| Peter Gorner, Tribune science reporter |
| Jun 12, 2005 |
| 1 |
| News |
| 1890 |
Ethicists may find the idea unacceptable, but at least two medical = centers in=20 the U.S. are in the final phases of planning for a controversial new = procedure:=20 a face transplant.
Surgeons say they are ready to remove the face of a cadaver and = stitch it=20 onto an adult who has been severely disfigured by trauma, burns or = tumors. The=20 goal is helping people who often say they are shunned by society and = lead=20 extremely unhappy lives.
Currently doctors try to reconstruct faces by transplanting tissue = from other=20 sites on the body in multiple operations-- sometimes 120 or more = separate=20 surgeries--and by implanting prosthetic devices.
A face transplant would permit surgeons to mold an actual face and = underlying=20 tissue, which proponents say is closer to what nature intended. They = want=20 patients to regain the ability to eat, drink and communicate with others = through=20 the vast array of facial expressions that few people think about unless = they are=20 lost.
Critics note that face transplants won't save or prolong lives but = will=20 require recipients to take powerful and perhaps dangerous = immunosuppressive=20 drugs for the rest of their lives. Such drugs normally are given to = organ=20 transplant recipients whose only other option is death.
And if the surgery goes wrong--if the body rejects the face, for = example--the=20 consequences could be dire.
"The risks to the patient are staggering. This is a terrible idea = that should=20 not be tried," said Arthur Caplan, chairman of bioethics at the = University of=20 Pennsylvania.
Christine Piff said she used to feel that way. But today she stands = among the=20 few patient advocates who have come out in favor of the operation.
"When I first heard of face transplants, I was truly horrified. But = over the=20 years, I met so many miserably unhappy people, I've changed my mind," = said Piff,=20 an Englishwoman who founded Let's Face It, an international self-help = network=20 for facially disfigured people.
Piff, whose face was ravaged by surgery on a cancerous tumor in her = left=20 cheek, said many disfigured people never leave home.
"We don't go out because of the way we look," she said. "We're = frightened=20 because of how the public stares at us. Children at school are bullied = if they=20 look different. Society tends to be very cruel if you don't look the = same.
"So disfigured people just shut themselves away. They only leave home = at=20 night with hoods over their faces. For them, face transplants could mean = a=20 chance at a normal life."
Surgeons make case
Transplant surgeons say the operation would allow the patient's face = to move=20 instead of being like an insensitive mask, which is often the case after = skin=20 grafts.
The new face would probably resemble a cross between the donor and = recipient,=20 depending on the amount of facial muscles used in the operation. A = person's=20 facial identity is mostly determined by the underlying skull, which = would not be=20 transplanted.
The surgeons say they can perform the surgery and are tired of being = stymied=20 by the squeamish.
"It's time to do face transplant. Technically, it could have been 10 = years=20 ago," said Dr. John H. Barker, director of plastic surgery research at = the=20 University of Louisville, which performed the nation's first hand = transplant in=20 1999.
He is seeking permission from his institution to perform 10 face = transplants,=20 all on severely burned victims.
"Before we did the hand, there was rat, rabbit and pig research = saying it=20 would work. And there was a lot of ethical debate advising against it," = Barker=20 said. "Now, there have been 25 hands transplanted in 19 human beings, = some out=20 five years post- transplant."
The success of hand transplants suggests that face transplants would = work,=20 since both operations involve multiple tissues--skin, muscles, bones, = tendons,=20 cartilage, fat, nerves and blood vessels. The drugs that would be used = to=20 prevent rejection are being safely used by thousands of kidney = transplant=20 patients, Barker said.
"Face transplants will be done," he said. "There is a great need. = There may=20 be ethical issues, but there comes a point where you've got to just do = it, and=20 let the cards fall where they may."
Ethicists say the risks are just too great. Given the potential = problems--the=20 possibility of tissue rejection, side effects of anti- rejection drugs,=20 unforeseen psychological difficulties--a high price could be paid for = the hope=20 of looking normal.
"It's not certain that the transplant will provide a functioning or = even=20 partial-functioning face," Caplan said. "The drugs required are = powerful,=20 noxious and potentially life-threatening."
No one knows for sure how the body's immune system will react to a = new face.=20 If acute rejection occurs shortly after surgery, "the subject may die = with the=20 entire graft sloughing off his or her face," Caplan said.
'Not for vanity'
Transplant surgeons say such comments are made by individuals with no = experience in this field. Their first "rescue strategy" would be to = transplant=20 another face; otherwise, they would revert to normal reconstruction=20 procedures.
"It's essential that people understand this surgery is not for = vanity. The=20 people seeking facial transplants are isolated and desperate," said Dr. = Maria=20 Siemionow, director of plastic surgery research and training for the = Cleveland=20 Clinic Foundation.
In October, her institution became the first in the U.S. to give = permission=20 for face transplants and allowed her to start screening patients. = Transplant=20 surgeons agree that only people who have specifically agreed in advance = to be=20 face donors would be considered. Potential recipients would undergo = intense=20 psychological evaluation.
Siemionow has published hundreds of studies about circulation and the = successful transplantation of face, limbs and other tissue in laboratory = animals. Mock transplants performed on cadavers have taught her the = amount of=20 tissue required in such surgery on humans, she said.
Her 15 years of research is evidenced by the white lab rats with = brown=20 faces--and half-brown faces--that occupy cages in her lab.
