The right patient is key to success for face transplants

September 14, 2006

The key to successfully performing the world's first full face transplant is selecting the right patient, according to the lead surgeon on the UK face transplant team.

Dr Peter Butler, who comes from Cork, and who trained at the Royal College of Surgeons in Ireland (RCSI), has been working towards facial transplantation for more than 14 years.

Dr Butler and his team of 30 at the Royal Free Hospital in London have ethical approval to begin screening patients, although they do not yet have approval to proceed with the transplant. This could come in the next year, according to some reports.

Screening has begun

Dr Butler told Irish Medical Times that his team has already begun screening patients, using both a surgical and psychological selection process.

"From a psychological point of view, it's not 100 per cent clear cut as to exactly what criteria we need because, by definition, the person who has psychological distress in relation to their facial deformity may have a problem with a facial transplant, so they will need a lot of support," said Dr Butler.

"It really needs to be somebody who is psychologically robust, somebody who has gone through their facial deformity and who has come out the other side following reconstruction, and has dealt with the issues that arose as they went through that."

The partial face transplant done in France last year resulted in months of public debate and speculation, which still continues.

Ms Isabelle Dinoire received the world's first face transplant in November when her pet Labrador chewed off her lips, nose and part of her jaw after she took sleeping pills.

Attempted suicide

Many people were uneasy about the procedure after it emerged that Ms Dinoire had allegedly tried to commit suicide, and that the face donor was a suicide victim. It was said that the procedure was unethical. The French surgeons who performed the operation denied that Ms Dinoire had attempted suicide.

According to Dr Butler, ethical issues surrounding transplantation should not be used as reasons to oppose a face transplant, rather, he said, they should be used to summarise and frame the argument.

"The ethical argument is used by some people as a block or a barrier, but really it should be used to summarise all the pluses and minuses and bring them together. Ethics is a way of framing the argument for face transplants," he said.

"I can get you a professor of ethics from one of the London universities who will argue against it, saying it is an abomination and shouldn't happen. I can also get you another professor who will argue for it and say it should happen. So ethics itself should not be used as a barrier or an absolute. It is a way of framing the argument."

Dr Butler told IMT that there is a delay in getting ethical approval for the operation because a lot of people feel the risks outweigh the benefits. He, obviously, disagrees.

Speaking at the European Academy of Facial Plastic Surgery in Dublin last week, Dr Butler explained that ethical arguments should not block progress.

"From my point of view, the patient seeking a face transplant feels that the risk of potential immunosuppression, which is the main risk, is outweighed by the benefits of the procedure."

After the French partial face transplant last year, Dr Butler was contacted by colleagues who had previously been against the operation. They began sending him potential face transplant recipients for screening.

Highly sceptical

"The French transplant changed a lot of people's perceptions. There were a number of surgeons I originally spoke to about my idea who were highly skeptical. It changed their minds totally and they are now sending me patients for assessment and consultation. It helped my process tremendously," he told IMT.

The ideal face transplant recipient, according to extensive research by the UK team, should be at the right point between psychologically distressed and facially disfigured.

"We have worked very hard over the last four to five years on our patient selection criteria. This is the key to the success or failure of the project," said Dr Butler.

"The ideal patient has to be either maximally disfigured or maximally psychologically distressed, or maximally disfigured with minimal distress; we certainly don't want a patient with minimal disfigurement and distress."

Dr Butler believes the risks and benefits of facial transplantation need to be discussed from a number of perspectives.

Societal, psychological, technical, ethical, and immunological risks and benefits should be debated, he said.

From a technical point of view, microsurgical operations now have a success rate of around 98 per cent.

Surgeons have also learned a lot from the partial transplants done, and from hand transplants, 24 of which were done between 1992 and 2003.

"We have learned a lot from the French transplant. We've learned less from the Chinese face transplant. Unfortunately my experience with the Chinese is that they only report results when they're good. We don't have much data from this transplant," said Dr Butler.

