The first facial transplant

Abstract

Last week, French surgeons performed the first partial facial transplant, using the nose, lips, and chin from a brain-dead living donor to repair the face of a 38-year-old woman who had been mauled by a dog. Initial reports indicate that the recipient is doing well.Over the past several years, there has been intense debate over whether enough is known of the risks and benefits of facial transplantation to allow such an operation to be done. The procedure, though technically demanding, does not carry a great risk in itself. The risk comes from the threat of graft rejection and the immunosuppressive regimen given to prevent rejection. During the first year, the risk of acute rejection is estimated to be about 10%, and the risk of loss of graft function due to scarring from chronic rejection is predicted to be 30–50% over 2–5 years. The risks due to immunosuppressive treatment include life-threatening infections, cancers, and organ damage. And, because the surgery involves the face, there are concerns that patients will experience psychological trauma that could be profound.Solid organ transplantation carries similar risks but is considered justified because it is life-saving. A key question, then, is whether a facial transplant patient should undergo a potentially life-threatening procedure to treat a disfigurement, albeit a major one. Indeed, because so much is uncertain about the true risks and benefits of facial transplantation, it has been argued that it is impossible to provide a prospective patient with the information needed to give truly informed consent.But the time comes when enough is known to do an experiment and when an experiment may be the only way to answer the questions that remain. According to press reports, the French surgical team took care to select a patient who was unlikely to benefit substantially from standard restorative surgery and prepared her psychologically for the operation and its aftermath. They proceeded with the approval of French medical and ethical authorities. Although the decision to operate will no doubt be debated, the French team has taken a cautious and justifiable first step. Last week, French surgeons performed the first partial facial transplant, using the nose, lips, and chin from a brain-dead living donor to repair the face of a 38-year-old woman who had been mauled by a dog. Initial reports indicate that the recipient is doing well. Over the past several years, there has been intense debate over whether enough is known of the risks and benefits of facial transplantation to allow such an operation to be done. The procedure, though technically demanding, does not carry a great risk in itself. The risk comes from the threat of graft rejection and the immunosuppressive regimen given to prevent rejection. During the first year, the risk of acute rejection is estimated to be about 10%, and the risk of loss of graft function due to scarring from chronic rejection is predicted to be 30–50% over 2–5 years. The risks due to immunosuppressive treatment include life-threatening infections, cancers, and organ damage. And, because the surgery involves the face, there are concerns that patients will experience psychological trauma that could be profound. Solid organ transplantation carries similar risks but is considered justified because it is life-saving. A key question, then, is whether a facial transplant patient should undergo a potentially life-threatening procedure to treat a disfigurement, albeit a major one. Indeed, because so much is uncertain about the true risks and benefits of facial transplantation, it has been argued that it is impossible to provide a prospective patient with the information needed to give truly informed consent. But the time comes when enough is known to do an experiment and when an experiment may be the only way to answer the questions that remain. According to press reports, the French surgical team took care to select a patient who was unlikely to benefit substantially from standard restorative surgery and prepared her psychologically for the operation and its aftermath. They proceeded with the approval of French medical and ethical authorities. Although the decision to operate will no doubt be debated, the French team has taken a cautious and justifiable first step.