Last month, the most extensive face transplant to date took place at the University of Maryland Medical Center, providing the patient with new tissue from the scalp to the neck, along with teeth, both jaws, and part of the tongue. This young procedure has already succeeded in giving back the lives of severely disfigured people. For them, living in isolation, hiding behind masks, unable to speak or eat normally, the chance to receive a functional, new face is the opportunity to live again. Dr. Bohdan Pomahac, who has performed some of the U.S.’s first face transplants, including the first full-face procedure in March 2011, describes some of the advances that have made this medical achievement possible and the huge impact on patients’ lives.
“You don’t often see horribly disfigured faces on the street, but when you do, you always remember it,” observes Dr. Bohdan Pomahac of Brigham and Women’s Hospital (Boston). Severe facial injuries trouble us so, because the face is a major point of social interaction and carries so much information important for communication. “Not one of us knows what it’s like to live without a face.” For the past six years, the plastic surgeon has devoted his research to helping those who do.
Earlier this year, Dr. Pomahac presented his work in advancing face transplant procedures to an audience at the Natick Soldier Systems Center, a U.S. Army research center, west of Boston. The funding for this research came from the military, which sees promise in it for severely wounded soldiers. Today, twenty centers around the U.S. are interested in starting their own face transplant programs. Following his presentation, Dr. Pomahac invited his first face transplant recipient, James Maki, to share his experience. The very fact that, today, this man can stand up in public and speak before a crowded auditorium, is testament to the huge progress in medicine’s ability to help people with severe facial disfigurement.
“It takes an enormous amount of courage on the patient’s side,” the surgeon says. Doctors are still learning about the complex body systems that participate in a face transplant and the best strategies for carrying out the operation. At the same time, plastic surgeons treating severely disfigured patients are aware of these individuals' desire to improve their own well-being, and their willingness to risk anything for it. Dr. Pomahac recalls discussing with a patient the potentially serious risks associated with the new face transplant procedure. “He told me, ‘Considering the life I have now, death doesn’t seem so dreadful.’ Life for them is horrendous. After the transplant, it is exponentially improved.”
Conventional methods “very, very suboptimal"
In 2005 Mr. Maki fell face-first onto a high voltage subway rail, resulting in massive trauma to the entire central portion of his face: nose, lips, chin, cheeks, upper teeth, and even the roof of the mouth. He has been in Dr. Pomahac’s care since immediately after the accident, undergoing multiple reconstructive surgeries, aimed at rebuilding his face. As with virtually all conventional reconstructions, though, the results were far from returning Jimmy to anything resembling normal appearance or function. (Photos available here.) “Conventional methods are very, very suboptimal,” Pomahac explains, “and initial results may worsen, due to scar maturation. The results are just horrendous; they have nothing to do with the face.” Before-and-after photos show that, while patients’ wounds may be successfully managed by skin grafts and other surgical interventions, their appearance remains, to put it bluntly, grotesque. They may live as recluses, unable to participate in society. Richard Lee Norris, victim of a gun accident and recipient of the most recent face transplant, in March, lived as a recluse for 15 years, wearing a mask to hide his deformity and doing his shopping at night. Jimmy Maki explains that, for several years prior to the face transplant, he had been going through life with a hole in the middle of his face. “When I went out in public, you wouldn’t want to hear what people said.”
In addition to intense psychological suffering, patients of reconstructive surgeries often have serious problems with function. Before the transplant, Jimmy’s speech was difficult to understand, due to an obstructing flap of soft tissue between his nose and mouth. Patient Charla Nash, who was attacked by a friend’s pet chimpanzee in 2009, was given dimples resembling nostrils, but had no real opening to her airways; she breathed through a tracheotomy and ate meals through a straw placed in a small hole where her mouth once was.
Dr. Pomahac hoped to change all that by bringing “a whole, functional face from a donor to a recipient. The goal of transplantation is to restore, rather than reconstruct, form and function.” The world’s first face transplant was performed in France, in 2005, by the team of Bernard Devauchelle. The patient, Isabelle Dinoire, had been mauled by her dog and lost her nose, lips and chin. Pomahac is quick to credit the French group with opening the door for this new procedure. “Finally, somebody did it right and you could see the amazing results. I thought, ‘I could operate on her 100 times [with conventional reconstruction methods] and not come close to the results of one transplant surgery.’” He thought of Jimmy Maki, and his other patients, and about what might be possible for them.
Full-face transplants thought beyond reach
Before the first successful face transplants, full-face procedures had been considered impossible, due to blood supply requirements for the face. “If you look at the face conceptually,” Dr. Pomahac explains, “it needs an enormous amount of blood supply from all directions. People said you needed at least four major vessels.” The trouble is, including as many as four inputs from the blood supply “makes the operation much harder. The dissection is very long and cumbersome, and you can’t connect all the nerves, which limits the functional outcome [of movement and sensation].” The ability of the transplant to function normally is very important to the patient’s well-being, but the face is complex – all five of the senses operate here – and the structures are packed into a very small space. This puts a limit on the fine surgical manipulations that can be performed.
The conventional wisdom around the minimum necessary blood supply came from blood flow studies carried out on cadavers. In the cadaver lab, a dye is injected into a vessel and tracked as it flows through the circulatory system. The area it covers can be observed, and studies showed that four vessels were needed to perfuse the whole face with blood. The system in a living body, however, provides more overlap. Vessels will fill in for missing neighbors, to an extent, and perfuse a larger area. This limitation of cadaver studies gave Pomahac reason to think a reduced blood supply might be sufficient in a real patient, making the transplant of an entire face far more feasible.