Sensory recovery

But he said the best evidence, from a technical point of view, for full facial transplantation comes from the face replants that have been done. Dr Butler's team reviewed five facial replants that were done around the world and found that 95 per cent of patients have had "some form" of sensory recovery.

"What we will get is perhaps not normality, but huge improvement."

The operation itself consists of a series of operations requiring rotating teams of specialists. With issues of tissue type, age, sex, and skin color taken into consideration, the patient's face is removed and replaced (including the underlying fat, nerves and blood vessels, but no musculature).

What is important, however, is that the transplant does not give the recipient the appearance of the deceased donor's face, because the underlying musculature and bones are different. The personality, as expressed by the face, remains that of the recipient.

The idea of someone taking immunosuppressive drugs for the rest of their life is the main reason for opposing facial transplantation. It is estimated that the drugs decrease lifespan by 10 years, and there is still the initial risk of rejection. It has also been found that long-term immunosuppression increases the risk of developing life-threatening infections, kidney damage, and cancer.

"Really what you're trading off is a potential improvement in quality of life versus a decrease in quantity of life," said Dr Butler. "But most facial deformity patients we've studied have said they'd trade this without question because their current quality of life is so poor. From an immunological point of view, again, we can look at the success of hand transplants. We learned a lot from them because the hand, in terms of muscle and bone, is similar to the face."

Dead person's identity

The face is the organ of identity and communication. Another common problem some people have with the procedure seems to be the worry that the recipient may be accepting a dead person's identity. Dr Butler and his team are working to dispel this fear.

"Society seems to view this process as identity transfer, wondering if they will see the face of their loved one walking down the street. We have tried to explain that that wouldn't happen," said Dr Butler. "Other worries are that it could be used for cosmetic surgery, and I still try to explain to people that this won't happen, it wouldn't work as well as a normal face. We will never see it being done for cosmetic reasons."

Another worry is that face transplant recipients may be swapping the stigma of facial disfigurement for the stigma of having a dead person's face.

Research conducted by the team in Louisville, Kentucky, asked members of the public, renal transplant recipients and facial deformity patients how they would rank transplants, in terms of which they would get first, disregarding any risk. Full face was ranked first as a desirable transplant.

Research conducted by Dr Butler's team asked doctors if they believe a face transplant should be done. Sixty-nine per cent of transplant professionals said one should be done now, 60 per cent of the public said now, and only about 20 per cent of plastic surgeons said now. Their worry was about the immunological risk. If this risk was lessened or proven to not be a problem, almost 90 per cent said one should be done now.

According to more research by Dr Butler's team, there are about 400,000 people in the UK with some form of facial deformity, and 250,000 of these are severe.

He said 60 per cent suffer from social isolation, and they have four times the national suicide average rate, mainly due to the lack of surgical options.

Life is spent indoors

"The classic story we get from most of these patients is that their life is spent indoors, with little or no interaction. They go out once a week to the corner shop or off-license with their face covered, or wearing a hat or mask. That's how they spend their life. Some people would say that's not a life, it's an existence."

By December of last year, 20 patients had already approached Dr Butler's team hoping to be the recipient of the first full face transplant.

One of these was 27-year-old Jacqueline Saburido from Venezuela, who suffered severe burns after a car accident in Texas seven years ago.

Jacqui went from an attractive 20-year-old to spending her time, as Dr Butler described it, with a pen cellotaped to a glove covering her burned hand, tapping away at a computer screen. She was burned on over 60 per cent of her body. Her fingers were amputated, and she lost her hair, left eyelid, nose, ears, and most of her vision. She has had over 50 operations since the crash.

"The important thing to remember is that this is about the patients. We have a chance to improve their lives. That's where we start the ethical argument," said Dr Butler. "We haven't moved that far forward since the 1940s and 1950s in the aesthetic result of full facial reconstruction. What we end up with is a slab of meat on the side of a face, and we slap ourselves on the back and say we've done a good job. We've reached the end of the reconstructive ladder. We want to give these patients what they're missing and replace like with like."

This article posted October 1, 2006.