Face Reconstruction

Technical

Hettiaratchy and Butler discussed the potential for face transplantation in an article in the Lancet in July 2002 and at the winter meeting of the British Association of Plastic Surgeons (December 2002) and this led to widespread interest regarding facial transplantations with considerable media coverage.

A working party was set up by the Royal College of Surgeons of England, with representation from the British Association of Plastic Surgeons, to examine all aspects of the proposed procedure including the technical aspects of the surgery, the immunologic aspects, psychological aspects and ethical issues. Their report in November 2003 stated that 'facial transplantation would constitute a major breakthrough in restoration of a quality of life to those whose faces have been destroyed by accident or tumour'. It also stated that 'it would be unwise to proceed with facial transplantation until further research was performed' (5). The Comité Consultatif National d'Ethique (CCNE) in France also produced a report in February 2004. They concluded that a partial face transplant involving the mouth-nose triangle had a potential clinical application.(6)

Researchers at the UK face transplant team at the Royal Free Hospital in London have developed a surgical and psychological screening process for patients seeking facial transplantation (7).

Other teams researching facial transplantation include the University of Louisville (USA) and the Cleveland Clinic in Ohio (USA) who gained IRB approval for patient selection in September 2005.

Meanwhile, surgeons in France have performed the first successful partial face transplant on a 38 year old female (27/11/2005). The team continue to monitor her progress with regard to long term benefits.

1. Lee WPA, Yaremchuk MJ, Pan YC, Randolph MA, Tan CM, Weiland AJ. Relative antigenicity of components of a vascularised limb allograft. Plas Reconstr Surg 1991; 87:400-11.

2. Petit F, Minns AB, Dubernard JM, Hettiaratchy S, Lee WP. Composite tissue allotransplantation and reconstructive surgery:first clinical applications. Ann. Surg 2003; 237: 19.

3. Petit F, Paraskevas A, Minns A, Lee WP, Lantieri LA. Face transplantation: Where do we stand? Plas Reconstr Surg 2004; 113(5):1429-33.

4. Face transplants not just science fiction. CNN.com/health. CNN_com - Face transplants not just science fiction - Nov_ 28, 2002.htm

5. Working Party Report- The Royal College of Surgeons of England: Face Transplantation. 203; 1-24

6. Working Group-Comité Consultatif National d'Ethique (CCNE) : Composite Tissue Allotransplantation of the Face (Full or Partial Facial Transplant). 2004 : 1-20

7. Clarke A, Butler PEM. Face transplantation : psychological assessment and preparation for surgery. Psychology, Health & Medicine. 2004, 9(3) : 315-26.

Blood Supply
One of the principal concerns in performing this surgery is ensuring that the donor tissue receives an adequate supply of blood.

A wealth of anatomical knowledge detailing the blood supply to the skin and their underlying muscles has made it possible to transplant specific territories of skin, individual muscles, and segments of bone (separately or in combination) to reconstruct volume defects anywhere on the body. This technique is known as 'free tissue transfer' and is achieved by disconnecting the blood supply of the tissue to be transferred (the donor tissue) and reconnecting these to different vessels at their new location under microscope control (figure 1).

Figure 1 - A surgeon working with a microscope

Microsurgery of this kind occurs in many plastic surgical units and is a well developed technique with a success rate of 96-98% in most units. These same techniques and principles will be applied during a facial transplantation. Connecting the facial artery and vein on either side of the face would provide sufficient blood supply, but connecting additional vessels will help to make sure that the transplant is successful (figure 2).

Figure 2 - A successful anastomosis of a vessel

Maintaining facial function
Patient selection will determine facial function after transplantation. The UK approach is to reconstruct patients requiring new skin and subcutaneous fat. The facial function returning after facial transplantation will occur because the burnt skin and scar, which restrict movement, will be removed and the patient's muscle will be free to move. Some groups have suggested using facial nerves and muscles in the facial transplant. The UK group have avoided this approach because of potential limited recovery of the facial nerve.

Repair of an avulsed face
A facial transplant is technically possible. This was demonstrated by a surgical team in India that reattached the face of a girl who sustained a severe avulsion injury (her face was ripped off when her hair became caught in a machine) to her face in 1994. (figure 3 & 4).

Figure 3 & 4 - The avulsed face and the eventual result following surgery (images courtesy of http://www.health.discovery.com)

How Much of The Face is Transplanted?
Depending on the severity of the recipient's facial damage several variations of the transplant have been proposed:

Transplanting a particular facial aesthetic unit (part of the face)
Using only the superficial skin and fat, much like a mask with a blood supply
Using skin and fat and also some or all of the facial muscles, nerves and glands
Using all the soft tissue of the face
Using all of the face including some of the bone architecture