WebMD Medical News
Daniel J. DeNoon
Laura J. Martin, MD
Aug. 12, 2011 -- What, exactly, is a face transplant?
The question is being asked anew with the release of dramatic before-and-after images of Charla Nash, the Connecticut woman mauled by a chimpanzee and the latest person to receive a face transplant.
Some 17 people in the world now have undergone the experimental and still misunderstood procedure, says Maria Siemionow, MD, PhD, director of plastic surgery research at the Cleveland Clinic.
Siemionow, who led the team that performed the first U.S. face transplant, says that in one way, a face transplant is like a kidney transplant: It comes from a human donor.
"But a face you can see and a kidney you cannot," Siemionow tells WebMD. "So this becomes much more of an issue. The face has many arteries, veins, muscles, and nerves which have to be reconstructed to the extent they will bring back facial motion. The patient has to be able to smile, to purse the lips, to present happy expressions. This is very different from any other transplant."
Nash, who was initially under the care of Cleveland Clinic surgeons, eventually received the transplant at Brigham and Women's Hospital in Boston. She is still recovering from complications of surgery, but issued a dramatic statement thanking her doctors -- and most of all thanking the anonymous deceased woman who donated her face.
"I will now be able to do things I once took for granted," Nash says in the statement. "I will be able to smell. I will be able to eat normally. I will no longer be disfigured. I will have lips and will speak clearly once again. I will be able to kiss and hug loved ones. I am tremendously grateful to the donor and her family."
Facial reconstruction surgeon John Girotto, MD, director of the craniofacial anomalies center at the University of Rochester's Golisano Children's Hospital, says face transplants can indeed fulfill such expectations.
"Does it really work? Yes. Do you look like the donor? A little bit, but you still look like yourself," Girotto tells WebMD. "We are not quite there yet -- it is still an experimental thing -- but face transplant holds great promise for people with terrible injuries and no other established options."
Who is a candidate for a face transplant?
"It is a very drastic procedure, so you need to have an extremely disfiguring facial injury or birth defect for which other standard reconstructive techniques aren't good enough," Girotto says. "Things like shotgun wounds to the face; large, full-skin-thickness burns; and in Asia, it's also been used for people with neurofibromatosis [a disfiguring genetic disease]."
But not every disfigured person is a candidate for face transplant. As with other transplants, face recipients must stay on immunity-suppressing drugs for the rest of their lives in order to keep their bodies from rejecting the face.
"Like all transplants, a face can be rejected, and this can happen any time: three, five, even 20 years later," Siemionow says. "This is very important when accepting patients, to check if they have enough normal skin and muscle and bone in their body so we can cover their face, maybe not perfectly but enough to save their lives, if the transplanted face rejects."
Another issue is psychological. A person's face is, after all, a person's identity. There are very complex emotional decisions a patient must face, Girotto says.
"Getting a new face to replace your disfigured one seems easy, right? But it is not your face that you get," he notes. "The vast majority of interactions with people around you involve your face and facial expression. When that is taken away, your interaction with people outside your house is extremely limited. Then when you have a transplant, when tissues of someone else's face are applied to you, you are truly a new person. You are not back to the person you were before your injury."
Another issue is maintaining the transplant. Anti-rejection medications must be taken every day at the prescribed time, and the transplant must be constantly inspected for signs of rejection. Moreover, nerves and muscles don't grow back correctly unless the patient constantly exercises his or her facial muscles as part of rehabilitation therapy.
But Siemionow says most face transplant recipients accept the downsides of the procedure.
"At least from reports we get, most transplant patients are happy to get back a normal human face," she says. "They are happy when they wake in the morning that they can feel a nose instead of a hole."
But for an operation performed on people whose lives are not in danger, it's an extremely high-risk procedure. Of the 17 patients known to have received face transplants, Siemionow says, two have died.
Balancing the risk are substantial potential rewards.
"Our patient, Connie Culp, before transplant did not have a nose so she was breathing through a tube in her neck. She did not have a palate, so she could not eat solid foods and used a feeding tube in her abdomen. She could not smell. She could not smile," Siemionow says. "But after transplant she can breathe through her new nose and also speak intelligibly and eat with the return of a normal palate. She actually is smiling, she is kissing her grandchild, she can make funny faces. It is amazing how great is her functional recovery."
Exactly what gets transplanted from the donor to the recipient during a face transplant depends on the needs of an individual patient. Technically, the face extends from the bottom of the eyes to below the chin. The brow is not transplanted, as it is part of the skull and has a different blood supply than the lower face. Eyes are not transplanted, either, although eyelids may be part of a face transplant.
"Currently, face transplant can involve soft tissues, nerves, and some of the bony elements from the upper jaw, around the eyes, the mid-face, and the palate," Girotto says. "The facial nerve comes out through that soft tissue and helps you move the muscles, so you must reattach nerve channels to the new tissue. Then the body and the brain must grown new nerve down those tunnels you created. That is the part that takes the longest to heal."
Siemionow notes that outside the U.S., two face transplants have also included the lower jaw.
It's far from a simple operation. Two teams work simultaneously, one on the donor and the other on the recipient. In the donor's case, a cast is made of the face so that an artificial face can be applied to preserve the appearance of the corpse.
"In our case, there were over 50 medical personnel, including eight reconstructive surgeons, four anesthesiologists, and two transplant surgeons," Siemionow says.
Heightening the drama is the fact that surgeons don't know whether the 22-hour operation has worked until the last two hours.
"For 20 hours you don't know. You know only when you connect the arteries," Siemionow says. "Then when the white face gets blood and becomes pink, this is when you know the surgery works."
Siemionow says she's calculated that the face transplant performed by her team cost $350,000. But that astronomical figure is actually about $4,000 less than the cost of the 20 failed surgeries her patient underwent before the transplant.
So who does a face transplant recipient look like: the donor, or the patient?
"Each patient differs, because it depends on the deformity. We do not replace the normal part of the face, just the missing pieces," Siemionow says. "So the patient will never look like himself or herself -- but will not look like the donor, either. It will be a mix of donor and recipient, like a chimera, a little of their own tissue and tissue from the donor."
"They will resemble the donor with respect to skin texture and color," Girotto says. "They have more of the donor's nose than their own nose. But depending on how much bone has to be moved, the skin will re-drape and find the skeletal structure of the transplanted person. The skin will adapt to your bony skeleton over time."
Who the patient actually is does not change.
"The identity of the patient will be the same," Siemionow says. "The patient still has the same gestures, the same voice, the way the eyes look, so it is never a situation where the face of the patient will be transformed totally into the donor -- although many of the features of the donor will be preserved."
SOURCES:Maria Siemionow, MD, PhD, director of plastic surgery research and head of microsurgery training, Cleveland Clinic.John A. Girotto, MD, director, Golisano Children's Hospital Cleft and Craniofacial Anomalies Center and associate professor of pediatrics, plastic surgery, and neurosurgery, University of Rochester, N.Y.News release, Charla Nash.
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