FACIAL TRANSPLANT

Paper Presented at THE 2002 ANNUAL MEETING OF THE AMERICAN SOCIETY FOR RECONSTRUCTIVE MICROSURGERY. Cancún. Mexico. January 2002

Published in Plastic and Reconstructive Surgery Journal Vol 110 (5) Oct 2002, 1374-1375.

Several times the imagination has preceded the medical advances, leg transplant between Cosme and Damian saints preceded the limb transplant, and probably the facial transplant in the movie Face Off is preceding the facial transplant in humans.

We present here our research about facial transplant in animals as a previous step to the facial transplant in humans.

Luis Eduardo Bermúdez MD. , Alida Santamaría MD., Tomas Romero MD., Diego Fernando Calderón MV.

(The pictures found herein may not be duplicated or redistributed in any form without the prior written permission of Luis Eduardo Bermúdez MD. All rights reserved )

BOGOTÁ. COLOMBIA.

WHY  BACKGROUND  PREVIOUS STUDIES  HYPOTHESIS  THE SURGERY

DISCUSSION

 

INTRODUCTION: 

Treatment of severe facial soft tissue deformities is a challenge. Final results following complex surgical procedures to treat pathologies like severe burns or noma, are faraway from the ideal. Composite tissue allotransplantation has been used recently to restore limb function in humans (1,2), and could be used for facial reconstruction. 

 

Picture 1: Today there is not a reconstructive surgical procedure able to fully restore the normal appearance of patients like this one. Pictures before and after an aircraft accident during the first world war (taken from the Gillies Archives).

Picture 2. When whe asked her what she would like to correct, she answered " The face, because I can use my other hand".

 

BACKGROUND:

 After a wide experience using different reconstructive procedures in severely deformed patients and thinking that a single flap reconstruction is the solution in these patients, we started using the complete facial reconstruction with a single unit flap described by Angriniani (3). Against our initial excitement about that surgery we found the final outcome greatly unsatisfactory because of the quality of the transferred skin (back). There is a huge difference between face and back skins, and also there are many different skin qualities in the face. The only way to obtain good results would be using a single flap of skin with different qualities as the facial skin; but there is no other place in the body like that. That is why we proposed the facial transplant as the ideal treatment (4).

 In September 2000, at the Annual Meeting of the American Society of Plastic Reconstructive Surgery and the Plastic Surgery Educational Foundation in Los Angeles, CA. we presented the proposal of the facial transplant in animals as the first step in the development of that surgical procedure in the human being (if you want to see the paper click here).

There are several differences between facial reconstruction and hand reconstruction, but from the transplantation point of view the need of function is different. Most of the patients who would receive the facial transplant, are patients who would not need a functional facial transplant (in other words the only need skin and/or cartilage), the main goal would be restore the external look of the face. Let’s see the perfect  clinical example of skin-cartilage transfer, the ear microsurgical reimplantation, there is not a better result with any other technique (don't you agree?), I think it would the same with the facial skin transplant.

HYPOTHESIS:

 Hand transplant procedure has multiple successful replantation of severed hands as background, however the only facial replantation described is the one by Thomas and Obed (5) in 1998, they reported a total face and scalp replantation in an 11 year-old-girl using facial and temporal vessels. Our hypothesis were: 

  1. The whole face survive with just two pedicles (facial arteries and veins)?
  2. Is it possible to transplant the whole face using just the facial vessels?

 Our study is not an immunological transplant study, there are several studies about the immunology in composite tissue allotransplantation  in animals and  in humans ( 6,7,8,9,10,11,12,13,14,15,16,17,18).

MATERIALS AND METHODS:

 After facial dissection in rats, rabbits, pigs and dogs, we found that the animal with a facial vascular anatomy more similar to the human being was the dog. Before the surgical procedure, the facial arterial anatomy of the dog was studied in four animals (4).

We performed a hemi-facial transplant between two dogs, to prove the possibility of a facial transplant. We performed the hemi-facial transplant because the complete facial transplant is in fact two hemi-facial transplans, and the hemi-facial transplant would be less morbid.

next

We are really interested about the ethical aspects of the present study please let me know what do you think.

 bermudez@ciruestetic.com

REFERENCES:

 

  1. Dubernard JM, Owen E, Herzberg G, Lanzeta M, Martin X, Kapila H, Dawahra M, Hakim NS.  Human hand allograft: report on first 6 months. The Lancet. 353: 1315, 1999.
  2. Jones JW, Gruber SA, Barker JH, Breidenbach WC. Successful hand transplantation. One year follow-up. N. Engl. J. Med.  343: 468, 2000.
  3. Angriniani C.; Total Face Reconstruction with One Free Flap. Plast. Reconst. Surg.  99;1566-75;1997.
  4. Bermudez LE, Santamaria A.  Total face reconstruction with one free flap. Is it worth it ? . Plastic Surgical Forum XXIII. Proceedings of the 69th ASPRS Scientific Meeting , Los Angeles, CA., Oct 14-18, 2000. Page 502..
  5. Abraham T., Vijay O.; Total Face and Scalp Replantation. Plast. Reconst. Surg.; 102:2085-87;1998.
  6. Lee WP, Mathes DW. Hand transplantation : pertinent data and future outlook. J. Hand Surg. (Am). 24: 906, 1999.
  7. Hewitt CW. Update and outline of the experimental problems facing clinical composite tissue transplantation. Transplant Proc. 30 : 2704, 1998.
  8. Ren X, Shirbacheh MV, Ustuner ET, et al. Osteomyocutaneous flap as a preclinical composite tissue allograft: swine model. Microsurgery. 20 : 143, 2000.
  9. Üstüner ET, Zdichavsky M, Ren X, et al. Long-term composite tissue allograft survival in a porcine model with cyclosporine/mycophenolate mofetil therapy. Transplantation. 66 : 1581, 1998.
  10. Jones JW, Üstüner ET, Zdichavsky M, et al. Long term survival of an extremity composite tissue allograft with FK506-mycophenolate mofetil therapy. Surgery. 126 : 384, 1999.
  11. Simmons PD. Ethical considerations in composite tissue allotransplantation. Microsurgery. 20 (8):458, 2000.
  12. Lee WPA, Rubin JP, Cober S, Ierino F, Randolph MA, Sachs DH. Use of swine model in transplantation of vascularized skeletal tissue allografts. Transplant Proc. 30: 2743, 1988.
  13. Schuster KM, Hewitt CW, Basic science foundation for clinical composite tissue transplantation. Transplant Proc 33 : 1717, 2001.
  14. Llull R. An open proposal for clinical composite tissue allotransplantation. Transplant Proc 30 : 2692, 1998.
  15. Kann BR. Composite tissue (hand) Allotransplantation : Are we ready ? . Editorial. Plast. Reconstr. Surg. 107: 1060, 2001.
  16. Lee WPA, Yaremchuk MJ, Pan YC, Randolph MA, Tan CM, Weiland AJ. Relative antigenicity of components of a vascularized limb allograft. Plast. Reconstr. Surg. 87: 401, 1991.
  17. Lee WPA. Composite tissue transplantation: more Science and Patience needed. Editorial.  Plast. Reconstr. Surg. 107: 1066.
  18. Siegler M. Ethical issues in innovative surgery: should we attempt a cadaveric hand transplantation in a human subject? . Transplant. Proc. 30: 2779, 1998.