The procedures behind the near-total face transplant undergone by US citizen Connie Culp are detailed in an Article published Online First and in an upcoming edition of the Lancet, written by Professor Maria Siemionow, Cleveland Clinic, Cleveland, Ohio, USA, and colleagues. Connie was shot in the face with a shotgun by her husband in 2004, and the paper charts her pioneering surgery and recovery to date.
The shooting left Connie, 46 and a mother of two, with most of the middle part of her face missing, including loss of her nose—as well as mouth, nerve, skin and other structural damage. Though lucky to survive the attack, her face was completely disfigured—she could not drink from a cup and her speech was slurred. She also lost her sense of smell. From 2004 to 2008, she underwent 23 major reconstructive operations—which sadly failed to restore her disfigured structures and left her feeling humiliated in public. Doctors decided that the last resort to enable her to regain facial function and a normal appearance was a full face transplant. Connie was told of the risk of serious complications—including the need for lifelong immunosuppression— and signed the consent form.
The donor was a brain-dead woman who matched Connie in age, race, and skin complexion. The operation was carried out in December, 2008, by an eight-surgeon team, including Professor Siemionow. The operation lasted 22 hours. The donor face covered 80% of the area of where Connie's face had been, and contained various structures including the nose, upper lip, lower eyelids, the upper jaw (plus incisor teeth), palate, and various glands. Once bone components of the graft were secure, connections of the arteries and veins were made. Some 2 hours 40 minutes after the connections were made, the donor tissue began to pink up, confirming the graft's viability. Facial nerves were then connected.
A collection of immunosuppressant drugs were given to Connie immediately following the operation, and she remains on immunosuppressant medication to prevent rejection of her new face. So far, she remains negative for cytomegalovirus and other opportunistic infections. Physiotherapy and speech therapy began 48 hours after surgery, once a day for the first six weeks, then three times per week during follow up. Regular assessment was done of Connie's ability to speak, smell, swallow, make facial expressions, and other muscle control functions in her new face. Psychological support was given once a day during the first six weeks, then three times per week.
There was one episode of rejection of the graft lining on day 47, but this was reversed with a 1g dose of methylprednisolone. At 6 months, facial sensation returned. Motor (muscle) recovery—assessed by repose*, pucker, smile, and pronunciation of vowels—is slow but progressing. Connie's upper lip and lower eyelid movements remain imperfect but it is too soon to expect complete recovery in this area. However, major functions—which she had lacked for 4 years, are now restored. She can now smell, eat solid foods, drink from a cup, and her speech is intelligible. The pain she felt due to scarring and contracted tissues in the affected area—which she rated as 8 out of 10 in severity before the transplant—she now rates as 1 out of 10. The authors say: "Aesthetic outcome will be improved by excision of the redundant skin, which is planned about 1 year after transplantation…Psychologically, she is doing well. She has no symptoms of depression or post-traumatic stress disorder."
Having rated her own appearance as 5 out of 10 three weeks post-transplantation, at 5 months this had improved to 8 out of 10. The authors add: "Since surgery, she has recovered self-confidence, and looks forward to rebuilding her social life and to helping others who have been similarly disabled by trauma."
The authors say that ethical challenges remain for patient selection for future operations, medical support, and appreciation of the moral, professional, and financial responsibilities of the patient. All of these will be specific to the geographic, cultural, and economic conditions of that particular patient. The authors say: "Nevertheless, in complex physically and functionally disabling cases, the patient's ethical right to make decisions should be respected, after being informed of the risks and benefits of the procedure and the need for life-long immunosuppression."
They conclude: "We show the feasibility of reconstruction of severely disfigured patients in a single surgical procedure using complete facial allotransplantation. Therefore, this should be taken in consideration as an early option for severely disfigured patients."
Professor Siemionow adds: "The outcome of this particular case supports facial allotransplantation as a means of early intervention for patients with severe facial deformities. It is with great pride that we share the outcome of this surgery; our patient is doing remarkably well and is very pleased with the result."
In an accompanying Comment, Dr Chenggang Yi and Dr Shuzhong Guo, Institute of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China, say: "In our view, all of the problems in human facial transplantation, immunological status, selection of the recipient and donor, surgical technique, and psychological considerations are all important…Technically, Siemionow and colleagues' surgery was very complex, and the patient gained good functional recovery. So far, total facial transplantation has not been reported. We think the most difficult part of the face transplantation is the aesthetic and functional recovery of the upper eyelids."
"Some key points in facial transplantation remain intractable. Therefore the objective is to identify potential problems, and develop management strategies to resolve them. The day may not be far when facial transplantation becomes the standard of care for disfigured patients."
For Professor Maria Siemionow, Cleveland Clinic, Ohio, USA, please contact Angela Kiska, Media Relations T) +1 216 444-6002 E) KISKAA@ccf.org OR Eileen Sheil T) +1 216-444-0141 E) SHEILE@ccf.org
Dr Shuzhong Guo, Institute of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, China T) +86-029-84775301 E) yichg@163.com / Mzf0709@fmmu.edu.cn
For full Article and Comment, see: http://press.thelancet.com/usfacetrans.pdf
Also see below for links to the three figures in the Article (all of which you can use in your publications, please credit the Lancet)
http://press.thelancet.com/facefig1.JPG
http://press.thelancet.com/facefig2.JPG
http://press.thelancet.com/facefig3.JPG
Notes to editors: *Repose means expressionless features or facial expression devoid of emotion
Journal
The Lancet