Full details of the world鈥檚 second and third face transplants are unveiled today.
One operation was on a Chinese man whose face was slashed by a bear. The other was on a Frenchman whose face was disfigured for many years by a massive tumour.
Although neither is a full facial transplant, both procedures break new ground compared with the world鈥檚 first face transplant in November 2005 on Isobelle Dinoire, a French woman savaged by a dog.
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The Chinese team, led by Shuzhong Guo of the Fourth Military Medical University in Xi鈥檃n, is the first to include facial bone in a face transplant, carried out on 13 April 2006. 鈥淲ithout the facial bone framework, reconstruction of the nose and upper lip would not be possible,鈥� the team state in their report.
Like the triangular face flap grafted onto the face of Dinoire, the Chinese graft included muscles, nerves, blood vessels, cartilage and skin. Another first was that it included an intact salivary gland.
Two years on from the procedure, the man can eat, drink and speak, thanks to the gradual fusing of transplanted nerves and muscles with what remained of the patient鈥檚 own.
Complete paralysis
The French team, meanwhile, came closest to transplanting an entire face. On 21 January 2007, they transferred a graft that was three times the surface area of the one given to Dinoire.
Their most difficult task was to remove a huge tumour that had completely infiltrated and disfigured their patient鈥檚 face, leading to complete paralysis on one side and partial paralysis on the other. The tumour was caused by an inherited condition called neurofibromatosis type 1, and gave the man the appearance of the 鈥淓lephant Man鈥�, .
鈥淚t鈥檚 more a malformation than a tumour, so there was no clear-cut division between healthy and abnormal tissue,鈥� says Laurent Lantieri, head of the team which performed the surgery at the in Cr茅teil, France. 鈥淲e removed all the lower part of the face, including muscle and nerves, and replaced it all with the transplant.鈥�
For two to three months, the man couldn鈥檛 move his face, but then began to recover mobility and sensation. 鈥淣ow, he can close his mouth completely, speak and eat,鈥� says Lantieri. 鈥淏ut he still has some problems smiling because the way we set the muscles wasn鈥檛 perfect.鈥�
He has also recovered an ability to blink, lost for 10 years, and says that as little as a month after the surgery, his self-image in dreams had reverted from his old to his new appearance, reinforcing his acceptance of the graft. 鈥淭he psychological results are very good,鈥� says Lantieri, adding that the man has since returned to work as an accountant.
New material
Just like Dinoire, both patients suffered bouts of acute rejection of the new tissue, but both were stabilised with strong immunosuppressive drugs.
Since the procedure, the French patient has drastically cut down on immunosuppressive drugs. Lantieri believes that the chimeric tissue formed between the native and transplanted tissue has gradually helped his body accept the new material as 鈥渟elf鈥�.
With the success of all three operations, the stage could now be set for a full face transplant. 鈥淚 think it might be possible, but we have to find a patient, and there鈥檚 a technical problem transplanting eyelids,鈥� says of the Edouard Herriot Hospital in Lyon, and co-leader of the team that did the first face transplant.
Lantieri agrees that the eyelid is the main technical challenge, because the nerves and muscles that operate it reside both outside the eye socket and within it. But he and his colleagues are researching ways to overcome the problem. 鈥淲e鈥檙e still working on the possibility of transferring the whole face,鈥� he said.
Dubernard said that Dinoire is still doing very well, and has now recovered an estimated 95% of normal facial function, none of which could have been restored by conventional surgery. 鈥淪he can speak, drink without spilling liquid and eat normally,鈥� he says. 鈥淪he can smile, grimace, kiss and do almost everything,鈥� says Dubernard.
The other gratifying thing in all three cases is that none has suffered the feared psychological consequences of receiving parts of other people鈥檚 faces.
鈥淭he psychological results are very good,鈥� says Lantieri. Dubernard, meanwhile, repeated a statement from Dinoire three months ago that the transplant 鈥済ave me back an identity, because without a face, I am nothing鈥�.
鈥淲e鈥檙e very encouraged by these results,鈥� says Maria Siemionow of the Cleveland Clinic in Ohio, and the only holder in the US of approval to do a face transplant, granted in 2004. 鈥淏ut as we can see, there鈥檚 still incidence of acute rejection, so we need to work on immunosuppressive procedures that are less harmful,鈥� she says.
Siemionow says that her team is still preparing for the possibility of doing face transplants, but that everything needs to be in place beforehand. 鈥淚t鈥檚 taking time to get agreement on this, not just in the institutions involved, but in society generally,鈥� she says.
Journal reference: (vol 372, p 361, p 639)
