In May last year, a 46-year-old military veteran from Arkansas, United States, who survived a work-related high-voltage electrical accident, underwent the world’s first whole-eye and partial-face transplant. The surgery helped transplant the patient’s entire left eye and a portion of the face from a single donor, making it the first-ever human whole-eye transplant in medical history and the only successful combined transplant case of its kind.
In 2017, US national Katie Stubblefield became the youngest face transplant recipient at the age of 21. Stubblefield, who was featured in the cover story of National Geographic magazine’s September 2018 issue titled The Story of a Face, was just 18 when she put the barrel of her brother’s hunting rifle below her chin and pulled the trigger because of which she lost her face. Her new face came from Adrea Schneider, who died in 2017 after a drug overdose.
The surgery effectively replaced 100% of Stubblefield’s facial tissue, as per reports. However, her eyes are often dry and painful, so she wears a protective plastic film over them, add reports.
It’s been close to 20 years since the first partial face transplant was conducted in 2005 on a French woman named Isabelle Dinoire, followed by a first full-face transplant in 2010 in Spain on a 30-year-old man with a severe facial deformity – but the number of such successful procedures has not gone beyond 50. The survival rate varies; generally, it is about 80-90% for the first year, with longer-term success depending on ongoing care and adherence to medication, says Dr Vipul Nanda, chief of cosmetic and plastic surgery at Gurugram’s Artemis Hospital.
Catching up
The low success rate doesn’t deter the All India Institute of Medical Sciences (AIIMS) in New Delhi from taking a shot at the one-of-a-kind and rare surgery, which might soon become a reality as a team of plastic, reconstructive, and burn surgeons at the premier medical institute is preparing to offer face transplants in the country.
A face transplant is a complex surgical procedure that involves replacing a patient’s damaged or missing facial tissue with a donor’s facial tissue. It has been seen that it is usually recommended for people with severe facial deformities or injuries that cannot be repaired through conventional methods like reconstructive surgery.
Speaking with FE, Dr Maneesh Singhal, the head of the department of plastic, reconstructive, and burns surgery at AIIMS Delhi, says, “We are right in the phase zero of the transplant, that is, we are preparing ourselves.”
On the kind of patients who will be eligible for the transplant, Dr Singhal says, “Going by how the earlier institutes have performed this surgery all over the world, the usual practice has been to treat those with severe facial trauma and deformity after gunshots, accidents, and huge animal bites, besides acid attack and burn survivors. This can also include cases of congenital conditions that significantly impair facial functioning and its appearance.”
As per Dr Singhal, there will be a core team of 10 surgeons with other support staff who will be undergoing the training at present. “AIIMS has all the technical expertise to perform transplants and has a similar kind of transplant already happening in India – hand transplant – having enough centres working on this,” he says, adding, “AIIMS will reach out to the ‘best people’ for training. However, the training will be mostly internal and to gear up for the procedure. It will at least take two to three years for face transplants to be offered to patients in India.”
Understanding it
It is important to understand that a face transplant differs from a facial reconstruction treatment. “Facial reconstruction involves repairing or reconstructing damaged or malformed facial structures using various techniques, such as grafts, flaps, or prosthetics. In contrast, a face transplant replaces the entire facial structure with donor tissue, aiming for a more comprehensive restoration of appearance and function compared to conventional reconstruction methods,” explains Dr Nanda of Artemis Hospital.
Face transplant procedures may take between 10 to 24 hours, sometimes even 36 hours. The procedure involves identifying the donor and preparing the recipient. Donors go through complete checkups and doctors need to have a full understanding of the defect in the recipient. As far as matching criteria are concerned, it requires blood type compatibility, tissue and bone structure matching, and minimising the risk of organ rejection.
As per Dr Singhal of AIIMS, matching the Human Leukocyte Antigens (HLA) is important between recipient and donor tissues. “Once the HLA matching is there, then the procedure may take anywhere between 10 to 18 hours and after that, we have to see very carefully how much the tissue is matching and close the parameters,” he says. He, however, cautions that there is a full chance that some grafts may not be well-received by the body for which further surgery might be required.
