December 29, 2011
Study Gives An Inside Look At Face Transplantation
Face transplantation, a procedure popularized in fiction, most notably from the movie Face Off, starring Nicholas Cage and John Travolta, is now reality, thanks to researchers at Brigham and Women´s Hospital (BWH) in Boston, who have successfully performed three such operations this year.
The details of the three groundbreaking full facial transplants (FFTs) were released in a research article published Wednesday in the New England Journal of Medicine.
A surgical team at BWH performed the first such transplant in the United States in March, and then went on two complete two more. The researchers describe details of preparation, design and execution of the transplants in the release. They also describe immunosuppression protocol that allows for the lowest long-term maintenance drug regimen after the procedure has been completed.
The procedure is being touted by the researchers as a viable option in the treatment of severe facial deformities and injuries.
All three procedures were fully documented, from the screening process to surgery and recovery. In the article, the team only refers to the patients as 1,2 and 3. But they are recognizable in their photographs as Dallas Wiens, Charla Nash and Mitch Hunter, whose transplants Boston made national headlines.
Wiens was burned by an electrical line and lost his sight, Nash was attacked by a friend´s chimpanzee, and Hunter was in a car accident and was burned by a fallen power line.
Although each surgery was extensive, the patients had fairly quick recoveries. Wiens, for example, regained his sense of smell within three days, and after four months he began to feel sensation and muscle movement in the right side of his face. After two months, Nash could breathe through her nose and mouth. And four days after surgery, Hunter was able to talk, eat and drink.
But the operations weren´t without complications as well. Both Nash and Hunter rejected their transplants before receiving anti-inflammatory medications that allowed them to recover. There were also infections that had to be treated in the patients.
“Unlike conventional reconstruction, facial transplantation seeks to transform severely deformed features to a near-normal appearance and function that conventional reconstructive plastic surgical techniques cannot match,” said Dr. Bohdan Pomahac, director of plastic surgery and transplantation at BWH. “It truly is a life-giving procedure for these patients,” he added.
Pomahac said he was uncertain about the procedure when he received the file on his first patient in need of FFT.
Wiens, 25, suffered his injuries nearly 30 months ago. After 22 surgeries, he was left with a face void of any features, except for a lipless mouth and a goatee. Even his eye sockets were smoothed over with skin taken from other parts of his body.
Pomahac, in checking with the chart of the potential FFT recipient, thought the procedure was very risky.
“I was worried the defect was too extensive,” said Pomahac. “I was worried that his nerves were damaged to the point that we wouldn´t be able to reconnect them.”
But Pomahac said Wiens was young and his face could be repaired back to the way it was should something go wrong. “We don´t want patients to end up with worse deformity than before if the face is rejected,” said Pomahac.
But things went remarkably well, despite Pomahac´s fears. They found a matching donor face, allowing for the procedure to take place. The screening and preparations, however, took months. Pomahac said it was the “most extensive consenting” he has ever done.
Pomahac called the novel technique a “unique way to simplify anatomy.” Facial tissues are extracted from the donor as one block, including the skin and underlying muscles and nerves and reconnected to the recipient. In Wiens´ case, the nasal bone was also transferred.
Despite successful procedures, Pomahac doesn´t call the procedure a move from science fiction to real life. The science behind FFTs is still a long ways from replicating the facial transplantation found in the film Face Off.
Surgeons expected the recipients wouldn´t look like themselves before their injuries, and they also expected the facial changes they would experience as their new faces molded onto their frames would keep them from looking like their donors.
“We anticipated that the underlying skeleton and facial volume would shape the final facial appearance, making resemblance to the donors unlikely,” the authors wrote. “It is our subjective opinion, as well as that of two of the donor families, that the patients do not look like their donors.”
Each patient´s surgery was described in separate televised press conferences that Pomahac said may have made the procedure seem like isolated cases that were difficult to reproduce. But his team is working to make the procedure accessible. Pomahac said one patient is now listed for the transplant and waiting for a suitable donor.
“We can do it now so much better than the first cases,” said Pomahac. “The extent of how it will be used is undetermined, but it´s here to stay.”
“Our focus moving forward continues to be on monitoring and documenting the progress of patients who have undergone FFT, and refining the use of immunosuppressants, with the hope that one day patients will eventually need to take little or none,” Pomahac concluded.
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