The bear-attack patient after the successful transplant
A Chinese medical team led by Shuzhong Guo of the Fourth Military Medical University in Xi’an has successfully completed the first transplant to include facial bone in a transplant on a man whose face was slashed by a bear. The Chinese graft included muscles, nerves, blood vessels, cartilage and skin and included an intact salivary gland, another first. Two years after the procedure, the man can eat, drink and speak, thanks to the gradual fusing of transplanted nerves and muscles with what remained of the patient’s own.
This transplant together with the another ground breaking transplant last year by French doctors that removed a huge tumor that had completely infiltrated and disfigured their patient’s face, now sets the stage for a full facial transplant.
Full details of the world’s second and third face transplants are unveiled today.
One operation was on a Chinese man whose face was slashed by a bear. The other was on a Frenchman whose face was disfigured for many years by a massive tumour.
Although neither is a full facial transplant, both procedures break new ground compared with the world’s first face transplant in November 2005 on Isobelle Dinoire, a French woman savaged by a dog.
The Chinese team, led by Shuzhong Guo of the Fourth Military Medical University in Xi’an, is the first to include facial bone in a face transplant, carried out on 13 April 2006. “Without the facial bone framework, reconstruction of the nose and upper lip would not be possible,” the team state in their report.
Like the triangular face flap grafted onto the face of Dinoire, the Chinese graft included muscles, nerves, blood vessels, cartilage and skin. Another first was that it included an intact salivary gland.
Two years on from the procedure, the man can eat, drink and speak, thanks to the gradual fusing of transplanted nerves and muscles with what remained of the patient’s own.
The French team, meanwhile, came closest to transplanting an entire face. On 21 January 2007, they transferred a graft that was three times the surface area of the one given to Dinoire.
Their most difficult task was to remove a huge tumour that had completely infiltrated and disfigured their patient’s face, leading to complete paralysis on one side and partial paralysis on the other. The tumour was caused by an inherited condition called neurofibromatosis type 1, and gave the man the appearance of the “Elephant Man”, John Merrick.
“It’s more a malformation than a tumour, so there was no clear-cut division between healthy and abnormal tissue,” says Laurent Lantieri, head of the team which performed the surgery at the Henri Mondor Hospital in Créteil, France. “We removed all the lower part of the face, including muscle and nerves, and replaced it all with the transplant.”
For two to three months, the man couldn’t move his face, but then began to recover mobility and sensation. “Now, he can close his mouth completely, speak and eat,” says Lantieri. “But he still has some problems smiling because the way we set the muscles wasn’t perfect.”
He has also recovered an ability to blink, lost for 10 years, and says that as little as a month after the surgery, his self-image in dreams had reverted from his old to his new appearance, reinforcing his acceptance of the graft. “The psychological results are very good,” says Lantieri, adding that the man has since returned to work as an accountant.
Just like Dinoire, both patients suffered bouts of acute rejection of the new tissue, but both were stabilised with strong immunosuppressive drugs.
Since the procedure, the French patient has drastically cut down on immunosuppressive drugs. Lantieri believes that the chimeric tissue formed between the native and transplanted tissue has gradually helped his body accept the new material as “self”.
With the success of all three operations, the stage could now be set for a full face transplant. “I think it might be possible, but we have to find a patient, and there’s a technical problem transplanting eyelids,” says Jean-Michel Dubernard of the Edouard Herriot Hospital in Lyon, and co-leader of the team that did the first face transplant.
Lantieri agrees that the eyelid is the main technical challenge, because the nerves and muscles that operate it reside both outside the eye socket and within it. But he and his colleagues are researching ways to overcome the problem. “We’re still working on the possibility of transferring the whole face,” he said.
Dubernard said that Dinoire is still doing very well, and has now recovered an estimated 95% of normal facial function, none of which could have been restored by conventional surgery. “She can speak, drink without spilling liquid and eat normally,” he says. “She can smile, grimace, kiss and do almost everything,” says Dubernard.
The other gratifying thing in all three cases is that none has suffered the feared psychological consequences of receiving parts of other people’s faces.
“The psychological results are very good,” says Lantieri. Dubernard, meanwhile, repeated a statement from Dinoire three months ago that the transplant “gave me back an identity, because without a face, I am nothing”.
“We’re very encouraged by these results,” says Maria Siemionow of the Cleveland Clinic in Ohio, and the only holder in the US of approval to do a face transplant, granted in 2004. “But as we can see, there’s still incidence of acute rejection, so we need to work on immunosuppressive procedures that are less harmful,” she says.
Siemionow says that her team is still preparing for the possibility of doing face transplants, but that everything needs to be in place beforehand. “It’s taking time to get agreement on this, not just in the institutions involved, but in society generally,” she says.
Via New Scientist