Facial transplantation: a working party report from the Royal College of Surgeons of England

BACKGROUND At the winter meeting of the British Association of Plastic Surgeons in December 2002, Mr. Peter Butler presented a paper entitled “A Large Animal Model of Limb Transplantation without Long-Term Immunosuppression.” This led to widespread comment in the media about the possibility of facial transplantation. Three months later, press speculation had extended to trying to identify the possible recipient of the world’s first face transplant. The charity Changing Faces wrote to the Royal College of Surgeons of England, issuing a press release in March 2003 that called on the College to “attempt to create a moratorium on further media coverage of the issue.” This is something the College has never had the power to do. Both the College and the British Association of Plastic Surgeons, however, shared the concerns expressed by Changing Faces and others. Sensationalist coverage and a media hunt for the first patient could impinge on the privacy and well-being of any potential patients and their families. Any discussion of facial transplantation must also involve issues that are technical, psychologic, medical, and ethical. If such a procedure were to take place, it must be preceded by careful and open debate. In response to these concerns, the College set up a small working party to examine all aspects of the proposed procedure. This met three times between April and September 2003 and was also in contact by e-mail and fax. The relevant literature, both experimental and human, was reviewed. Members also met with Mr. Peter Butler to discuss his research. This article presents a review of the current situation in relation to facial transplantation as the working party members perceive it. It is published by the College to help inform and contribute to the ongoing debate about the ethics and practicalities of facial transplantation. The working party is interested in the opinions of the transplantation clinical community and therefore its reproduction as a special feature in this journal. TECHNICAL ASPECTS Transplantation to save and prolong life has become a regular part of medical and surgical practice. Most people are now familiar and comfortable with the transplantation of organs such as the heart, liver, or kidneys. In September 1998, the first human hand transplant was carried out in Lyon, France. Since then, 20 hand transplants, 9 abdominal wall transplants, and a laryngeal transplant have been performed. Most recently, in July this year, the world’s first tongue transplant was reported. Such procedures are referred to as composite tissue allotransplantation (CTA) to distinguish them from organ transplantation. In most instances, the aim of CTA surgery is to improve the quality of life and not to cure disease or save life. No CTA has been carried out in the UK to date. Principles of Tissue Transplantation These principles form the basis of all modern plastic and reconstructive surgery. The patient’s own (autologous) tissues in the form of flaps or grafts are transferred into defects created usually by trauma or ablative cancer surgery. A skin graft is a thin piece of skin, with no intrinsic blood supply, that relies on the ingrowth of vessels from the recipient bed (e.g., muscle). A flap has its own blood supply consisting of an arterial input and venous drainage (Fig. 1). Figure 1.Transfer of a flap may involve division of that blood supply and reconnection or reanastomosis of the vessels at another site of the body, using what has become known as microsurgical techniques. There is considerable experience in this type of surgery, and such flap transfer is known as a free-flap or free-tissue transfer. This is an autotransplant, and a similar flap transferred from one person to another person is an allotransplant. Facial Transplantation It is assumed that in the current discussions concerning facial transplantation that the potential recipients would be limited to those who have suffered severe burn injuries and have survived the initial treatment. Treatment of facial burns at present involves the use of flaps or grafts. The disadvantages of these methods mainly consist of an unacceptable cosmetic appearance and loss of function with tight scars and lack of facial expression. The aim of facial transplantation would be to replace unacceptable grafts and flaps with tissue that has the appearance of a normal face and allows mobility of the deeper structures. Facial transplantation differs radically from the normal methods used at present, which involve autologous tissue. The face would be taken from a donor, and transplantation would involve using a large amount of tissue, requiring an arterial input and venous drainage as for a microvascular flap transfer (Fig. 2). Figure 2.Although facial transplantation has not been carried out to date, there have been several replants of facial tissue involving replacement of parts such as the nose, ear, or scalp that have been torn or cut off (avulsed). In 1998, a patient’s own face and scalp were replanted (1). The only incidence of tissue being used for facial or scalp reconstruction from another person was a report that described using tissue from an identical twin for scalp reconstruction (2). There is also considerable literature on experimental CTAs and indeed a description of a rodent model of facial transplantation (3–5). Anatomic Considerations Survival of the transplanted facial tissue will be dependent upon adequate arterial input and venous drainage. Venous drainage is more constant in position than the arterial supply, and recent studies (unpublished data presented to Facial Reconstruction Working Party, September 17, 2003, at Royal College of Surgeons of England, Butler P) have shown that the course of the superficial temporal artery is more constant than the facial artery. The generous anastomosis between the various arterial territories ensures the feasibility of restoring the blood supply of a transplanted face by microanastomosis of selected vessels. A microanastomosis of the facial artery and vein on each side would most probably be sufficient for facial viability, but other venous anastomoses would render the transplant safer and more likely to succeed (Fig. 3). Figure 3.Several variations of tissue transfer may be considered, including the following: Skin and fat only used as a vascularized skin envelope; Skin and fat, but transfer includes some or all of the facial muscles, facial nerve, and the parotid gland; A subperiosteal facial transplant, which would include all of the soft tissues; or All of the above variations, but some of the bony architecture of the face would be included. At present, only the first option from the above variations is envisaged. The transplant consisting of skin and subcutaneous tissue would be placed directly onto muscle. This would involve removing the recipient’s scar tissue, including previous grafts or flaps. Appearance of the Facial Transplantation This is difficult to predict. Studies using computer modelling (unpublished data presented to Facial Reconstruction Working Party, September 17, 2003, at Royal College of Surgeons of England, Butler P) suggest, however, that the face looks neither like the donor nor the recipient preinjury but would take on more of the characteristics of the skeleton of the recipient than the soft tissues of the donor. There is a reasonable expectation of mobile facial expression, which is dependent upon the depth of scarring before the operation. New mobile skin and subcutaneous tissue may indeed move better than the previously grafted face (Fig. 4). Figure 4.Failure of the Facial Transplantation As with any microsurgical procedure, there is the possibility of clotting of the arteries or veins that have been anastomosed. If this it would be If of the were the anastomosis be by and reanastomosis of the vessels. If that surgery the transplant would have to be This is to the the transplant. 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