His own clinical experience also made the surgeon suspect fewer vessels were truly needed to perfuse the face. One that runs in front of the ear, for instance, was once thought to be critical, but he knew from performing cosmetic procedures, like face or brow lifts, that this supply is cut off during surgery, with no adverse effects. It couldn’t be truly critical, then. What Pomahac and colleagues found, in fact, was that just one vessel ought to be sufficient to provide blood to the entire face, hugely simplifying the procedure. “But all of this was just a hypothesis,” he says, “so, at some point we had to try.” In the end, partly by precaution, they connected a pair of vessels to the transplant, a technique that has recently proven itself capable of perfusing the whole face, including the upper and lower jaw.
Immunosuppression: The price to pay
Even after the complex and lengthy surgery – 36 hours for the latest, most extensive procedure to date – face transplant patients, like recipients of lungs, kidneys or any other organ, do pay a price in having to take drugs to prevent rejection of the donor tissue. This was an obstacle when Bohdan Pomahac was seeking approval to attempt the first procedure of the kind at Brigham and Women’s, the teaching hospital affiliated with Harvard Medical School: Was the need for immunosuppression an acceptable consequence of treating something that was not actually life threatening?
Today, he finds that patients do not consider it a problem to take a few pills in the morning and in the evening. “Knowing that faces…have a higher rejection rate, we picked the safest method, based on the past 60 years of transplantation experience. After inducing immunosuppression, to make sure there won’t be rejection at the start, we start chipping away at the medication. There’s nothing to guide us as to where the right dose is for each patient.” When the levels of the immunosuppressive drugs drop too low and an episode of rejection begins, doctors boost the meds again. In the end, the dosage does become quite stable and patients may return for a check-up just once every three months.
The Future for Face Transplants
Dr. Pomahac hopes that immunosuppression will be a place where future improvements to face transplant strategy lie. Immune tolerance is a state, observed in 5 to 10% of patients, where the transplant recipient never rejects the donor tissue, even without medication. Understanding this process and knowing how to control it, he says, is the holy grail of transplant research. “We don’t know the mechanism; we don’t know how to induce it. If we could, it would open doors for all other types of transplant.”
With more experience, the face transplant procedure should also become more efficient, reducing the time needed to collect the donor face – already down from six hours to four – and requiring less pre-operative workup and fewer tests. Such improvements should help lower the cost, which, today, runs about $250,000 per case, including the operation and three months of care. After this, according to a pre-arranged agreement, an insurance company usually covers the immunosuppressive medications. The cost for these ranges from $5,000 to $13,000 per year.
Further progress in face transplantation will determine whether the procedure becomes a standard tool in treating severe facial trauma, and whether the costs will fall enough to make it a legitimate option for more than the most extreme cases. Regardless, Dr. Pomahac feels this research is valuable for advancing our understanding of the human body. “The face transplant might not even be the most important thing that comes out of this. Ten or 20 years from now, the biggest benefit of all this could be that we’ll learn how the brain retrains itself for different [transplanted] areas, to re-employ the neurons. It’s like any research: you take the next step forward and don’t know what else you’ll find.”
New faces bring new lives
For Jim Maki, as for other recipients, his own face transplant is surely benefit enough. He says he is not disappointed with a thing, following the procedure, and is most pleased simply to have a nose again. Dr. Pomahac has seen positive personality changes in his patient, too. “He used to want to just get out of the office. Now he can talk about [Boston’s baseball team] the Red Sox for an hour and I have to kind of show him the door.”
Opponents of face transplantation used to fear that receiving a new face would have a profound psychological effect on the recipient, that the new face would disturb the person’s sense of self. This has not proven to be the case, though. Pomahac points out that severely disfigured patients are starting from a very different point than their old self; regaining their old appearance becomes irrelevant.
A related concern was that we would have “dead people walking the streets, if recipients looked like their donors,” Dr. Pomahac recalls. But doctors and families on both sides state that this resemblance does not exist. “Because the ultimate appearance of the face is the summation of the soft tissue – its thickness, its anatomic structure – and the underlying bone, the recipient’s new appearance is a combination of the two.” He also finds that his patients’ own identity continues to shine, through their voice and their body language, “all those things we pay attention to without even realizing they’re there.”
In other words, although significantly altered, face transplant recipients are able to be themselves again, in a way that was not possible when they bore the traumatic mark of their accidents. They may regain the ability to eat normally, speak more clearly, smile, even if just a little, smell again, and feel their children’s kisses. The hope is that, from here, they will be able to reintegrate society. Some 20 patients have received face transplants, and a few have returned to work, while others have additional health concerns that have prevented it for the time being. For soldiers, the ultimate goal is that they could one day return to active service. Bohdan Pomahac’s phrase expresses it well: the procedure may not be life-saving, but it is indeed life-giving.
1st Appearance for Full Face Transplant Patient (Video contains some graphic images)
To find out more:
Face transplants – a short history http://www.guardian.co.uk/science/2012/mar/28/face-transplants-history
“Three Patients with Full Facial Transplantation” – The New England Journal of Medicine http://www.nejm.org/doi/full/10.1056/NEJMoa1111432
University of Maryland completes most extensive full face transplant to date http://www.umm.edu/news/releases/face-transplant.html#ixzz1ri8iZDY