Face transplant judgment—Successful, Ethical?

Tackling the controversy about face transplants and judging their worth isn’t easy, even if it’s a qualitative assessment as the following will be. A registry of all transplant patients promises to allow a more quantitative assessment in the future. In my last blog, I did say that—no matter the judgment—facial transplants strike me as a better use of scarce surgical skills and resources than the endless tummy tucks and face lifts that dominate today’s plastic surgery landscape. 

It’s clear from the “where are they now” stories in my prior blog that facial transplants have worked for most of the American patients whose stories were told. (The fate of several patients in other countries—including France which pioneered the technique—is less clear than here in the US, though a few facts are noted below.*) 

About-face on the face transplant.

According to Dr. Lawrance Altman who wrote in April, 2014 about how experts have flip-flopped regarding this rarest of transplants in the US. Such operations  “have transformed the lives of nearly all the surviving recipients. ” Dr. Altman quotes a study by transplant surgeon Dr. Eduardo Rodriguez of NYU. The surgeon studied 28 facial transplants (11 were full facial graphs as depicted in the diagram below). He and his research team concluded, “The idea of one individual wearing another’s face initially frightened some critics. But contrary to such fears, no recipient physically resembles the stranger who gave it.”

Other findings from Rodriquez’ year-long study of  immunological, psychological and other functional and behavioral factors found:

—”New faces initially feel numb, as if the recipient had come from a dentist’s office. But the numbness[only] lasts for months.”

—”Skeptics doubted that recipients would ever regain normal facial sensations — feeling a kiss or a fresh breeze, smelling freshly mowed grass. But some did, as early as three months after the transplant.”

—”Some critics said nerve repair would take too long to achieve functional gains, for instance in eating and swallowing. Although restoration of motor function was slower, some patients could bring their new lips together by six months and close their mouths by eight months. By three months, some were able to swallow and produce intelligible speech. Smiling began later, after about two years, and continued to improve after eight years.”

According to the Times article:[There were] early objections like those of the Royal College of Surgeons in Britain and a national ethics committee in France. These and other critics said that the operation was not lifesaving and that the risk of mandatory lifelong immunosuppressant drugs and the constant threat of infections far outweighed the benefits for otherwise healthy people.”

What happened in response to these concerns was doctors implemented “a rigorous pre-transplant effort to identify candidates who would be motivated to stick to an anti-rejection regimen and who had a strong social support system. Deciding who is and who is not a face transplant candidate can be more grueling than the surgery, which can take longer than a day. Surgeons can spend years training for the procedure and then spend months more seeking a donor with a compatible complexion, bone structure and other important characteristics.”

Judgment re transplant success and ethics.

Success has been remarkable: most US transplant patients have regained their ability to eat, drink, speak more intelligibly, smell, smile and blink; many have emerged from ostracism and depression. And most agree that ethical concerns have been largely assuaged. Dr. Maria Siemionow, director of plastic surgery research at the Cleveland Clinic, says, “The major problem is the selection of the candidate — who is and who is not the face transplant candidate. For instance, doctors at the Cleveland Clinic would not consider someone who is totally blind because one of the requirements is to be able to exercise one’s face in front of a mirror, ‘to make the face adjusted to the brain.'”

Confirming the above judgment: a report published by The Lancet recently, said the face transplant  procedure is generally safe and feasible, and should be offered to more patients. The endorsement is cautious, though: the operation is still experimental, risky and expensive (at least $300,000). However, victims of genetic disorders, gunshots, animal bites, burns and other accidents can ease or erase the grotesque deformities that leave them subject to taunts, discrimination, isolation and serious depression.

* Transplants outside the US:
A team in Amiens, France, performed the first partial face transplant on Isabelle Dinoire, then 38, who was disfigured by her dog.

Chinese doctors did a partial face transplant on a farmer, 30, who lost part of his face in a bear attack. The pt.lost his transplanted hands and then died.

Doctors in Barcelona performed the first full face transplant on a man, 30, who accidentally shot himself in the face.

Ugur Acar, 19, had a full face transplant in Turkey after childhood burns.

Poland and Belgium have also had experience with face transplants.

 

                     Dr. Eduardo Rodriguez.       J. Bright, NY Times

 

 

 

 

 

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