A face transplant given to a man two years ago after he had part of his face torn off in a bear attack has shown promising results.* The procedure could thus be used for long-term restoration of serious facial disfigurement, although it is not without complications. These are the conclusions of authors of the first of two Articles on face transplantation published in this week's edition of The Lancet, written by Professor Shuzhong Guo, Institute of Plastic Surgery, Xijing Hospital and Fourth Military Medical University, Xi'an, China and colleagues.
The 30-year-old Chinese man was attacked by the bear in October 2004, and allograft** tissue transplantation was done on April 13, 2006. The surgery included connection of arteries and veins, repair of the noise, lip, and sinuses, as well as other structures in the damaged part of the face. Four different drugs were used to modulate the immune system and decrease the chances of tissue rejection. Other drugs were also given to prevent infections taking hold – the nature and dose of these drugs were based on the bacteria taken from swab samples of the patient's nose, throat, and other areas.
The researchers found that the tissue flap survived well. There were three acute rejection episodes at three, five, and 17 months after transplantation, which were controlled by dose adjustment of one of the immunomodulatory drugs or application of a steroid. The patient's kidneys and liver functioned normally, and there was no infection. The authors conclude: "Facial transplantation could be successful in the short term, but the procedure is not without complications…This case suggests facial transplantation might be an option for restoring a severely disfigured face, and could enable patients to readily integrate themselves back into society."
The second of the two Articles is authored by Professor Laurent Lantieri, Department of Plastic and Reconstructive Surgery, CHU Henri Mondor (APHP)**, Créteil, France, and colleagues. They discuss a patient with a seriously disfiguring facial tumour who had a face transplant at the start of 2007, who now has a more functional face and has not rejected the new tissue. The authors conclude that the case demonstrates the feasibility of surgically removing a large part of the face and replacing it with the donor tissue (composite tissue allograft).
The 29-year-old male patient, with a facial tumour called a neurofibroma which was infiltrating the middle and lower part of his face, underwent transplantation surgery on Jan 21, 2007. The surgery aimed to restore both appearance and function to his face, to give back communication capacities and facilitate social reintegration. The patient was given drugs to suppress his immune system to decrease the chances of rejection.
Following the surgery, two episodes of clinical rejection occurred on days 28 and 64. The second was associated with cytomegalovirus infection, caused by the donor tissue being cytomegalovirus positive. However, both rejection episodes had favourable outcomes, making the reduction of immunosuppressive treatment possible. One year after surgery, the functional outcome was very good, with sensation and motor function returned in the transplanted territory. The patient's psychological recovery was excellent, with complete social reintegration. He also began full-time work 13 months after the transplant. The authors conclude: "Our case confirms that face transplantation is surgically feasible and effective for the correction of specific disfigurement, due in this case to a genetic disorder…Long-term follow-up is needed to assess the risks linked to the immunogenicity of allogenic composite tissues, particularly as regards life expectancy. Following this initial success, other patients are currently being assessed."
In an accompanying Comment covering both Articles, Dr Jean-Michel Dubernard, E Herriot University Lyon I Hospital, France, and Dr Bernand Devauchelle, Amiens-Nord University Hospital, Amiens, France, say that cooperation between the pioneering teams responsible for these operations is necessary "to answer the many technical, functional, immunological, and psychological questions raised by face transplantation." They conclude: "The definition of the best indications — eg, trauma, malformations, benign tumours, burns — will also greatly benefit from this cooperation. The International Registry on Hand and Composite Tissue Transplantation would be an ideal forum to help solve these challenges and define new indications. Our main objective is to give back a normal life to disfigured patients."
Notes to editors:
*links to photographs in both Articles are provided below
**Allograft : Transplanted tissue that comes from another non-genetically-identical person, ie, anyone but an identical twin.
***APHP = Assistance Publique Hopitaux de Paris
Professor Shuzhong Guo, Institute of Plastic Surgery, Xijing Hospital and Fourth Military Medical University, Xi'an, China T) +86-28-84775301 / +86 13 89 2898889 E) mzf0709@fmmu.edu.cn / yichg@163.com
Professor Laurent Lantieri, Department of Plastic and Reconstructive Surgery, CHU Henri Mondor (APHP), Créteil, France T) +33 6 83017756 E) Laurent.lantieri@hmn.aphp.fr
Dr Jean-Michel Dubernard, E Herriot University Lyon I Hospital, France T) +33 6 07 76 21 72 E) jean-michel.dubernard@chu-lyon.fr
Full Article:
http://press.thelancet.com/facetransplantfinal.pdf
Below are links to the photographs in the Articles which you can use in your publications, please credit 'The Lancet'
http://press.thelancet.com/bearattack1.JPG
http://press.thelancet.com/bearattack2.JPG
http://press.thelancet.com/bearattack3.JPG
http://press.thelancet.com/bearattack4.JPG
http://press.thelancet.com/bearattack5.JPG
http://press.thelancet.com/tumour1.JPG
http://press.thelancet.com/tumour2.JPG
Journal
The Lancet