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News Americas

Richard Norris, now age 39, underwent in March 2012 what is widely considered the most extensive facial transplantation after a gunshot accident a decade earlier had ravaged the lower part of his face. (Photo: The Lancet)
May 20, 2014 | News Americas

Facial transplants: Researchers review development over past nine years

by Surgical Tribune

BALTIMORE/NEW YORK, USA: Plastic and reconstructive surgeons from the U.S. have undertaken the first comprehensive retrospective study of all facial transplants performed worldwide to date. Reviewing 28 cases over a period of nine years, they concluded that the procedure is relatively safe and increasingly feasible. Overall, facial transplantations improved the appearance and social life of the severely disfigured patients significantly.

The researchers reviewed immunological, functional, psychological and esthetic outcomes of facial transplantations since the first procedure in 2005, which was performed in France on a 38-year-old woman who lost parts of her face owing to a dog bite.

The team noted that those transplants still pose lifelong risks and complications from infection and sometimes toxic immunosuppressive drugs. They reported that all face transplantation recipients had an acute rejection episode of variable severity within the first year of transplantation. However, none chronically rejected their new organs and tissue. Infectious complications occurred in at least 11 patients. All but three patients are still alive today. The few deaths were due to infection and cancer, not directly to their transplants.

The transplants appeared to be highly effective at restoring people to fully functioning lives after physically disfiguring and socially debilitating facial injuries, the team noted. Rapid restoration of sensory feedback was reported consistently. While some recipients claimed feeling thermal sensations as early as three months after surgery, satisfactory restoration of sensation and the patients' ability to open and close their mouths and move their lips often took eight months or longer. In the long term, recovery of the ability to smile was noted as late as two years after transplantation, the researchers said.

Recovery of intelligible speech was reported within one month of transplantation for four patients, and significant improvement in swallowing, breathing and sense of smell immediately after surgery was reported for another. The researchers also found that many patients could speak, drink and eat normally two years after surgery.

With regard to psychological outcomes, the researchers noted that most recipients reported a renewed sense of self and body image, and showed fewer signs of depression. Overall, the surgery improved the patients' quality of life, with several patients returning to work. Initial concerns about feelings of depersonalization towards the new face and donor identity transfer have not been substantiated, the researchers said.

As powerful drugs are used to prevent organ rejection and to accelerate nerve repair and growth at a fairly young age, potentially lifelong immunosuppression and its serious side effects, such as infections, cancer, graft loss and death, were among the main concerns raised with regard to the procedure. Other ethical concerns about the high costs, which amount to an estimated $300,000, of face transplantation continue to be debated.

The researchers pointed out that several secondary procedures, including dental and jawbone alignment, and dental implants, to achieve optimal occlusion were common among the transplant recipients.

In order to improve the procedure and to make it more widely available in the future, the team is planning to conduct further research to minimize immunosuppression and develop better tools for screening patients best suited to the therapy. They are also planning to explore the feasibility of performing face transplants on severely disfigured children.

The study included cases of 22 men and two women. Patient histories included animal bites, gunshot accidents, and severe electrical and fire burn injuries. The first full-face transplant was completed successfully in Spain in 2010 on a 35-year-old man who had shot himself in the face accidentally. About two years ago, surgeons at the University of Maryland in Baltimore performed the world's most extensive full-face transplant to date by transplanting an entire face onto a 37-year-old man, Richard Lee Norris, who was left severely disfigured after a gun accident. As reported by Dental Tribune ONLINE at the time, they also transplanted a tongue, teeth, maxillae and a mandible successfully, along with facial tissue.

The study, titled "Facial Transplantation: The First 9 Years," was published online on April 28 in The Lancet journal ahead of print. It was conducted at NYU Langone Medical Center in New York in collaboration with the University of Maryland Medical Center.

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