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| Archive : Winter 2006 |
THE NEW TOOLS OF RECONSTRUCTION:
Skin from a deceased donor's face // Fat // Milled bone chips // Resorbable tacks // Fibrin glue // Biodegradable scaffolding // And most critical, not expecting too much too soon.
Saving Faces [page 3]
 By Anita Slomski
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"Any kind of microvascular transplant is all or nothing," says Papel. "If you have a complication—perhaps the blood supply to the transplanted tissue is interrupted or the vessels aren't capable of maintaining circulation—you could lose the entire face, a devastating complication." If the transplanted face sloughs off, the patient will likely have to repeat the multiple skin grafts she may already have endured. "That could set a patient back years in terms of physical pain and emotional suffering," Papel says.
Even a successful transplant may leave the recipient with significant psychological issues. Though he or she won't assume the donor's facial features—a common notion Siemionow ascribes to Face/Off, a 1997 movie in which two men trade faces—it's not clear exactly what the recipient will look like.
At least initially, candidates for a face transplant (technically, a facial composite tissue allograft) will be burn victims whose soft tissues, facial muscles and bones are intact. The donor will provide only the envelope of skin, with attached fatty tissue, nerves and blood vessels, to resurface the recipient's face, leaving the eyes, mouth and ears largely unchanged. Yet while he or she will lose the aftereffects of previous reconstructive procedures—typically, a patchwork of unmatched skin grafts and feature-contorting scar tissue—the recipient is unlikely to regain a fully expressive face because nerve hook-ups aren't perfect and the facial muscles may have been damaged by scarring.
What will it be like to awaken from surgery with a new face, however much or little it resembles the recipient's old one? That's something most burn victims have already experienced, says Siemionow. "People who have been burned no longer look like themselves. They lose their identity not only after a terrible accident but also after each reconstructive procedure, and 30 to 50 surgeries are typical after a severe injury."
Siemionow is not the only surgeon who wants to push forward with the face transplant. Doctors in Spain and at the University of Louisville also hope to gain approval. Meanwhile, in November, Jean-Michel Dubernard, the French surgeon who performed the first hand replacement, transplanted the nose, lips and chin from a brain-dead woman to the face of a severely disfigured 38-year-old woman. Some physicians have criticized the French surgical team for not first attempting conventional reconstructive procedures, but Dubernard has said that more conservative surgery would not have worked for an injury that left his patient unable to speak or chew.
Ethics committees in France and England have refused to allow full transplants, arguing that the risks outweigh potential benefits. But the French group permits the less radical partial procedure. When the Cleveland Clinic gave Siemionow the go-ahead in 2004 after a 10-month review, it went against a position statement from the American Academy of Facial Plastic and Reconstructive Surgery that calls for the first face transplants to be conducted on people with severe facial trauma, tumors or burns—whereas Siemionow is seeking candidates (primarily burn victims) whose bone structure is intact and who are free of disease or other complications. So far, though, she has found neither an ideal candidate nor potential donors. Yet Siemionow remains optimistic that success will come—and that once adult transplants are routine, surgeons will be able to replace the faces of severely burned children.
Though a transplanted face could eventually bring relief to burn victims and others with major facial disfigurement, it's unlikely to be a perfect solution. Much better, suggests Vacanti, chief of pediatric surgery and director of pediatric transplantation at the MGH, would be to coax Mother Nature into giving such patients new skins. "Imagine you start with the patient's own cells, infuse them on a structure that duplicates the face, use computer-chip technology to fabricate blood vessels down to submicron levels, hook up those blood vessels and reanimate the tissue with nerves," says Vacanti. "You'd have a better face transplant than with donated skin, and you wouldn't need immunosuppression."
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Left to right: Photo by Erin Patrice O'Brien/Getty Images; Photo by Erik von Weber/Getty Images;
Photo by Erik von Weber/Getty Images; Photo by David Sacks/Getty Images
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