Update on world experience with facial transplantation

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Thirteen years after the first successful face transplant, trauma surgeons should be aware of the current role of facial transplantation for patients with severe facial disfigurement – including evidence that the final appearance and functioning are superior to that provided by conventional reconstructive surgery. That’s the message of a special update on ‘Face Transplantation Today’.

Dr Eduardo D Rodriguez and colleagues of the Hansjörg Wyss department of plastic surgery at NYU Langone Health, New York, summarise the world experience with facial transplantation to date, along with a new study showing better aesthetic outcomes with facial transplant, compared to conventional reconstruction. The researchers write, “It is therefore important for trauma surgeons who deal with these injuries regularly to be familiar with the literature on face transplantation following traumatic injuries.”

The researchers provide an update on all full or partial facial transplant procedures performed to date – emphasising the risks and benefits, surgical indications, and aesthetic and functional outcomes. They write, “Face transplantation has evolved…into a safe and feasible reconstructive solution, with good aesthetic and functional outcomes for patients with severe facial defects are not amenable to reconstruction through conventional and autologous (using the patient’s own tissues) approaches.”

Face transplantation may be considered for patients with defects involving at least 60% of the facial surface area, with irreparable damage or loss of the “aesthetic units” of the central face (eyelids, nose, lips). While such severe facial injuries are rare, the trauma mechanisms causing them are not. Rodriguez and colleagues note that most facial transplants performed to date have been in patients who suffered ballistic (firearms) trauma or burns.

In such severe cases, skin grafts and other conventional reconstructive techniques fall short of providing adequate aesthetic and functional outcomes. Trauma surgeons need to be aware of the potential benefits and limitations of facial transplantation. “This can potentially expedite the reconstructive process for patients who may benefit from face transplant,” the researchers write.

Yet there are still important gaps in research on the full benefits of facial transplantation. In a new survey study, Rodriguez’s group asked members of the general public to rate before-and-after pictures of patients with severe facial deformities, treated by either conventional reconstruction or facial transplantation.

Ratings were performed using a validated nine-point scale, from minimal (1 point) to severe (9 points) disfigurement. The average perceived disfigurement scores were 4.9 points for the facial transplant recipients versus 8.5 points for those who underwent conventional reconstruction (compared to 1.2 points for a group of individuals with no apparent facial disfigurement).

That supports the impression, communicated to patients considering facial transplantation, that while they may not appear completely normal after the procedure, their appearance “will likely improve dramatically” compared to conventional reconstructive surgery. Recipients have also reported becoming more active in their communities after facial transplantation, due to feeling less conspicuous when out in public. Further research is needed, including assessment of the impact on quality of life and other patient-reported outcomes.

Rodriguez and co-authors hope their studies will help to make the trauma community more aware of the option of facial transplantation in appropriate cases, and provide a step toward comparing its outcomes to those of conventional reconstruction. With ongoing advances – including the development of less toxic, more effective immunosuppressive therapies to prevent rejection – facial transplantation may become a more widely available alternative for patients with severe disfiguring facial trauma.

Abstract 1
Face transplantation has evolved over the last 12 years into a safe and feasible reconstructive solution, with good aesthetic and functional outcomes for patients with severe facial defects who are not amenable to reconstruction through conventional and autologous approaches. Among patients who underwent face transplantation to date, a significant proportion did so following trauma, mostly ballistic and thermal injuries. It is therefore important for trauma surgeons who deal with these injuries regularly to be familiar with the literature on face transplantation following traumatic injuries. In this study, we provide a focused review on this topic, with an emphasis on highlighting the limitations of conventional craniomaxillofacial reconstruction, while emphasizing data available on the risks, benefits, surgical indications, contraindications, as well as aesthetic and functional outcomes of face transplantation. The authors also provide an update on all face transplants performed to date including traumatic mechanisms of injury, and extent of defects. They finally describe 2 cases performed by the senior author for patients presenting with devastating facial ballistic and thermal injuries. The authors hope that this work serves as an update for the trauma surgery community regarding the current role and limitations of face transplantation as a craniomaxillofacial reconstructive option for their patient population. This can potentially expedite the reconstructive process for patients who may benefit from face transplantation.

Authors
Scott J Farber, Rami S Kantar, J Rodrigo Diaz-Siso, Eduardo D Rodriguez

Abstract 2
Facial transplantation (FT) has attracted the interest of individuals with facial disfigurement as a path to social reintegration. The perception among face transplant recipients and the reconstructive surgery community appears to be that superior functional and esthetic outcomes can be obtained with FT compared to autologous reconstruction (AR). Although lifelong immunosuppression adds well-known risks to FT, its benefits have proven difficult to quantify, especially because of its non-life-saving nature. Evidence that the general public perceives facial allograft recipients as less disfigured than AR patients may dramatically alter the currently accepted risk/benefit ratio of this novel procedure. A survey containing independent images of individuals in nondisfigured (ND), autologous facial reconstruction, and FT groups was administered to the general public in an urban environment. Participants assigned a disfigurement score to each photograph using the Observer-Rated Facial Disfigurement Scale, a validated instrument used to rate facial disfigurement among head and neck cancer patients. One-way analysis of variance was used to calculate differences in mean level of perceived facial disfigurement among the 3 groups. A total of 250 participants completed the survey. Mean perceived disfigurement scores assigned to the ND, FT, and AR groups were 1.2 ± 0.4, 4.9 ± 1.3, and 8.5 ± 0.6, respectively. A significant difference in disfigurement score was observed between all 3 groups (P < 0.001). This pilot study suggests that the general public perceives the esthetic outcome of FT to be superior to those obtained with AR in patients with severe facial defects.

Authors
Alessandra E Cabrera, Laura L Kimberly, Rami S Kantar, Elisa K Atamian, Amit K Manjunath, Lauren K Rangel, Michelle W McQuinn, J Rodrigo Diaz-Siso, Eduardo D Rodriguez

Wolters Kluwer Health material
Journal of Cranio-facial Surgery abstract 1
Journal of Cranio-facial Surgery abstract 2


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