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Volume 18, Number 1, March 2006
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On 30 November 2005, the world's first face transplantation was performed in Amiens, France, by maxillofacial surgeon Professor Bernard Devauchelle and transplant surgeon Professor Jean Michel Dubernard. Since then, the world's media has had a field day combining admiration, concern, and reproach, but above all, an inescapable element of sensationalism. So what's all the hype about? Before we can consider the answer, let us review some facts.
Background
Most people are familiar and comfortable with the transplantation of organs (kidney, liver, heart) from other people (known as allogeneic transplants or allotransplants). In general, donation is from brain-dead individuals who have been involved in accidents, and there is a well-established system in place, in almost every part of the world, for acquiring and transplanting donated organs in terms of ethics and technique. Very recently, a new type of transplant was pioneered by Dubernard in Lyon in 1998 when he transplanted a hand. This type of transplant is termed composite tissue (as opposed to a solid organ) allotransplant, and recent additions to this category include the larynx, the tongue, and now ¡K. The Face. In contrast, autologous transplants or autotransplants are those involving the transfer of tissue from one site of the body to another site in the same individual, and these are extremely common in everyday surgical practice.
Technical Aspects
In all transplants (autologous or allogeneic), the arterial blood supply and venous drainage of the
transplanted tissue or organ need to be re-established at the recipient site by microvascular anastomosis between the vessels of the donor tissue and those of the recipient site. As a technique, this is well established, but the risk of anastomosis failure (mainly due to thrombosis) is approximately 5% in experienced units.
Immunological Aspects
The allotransplant recipient has to take life-long immunosuppressive therapy to minimise the risk of rejection of the transplanted tissue. Rejection (and hence necrosis and loss) of transplanted tissue may be acute (occurring in days to weeks) and the risk is approximately 10% despite therapy. Slower, or chronic, transplant rejection (involving fibrosis, shrinkage, and loss of function of the transplanted tissue or organ) is a much more common problem and the risk is 30% to 50% over 2 to 5 years. Furthermore, immunosuppressive drugs have their own drug-specific side effects as well as causing a generic predisposition to life-threatening infections and the development of cancer in long-term survivors.
Psychological Aspects
Transplant recipients have a multitude of stressors: fear related to organ viability and ultimate function, transplant rejection, side effects of immunosuppression, including infection and malignancy, compliance with treatment requirements and a new lifestyle, integration of the transplant into a new body image, gratitude, and guilt related to the donor's family.
So, is there anything special about a face transplant (as opposed to other conventional organ transplants) to justify the interest of the media and general population?
Well, yes. The face is an organ of identity and communication. A facial transplant, in addition to all the previously mentioned facts, conjures up issues of dealing with the reactions of others to altered appearance and the perception of identity. However, I doubt that this is the explanation for the media's interest. Rather, it is the erroneous perception that a face transplant is the ultimate appearance-enhancing procedure and, as such, the following is already happening or might happen if not nipped in the bud: recipients, donor families, and surgeons may become the subject of intrusive media interest and the general public will develop unrealistic expectations and will hound professionals in an attempt to secure such a service. The worst example imaginable is if the ageing rich were to create a demand for a more youthful face. However, the realistic indication for a face transplant today is the severely burned and non-functional face, or major facial tissue loss resulting from trauma, provided all other criteria for transplantation are met. I am certain that once the medical facts are explained, facial transplantation will come to be regarded as any organ transplantation should be, and not as a special focus of curiosity for the media and general population.
Acknowledgement
When preparing this text, I have consulted the report of a working party on facial transplantation by the Royal College of Surgeons of England published in November 2003.
Nabil Samman
Editor-in-Chief
Asian Journal of Oral and Maxillofacial Surgery
Asian J Oral Maxillofac Surg. 2006;18:5-6.
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