Other factors like the donor’s age, overall health, and facial dimensions are also important. “During the procedure, precise alignment of blood vessels and nerves is necessary to ensure proper integration and function,” says Dr Nanda.
The donor can only be a cadaver (facial tissue from a dead person) unlike a kidney or liver transplant which can be taken from a person who is alive.
As per Dr Nanda, the damaged facial tissue is removed from the donor which is then transplanted onto the recipient’s face, including skin, muscles, and bones. Surgeons then reconnect blood vessels, nerves, and tissues to ensure proper function and integration, he explains.
Can this procedure impact senses like smell, touch, and vision? Dr Singhal says a face transplant is not going to make any changes to the senses as they are inherent in a patient.
However, there are examples like that of Dallas Wiens, a 25-year-old from Texas in the US who received a new face in March 2011, after it was burned by a high-voltage electrical line in 2008, and lost the sensation of his face and smell. It was only after a year of his transplant that he said in a media interview he could feel his daughter’s kisses which brought him to tears on multiple occasions.
Worth the risk?
Being one of the rarest and most novel surgeries in the world, it also comes with a fair share of risks and is unpredictable as to how the recipient’s body will respond to the transplant and the final appearance.
It is also associated with infection, rejection of the donor tissue, and complications related to immunosuppressive medications required to prevent rejection. The psychological effects and issues with aesthetic outcomes are also likely to arise, points out Dr Nanda.
As cases of such transplants are limited worldwide, surgeons cannot effectively preempt how it may impact a recipient’s immune system.
For any organ transplant, immunosuppressants are to be prescribed to avoid rejection and other issues. Dr Singhal says immunosuppressants in face transplants are almost lifelong because it is a multi-tissue graft where cartilage, skin, and bones are substituted unlike transplants of kidney, heart, liver, and other organs where there’s only one tissue, making the prescription of immunosuppressants a little more tedious in face transplants. However, precautions and aftercare will have to be more or less the same as other transplants, he says.
The world’s first face transplant recipient, Frenchwoman Isabelle Dinoire, died in 2016 (nine years after the surgery), battling a long illness as her body had rejected the transplant the previous year and she had lost part of the use of her lips. However, in the case of the first full transplant that was done in Spain, the man was discharged after four months with near-total sensation, partial-motor recovery, and excellent acceptance of his new facial appearance. The early success was attributed to the technical and clinical feasibility of transplanting all the tissues with all their aesthetic and functional units intact.
According to a study published in the Journal of Plastic, Reconstructive & Aesthetic Surgery in December last year, out of a total of 48 procedures performed in 46 patients, adverse outcomes were gleaned in 14 cases (29%), including seven allograft losses (14.6%), and the death of ten patients (21.7%).
The study said that chronic rejection was the leading cause of graft loss taking a median of 90 months for irreversible rejection. In the cases of deaths, the causes were infectious complications, followed by malignancies (cancer), non-compliance to immunosuppression, and suicide. The median time to death was 48.5 months (4 and a half years). Immunosuppressant medicines have risks of kidney damage, development of cancer, diabetes, and other serious health conditions.
So is the procedure worth the risk? “It’s a surgical challenge. There are a lot of risks involved. But we have to move on with whatever best is happening around us. It’s a reasonable solution for somebody who is crippled for their whole life. At least, a solution exists today. I am sure in the next 20 to 30 years, it will evolve, but to begin with, I think it is something that we should do for our patients,” offers Dr Singhal.
One-of-kind-treatment
50: No. of known cases of successful face transplants worldwide
2005: First partial face transplant conducted on a woman in France
2010: First full-face transplant conducted on a 30-year-old man in Spain
80-90%: Survival rate for first year, longer-term success depends on ongoing care and adherence to medication
Risks involved
Graft infections, malignancies (cancer)
Need for lifelong immunosuppressants
Immunosuppressants may cause kidney damage, diabetes