SciTech

Cleveland Clinic board approves facial transplant procedure

On October 15, after 10 months of deliberation, the Cleveland Clinic?s Institutional Review Board approved human facial transplants for disfigured patients. This announcement closely follows the June press release made by physicians at University of Louisville that they were seeking approval for a similar operation. This research is not restricted to just the United States; teams of surgeons in France, the Netherlands, and England are also making strides toward this much-disputed procedure. However, both the Royal College of Surgeons of England and the French National Ethics Advisory Committee have rejected proposals for face transplants.
Some of the earliest surgical reconstruction procedures were meant for the face. Around 1000 BCE, an Indian surgeon named Sushruta wrote Sushruta Samhita, a three-volume work which explained surprisingly modern methods of reconstructive surgery. In one section, he described removing portions of skin from the forehead or cheek of a patient to repair the appearance of a mutilated or severed nose.
In the mid-1500s, Gaspare Tagliacozzi, an Italian professor of surgery, adapted Sushruta?s methods in his own interpretation of rhinoplasty, or plastic surgery of the nose. He would cut a flap of skin on the upper arm loose and attach it to the open wound on the patient?s face. When the new skin grew to cover the wound, he would cut it free from the arm and tailor it to the nose. Although Tagliacozzi suffered harsh criticism from his contemporaries and representatives of the church for his unorthodox methods, his research paved the way for study of transplant rejections.
Moving tissue from one portion of a patient?s body to another, called an autograft procedure, has been popular since the 1800s. Autografts are now commonly used to reconstruct that which a patient has lost to a traumatic injury or severe burns. Due to a lack of suitably large donation sites on the body, it can take many surgeries to complete this process. When used on the face, this transplanted tissue can sometimes limit expressions or speech.
The technique currently being debated involves harvesting a large portion of facial tissue from a brain-dead donor or cadaver and affixing it to the recipient in a grueling, five to ten-hour surgery. Maria Siemionow, section head of plastic surgery research at the Cleveland Clinic, practiced with cadavers to get a feel for the length of the procedure. The task includes preparing the site by removing the current skin along with some muscles and fat, then transferring over tissue from the donor. Once placed, microsurgery techniques would need to be employed to connect the blood vessels, veins, and arteries in the face.
One of the inevitable challenges faced is the possibility of rejection. The current method of countering transplant rejection is treating the patient with immunosuppressants that defeat the body?s natural ability to fight off intruding foreign cells. Although the pharmaceutical community has recently been making progress in drugs that have fewer side effects, there are many consequences associated with using anti-rejection medication, including an increased susceptibility to communicable diseases and higher chances of malignant cancer or diabetes. Many patients can become apathetic about their regimen of immunosuppression agents and stop taking them, leading to necrosis of cells in the transplant region. In the case of Clint Hallam, the world?s first hand transplant recipient, doctors blamed the eventual amputation of the limb on his refusal to continue taking his medication. Hallam denied the allegations, suggesting instead that he was disgusted by the appearance of the hand and never felt as though it was his.
Patients interested in the procedure will have to sign a consent form acknowledging the possible risks and undergo rigorous psychological examinations before becoming a candidate. Numerous psychological consequences can affect a transplant recipient as the result of being placed in an unprecedented situation. ?To know that what you have within you ? and that what?s keeping you alive ? is a part of somebody who is no longer living can be somewhat disturbing,? said Alan Meisel, director of University of Pittsburgh School of Law?s Center for Bioethics and Health Law. Patients will inevitably undergo counseling and face some of the moral questions that developed as a result of the surgery and seeing a new visage in the mirror.
Opponents of the surgery worry that the transplants will result in the recipient looking similar to the donor. This can be hard to predict, according to Dr. Victor Weedn, a visiting professor of forensic science at Duquesne University. ?It really does depend upon how much of the face they do transplant,? Weedn said. Possible variations of the procedure include leaving the patient?s facial muscles, nerves, or soft tissues intact. ?You may be able to retain the recipient?s nose or eyebrows. That will have a marked effect on the extent that the recipient will look like the donor,? said Weedn.
Public acceptance of the procedure will likely come down to the ethical considerations, according to Meisel. He said, ?This will be significantly different, because the face is really our public identity. We don?t usually recognize each other by characteristics other than the face.... We equate the face with the person.?