Dec 19, 2008

Health - Behind a Face Transplant Breakthrough

Jeffrey Kluger

It can take just an instant to fall in love with a face; it can take a lifetime to forget one. Now, according to an announcement from the Cleveland Clinic on Wednesday, it has taken a team of eight surgeons 22 hours to replace one. Sometime during the past two weeks, the clinic successfully performed the world's first near-total facial transplant, lifting a face nearly whole from a recently deceased donor and grafting it onto an anonymous woman who had suffered extreme disfigurement to more than 80% of her own face. Her upper eyelids, forehead, lower lip and chin are all that remain of her original features. The rest is entirely new — and so, the doctors say, is the life that has been restored to her.

"I'm very proud and very emotional," says microsurgeon Maria Siemionow, who headed the surgical team. "Our patient is someone who had been called names and humiliated, who suffered whenever she appeared in public. Now, she may be able to go comfortably from her home and face the world."

The breakthrough achieved by Siemionow and her team was a longtime goal in facial surgery. Partial face transplants had been successfully performed by teams in France in 2005 and 2007 and in China in 2006, all on patients who had been disfigured either by animal attacks or disease. But no one had ever attempted a procedure on the scale undertaken by the Cleveland team.

In 2004, the Cleveland Clinic gave Siemionow the green light for the improbable operation, one that involved the transplantation of about 500 sq cm of skin, arteries, veins, nerves, muscles and bony structure, all of which had to be attached with sufficient dexterity to restore the patient's ability to feel, blink, eat, smell, speak and — not incidentally — smile. This was not what doctors call solid-organ transplant; it was a multitissue transplant, which is an order of magnitude more difficult than, say, a heart transplant or a hand graft.

"You have to find all of the appropriate vessels and nerves and you must connect them all properly," explained Siemionow. "And much of it is done microsurgically."

Before the doctors could proceed, they needed not only extensive practice, but also to resolve the complex issues involved in selecting the right patient for the landmark operation. That's because transplanting a face transforms a patient's identity. Even though differences in the underlying bony structure mean the recipient is unlikely to resemble the donor once the procedure is completed, it's impossible for the patient's sense of self not to be profoundly shaken. "Picture yourself as a person who has received a face transplant," says Dr. Eric Kodish, the team's lead bioethicist. "Now use your moral imagination."

Those concerns prompted the doctors to establish very high standards for surgical candidates. They had to have exhausted all other reconstructive procedures, had to be emotionally stable and had to understand fully the implications and risks of the procedure. And, of course, they truly had to want the operation. Says Siemionow: "We asked all of the patients, 'Is it you who wants a face transplant or is it someone in your family. Do you understand you'll be living with the face of someone who is deceased?' "

It took four years of screening before the team had chosen its recipient, a woman whose cause of disfigurement is being kept secret along with her name. Once she'd been chosen, the surgical team had to await a compatible donor — someone whose tissue matched the recipient's, but also, for esthetic and psychological reasons, who was of the same race, gender and approximate age. The call to alert Siemionow that a donor had finally been found came in the middle of the night earlier this month, and her team was hastily gathered. The operation began at 5:30 that afternoon. As the recipient was being prepped, the transplant tissue was harvested from the donor, an exhaustive procedure that took more than nine hours. "The doctors transferred all of the facial muscles, the upper lip, all of the nose, most of the sinuses and some of the teeth," says Dr. Toby Cosgrove, the CEO of the Cleveland Clinic.

At 5:10 the following morning, the grafting of that harvested tissue began. Just two hours and 40 minutes later, the surgeons saw the key sign of their success: the transplanted face began turning a healthy pink, indicating that blood flow had been restored.

The recipient has a long, long way to go before she can leave the hospital and resume her life. It will be weeks or months before the postsurgical swelling goes down, and only then will she be able to begin physical therapy. It will be a year or more before sensation and muscle control will be achieved, and it is by no means certain that either one will be fully restored. And the patient must overcome the always-present risk of tissue rejection, for which she will require immunosuppressant drugs for the rest of her life. "You can see rejection immediately if it begins," says Siemionow. "It will appear as a rash or redness or swelling. So far, none of this has happened with this patient."

The Cleveland team is now consulting with the Department of Defense to explore facial transplants for severely disfigured soldiers, though it will be quite some time before the procedure becomes even remotely routine. For now, the doctors are focusing on their first successful transplant patient. And while she has not even gotten a good look at her new face yet, she has found another way to experience it. "She has lifted her hands and run them over her face," says Siemionow. "She feels that she once again has a nose and a jaw." For someone who had lost so much, that, for the moment, is probably more than enough.

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