting the transplant even while being on the immune suppression drugs. Still others attribute it to inadequate blood supply to the face.
Despite the observed accelerated aging, transplant recipients report overwhelming satisfaction with their procedures and a great improvement to their daily lives. Having received a face, they have received a second chance at life.
Physician Assistant Student SUNY Downstate Medical Center
December 6, 2015