Elsevier

The Lancet

Volume 384, Issue 9960, 13–19 December 2014, Pages 2153-2163
The Lancet

Review
Facial transplantation: the first 9 years

https://doi.org/10.1016/S0140-6736(13)62632-XGet rights and content

Summary

Since the first facial transplantation in 2005, 28 have been done worldwide with encouraging immunological, functional, psychological, and aesthetic outcomes. Unlike solid organ transplantation, which is potentially life-saving, facial transplantation is life-changing. This difference has generated ethical concerns about the exposure of otherwise young and healthy individuals to the sequelae of lifelong, high-dose, multidrug immunosuppression. Nevertheless, advances in immunomodulatory and immunosuppressive protocols, microsurgical techniques, and computer-aided surgical planning have enabled broader clinical application of this procedure to patients. Although episodes of acute skin rejection continue to pose a serious threat to face transplant recipients, all cases have been controlled with conventional immunosuppressive regimens, and no cases of chronic rejection have been reported.

Introduction

Composite facial defects lead to severe functional impairment and have detrimental effects on an individual's psyche and quality of life. Facial disfigurement significantly affects social interactions and one's perception of body image, predisposing to depression, discrimination, and disability in many patients.1, 2, 3, 4, 5, 6, 7 Normal facial anatomy is also needed for many functions including air humidification, mastication of food, production of intelligible speech, clear vision, and the opportunity for social reintegration.1, 8, 9, 10

Conventional reconstructive techniques can fall short of restoring form and function to patients with complex facial deformity, often requiring numerous staged procedures to provide only suboptimal results. Facial transplantation is a single operation that can restore aesthetic and functional characteristics of the native face by giving ultimate expression to Sir Harold Gillies' principle of “replacing like with like” (figure 1).11

Unlike solid organ transplantation, which is potentially life-saving, facial transplantation is life-changing. The possible consequences of lifelong immunosuppression in otherwise healthy individuals—including cancer, metabolic disorders, opportunistic infections, and death—must therefore be carefully balanced to minimise risk and maximise benefit.10 Yet, surgical innovation has outpaced the scientific community's ability to fully address certain immunological and clinical challenges. Here, we review the immunological, neurological, and anatomical principles gleaned from the 9 years since the first facial transplantation with a discussion of ethical considerations, highlighting lessons learned from clinical experience.

Section snippets

Immunosuppressive strategies

Of the 28 facial transplants done to date (table 1), details of the immunosuppression strategy and outcomes have been published for 18.9, 10, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38 Most recipients—but not all14, 23, 39—had no panel-reactive antibodies. One patient who had 98–99% was treated with protein A immunoadsorption to 5% before transplantation.23 Anti-thymocyte globulin was used for induction for all but two patients,

Sensory nerves

Before the first face transplantation in 2005, restoration of normal facial sensation was thought to be unlikely.41 This assumption has not been borne out by clinical experience over the past decade: rapid restoration of sensory feedback has been reported consistently (table 2). Thermal and mechanical sensation can occur as early as 3 months after surgery,26, 39 with satisfactory sensory restoration often by 8 months (as defined by recovery of heat and cold sensation, discrimination of light

Post-transplantation revision

As the number of face transplantations done has increased, the postoperative focus has expanded to include refining and optimising aesthetic and functional outcomes.18, 72 Functional and aesthetic restoration can be assisted through several secondary procedures, including bone and dental realignment, soft-tissue resuspension and contouring, full-thickness skin grafting, fat injection, and dermabrasion.73, 74 The goals of these revisionary procedures are to optimise functional outcomes,

Ethical dilemmas

The major ethical concerns about face transplantation are similar to the early ethical debates about hand transplantation.85 Because of the complexity of the procedure, and the unknown risks and benefits, the most important decision is still the selection of the candidate. The best candidate is one who: fully understands the implications of potentially lifelong immunosuppression and its serious morbidities, including infections, cancer, graft loss, and death; is motivated, committed, and

Conclusion

In the past 9 years, face transplantation has emerged as a viable and successful option to restore the appearance and function of patients with severe, devastating facial injuries. Depletional induction therapy and a standard three-drug immunosuppression regimen has enabled successful graft survival with highly encouraging functional and immunological outcomes. Tacrolimus has been a cornerstone of nearly all immunosuppression protocols with target trough levels of 10–15 ng/mL for the first 1–5

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