April 11, 2009

Boston Hospital Completes World’s 7th Face Transplant

Doctors in Boston performed the world's seventh face transplant on Thursday, and are planning more. 

"Society is allowing us to do this. I think you're going to see more and more," said Dr. Frank Papay in an interview with the Associated Press.

Dr. Papay, a surgeon who assisted in the nation's first face transplant last December at the Cleveland Clinic, said this is particularly true for military personnel who have become disfigured in the wars in Iraq and Afghanistan.

The initial successes of the procedure have been remarkable.  Indeed, patients who could not previously eat or speak normally, or even be seen in public, now live without being recognized as someone who received a new face. 

However, face transplants are likely to remain rare, and to be limited to only those who are severely disfigured due to the substantial risks and lifelong need for medications that prevent rejection.

"It's not going to be like some people imagine "” routine, like people getting a facelift, or cosmetic surgery," Stuart Finder, director of the Center for Healthcare Ethics at Cedars-Sinai Medical Center in Los Angeles, told the AP.

"We have what appears to be success," he said, adding that there is always the risk that some patients may have serious rejection problems or refuse to take drugs for the rest of their lives.

Boston doctors emphasized the exhaustive psychological screening process they required before conducting the nation's second face transplant on Thursday. The surgery, at Harvard-affiliated Brigham and Women's Hospital, was performed on a man who experienced traumatic facial injuries from a bizarre accident.

Face transplants extend far beyond merely transferring of skin and facial features, and use bone and cartilage for facial reconstruction.

The Boston team, led by plastic surgeon Dr. Bohdan Pomahac, replaced the patient's nose, upper lip, palate, muscles, nerves and some skin with those of a dead donor.

Although the hospital would not disclose the recipient or donor, the donor's family members released a statement saying they hope the procedure motivates others to donate.

"The fact that we are able to give this gift was a tremendous comfort in our time of grief," the statement read.

"There is no risk of recognizing the donor on the new patient. There's a 60 percent chance the patient will look how he used to look," said Pomahac during a news conference on Friday.

During his interview with The Associated Press, he said the man's injury had occurred years ago, and had left him with "no teeth, no palate, no nose, no lip."

"It was difficult for him to speak, to eat, to drink. It certainly caused a lot of social problems," Pomahac said.

The man, who had been Pomahac's patient for a long time, decided to undergo a face transplant after previous treatments left him still badly disfigured.

Pomahac said it took three months to find an appropriate donor, who also donated some organs for transplant in other patients as well. Doctors extensively evaluated the patient psychologically in and outside of Brigham before going forward with the surgery.

The operation, which took 17-hours, got underway at 1:15 a.m. on Thursday.  The donor and recipient were in operating rooms across the hall from each other.  As of Friday, the patient was still recovering from anesthesia.

"He's still not fully awake so he has not seen himself. We have not really had a meaningful conversation so far," Pomahac said.

"He was incredibly motivated to go forward with it,"  Pomahac said.

"We really made sure that nothing was left to chance."

The seven primary surgeons and others all donated their time and services, Pomahac said.

"We are essentially making a lifelong commitment to help him."

Dr. Pomahac graduated from Palacky University School of Medicine in the Czech Republic before coming to Brigham for a surgical research internship in 1996.   At 38, he is now associate director of its burn center, where he works with trauma and plastic surgery patients.

The hospital's board approved Pomahac's plans to conduct face transplants a year ago.

The first transplant in the world was performed in 2005, led by Dr. Jean-Michel Dubernard in Amiens, France.  The patient, Isabelle Dinoire, had been mauled by a dog and was left severely disfigured. Today, Dinoire's appears virtually normal.

The United States' first face transplant, and the most extensive to date, was performed last December by doctors at Cleveland Clinic. The surgeons replaced 80 percent of a woman's face with that of a female cadaver.  Neither the patient's identity nor the circumstances that led to the transplant have been disclosed.

The woman left the hospital in February and is doing  "phenomenally well," Papay said.

"Her speech is improved so everyone can understand her now, and she has a great outlook on life. She's very comfortable with the way she looks now and she's very happy."

While the initial successes of face transplants are promising, this should not lead to over-excitement, according to Finder, a Los Angeles-based ethicist.

"This is still very new and hence requires a hyper-vigilance about helping patients understand what they're getting into," he told The Associated Press.

Indeed, some who have received other types of transplants sometimes find they replaced one set of problems for another. Some get tired of constantly taking the medicines needed to maintain the transplant.  At least one hand transplant recipient ultimately had the hand amputated for this reason.

Pomahac originally considered operating only on those who had already received a kidney or other organ transplant, since they would already be taking the immune-suppressing medicines and would carry a low risk of rejecting their new face.

"I still think that's the best group of patients but we have enlarged the protocol" to include those with severe facial deformities.

"It's really in its infancy in terms of knowing what will happen," he said.

"Each of the cases is its own unique story."

Surgeons hope to ultimately create waiting lists of face transplant candidates "just like for any other organ," Pomahac said.