October 30th, 2012
There has been lots of talk in the news recently highlighting a number of courageous patients who have undergone transplants of part or all of their faces. Both they and the team of doctors that are taking care of them are to be commended – these operations are pushing the boundaries of what is medically possible further and further. Not to toot my own horn, but plastic surgeons are on the leading edge of these advances, and have been from the start of transplant surgery.
Little known fact: Dr. Joseph Murray, who performed the first transplant of a human organ in 1954, was a plastic surgeon.
What you may not know is how much planning, preparation, and care goes into a surgery of this type. The (bad) movie Face/Off has given the public an overly simplistic view of what is an incredibly complex undertaking. I’ll use it as an example to illustrate what goes into a face transplant. Big disclaimer: I’ve never been involved in a face transplant, and this is information available through our journals and professional publications.
First, the recipient has to be psychologically screened and must be able to understand the risks of surgery. Essentially, they must understand that if the transplant fails or their body rejects the transplant, they will be left without a face, which poses an ethical dilemma: is the patient willing to live his/her remaining days with a much worse disfigurement than they start with (going from horrible to unimaginably horrible), and, if not, are they and their doctors willing to withhold life-sustaining measures – food, water, and medications, and allow them to die?
Needless to say, this is not a procedure that is undertaken lightly by anyone, and the screening and risk/benefit discussion is of utmost importance to all involved.
Next, a suitable donor must be identified based on blood and antibody typing. Once this happens, the “real” parts of the operation begin. An impression of the donor face (John Travolta) is made and a prosthetist begins creating a mask for the donor to allow him to be “complete” for burial – very important for the donor’s family and friends. The face is then meticulously harvested – major blood vessels, nerves and muscles that control facial function (smiling, chewing, etc), and the upper and lower jaw bones are all removed as one piece. Simultaneously, a second team of surgeons works to remove what is left of the the recipient’s face (Nicholas Cage in our example) and prepare the vessel and nerve stumps for the surgery.
Once this is all completed, the donor (Travolta) face – bones, muscles, nerves, and all – are positioned properly and the bones are secured with metal plates and screws to the remaining skull. Under an operating microscope, the nerves and blood vessels are attached to the recipient’s (Cage) nerves and blood vessels. The recipient is then given powerful drugs to suppress his/her immune system and prevent his body from rejecting (essentially, killing) the donor (Travolta) face. While these are slowly taken away over time, the recipient (Cage) will likely need some form of anti-rejection medication for the rest of his life.
It’s then a waiting game – it takes around a year for all the nerves to grow back and the face to begin to function. Even then, it’s never quite 100% and there is always some weakness and numbness that remains. However, given where most patients have started, it’s a dramatic improvement.
While face transplants raise a number of questions that need to be answered, the procedure gives life back to people who were so disfigured that they lived in total solitude, and is a wonderful advancement for plastic surgery and medicine in general.
Sorry for being a bit long-winded, and thanks for reading.
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