Facial Transplantation - A Working Party Report

Newswise — The first facial transplantation surgery should not be attempted, at least until further research has been performed to define the risks, concludes a special report in the Feb. 15 issue of Transplantation.

Transplant groups in several countries are reportedly ready to attempt facial transplantation from a cadaver donor to a patient with severe facial disfigurement. However, the report by a Working Party of the Royal College of Surgeons of England cites the lack of data on risks—including psychological as well as physical risks—as an obstacle to the procedure and recommends that the first facial transplantation surgery should not be attempted, at least until further research has been performed to define the risks. The working party report was triggered by British media reports speculating on the identity of the world's first face transplant recipient.

Interest in facial transplantation was spurred by progress in the transplantation of so-called "composite" tissues, such as hand transplantation. Facial transplantation would involve transplanting the face of a dead donor onto a recipient with severe facial disfigurement—for example, from severe burns. Although challenging, the techniques used would be similar to those already used in composite tissue transplantation.

Although the final appearance is difficult to predict, the facial transplant recipient would be unlikely to look like the donor. In all probability, the transplanted face would take on "more of the characteristics of the skeleton of the recipient than the soft tissues of the donor," the new report suggests. The authors of the report also cite a "reasonable expectation" that facial transplantation would improve the recipient's facial mobility, depending on the depth of pre-existing scarring.

However, the first facial transplant recipient would be at risk of serious complications. Based on other types of transplant procedures, the authors estimate a ten percent risk of acute rejection. Because transplanted skin is particularly vulnerable to rejection, the long-term risk might be even higher.

The recipient would require lifelong drug treatment to suppress immune system function. Patient failure to take immunosuppressive medication is a widespread problem after transplantation—in fact, it was responsible for the failure of the first attempted hand transplant. Researchers are looking for ways of inducing "immunologic tolerance" in transplant recipients, but any practical technique is years away.

Given the central importance of the face to identity and communication, facial transplantation also raises a host of psychological and social issues. Patients' adaptation to facial disfigurement has more to do with their self-esteem and resiliency than with the severity of their disfigurement. The authors raise the concern that the patients who are most "psychologically vulnerable" may be the most likely to seek facial transplantation. Dealing with unrealistic expectations, the possibility of transplant failure, and others' reactions to their altered appearance would be just a few of the psychological challenges.

The report also raises a key ethical objection to facial transplantation. Obtaining valid patient consent to any form of treatment requires information on the risks of the procedure. The first facial transplant would be highly experimental and likely very hazardous. "The working party believes that until there is further research and the prospect of better control of these complications it would be unwise to proceed with human facial transplantation," the authors conclude.

The report "does not underestimate the suffering" of patients considering facial transplantation, nor exclude the possibility that facial transplants may be a viable option in the future. Rather, the authors believe that research on facial transplantation "should take a much more incremental approach rather than some of the current hype surrounding it has suggested."