"The procedure is very difficult," Siemionow said. "It takes more = than 6 1/2=20 hours to transplant a full facial graft in a rat. The hemi-face is a = shorter=20 procedure to test rejection events."
She is trying to develop a process that would head off the need for=20 anti-rejection drugs by giving transplant recipients special antibodies = in=20 advance. The idea has been tested in animals but so far is not = transferable to=20 humans.
"Currently, the rats receive only seven days of medication and will = accept a=20 leg from another rat for life," Siemionow said. "I'm not saying that = face=20 transplants should wait until we figure this out. I'm saying that our = work in=20 induced-tolerance should be considered by those who have doubts about = the future=20 of this line of research."
Some critics point out that a face transplant is not necessary to = preserve=20 life. But that objection has not prevented other types of transplants = from being=20 performed in various countries, including hand transplants, abdominal = wall=20 transplants, a larynx transplant that enabled the recipient to speak, = and the=20 first total tongue transplant.
Even if the first operations went well, Caplan said the possible = impact on=20 organ donation must be considered.
"Most donation involves organs and tissues that can be removed from a = cadaver=20 without causing grave disfigurement to the body," he said. "This will = not be=20 true of face donation. ... There could be an adverse impact on the = public's=20 willingness to support organ and tissue donation."
The issue of informed consent by face transplant recipients could be = another=20 problem, ethicists observed.
"They may be so desperate to do something about their severe = disfigurement=20 that they'll clutch at straws," said Carson Strong, of the University of = Tennessee College of Medicine.
"I don't think we'd be able to make sure that wasn't the case with = any=20 particular patient."
Medical teams in Europe also hope to perform the procedure. In = Britain, an=20 influential working party report from the Royal College of Surgeons = advised in=20 November 2003 that although it was optimistic about the idea, "it would = be=20 unwise to proceed with human facial transplantation" until more=20 research--psychological as well as physiological--is done.
The following March, an ethics board in France rejected a face = transplant=20 proposal, even though that country had performed the world's first hand=20 transplant.
Doubts and divisions
Conflicts in the field are evident. For example, the U.S. director = for the=20 international support group founded by Piff said she sees little need = for facial=20 transplantation because other steps can be taken.
Rickie Gill, executive director of Batavia-based AboutFace USA, has a = son who=20 was born with a severe birth defect that required his entire face and = cranium to=20 be reconstructed many times as he grew up.
"It would have to be a terrible, terrible reason to even consider = having=20 somebody slice off your face," she said.
"In fairness to transplant advocates, we also live with this = situation every=20 day," Gill added. "I'm open to anything that will save these = patients--be they=20 children or adults--from any more pain than they must endure, either = emotionally=20 or physically."
Piff suffered a cancerous tumor in her left cheek 28 years ago, when = she was=20 36 and had three young children. When chemotherapy and radiotherapy were = unsuccessful, Piff underwent an operation called maxillectomy.
"My kids gave me no choice," she said. "I had to live."
The operation cost Piff her left eye; half her palate, which held her = upper=20 teeth; and the maxilla bone, or upper jaw.
Coming out of surgery, she remembers a nurse's lulling voice: = "'Christine,=20 you still have got your eye.' I smiled a big smile and my teeth fell = onto my=20 chin," she wrote in an essay.
Piff wears a masklike facial prosthesis and an artificial palate that = enables=20 her to eat, drink and speak.
As she worked through the grief over her lost face and her = insecurities about=20 how she looked, Piff found there was little help available for people = like her.=20 In 1984 she founded Let's Face It. The group quickly spread to the = United=20 States, Australia, Germany, Denmark, Sweden and Norway.
"People who are shut away don't have much of a life," Piff said. = "These are=20 the patients, I think, who would really benefit from facial=20 transplantation."
pgorner@tribune.com
- - -
Face transplant procedure nears reality
Surgeons at two U.S. medical institutions say they are ready to mold = facial=20 tissue of human donors onto severely disfigured adults. The goal is to = provide=20 greater mobility of the face and help those who feel isolated from = society.=20 Critics, however, say the risks are too high.
RETRIEVING DONOR TISSUE
Incisions are made on the donor's face, in this case, from just below = the=20 hairline to below the chin. The skin and underlying tissue is removed. = Surgeons=20 will use as much of the recipient's healthy tissue as possible.
The time limit between removing tissue and reconnecting it is about = 10 to 15=20 hours, the length skin can last without blood nourishment.
PREPARING THE RECIPIENT
Surgeons remove the face of the recipient, clamping off crucial veins = and=20 arteries to block the blood flow. Ideally, the eyelids are still intact = as they=20 are the most complicated to reattach.
Bone grafts may be required.
TRANSPLANTATION
In a 12- to 24-hour procedure, microsurgeons attach the recipient's = severed=20 arteries and veins to the donor's facial tissue. The nerves are = connected, then=20 the muscles and skin.
Sources: Popular Mechanics, KO Studios, The Royal College of Surgeons = of=20 England; Dr. John H. Barker, University of Louisville
Los Angeles Times/Chicago Tribune
-See microfilm for complete graphic.
Some critics point out that a face transplant is not necessary to = preserve=20 life. But that objection has not prevented other types of transplants = from being=20 performed in various countries, including hand transplants, abdominal = wall=20 transplants, a larynx transplant that enabled the recipient to speak, = and the=20 first total tongue transplant.